Participants
A total of 25 respondents were interviewed: nine (9) healthcare workers (HCWs) from primary care facilities, eight (8) caregivers of children with chronic/recurrent respiratory symptoms, two (2) Village Health Team (VHTs), four (4) herbalists and two (2) drug shop attendants (DSA). The healthcare workers included general medical doctors, clinical officers, and nurses. All the healthcare workers had been involved in the clinical practice for at least 2 years (range 2-27 years) and management of illnesses in children less than five years for at least 6 months. The majority (7/8) of the caregivers were female while most healthcare providers (11/17) were males. In this study, health care workers, drug shop attendants, herbalists and VHTs are collectively referred to as healthcare providers.
Themes
The major themes identified were: 1) caregiver’s description, understanding and management of the respiratory symptoms, 2) healthcare workers practices in assessing, diagnosing, and managing young children with respiratory symptoms, 3) Caregivers’ experiences with the healthcare system and 4) health system experiences of healthcare workers in providing care for children with respiratory illnesses.
Description of the child’s illness: scope and course of symptoms, and triggers
Caretakers views
Several caregivers indicated that the common symptoms included a running nose, an irritating cough that sometimes took several days to weeks to go away, difficulty in breathing and wheezing. Wheezing was commonly described as ‘a sound made by a sick chick’, ´noise in the lungs´ or ‘sleeping cat’, and this was commonly referred to as ‘okukyolya’ (wheezing) in the local language.
‘Since childhood, about six months old, when he catches a mild flu that you would regard “little”, there’s a way he breathes that’s so desperately difficult. In fact, most of the time we have been admitted to the hospital. It’s been happening till now’ (Caregiver 7)
“He was 2 years old. I struggled to treat pneumonia, I used to take him back for medicine, but since then, he is still getting the same type of medicine; they have not changed. Whenever he feels cold, he gets attack of that disease and cannot breathe, we start thinking that he is going to die. He coughs and makes noise in the lungs like a sick chick.” (Caregiver 3).
The symptoms were often described as recurrent, as frequently as every two weeks to 3 months. They described a cough that started as a mild one but quickly progressed to an irritating type, associated with difficulty in breathing and that in most cases, they ended up in the health facilities because the children could hardly breath. They further reported that the symptoms started mainly during infancy, as early as 3 months of age, but in some cases, the symptoms started at around 2 years, and that the frequency reduced as the children got older.
‘That child started at three months. He had difficulty in breathing and when I took him to hospital, the doctors diagnosed pneumonia. We kept on treating and he improved but after every two weeks he would again fall sick, and we could go back. He continued up to now, though per now he doesn’t fall sick like when he was still young, because then he would fall sick like after every week or two weeks but for now, we can go back to hospital like after a month’. (Caregiver 1)
Another key finding that was commonly told by the caregivers was the fact that the symptoms did not seem to improve despite seeking care and the medications that were given would offer short-term relief or none, and this greatly contributed to the caregivers’ frustrations.
‘As I talk now, she is fed up of going to the health facility. She is fed up. Every time she is in the hospital. She is tired of moving up and down due to the child’s sickness.’ (Caregiver 3)
‘The third time we took him to the government health facility, that’s what they wrote for him. You know they just write for you medication and you go to the pharmacy and buy. So, whenever he gets those conditions, I go and buy that medicine.’ (Caregiver 4)
The most common triggers for the respiratory symptoms that were mentioned by the caregivers were cold weather and a common cold. Other caregivers thought that the symptoms were inherited from the parents, or that the babies had aspirated meconium at birth.
“It had rained on him during day. You know young children. I think he played in the rain while at his grandmother’s home, so it started getting cold in the evening and he started coughing. The coughing kept on getting worse and he developed difficulty in breathing and wheezing. In fact, by the time, they rushed him to the facility, he had fainted.” (Caregiver 2)
‘whenever he gets flue, he also gets cough, and it worsens. Within a short time, he develops difficulty in breathing’ (Caregiver 4)
HCWs views
Health care workers indicated that they recognized that some children had recurrent/chronic respiratory symptoms especially a running nose, long standing coughs, commonly associated with difficult breathing and wheezing. Some children presented with fever, headache, vomiting and poor appetite, in addition to cough and/or difficult breathing. They also recognized that there were multiple ways the patients presented including those with short duration of the symptoms (3 to 5 days), long duration (more than 2 weeks) and on and off symptoms. They also indicated that from their (HCWs) experience, they had recognized a pattern where children first developed a common cold, followed by breathing difficulties, without fever and that when they treated some of those children with bronchodilators and steroids, they would get better, only for the symptoms to recur after about one month.
‘There are those who come with cough below 5 days, there are those who come with cough that has been there for more than three weeks, and there are those who come with cough that has been on and off’. (HCW 5)
Health workers further described that when children presented with difficulty in breathing and had chest indrawing, they considered that to be a serious problem, but for those who presented without those breathing difficulties, even when the cough was recurrent or long term, they referred to it a simple cough. Interestingly, one of the HCWs seemed to imply that when caregivers indicated that their children had had cough for a long time, say 6 months, the caregivers were mistaken and thought that they probably meant that the symptoms had been on and off.
The HCWs also indicated that in a few cases, some parents with asthma would tell them that their children might have asthma because they observed that the symptoms the children had were similar to those in their parents including frequent cough, difficult breathing, and a sound in the chest.
‘Some parents were diagnosed with asthma, so if they notice some of the symptoms in their children, they come saying that “health worker, I think my child is developing asthma like me because the health workers told me that I have asthma.Then you ask her why and she explains that when the attack comes, she gets difficulty in breathing and there is noise when breathing.’(HCW 9)
One HCW noted that HIV positive children also presented with on and off coughs, but without wheezing, with weight loss and failure to thrive and that when they gave antibiotics, they would improve but then symptoms would recur in a few weeks. For such children, they investigated them for possible TB by performing a chest radiograph, and where possible, they collected sputum and sent for analysis using the GeneXpert test.
The most common causes/triggers of respiratory symptoms that were mentioned by the healthcare workers were; cold weather, common cold, dust, overcrowding in homes, exposure to tobacco smoke, poor ventilation, malnutrition, and witchcraft.
The drug shop attendants (DSA) indicated that in most cases, the caregivers did not go with the children when buying medication, and that they (DSA) mainly focused on providing what the caregiver wanted or based on the prescription they presented. However, in a few cases, they asked about symptoms, and they reported that caregivers mentioned cough, breathing difficulties, common cold and fever. When asked about what they thought caused these symptoms, they (DSAs) mentioned cold weather and dust.
On the other hand, herbalists were commonly consulted by caregivers when children had respiratory symptoms, and in some cases, the caregivers took the children along when seeking the care of the herbalists. They described the common presentation as cough, breathing difficulties and wheezing, and that they had encountered children who had had chronic or recurrent symptoms. According to the herbalists, the common causes of respiratory symptoms were cold weather, a common cold, and dust. Other possible causes of the symptoms that were mentioned included malnutrition and that the children inherited from parents.
‘Asthmatic children have a common symptom of reacting to cold weather. When it’s cold they cannot even go out of the house. And the child cannot go to school if they don’t have enough clothing or a thick jacket that keeps them warm. They cannot move in the rain. When they get a fever, they cannot breathe through the nose normally. They wheeze and have shortness of breath. They avoid dust and cold. The child wheezes and reacts to dust and cold. When they feel cold, they get shortness of breath, and their condition deteriorates.’ (Herbalist 2)
The VHTs had not encountered many children with chronic/recurrent respiratory symptoms, but when they did, they referred them to the health facility for care. As such, they did not have much information to describe the scope and pattern of the symptoms. However, like other healthcare providers, they indicated that cold weather was a common cause of coughs in children in their communities.
Diagnoses
Caregivers perception of diagnoses
When the caregivers were asked about the name of the disease which their children were suffering from, they mentioned ‘diseases’ that included suffocation, pneumonia, tuberculosis or malaria or asthma
‘When he made three months, he developed cough and difficulty in breathing. He would breathe badly in the chest, and I would think that it was pneumonia. I took him to the nearby government health facility, and they said he had malaria’ (Caregiver 4).
‘I was suspecting of TB and I was planning to take them to Nalufenya (Jinja children’s hospital) for TB testing’. (Caregiver 6)
‘I think it could be tuberculosis’. (Caregiver 5)
‘I call it malaria’. (Caregiver 4)
Some caretakers thought about the possibility that their children could be having asthma. One caretaker who had medical training mentioned asthma, based on the symptoms she had observed in the child, however, the healthcare worker had instead told her that the child had severe pneumonia.
‘There was a time I accepted it as asthma because it was too much. All the signs were those of asthma but when I go to hospital, many doctors still insist that it is not asthma, maybe with time but as for now they say its pneumonia. But I thought the boy had asthma’. (Caregiver 1)
‘Asthma. The child is asthmatic’. (Caregiver 2)
The caregivers also re-told the diseases that were communicated to them by the healthcare providers after assessing the children. When children presented with acute symptoms of cough and or difficulty in breathing, even when they were recurrent, the caregivers were told various diagnoses by the different health care workers including pneumonia, bronchitis, upper respiratory tract infections and malaria. In a few cases, the healthcare workers told the caregivers that their child had severe pneumonia and were likely to have asthma in the future. The HCWs also told such caregivers that their children would outgrow the asthma symptoms.
‘Initially they used to say that he had malaria, and it was causing the dry cough until he developed difficulty in breathing and the diagnosed asthma at four years old’ (Caregiver 4).
‘When he made three months, he developed cough and difficulty in breathing. He would breathe badly in the chest, and I would think that it was pneumonia. I took him to the nearby government health facility, and they said he had malaria’ (Caregiver 4).
“So, some doctors would say the boy is suffering from bronchitis, others could diagnose asthma, others would say severe pneumonia. Each doctor would give a different diagnosis.’ (Caregiver 1)
‘I took him to the health facility when he was about 3 and a half years when the difficulty in breathing had intensified, and I was told that he has asthma’ (Caregiver 2)
Health Care workers diagnoses
One of the HCWs mentioned that sometimes caregivers who had asthma asked them if their children had asthma, because they (caregivers) had observed the same symptoms as theirs. However, the health worker responded by telling them that it was allergic cough. In a few cases, the HCWs considered a diagnosis of asthma but did not write it and instead used the term ‘reactive airways disease’ or ‘allergic cough’.
HCWs reported that the diagnoses that they commonly made when children presented with respiratory symptoms included pneumonia, upper respiratory tract infection and tuberculosis and malaria. Few HCWs diagnosed children who presented with acute symptoms as having bronchiolitis although they treated such children with asthma medicines (short-acting beta agonists and steroids).
It was also noted that often the assessment for possible asthma focused on the physical examination findings, especially auscultatory wheeze, and not on the history, and when such signs were absent, asthma was not considered as one of the possible diagnoses. When children presented with fever in addition to the respiratory symptoms, HCWs did laboratory investigations for malaria.
‘There are those I diagnose bronchiolitis but there are those beyond two years to five years, in most cases I take it as congestive respiratory illness though I don’t classify it as asthma but in most cases when you give them a broncho dilator, they become better.’ (HCW7)
‘Like for some of those children that have a wheeze, that’s what the mothers usually refer to as some sound in the chest. Most of the time, I diagnose it as bronchiolitis and in most cases I put them on steroids.’ (HCW 7)
Some HCWs recognized the acute symptoms of asthma like wheezing and difficult breathing and would have given nebulized salbutamol but this was not available in the health facilities and were forced to use oral salbutamol. Furthermore, HCWs indicated that they did not make a diagnosis of asthma in children less than five years. Instead, they assigned a diagnosis of bronchiolitis for children less than 2 years and congestive respiratory illness, and allergic cough if the child was more than 2 years. HCWs also indicated that they did not rush to make a diagnosis of asthma because pneumonia was more common, and the symptoms of asthma were like those of pneumonia. In such cases, they thought about asthma if children did not improve on treatment for pneumonia.
‘In most cases we don’t rush so quickly to diagnose asthma because these children are so prone to pneumonias. Usually, I first treat pneumonia and when the treatment fails, that’s when I resort to the asthma treatment like aminophylline.’ (HCW 9).
‘I use the term reactive airway disease and I don’t necessarily label them asthma.’(HCW 2)
‘I don’t diagnose asthma in young children because what you may call asthma may not really be asthma because they tend to get asthma related respiratory infections and they are common. Not until they grow up and when they grow up, some of those symptoms go away and you may not hear of them again. So, I would say it’s not proper to diagnose asthma in children. I think it would be some obstructive airway disease’ (HCW 7).
‘Below five with signs of asthmatic, we do not diagnosis asthma, we diagnose bronchitis. Sometimes with pneumonia and that’s why even the doses are not very tending to overlook at pneumonia, many of them are pneumonia.’ (HCW 6)
Children who presented with longstanding symptoms were clinically assessed for pulmonary tuberculosis, and investigations like chest radiographs and GeneXpert for sputum analysis for those children who could cough up the sputum, were done.
Interestingly, some HCWs had an opinion on the diagnosis even before examining the child, depending on the perceived severity of the symptoms. Children who presented with breathing difficulties were perceived to have a serious problem involving the lower respiratory system, whereas those who did not have such symptoms were regarded as having a simple cough, which was labelled allergic cough or just allergy.
When asked about how they assessed children with on and off coughs, they indicated that they focused on possibility of TB and /or HIV and asked about the status of the parents. They also attributed the recurrent symptoms partly due to failure of the caregivers to give the whole course of the medicines as prescribed, like not giving the medicine on time or for a shorter duration.
The herbalist mainly received children who had longstanding coughs, and the most common diagnosis they thought about was tuberculosis, and in some cases asthma. For children who had breathing difficulties, with what they described as congestion of the lungs with mucus, they made a diagnosis of asthma and treated as such. For other presentations, they referred children to health facilities for investigations and care.
‘I tell them that basing on the symptoms the child is having, the child might be having asthma or TB, so the child needs to be investigated. I tell them to take the child for testing, then we proceed with the treatment.’ (Herbalist 1).
‘You may find it’s too much congestion due to much mucus secretions that fail the child to breathe. When they come to us, we take a critical look and examine the child and find that we can help the child just by giving them our medicine which can clear the lungs of the congestion. You find that in a very short time the child starts feeling better They have been treated and they are not successful at getting help. I mean that they have failed elsewhere. We have never got someone who is coming to us as first resort. We’ve never been the first hands on any patient unless it’s we ourselves who are suffering.’ (Herbalist 4)
Although the drug shop attendants did not interface with most of the children, they ‘treated’, they thought that the most common diagnosis in relation to cough symptoms was pneumonia. For some of the children whose caregivers reported repetitive symptoms, they told them that their children had asthma, and that it was incurable, but that they would give them (the children) medicine to relieve them.
‘In actual sense, most of the time people come to buy tablets. So, at times we don’t see the patients. But somebody just comes and says I want drugs. At times we assist them by asking how the patient is so that the person who has come to buy the drugs tells us that the patient is like this and this. And usually, they just present symptoms and signs. So, we don’t usually come to a diagnosis.’(DSA1)
‘I tell them it’s pneumonia. It’s the most common around here. Asthma is there but most of the time its pneumonia and cough. The child can have a dry irritating cough for a whole month. I tell them that your child might be having pneumonia or asthma, so I refer them.’ (DSA 2)
‘If its asthma I explain that its incurable, but we can treat the child when in attack and improves. But for pneumonia I tell them the truth because there are some children that even suffer from pneumonia for seven years, falling sick every month.’ (DSA 2)
The VHTs did not assess or treat the children and referred them to the health facilities for assessment and care.
Treatment
Caregivers perception of treatment
The caregivers consistently described two clear patterns of how their children were treated; 1) starting with one type of medication, mainly antimalaria and antibiotics if the child had presented with acute symptoms, or antibiotics and cough syrups if they had chronic or recurrent symptoms and 2) the children were repetitively given the same/similar medicines, mainly antibiotics and cough syrups even when it was clear that the medicines were not helping at all or only offered short-lived relief.
Caregivers resorted to visiting multiple health care providers including drug shops or decided to buy the same medication based on previous prescriptions by the clinicians.
“They were still treating malaria because of the fevers, particularly he was given ACT, then after discovering that it was pneumonia, he was given injections of X-pen and Gentamycin and sometimes they would add Panadol and amoxyl. Whenever he had problems with breathing, they could treat him with X-pen and gentamycin and add Amoxil and Panadol.” (Caregiver 3)
“The third time we took him to the government health facility, he did not completely improve on the medicines given by health care workers which were mainly cough syrups and antibiotics like Co-trimoxazole and Amoxicillin. That’s what they wrote for him. You know they just write for you medication and you go to the pharmacy and buy. So, whenever he gets those conditions, I go and buy that medicine.” (Caregiver 4)
The caregivers also frequently thought that the child had pneumonia and so would go to pharmacies and buy antibiotics.
Caregivers also indicated that in some cases, the children were prescribed inhalers for asthma medicine (SABA), but these were not available in the health facilities, so they were expected to buy them from private pharmacies. Some caregivers had health insurance and were able to access them through the private pharmacies. In both cases, the caregivers did not give the inhalers to their children because they did not think that the children had asthma.
“We were given some inhalers but me; I have never used them because I didn’t accept that it is asthma because in the family background, we don’t have anybody having asthma.” (Caregiver 1)
The caregivers were also told by some health workers to give herbal medicines to treat the symptoms because the children were still too young to use asthma medicines and, in some cases, they were told that the children would outgrow the asthma.
“I was told to get for him herbal medicine at the health facility because he was still very young to use asthma medicine. I was told to be using herbal medicine in the meantime until he grows up to start using asthma medicine’. ‘Yes, I give him herbal medicine. I buy it from our market. He has used it for a month so far. I give him a tea spoonful three times a day. I was told to give him after a meal that is after breakfast, lunch, and supper.” (Caregiver 2)
The caregivers expected to get medicines to cure the disease but were disappointed when they were told that the medicine only relieves symptoms.
Other management practices used by caregivers included keeping the children warm to prevent them from getting cold, because the cold would trigger the symptoms and giving the children raw eggs to drink, but these did not help.
“When it is cold, we keep him warm, so he doesn’t take in the cold air. Whenever the weather is bad, I try hard to cover him with socks and a jacket, so he doesn’t get affected by the cold. We are told to find suitable clothes like sweaters to keep these children warm, because the more air they take in, the more the situation worsens, that is the information and the medicine they are given only that I do not take trouble to know which kind of medicine they are given.” (Caregiver 8)
'We try to cover him with a jacket or sweater to prevent coldness, but His grandmother would give him raw eggs of a local chicken because she also has a child who is asthmatic, and she is experienced.’ (Caregiver 2)
HCWs treatment
Antibiotics
All HCWs that were interviewed reported that they prescribed antibiotics for children who presented with acute symptoms of cough and difficult breathing because they had made a diagnosis of pneumonia. Some of them also prescribed antimalaria medication when children presented with fever in addition to the antibiotics.
Some HCWs prescribed antibiotics even when they noted that the children had no signs of pneumonia, and had clearly been classified as ‘No pneumonia, cough or cold’ according to IMCI guidelines.
When HCWs decided that the child had a cough which they considered simple (no breathing difficulties), they treated with oral antibiotics like Septrin (Co-trimoxazole) and added cough linctus and when they thought that the cough was serious/severe (breathing difficulties and chest indrawing) they prescribed intravenous antibiotics like gentamycin, benzylpeniccilin and ceftriaxone.
If it is a simple cough, we initiate them on Septrin and if they respond, then that’s ok. We are also giving cough mixture called Beta-linctus. if it’s a severe cough, we give IV treatment.’ (HCW 3)
A few HCWs adhered to the guidelines and did not prescribe antibiotics. They would prescribe cough syrup, Vitamin C and antihistamines if the children had a common cold and advised the caregivers to give the child fruits. However, some mothers complained about not getting the antibiotics as they expected and the HCWs explained to them why the child did not need antibiotics. For children with recurrent or chronic coughs, the HCWs prescribed antibiotics and sometimes added cough syrups.
Asthma medications
In a few cases, health workers gave oral bronchodilators, but when the children were referred to the regional referral hospitals where there are specialists, some were given inhaled medicines.
“I have realized that many of the children suffer from allergic coughs, the biggest number and when you give a bronchodilator and at times a steroid, they tend to get better very fast… I feel it’s not really good for them because most of these drugs work in a way of dilating the respiratory tract so I wonder if this child is still small, how long would they need to take these drugs until adulthood.” (HCW9)
If they thought that the child had what they referred to as allergic cough (cough triggered by cold weather), they gave steroids, mainly oral prednisolone, and that such children tended to improve very fast. The HCWs reported that when children presented with breathing difficulties associated with wheezing, they would prescribe intravenous medications especially aminophylline and hydrocortisone and oral salbutamol and prednisolone to use at home
“If it is a simple cough, we initiate them on Septrin and if they respond, then that’s ok. Sometimes there is also running nose. We are also giving cough syrup called Beta-linctus then we advise them to take a lot of fruits if the cough has presented with fever, then we give some Panadol, if its due to either weather that it’s an allergic cough so we advise the caretaker on how to handle the kid, how to give some steroids (tablets). if it’s a severe cough, we give IV treatment.” (HCW 3)
Although they indicated that they knew about inhaled salbutamol they had never used it because it was not available at their health facilities (no inhalers or nebulisers).
While some healthcare workers indicated that they would prescribe inhalers to children with asthma symptoms (wheeze), others thought that inhaled medicines were not suitable for young children and would cause damage to the airways, and that if they started using them during early childhood, they would need to take the inhalers until adulthood. The HCWs also indicated that in a few cases, they would have wanted to give the child inhaled medicine, but that the caregivers did not want inhalers at all and would ask if there were no tablets instead.
” They don’t like it (inhaled medicine). If you tell them to buy it, they say that “if you use that one (inhaled medicine), your child may never heal. So musawo try your best and use other medicines”. “Can’t you use tablets or injections; my child may never heal if you use that one.’’ (HCW 9)
General advice from HCWs
Healthcare workers recognized the fact that many caregivers brought the children to the health facilities after trying out some medications including syrups from drug shops and herbal medication, and they asked about them to guide treatment choices.
In addition to medications, the HCWs advised children who presented with cough, difficult breathing and wheezing to avoid perfumes, mostly the sprays, exposure to tobacco smoke, cold weather, to keep the children warm and give them warm drinks.
HCWs indicated a challenge of caregivers not returning for follow up, which made it difficult for them (HCWs) to track progress/prognosis. The HCWs thought that This was largely attributed to poverty.
The herbalists explained that in most cases, caregivers went to them to seek care for their children at a point when they felt that the health system had failed them. Their (herbalists) perception was that asthma symptoms were not a big problem (minor) to treat. They indicated confidence that they could treat children with asthma, and that they got cured within a short time. They perceived themselves as problem solvers.
“Their parents take them to the hospital but no difference. Then they ask me if I had medicine that can cure asthma. I tell them that I do, give it to them and they are cured. They cure completely. I have one I treated whose telephone number I could give you, who could not even go to school but is now in school at Bilal in Busia.” (Herbalist 2)
The herbalists mainly used foods and believed that when the foods boosted the child’s immunity, the asthma symptoms disappeared. They also used different herbs from different parts of the country although they could not provide the names of the herbs. However, some of them recognized the importance of taking the children for a proper assessment by trained health care providers.
The drug shop attendants commonly provided what the ‘customer’ (caregivers) asked for or followed prescriptions. They sometimes advised use of antibiotics when they caregivers described symptoms which they thought were due to pneumonia.
“I tell them to seek care on the onset of any cough. Some children also develop asthma due to weather changes, so I tell them to keep the children warm during the cold weather because this is when some children usually get attacks. I advise them to seek care immediately if a child gets an attack. If its asthma I explain that its incurable, but we can treat the child when in attack and improves. But for pneumonia I tell them the truth because there are some children that even suffer from pneumonia for seven years, falling sick every month.” (DSA 2)
Experiences with the health system, and related consequences
The caregivers expressed being frustrated with the healthcare system. They repeatedly visited the health facilities, and most times were never given a diagnosis but still retained on the same ineffective treatment all the time. They were also confused because different healthcare provider provided a different diagnosis.
‘They never tell you anything there. You only describe and they prescribe.’(Caregiver 8)
“So, some doctors would say the boy is suffering from bronchitis, others could diagnose asthma, others would say severe pneumonia. Each doctor would give a different diagnosis. Of recent when he got that attack, when we reached the hospital, the paediatrician told us that he had severe pneumonia but might develop asthma in the future.” (Caregiver 1).
The caregivers were also frustrated because the drugs were unavailable at the health facilities and they had to buy them, yet in many cases, they lacked the money. For this reason (insufficient help in Healthcare center), some of them resorted to buying medicines using previous prescriptions whenever the children developed respiratory symptoms, instead of spending money for transport to the health facilities.
Similar sentiments of lack of medicines in the health facilities were expressed by the HCWs. They indicated that caregivers spent a long time at the facilities but ended up with no drugs. So, the next time a child got sick, the caregivers just bought medicines from the nearest drug shops.
“Then another issue is lack of drugs at government facilities. Our mothers come in, they pass through the system, someone comes in at 8 or 9am, goes through the line of laboratory, through the line of drugs, by 2pm, the dispensary is telling her that out of stock, out of stock. This is an embarrassment [in a frustrated tone].” (HCW 1)
The HCWs thought that, due to lack of drugs, confidence in the health facilities by communities had significantly reduced. They also indicated that lack and/or limited equipment like nebulizers and inhaled medicines as well as oxygen limited their ability to care for their patients many of whom resorted to self-medication. The herbalists thought similarly.
“Self-medication, sometimes with the wrong drugs. The problem I have faced is that most caretakers having children with these complications are frustrated with the system and don’t use qualified health workers. They self-medicate the children and seek care of medical personnel when the disease has advanced. They use whatever medication they imagine can cure the illness.’ (HCW 1).
“Another thing is that some caretakers don’t want to take children for investigations to get proper diagnosis, so they end up treating diseases blindly. They prefer treatment to diagnosis. For instance, when they have a child has those symptoms, they think its TB.” (Herbalist 2)
Apart from challenges related to the health system, the healthcare providers also had challenges related to the caregivers and these impacted on the care they extended to their patients, and outcomes. The main problems mentioned by the HCWs included poor adherence to medications, declining referral to higher levels of care and irrational medicine use by the caregivers.
‘Adherence to treatment because someone tells you, ‘I do not stay with the child the whole day, we live them with the maid, so I do not know whether this kid during the day gets treatment and I leave very early in the morning for work when the baby is still asleep.’’ (HCW 8)
“Mainly there is a lot of drug abuse before children come to our facilities. There is a lot of self-medication. People have crammed these drugs. So most of the children come when they have got the wrong treatment and of course apart from the wrong drugs, there are inappropriate doses. Many of them under dose. A few overdose.”(HCW 1)
In addition, HCWs had a challenge of caregivers taking their children to health facilities late when the symptoms had progressed, and after trying several options at home. There was also a challenge of loss to follow up, and health workers would not know if the child got better/if the medicine worked or not. However, they thought that some of these challenges were largely due to poverty.
“Then often with severe pneumonia, our mothers come in late. They wait for the situations to worsen because you ask’ how long has the child had fast breathing and they say four days and the chest in drawing, two days. I took the child to the drug shop and they gave me this syrup.” (HCW 1)