Ethics Statement

The Kenya Medical Research Institute National Scientific and Ethical Committees approved the study. Written informed consent was obtained from all study participants prior to participation.

Study Sites

The study was undertaken in 2010 and 2011 at two rural sites at the Kenyan coast: Kilifi and Msambweni. In Kilifi, the study was based at the Centre for Geographic Medicine Research (coast) - KEMRI. The Kilifi district has an estimated population of 719,000 people [15]. Undernutrition is common in Kilifi, as 40% of children under five show anthropometric signs of undernutrition, and 47% present with biochemical markers of iron deficiency [16]. Kilifi District is the second poorest district in Kenya, with more than 67% of the people living below the poverty line, indicating limited access to essential food and non-food items [17]. Most of the people in Kilifi depend on subsistence farming, but frequent rain failure has resulted in insufficient crop yields, compromising food access in the general population. The majority of the population in Kilifi belong to the Mijikenda ethnic group. Two Bantu languages are commonly spoken in the area, Kigiriama (the local vernacular) and Kiswahili (a lingua franca and the national language). In the study area, 47% of the population identify themselves as Christians, 13% Muslim, 24% Traditionalists, 12% ‘other’, and 4% unknown [12]. A significant proportion of the population retain elements of their traditional beliefs and practices, which sometimes guide their health-seeking behaviour [12]. A typical home in Kilifi comprises a large homestead with several small huts built in the compound. In these homes, extended families live together and share in the daily chores such as cooking and fetching water. It is typical for homesteads to have members of three different generations sharing in childrearing duties. The most senior male member of the household (seniority is largely determined by age) is usually considered to be the head of the household.

In Msambweni the study took place within the catchment area of Msambweni District Hospital. Msambweni district is situated at the South coast of Kenya, near the Tanzania border. The district has an estimated population of 283, 658 [18]. The community is rural and depends on crop agriculture as its major source of living. It is estimated that 57% of the population lives below the poverty line. The people belong predominantly to three ethnic groups, with the Digos being the majority, followed by the Durumas. The main language spoken is Kidigo with Swahili as the lingua franca. It is a malaria-endemic area with high rates of malnutrition. Ninety percent of the population is Muslim. The traditional way of life and customary beliefs of the Digo community are quite intact, and people still use traditional healing practices on a day-to-day basis [19]. Similar to Kilifi, it is common to find households with three generations, also consisting of a large homestead with small huts surrounding it, where people share various duties including childrearing and household chores.

Study Participants and Sampling

This study was carried out as part of a larger study looking at developmental outcomes and parenting behaviour in respect of children less than 18 months of age at the Kenyan coast. In the larger study more than 200 mothers were involved. We looked at health-seeking behaviour because an earlier study indicated that the health-seeking behaviour of parents was closely related to the quality of care-giving. A randomly selected sub-sample of a total of 53 parents and caregivers were involved (table 1 presents a detailed description of the sample). In-depth interviews were held individually with each of these parents and caregivers. Parents attending the Mother-Child Well Clinics were approached for informed consent to join the study during routine post natal visits to the health clinics. Selecting samples from the MCH provides as an opportunity to interview people with access to a hospital as well as traditional medicine. Such a sample allows us to study the decision making process where different alternatives are available. To clarify some of the issues raised during the initial interviews, another randomly selected sample (N = 5, 3 females and 2 males) was involved in the study. Here we largely focussed on a sample likely to give in-depth information on the meaning of indigenous health-related terminology and health-related practices.

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Table 1. Sample Characteristics.

https://doi.org/10.1371/journal.pone.0071998.t001

Data collection

Data was collected using in-depth interviews. Following informed consent procedures, parents were interviewed in a quiet corner away from the presence of other people. All interviews were audio taped. Each interview took approximately one hour. The interviews were guided by a standard set of questions to ensure standardisation. Probes and clarifications were sought as deemed necessary. Parents were asked to express themselves in the language in which they were most comfortable. Sessions therefore ran in both Kiswahili and Kigiriama or Kidigo interchangeably.

Interview tool

A checklist of questions was developed by the research team through discussion and consensus. Refinement was based upon the initial interviews and discussion of the initial transcripts. Table 2 presents the interview schedule used. The questions presented are core to the interviews; however, probes were introduced to clarify and enhance the quality of the interviews. Moreover, although the main focus of the study was childhood disease, sometimes adults did share their own experiences of health-seeking, and we included the information in cases where it helped to clarify the points raised.

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Table 2. Interview Schedule.

https://doi.org/10.1371/journal.pone.0071998.t002

Data Management and Analysis

The final transcripts used for analysis were based on the audio-taped materials. Data was analysed with the assistance of NVIVO 9 software programme according to the framework analysis [20], [21]. The transcripts of the interviews were reviewed and read (familiarisation), during which a coding scheme was developed. The transcripts were coded by creating ‘nodes’ in the NVIVO programme), with each node examined separately. The first author (AA) developed coding schemes and identified themes. The themes identified were then evaluated and checked by one of the authors (JG), who also independently coded five randomly selected transcripts. Themes identified by JG were compared with those identified by AA, with an emphasis on consistency and redundancy. Any disagreements in coding were clarified by consensus. Direct quotes arising from the discussion are presented to support identified themes. Three of the authors - AA, JG and GB - checked for the accuracy of the translations and interpretation of the quotes presented.

1. Preference of treatment

Under this theme, participants in our study indicated that biomedicine (hereby used to refer to both attendance to clinics and home treatment using drugs bought over the counter in shops) was their first preference for treatment. Among our coded responses in this node, we observed that the majority of parents approached a medical doctor to seek treatment or used home treatment compared to those who went first to a traditional healer and those who preferred prayers as their first intervention for a sick child.

“I monitor them myself first, I check for fever so that before taking them to hospital the fever should not be too high, I get them medicine to take and if their temperature keeps rising I will run to hospital” [ Mother, 32 ]

“First we buy medicine, we give it to them and if it does not work we take them to hospital” [Mother, 29].

Other mothers noted that:

“When he has fever and flu, I give him paracetamol so as to reduce the fever. And if the temperature is really high, I take a piece of cloth, put it in cold water and wipe the child” [Mother, 31]

“First I buy them drugs from the shops then bring them to hospital [if drugs did not help]” [Mother, 23]

“Hospital, but if at home we have drugs like paracetamol, we give them and we monitor them” [Mother, 34]

Despite this obvious preference for biomedicine, many participants still responded that they had also gone to traditional/spiritual healers. Among those we interviewed around a quarter claimed never to have gone for traditional healing. We therefore explored the factors that influence people to go for traditional healing.

2. Influencing factors

This theme had the following subthemes:

3. Traditional healing

Our participants reported various forms of traditional healing, including the use of herbs, the use of prayers, religious signs and symbols, and rites and rituals. The descriptions below show a religious form of healing

Spiritual healing

“We use medicine referred to as ‘kombe’….amongst us the healer will take verses from the Quran, write them on a piece of paper, put in a bottle with water and read over that …. The patient is given this (the bottle of water) to use.” [Mother, 22]

Example of herbal treatment

“You are given an amulet, and then given another medicine to apply on the forehead. ……..There are herbal roots that you are given to boil, then drink.” [Mother, 40]

Another participant explained, in a slightly more detailed form, his treatment after being possessed by a spirit and the hospitals could not offer adequate treatment.

“I had been employed at a construction site. In the evening when I was sleeping, I saw something like a bomb coming to hit me, then I had someone in my sleep telling me to wake up, not sure who but I think it was God's strength (grace), and when I woke up something {that could not be seen} hit my body. I went to the medical doctors; they examined me but they could not identify the problem. When I went to work I would cry and complain [because of pain], but no one could understand. So I went to a traditional healer who said that someone had sent to me a ‘jinii’ (spirit).

We looked for chicken, a goat, and some herbal roots. I was given some to use while bathing and the other to drink. The timing for using the medicine was just like the hospital one i.e. morning and evening; and with God's help I now feel OK.” [Father, 52]

4. Avoidance of traditional medicine

As noted earlier, most of our interviewees reported that they used both traditional and biomedicine. However, almost a quarter of those interviewed claimed never to have used any alternative healing at any point in their lives. Given the prevalence of its use in these two communities, we were interested in understanding what made this group of people not go for traditional healing. A common reason given was that traditional healing was found to be out-dated. People expressing this view thought that it was backward and irrelevant for people in the modern world to still go for traditional healing.

“Traditional healers are there, but the use of traditional healers belongs to the old days, that is why we now have hospitals. When you take your child to a traditional healer, they will pour cold water on them, and make them even more ill.” [Father, 32]

“I am civilised and educated, so my decision is to go directly to a medical doctor” [Father, 34]

For some of the participants, the main reason they did not go for traditional healing was because they did not find it efficient. These interviewees noted that they had observed certain members of the community consistently going for traditional healing, and yet their condition did not improve.

“It does not heal nor does it prevent ill health, to be honest.” [Father, 30]

Others reported that they have not been to a traditional healer because their children have not yet experienced any severe ill-health that could not be treated by the hospital.

5. Sources of authority

Almost half of the participants had the view that fathers were the ultimate decision-makers in seeking treatment. It was noted that whenever the child required medication or was ill, the child's father was consulted; as noted by one mother

“It is the father.” [Mother, 34]

A father's role seems to be very much defined by his status as the breadwinner in the family. It was observed the father had to be consulted so that he could provide money to go for treatment.

“From my husband….. Where else would I get money?” [Mother, 50]

These observations by the mothers were confirmed by the fathers:

“It is the father who makes the decision” [Father, 32]

Moreover, we inquired from the fathers whom they consulted while making such decisions. This is especially relevant in cases where the child has been undergoing treatment for some time with no signs of improvement; both parents make the decision on when, where and to whom to go and seek medical care from.

“It is the child's mother, we usually sit down and talk about it, plan on what to do next, since she is the closest person.” [Father, 36]

Similar sentiments were noted by other participants as is exemplified by the quote below:-

“It is me and my wife.” [Father, 34]

The role of the father as the decision-maker may vary as a result of living arrangements. It was observed that when the women were single parents or living away from their husbands, they consulted someone else. As noted by one participant

“Before one does anything they must first talk to the child's father, if they are living together.” [Mother, 31]

In cases where the husband was not around, most of the mothers reported consulting their own parents sometimes in-laws, and in rare cases they consulted older neighbours.

Traditional vs modern medical approaches

The recognition of biomedical treatment as the first choice of treatment is in line with expected health-seeking behaviour from a Western perspective. The practice of home treatment with drugs largely bought over the counter has been widely reported in Africa. For instance, in a Nigerian study [23] most of the 168 mothers included in the study used some form of home treatment in the first 24 hours of their children's illness. At the same time, the high prevalence of home treatment is a concern. Earlier studies indicated that without intervention, most people receive inappropriate medication or the incorrect dosage, which may contribute to the worsening of the condition or the development of drug resistance. There is evidence that community-based educational interventions can improve patterns of self-medication. A good example is the successful shopkeeper training programme in Kilifi, Kenya [24], [25]. In the shopkeeper programme, rural drug retailers were educated on symptoms of malaria, and learned to advice on selling the right drugs and the correct dosages. Evaluation indicated a significant improvement in the correct usage of anti-malaria drugs during childhood illness by both the retailers and the community.

The decision to go for traditional healing was motivated by two main issues: a) the perceptions of the cause of the illness, and b) the duration, severity and chronicity of the illness. We observed that in the communities in which we worked, diseases had been categorised into two types: the diseases that were taken to hospital, and those that were taken to traditional healers. The diseases not taken to hospital are largely those thought to arise from supernatural causes such as spirit possession, witchcraft and breaching of taboos, among others. From a Western perspective, it also seems that psychological and psychiatric problems are presented to the traditional healers. Our findings are in line with earlier findings from other parts of Africa, that the perception of ill-health in Africa is much more complex than the mainstream biomedical approach. The mainstream model or conceptualisation of health and illness is primarily biological approach. In this model, disease is perceived to be an abnormal physical state caused by bacteria, viruses, hormonal or chemical imbalance in the body [26]. However, in many non-western settings, the conceptualisation of well-being and ill-health is much more holistic, involving the body, the mind and in some instances the supernatural [26]. For example it was observed that among the Bira of Mobala and the Nande of Mukulia, of vthe Democratic Republic of Congo [26], the aetiology of ill-health could be attributed to seven different causes. These ranged from natural causes to transgression of cultural taboos (e.g. eating forbidden food) to witchcraft.

We found that there still exists a high prevalence in the use of traditional medicine; although there were some who observed that it was old-fashioned. According to the WHO 2002 report on traditional medicine, at least 80% of people in Africa use traditional medicine at some point in their lives [22]. These results imply that the efforts to improve health care access in Africa cannot ignore traditional health systems. Of interest here is that our results clearly indicate that traditional healing plays a limited but complementary role to the formal health system. It seems as if these two systems compete at a decision-making level within families, rather than publically competing against each other. Parents opt for one of the forms of treatment and if this does not appear to be working, they opt for the other. The fact that Africa has a severely under-resourced health care system, an approach where modern medicine and traditional health care systems complement each other may be the most efficient and cost-effective way to meet the huge need for health care in the African context. As recommended by the WHO [22], various approaches can be used to encourage integration between modern and traditional health systems. These could include enhancing medical doctors' sensitivity towards the role of traditional healing, and encouraging traditional healers to develop some collaborative work with medical doctors. There are various ways in which traditional healers can complement medical doctors, for example: acting as referral points {sending patients for biomedical treatment}; discouraging traditional healers from any practices that may potentially harm the patients; and encouraging and monitoring adherence to the treatment regimen recommended by medical doctors.

The collaboration between the biomedical and the traditional healing system has to be guided by the need to ensure that the population moves towards optimal health seeking behaviour. Our results indicate that traditional healing in these communities is a mix of various practices including herbalist, spiritualism and practices based on superstition which is consistent with earlier observation from researchers in this community. Previous studies in this area indicate that the key role of traditional healing has been to provide psychosocial and emotional support, an aspect of support that could be significant in helping families cope with chronic illness. Traditional healers were perceived to have better communication skills thus building trust and better communication skills [12], [27]. Experience from elsewhere [28] indicates that a successful collaboration would require sensitivity to ensure the implementation that trust and respect for each other leads to a successful partnership.

Our findings on the relationship between people's beliefs and health-seeking behaviour further support earlier reports on the link between behaviour and health outcomes. As noted by Taffa and Chepngeno [29], such associations between belief and behaviour enhance the possibility of reducing the occurrence of life-threatening illness, and its impact on child development, through the promotion of optimal health-seeking behaviour.

Decision makers of health seeking behaviour

The decision on when and where to take the child for treatment was ultimately made by the father. This view was held by both parents. Fathers took the ultimate decision based on their positions as head of the family, but also because they were the ones who provided funds for seeking treatment. Our results further emphasize the need to actively involve fathers in health interventions and programmes so that they can make informed decisions on behalf of their families. However, we also observed a much stronger position of women in the decision-making process compared to many of the earlier studies [5]. For instance, many of the fathers said they consulted with their wives when making decisions about treatment for their children. This was confirmed by the women we interviewed. In summary our data show that fathers play a crucial role in the final decision taken. It is therefore important to emphasize that in intervention and educational programmes, the different voices in the decision-making processes should be taken into account.

The pattern of our results indicate that social status, educational levels and power both within the family and larger community has the potential to impact on health seeking behaviour. For instance, some of the participants indicated the use of traditional medicine was outdated and for those with limited education. It would have been interesting to examine these patterns in greater details. However, our sample sizes were too small to allow for this level of analysis. Future studies investigating these effects are recommended.

We interviewed both mothers and fathers as a means of including the father's voice into the discourse. Our pattern of results indicate a high convergence between mothers and fathers in their perceptions of the person who is the decision maker, on where and when to go for treatment, and attribution on causation of illness. This indicates there is a generally accepted cultural pattern of reasoning about health-seeking behaviour in these two communities that may not differ by parental gender.

Limitations of the study

We used in-depth interviews only in our data collection. Triangulating our results with focus group discussion, observations and surveys could have been used to increase validity of our data. However, the high agreement in our respondents and the patterns of results closely mirroring earlier disease-specific studies (such as those by Kendall-Taylor [11], [12] and Mwenesi [30]) attest to the validity of both our data and our conclusions. Further study of the potential influence of socio-demographic aspects e.g. educational levels and psychological processes, e.g. trust in the biomedical sphere or in the traditional treatments, and concerning the timeframes for decision making (e.g., time taken to move from biomedical to traditional healing and vice versa) is urgently needed to ensure a more detailed understanding of the decision making processes at the individual level.

Conclusions

Traditional healing systems and biomedical treatment are used as complementary services in these communities. The decision to go to traditional healers is affected by the disease symptoms, the extended family, or the homestead the families live in. Parents differentiate between going to a hospital or to traditional healers, depending upon the complaints and duration of illness of their children. Fathers are found to make the ultimate decisions regarding health-seeking behaviour.