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Background Understanding communities’ beliefs about the causes of illnesses in sick young infants (SYIs) is key to strengthening interventions and improving newborn health outcomes. This study explored communities’ perception of the etiology of illnesses in SYIs 0–59 days old in four counties in Kenya. Methods We used an exploratory qualitative study design. Data were collected between August and September 2018 and involved 23 in-depth interviews with female caregivers aged 15-24years; 25 focus group discussions with female caregivers aged 15–18 years, 19–24 years and 25–45 years; and 7 focus group discussions with fathers aged 18–34 years and 35 or more years. Participants were purposely sampled, only those with SYIs 0–59 days old were eligible to participate. Data were analyzed using inductive thematic analysis framework approach. Results Female caregivers and fathers attributed illnesses in SYIs 0–59 days old to natural (biomedical) and supernatural causes which sometimes co-existed. There were commonalities in perceived natural causes of illness in SYIs across sites, age groups and gender. Perceived natural causes of illness in SYIs include unfavorable environmental and hygiene conditions, poor maternal and child nutrition, and healthcare practices. Perceived supernatural causes of illness in SYIs such as ‘evil eyes’ were common across the four counties while others were geographically unique such as the belief that owls cause illnesses. Conclusion Communities’ understanding of the etiology of illnesses in SYIs in the study settings overlapped between natural and supernatural causes. There is need for child health programmes to take into consideration communities’ beliefs and practices regarding disease and health to improve newborn health outcomes.
The qualitative data used for this paper were drawn from a formative assessment of a larger study known as the Ponya Mtoto project. More details about the project can be found at: https://www.harpnet.org/project/ponya-mtoto/. The Ponya Mtoto project aimed at assessing the feasibility, acceptability and sustainability of implementing the World Health Organization (WHO) Guideline for the Management of Possible Serious Bacterial Infection (PSBI) in SYIs 0–59 days old where referral is not feasible in Kenya [18]. The larger, original study used a mixed-method cross-sectional study design involving a health system capacity assessment and health facility assessments in combination with a qualitative exploration based on in-depth interviews (IDIs) and focus group discussions (FGDs). This paper focuses on and reports findings from an aspect of a qualitative study that explored community members’ understanding of the causes of illnesses in SYIs. The study was conducted in four counties, namely, Turkana, Bungoma, Mombasa, and Kilifi. Table 1 highlights key socio-economic indicators for these counties. The four counties were selected due to their distinct geographical, socio-economic and cultural diversity, and high NMR burden compared to the national average of 22 deaths per 1000 live births. Turkana is an arid and semi-arid region with a predominantly nomadic population dispersed across difficult terrains with limited access to healthcare facilities. Bungoma is largely a rural agrarian economy and predominantly occupied by the Bukusu tribe. Mombasa has a large coastal urban sub-population living in informal settlements faced with persistent health and economic inequalities. Finally, Kilifi represents a coastal region with both rural and urban sub-populations. In each county, the study was conducted in two sub-counties selected in consultation with respective County Health Management Teams (CHMTs). Within each sub-county, 12 facilities stratified by levels (hospitals, health centers and dispensaries) were selected as part of the larger project sites. Participants were drawn from villages surrounding these facilities. Source: Kenya Demographic Health Survey 2014/15 [2] and Kenya Population and Housing Census, 2019 [19] NA = not available Potential participants were female caregivers, defined here as, a mother, a family member, or a paid helper who regularly looks after a child, and fathers with a SYI (0–59 days) including those who lost a newborn within two months prior to the study date were deemed eligible and recruited to participate. We used purposive sampling and adopted a maximum variation approach based on participant’s age and region. Participants were selected to include 1) a range of caregiver age groups (15–18 years, 19–24 years and 25–45 years) to capture the experiences and views of adolescent, young and older caregivers/mothers regarding newborn and young infant care; and 2) fathers with SYIs aged 18–34 years and 35 or more years to capture the views of young and older men. Respondent selection ensured that each region and age group were represented. Eligible participants were identified in the community with the help of local leaders, mainly community health volunteers (CHVs) and village elders. We preferred to use local leaders as they were knowledgeable about the members of their community and in a good position to locate potential participants. Data collection was conducted between August and September 2018 and involved IDIs and FGDs (see Table 2). The purpose of the IDIs (total 23 collected) was to understand caregivers’ personal experiences of newborn care, and beliefs as well as care-seeking practices for SYIs 0–59 days old. The interviews explored caregiver’s understanding of causes of illnesses, recognition of danger signs, decision-making and care-seeking practices for SYIs as well as challenges and barriers to accessing SYIs health services including referral. The FGDs (total 32) explored community beliefs on causes of illness and care-seeking practices for SYIs. We had planned to conduct at least two FGDs with fathers (one with a younger group and another with older group) in each site, however, we managed only seven FGDs due to challenges recruiting participants in Bungoma. Research assistants with a social science background, experienced in qualitative research methods and trained by the study team on protocols and research ethics, conducted the IDIs and FGDs. Data were collected using a guide that was developed in English and translated into Kiswahili (widely spoken in the study areas) and Turkana language (for Turkana sites), and pre-tested in each site in a community outside the study’s sampling frame. The IDIs were conducted in participants’ homes while FGDs comprising of 8–10 participants were held at centralized places convenient for participants away from disturbances (mainly in school and church halls). All FGD participants received reimbursement for transport to and from the discussion venue. Each data collection session lasted 60–90 minutes and was audio-recorded with the consent of the participants. Audio-recorded interviews were transcribed verbatim, translated to English where necessary. We did not however back-translate transcripts into Kiswahili/Turkana to determine if any meaning was lost in the process. The transcripts were transferred to and analyzed using a qualitative software NVivo version 12 (QSR International Pty Ltd). Data were analyzed using a thematic framework approach—a method for identifying, analysing, and reporting patterns (themes) within data [20]. We specifically used an inductive approach to developing a codebook to guide our thematic analysis [21]. Ten members of the research team, including three of the authors (GO, CN and TA), read at least 2 transcripts from each site to familiarize with the content and obtain a broad overview of the participant’s responses. The transcripts were then annotated by highlighting ideas that were interesting or significant. A thematic framework or codebook of themes and sub-themes was then developed based on these highlights and topics on the guides. All transcripts were reread and coded for themes and sub-themes by four coders trained in qualitative data analysis. Analysis charts were then prepared for each thematic area and category of participants. These charts were used to identify common themes across participants and sites. Analysis for this paper is specifically focused on female caregivers’ and fathers’ understanding of the causes of illnesses in SYIs 0–59 days old. We followed the COREQ criteria in conducting the analysis and interpretation of the results [22]. This study received ethical approval from the African Medical and Research Foundation (AMREF) Ethics and Scientific Review Committee (as ESRC P430/2018) and the Population Council’s Institutional Review Board (as Protocol 838). Written informed consent was obtained from each participant before conducting an interview. Participants aged less than 18 years were considered emancipated minors, defined as individuals who have assumed adult responsibilities, such as household headship, marriage, or procreation [23].
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