Characteristics of households and participants are displayed in Table
. Twenty-five household case studies were included, encompassing interviews with 25 mothers and 56 other household members (N=81), with an average of 3.2 participants per household (range: 1 – 7). Mothers tended to be younger than other participants, with an average age of 30.7 compared to 47.4 for other participants. Most households’ primary source of income was from farming (84%); household organization was split between monogamous (56%) and polygamous (44%) marriages. Just over half of households (52%) were located in a village with a health center.
Demographic Characteristics of Participants (n=81) and Households (n=25)
The duration of the children’s illness episodes varied significantly. Eleven of 25 illness episodes (44%) persisted for longer than one month; three children died. Twenty-four of the twenty-five children were treated at a health facility at some point during their illness. Of these, 23 children were also treated using traditional treatments. The remaining child was treated only at home using both traditional treatments and modern pharmaceuticals (see Figure
). In 76% of illness episodes (n=19), the first treatment step took place inside the home, using either traditional treatments (48%, n=12) or modern pharmaceuticals (28%, n=7).
Overlap of traditional and modern medicines in treating severe febrile illness in children under 5 in Koulikoro, Mali (n=25).
Children’s illness episodes involved multiple treatment steps, with an average of 4.4 treatment steps per episode (range: 2–10). Treatment steps were classified into two categories: 1) home treatment, either with traditional treatments or modern medicines, and 2) treatment outside the home, either by a traditional healer or at a health center (local, regional, referral, etc.) Figure
applies these categories to children’s first three treatment steps (n=25), to demonstrate aggregate pathways of treatment-seeking behavior. For most children (76%), treatment began in the home; however, 80% of second treatment steps took place outside the home, half in formal facilities and half using traditional healers. By the third step, an even smaller proportion (14%, n=3) of treatments were home-based, demonstrating an escalating reliance on external sources of care as the perceived severity of the illness episode increased.
Treatment pathways for severe febrile illness in children in Koulikoro, Mali.
Treatment steps typically included recourse to a variety of different sources of care, and households rarely limited themselves to either modern or traditional therapies. Overlap between different sources of care is demonstrated in Figure
. Ten children (40%) received any type of modern medicine in the home (usually chloroquine and/or acetaminophen) and 24 children (96%) were treated using traditional treatments. Additionally, twenty-three children (92%) received care at a health facility, indicating the overlapping use of these three sources of care. While special attention was paid to identifying the sequence in which each treatment step was initiated, in many cases, treatments overlapped. For example, often the first treatment step of traditional treatment administered in the home was not discontinued when treatment with modern medicine commenced.
Of the twenty-three children who were treated at a health facility, twelve (52%) reportedly experienced subsequent treatment failure and eight later returned to the same or another health facility, which also did not always result in a final cure. Children brought to the health center earlier in their illness appeared to fare better than those brought later; however, this relatively low cure rate for health facilities likely explains some participants’ mistrust in formal health care, discussed below.
Of the children experiencing reported treatment failures, three died of their illness. Although none died on site at the health facility, two children were treated and discharged after it was determined that nothing else could be done, and died within 24 hours. One child was not brought to a health center at any point during the illness episode because of financial barriers. The treatment steps of these three children are displayed in Figure
, and suggest a reliance on traditional treatment and delays in bringing the child to a health facility, compared to the rest of the sample children.
Treatment steps for children deceased from their illness (n=3).
Signs of severity and convulsions
Many illnesses were managed outside of the formal health sector for long periods of time, either with traditional treatments or modern pharmaceuticals. Perceived severity of the illness was the most influential factor instigating treatment seeking at the health center, according to interviews. Signs of severity deemed alarming included excessive vomiting, extreme fever, inability to eat, persistent symptoms without improvement, and, notably, convulsions.
Convulsions were universally regarded as a sign of extreme severity, and the presence of this symptom always resulted in urgent care-seeking – either from a health facility or a traditional healer. If convulsions occurred during the illness episode, caregivers often (but not always) responded by seeking care at a health facility. However, if the child relapsed and convulsions occurred again after care had been sought at the health center, parents were less likely to return there, believing that health facility medicines were ineffective or that the illness has been misdiagnosed and therefore treated incorrectly. In illness episodes with no convulsions, caregivers often mentioned previous experience with convulsions as playing a role in their decision to seek facility-based care before the illness progressed to such a severe state.
Treatment failure in the formal health sector
Preference for modern treatment at a health facility was frequently stated, and 23 of 25 families brought their child to health center at some point during the illness episode. Compared to traditional treatment, modern medicines were often considered “faster acting” and “less tiring.” One father who expressed a strong preference for modern medicine stated:
"In regards to treatment, if I have the money, I go to the health center because I prefer this to the traditional healer. If I accept going to the traditional healer, it is because I do not have money. Running here, running there to treat with traditional remedies, all of this is because of a lack of means. Otherwise, if one has the means, you do not discuss – you execute. (Father, 14M1)"
However, treatment at health facilities was not always successful: 52% of children (n=12) treated in a health facility reportedly experienced treatment failure. Informants accounted for this in a variety of ways, citing the increased virulence of certain diseases, innate differences in people that cause them to respond differently to treatments, and misdiagnosis of the illness. Regardless of the reason, treatment failure often diminished faith in modern medicine and discouraged future care-seeking there. Two informants described their disappointment after a visit to the community health center failed to cure the illness of a sick child in their household:
"Often, I am not satisfied at all; this is why I say that I am discouraged. When you go to them for a headache, the health agents will often give you medicines for a stomachache. Can this cure this illness? Often they give injections that do not cure the illness. They try to treat you by trial and error. (Uncle, 05M3)"
"For this nyama of my daughter, we always go to the health center, but the child is not cured completely. This is what causes me to not believe the health agents any more. (Mother, 20A2)"
Treatment failures in the formal health sector often led informants to conclude that traditional treatments would have been a better choice, or that the child’s disease (particularly nyama, whose symptoms are believed to overlap with those of severe malaria) could not be treated using modern care. One grandmother explained:
"For three days, the medicines from the health center were given to the child, but they did not work. The health workers said that this illness was sumaya [malaria]. But no, ohh, it was nyama – if it’s nyama, the medicines that were given there cannot be effective. Oh, for nyama, you must give traditional therapy because the health workers do not know nyama. (Grandmother, 11M1)"
Others doubted the ability of health centers to cure all patients:
"You know, treatment is the sort of thing where there are treatments that work well for certain people, while the same treatment worsens the illness of another. The blood of one person can support one treatment, but the blood of other is not able to tolerate the treatment. Each person has their own blood – it is this that complicates the illness. (Mother, 06A1)"
Interestingly, even informants who downplayed the efficacy of modern medicines for some illnesses still professed to buy them:
"All of our children’s illnesses are managed the same way; the vendors who come to our village here selling candies and cigarettes also sell medicines. We buy some tablets from these vendors for illnesses that are a little serious but that don’t require going to the health center. But often we say that these modern medicines are of no use, we say that it does not treat our illnesses. When you use these medicines against certain illnesses, they do nothing. (Mother, 05A2)"
Economic barriers’ effect on treatment choices
Eighty-four percent (n=66) of informants stated that the foremost obstacle to seeking care at a health center was financial (either not having money or care was too expensive). The cost of treatment for each child varied dramatically (range: <1$ - 150$), however, most health care expenditures ranged between $4-7. Home treatment with modern medicines, as well as treatment from traditional healers, rarely exceeded $1 per treatment step. Financial implications of the illness episode were frequently the source of conflict in the household. One father, who argued with his brother over treatment for his sick child, stated: “If there are diverging ideas about where to treat a child - this is always about the problem of money.”
Seasonality was an important factor in financial decisions about care: many informants explained that “not all moments are the same.” If an illness occurs at a time when resources are available, care may be sought directly at a health center with little hesitation or discussion. However, if an illness coincides during a time of scarcity, for example during the rainy season, financial barriers may delay or prohibit prompt care-seeking:
"This illness began during the rainy season, and there was nothing. Before the harvest, we Bambara earn nothing and any money there is must go to pay for food …. The illness found us when there was truly an economic crisis. (Mother, 01A2)"
In the absence of household resources, informants collectively stated that they can seek credit among friends and family, or sell household goods in order to pursue treatment, and several households did borrow money in order to bring their child to the health center.
Many informants said the cost of treatment at the health center forced them to turn to traditional care. One grandfather explained, “Our people do the treatment that costs less; the health center is expensive… If you do not have the means, you must content yourself with traditional therapy.”
Furthermore, whereas sick children would be turned away from a health facility, participants said traditional healers could be relied upon to provide treatment “with a sense of pity, fraternity and good neighborliness.” Conversely, formal health structures were sometimes resented for their lack of empathy:
"Regardless of the severity of the illness, if you do not pay the money, the health workers will not treat your sickness. If you do not have the means, your sick child is going to die beneath the eyes of the doctor. He is not going to cure him because you did not pay the cost. This does not exist among us Bambara, where the traditional healer will treat your sick child without money and you can reimburse him afterwards. (Grandfather, 2CD)"