Understanding careseeking for child illness in sub-Saharan Africa: a systematic review and conceptual framework based on qualitative research of household recognition and response to child diarrhoea, pneumonia and malaria.

Diarrhoea, pneumonia and malaria are the largest contributors to childhood mortality in sub-Saharan Africa. While supply side efforts to deliver effective and affordable interventions are being scaled up, ensuring timely and appropriate use by caregivers remains a challenge. This systematic review synthesises qualitative evidence on the factors that underpin household recognition and response to child diarrhoea, pneumonia and malaria in sub-Saharan Africa. For this review, we searched six electronic databases, hand searched 12 journals from 1980 to 2010 using key search terms, and solicited expert review. We identified 5104 possible studies and included 112. Study quality was appraised using the Critical Appraisal Skills Program (CASP) tool. We followed a meta-ethnographic approach to synthesise findings according to three main themes: how households understand these illnesses, how social relationships affect recognition and response, and how households act to prevent and treat these illnesses. We synthesise these findings into a conceptual model for understanding household pathways to care and decision making. Factors that influence household careseeking include: cultural beliefs and illness perceptions; perceived illness severity and efficacy of treatment; rural location, gender, household income and cost of treatment. Several studies also emphasise the importance of experimentation, previous experience with health services and habit in shaping household choices. Moving beyond well-known barriers to careseeking and linear models of pathways to care, the review suggests that treatment decision making is a dynamic process characterised by uncertainty and debate, experimentation with multiple and simultaneous treatments, and shifting interpretations of the illness and treatment options, with household decision making hinging on social negotiations with a broad variety of actors and influenced by control over financial resources. The review concludes with research recommendations for tackling remaining gaps in knowledge.

A qualitative evaluation of exposure to and perceptions of the Woolworths Healthy Tuck Shop Guide in Cape Town, South Africa.

BACKGROUND: Both under- and over-nutrition pose a public health concern, especially for children in South Africa. Several initiatives exist in South Africa directed at promoting healthy eating and nutrition at schools. One of them is the Woolworths Making the Difference (MTD) Programme aimed at eliminating barriers to promoting healthy lifestyles that exist at schools, such as the availability of low-cost, unhealthy foods either from tuck shops (small food shops) or street vendors. The Healthy Tuck Shop Guide is a recent addition to the MTD Programme. The aim of this evaluation was to assess awareness, potential uptake, and perceptions of the Woolworths Healthy Tuck Shop Guide among parents and staff in a sample of schools that were exposed to the guide. METHODS: A qualitative study consisting of focus groups, interviews, and tuck shop observation was used to gather information on 13 schools and their exposure, comprehension, and use of the guide. A mix of schools was examined in terms of economic status and level of control over their tuck shop. Thematic analysis was used to extract findings. RESULTS: Findings show that despite overall positive attitudes about the guide several barriers to its implementation exist, including children's preferences for unhealthy foods, the higher cost of healthy foods, and other issues related to a lack of facilities, time and manpower. CONCLUSION: Findings suggest that the Woolworths Healthy Tuck Shop Guide would contribute more meaningfully to the creation of healthier food environments if executed within a larger support network to address barriers to implementation.