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Background: Diarrhoea presents a considerable health risk to young children and is one of the leading causes of infant mortality. Although proven cost-effective interventions exist, South Africa is yet to reach the Sustainable Development Goals set for the elimination of preventable under-five mortality and water-borne diseases. The rural study area in the Eastern Cape of South Africa continues to have a parallel health system comprising traditional and modern healthcare services. It is in this setting that this study aimed to qualitatively examine the beliefs surrounding and perceived quality of healthcare accessed for children’s acute diarrhoea. Methods: Purposive sampling was used to select participants for nine focus-group-discussions with mothers of children less than 5 years old and 11 key-informant-interviews with community members and traditional and modern practitioners. The focus-group-discussions and interviews were held to explore the reasons why mothers seek certain types of healthcare for children with diarrhoea. Data was analysed using manual thematic coding methods. Results: It was found that seeking healthcare from traditional practitioners is deeply ingrained in the culture of the society. People’s beliefs about the causative agents of diarrhoea are at the heart of seeking care from traditional practitioners, often in order to treat supposed supernatural causes. A combination of care-types is acceptable to the community, but not necessarily to modern practitioners, who are concerned about the inclusion of unknown ingredients and harmful substances in some traditional medicines, which could be toxic to children. These factors highlight the complexity of regulating traditional medicine. Conclusion: South African traditional practitioners can be seen as a valuable human resource, especially as they are culturally accepted in their communities. However due to the variability of practices amongst traditional practitioners and some reluctance on the part of modern practitioners regulation and integration may prove complex.
The study took place in the catchment of a rural district hospital in the O.R Tambo district in the Eastern Cape province. The catchment has a population of around 130,000 people and the area is considered deeply rural [17]. The area where the study took place is approximately 90 km from the nearest city of Mthatha [18]. O.R Tambo is one of 18 identified priority health districts in South Africa. The priority health districts have been selected according to maternal and child health and socio-economic indicators and focus is placed on those districts most in need of improvement [19]. The O.R. Tambo district is considered to have some of the poorest health indicators in the country with double the national infant mortality and triple the number deaths for children under 5 years old [20]. The incidence of diarrhoea in the district in 2007 and 2008 was 173.5 per 1000 [21] in comparison to the provincial incidence of 110 per 1000 children in 2009 [4]. The district is home to 183 government-run, modern facilities (hospitals, mobile clinics, community health centres and clinics) that provide modern medicine to people in the district [22]. It is estimated that there are approximately 10,780 traditional practitioners in the Eastern Cape and around 190,000 traditional practitioners practicing in South Africa. This means that there are in the region of 1797 traditional practitioners in each of the 6 districts in the Eastern Cape [23]. Historically, the area where the study was undertaken belongs to the AmaXhosa People, who converse in the language IsiXhosa and continue to practise certain cultural traditions. Prior to the start of the hospital by missionaries in the study area in the 1950’s [17], healthcare was exclusively provided by traditional practitioners, who were believed to converse with the AmaXhosa’s Godlike Supreme Being via their own ancestors to establish the cause of a person’s misfortune or illness [24]. Data was collected in the area, during 3 weeks of January 2011 by the corresponding study author. Data collection methods included both key-informant-interviews and focus-group-discussions with informants and participants being purposively recruited. The focus-group-discussion participants were recruited with the help of modern and traditional practitioners practicing in the area as well as other community members. There were 11 key-informant-interviews with modern practitioners (three doctors, one nurse and one therapist), two community members (one of whom was a minister) and four traditional practitioners, and nine focus-group-discussions with mothers who have children under 5 years old. Each discussion group had two to nine participants and a total of 32 participants took part. Ages of the women in the discussion groups ranged from 18 to 60 years of age. Data collection tools included a semi-structured questionnaire for the key-informant-interviews and an agenda for the focus-group-discussions respectively (see Additional file 1). These tools were created using existing literature on traditional and modern medicine, access to healthcare, the South African health system, diarrhoea and child health. Findings from other studies were assimilated to form a list of probable factors, which might influence where a mother would take her child if her child had acute diarrhoea according to the perceived quality of healthcare. The topics covered in the key-informant-interviews were beliefs (about the causative agents of diarrhoea, spiritual beliefs and belief in traditional medicine), tolerance of patients’ beliefs in traditional medicine and the degree of fit between the beliefs of modern practitioners and those of community members. The agenda for the focus-group-discussions utilised a scenario about a woman whose child is sick with diarrhoea. The participants were then asked questions regarding the choices she makes and asked what they might do in her situation. The focus-group-discussions covered the agendas concerning the reasons for utilising or not utilising services, participants’ cultural and religious beliefs, their beliefs in the causes of diarrhoeal disease, the perceived responsiveness of the healthcare providers, as well as social pressures. Key-informant-interviews were held in English where possible, but when it was not possible translation was undertaken on the site by a translator who was fluent in English and IsiXhosa. All focus-group-discussions were held in IsiXhosa and questions and answers were translated on the site by a professional translator. With the consent of participants, an electronic audio recorder was utilised in the interviews and focus-group-discussions. Mothers who were younger than 18 years of age were excluded as ethical clearance (University of Cape Town, HREC REF 557/2010) was only obtained to question those participants who were legally able to give informed consent to take part in the study. Anonymity is maintained in the reported results. A qualitative exploratory approach was used for data analysis. Both inductive and deductive processes were utilised to analyse the data. Based on a review of literature, a pre-determined coding scheme was developed and used to analyse the data, however other important themes identified during the process of data collection and analysis were also explored in order to examine issues that had not been anticipated prior to the collection of data. The electronic audio files were transcribed word for word into English. The quality of translation provided during the interviews and focus group discussions was ensured by the primary investigator verifying the translations of IsiXhosa to English in the transcriptions. Coding was done manually, by firstly identifying recurrent ideas, grouping these systematically into broader themes, reducing the themes into concepts and then seeing how they applied to the framework objectives developed prior to the study.
