Participant characteristics

A total of 35 respondents—27 in the focus group discussions and 8 individuals in the in-depth interviews—participated in the study. The average number of individuals in each focus group was 7. The mean age of respondents who participated in the focus group discussions and in-depth interviews was 40 (±12) years. The majority (n=24) of the respondents were female. Respondents also had a mean of 4 (±2) children. The majority (n=29) were married during the focus group discussions and in-depth interviews, and the majority were farmers. The majority of the study participants attend primary education or less.

Caregivers’ understanding of child illness

Respondents report that in Ethiopia, specifically in the study area (northern Ethiopia), mothers were usually the ones to first identify a child as sick. Mothers were primary caregivers and had close ties to their children. Fathers spent the majority of their time outdoors in on-field activities like farming. A majority of the participants conceptualised illness in a child under the age of 1 year as being manifested in strange symptoms such as mekremrem (restlessness), fenen fenen (irritability or continuous crying), a loss of strength or a lack of interest in breast feeding. Caregivers initially identified child illness when the child showed strange behaviours during playing and eating. For example, if a child could not play and run as usual, then caregivers understood that their child was sick. For a child under the age of 1 year, caregivers recognised child illness when the child stopped breast feeding or was unable to eat additional foods:

I recognised my child’s situation has worsened if my sick child decreases his breastfeeding gradually or if he stops taking breastfeed. Moreover, if the child has a fever, the temperature dropped or not, I can measure temperature by touching on their forehead and chest area. If the child’s situation worsens, his temperature would be high. But if he shows improvement, his temperature would lower gradually, and he would begin breastfeeding again. (woman aged 20–24 years old, interview)

Local names and causes of illness

Causes of childhood illness were constructed as environmental (eg, exposed to cold temperature and poor sanitation) and supernatural. Participants reported that sanba mich (pneumonia) and diarrhoea were the two most common diseases in children under the age of 1 year. Sick children mostly complained of fever. Moreover, they might have diarrhoea or sanba mich. Caregivers gave different reasons and causes for child illness. For example, if a child showed a sign of illness, such as a ‘shouting nightmare’ despite being awake, the caregivers perceived that the cause of the sickness was ‘evil eye’ or metet, for which magic and holy water were the preferred cure. Additionally, participants reported that the community recommend crossing a river if a child had been attacked by the evil eye. Once the child crossed the river, they would need to return home via another road because the evil eye would return if the child used the same road. Moreover, there was a traditional medicine that would be smelled by the patient, and a child who was attacked by an evil eye would also need to smoke a burning tyre:

There is some illness which we perceived as they can be caused by missing ceremonial activities for the lord of evil. Some women say this is the last day of the month late us celebrate, to not upset the evil. So, if a woman misses such ceremonies and her child becomes sick, she would directly relate with such incidents rather than accepting its real cause. Many households belief on traditional practices and norms for the cause of child illness. (woman aged 20–24 years old, group discussion)

Caregivers in the study area also explained a cause of illness is bird (exposure to cold temperatures). Caregivers understood that children could develop pneumonia if they were in a cold environment, and this could happen due to inadequate child-caring practices by the mother. If the caregivers put the child on a cold and muddy floor, the child might be exposed to bird. Moreover, if the child put on many clothes or thick clothes, and then took off these clothes, they might be exposed to bird. For example, if a child put on a cap and then removed these clothes, then they might be exposed to bird, or might experience a clash of hot and cold air and consequently develop a fever, then sanba mich:

Caregivers describe pneumonia as sanba mich; they understand that the cause of the disease was when a child has exposed to bird. They explained that my child was exposed to ‘extremely cold environment’, if he has high fever and cough. If a sick child has these symptoms, they would say my child has been developed sanba mich. (woman aged 25–29 years old, interview)

Home-based treatments for childhood illnesses

Participants reported that it was typical for caregivers and infants to stay at home, especially in the early postnatal stage. In northern Ethiopia, where this study was conducted, a majority of the population follow the Orthodox Christian religion, and according to religious norms, primary caregivers are not allowed to stay outside with the child before the child is baptised on the 40th day for male neonates and the 90th day for female neonates. However, participants reported that mothers would still attend health facilities for postnatal care and if an infant’s illness was very serious and could not be managed after many trials of home-based treatments. However, participants also reported that the death of a neonate at an early age was considered a tefa (stillbirth) rather than infant death; most of these deaths occur before the child is brought to the health facility and are not reported as neonatal deaths.

Home-based treatments for child illness were commonly reported for young children. When asked about home treatments for illness, caregivers reported providing a mixture of lemon, coffee and other ingredients to sick children with diarrhoea and vomiting. Zingibil (ginger root) was also used for stomachaches and respiratory problems. Most of the caregivers reported that they used feto (Lepidium sativum; garden cress), chewed or masticated with zingibil, at home to treat most child illnesses:

If the child has a cough, I will give tenadam [Ruta chalepensis; fringed rue] with coffee, garlic with coffee on coup… it would cure, we also used lega kibe [fresh butter without spices]. (emphasis added in bold; woman aged 25–29 years old, group discussion)

For child illness than one year, we can give tenadam, nechishinkurt [garlic] and feto with coffee for decreasing the cough. If he has delirium, biting his lip and his teeth, we will give yebuda medhanit [traditional herbal medicine for evil eye] per month. We also tie on his neck and hand. (emphasis added in bold; man aged 40–44 years old, group discussion with community member)

Caregivers’ access to health services

Participants reported that members of communities living far from the health facilities preferred to observe their children’s situation at home, hoping their health would improve with time. For example, if a child in a remote area was sick, caregivers would decide not to bring the child to the health centre immediately; instead, they would observe the child for 2 or 3 days. Caregivers from lowland areas found it hard to access services. It was difficult to transport sick children with the traditional ambulance (a stretcher made up from local materials) and it was not possible to build roads to such villages to increase ambulance access. The only option was to use human resources and travelling on foot to bring sick children to a health facility. Accessing health services using traditional transport services was very difficult. Additionally, it was difficult to get people who could provide aid to and also carry sick individuals to a health facility during the summer season. Without such support, caregivers determined that they could not bring children to the health facility. Participants reported that community members might not accept a request for support from sick individuals if the road was too muddy. In contrast, however, the social group (known as edir) would provide transport support when older individuals became sick.

Distance to the health institution it imposes a huge challenge to access health services. For example, there are clusters known as Tiba, Yetayiba, in this kebele. The road is not comfortable for health individual, give alone for a sick person to come in such muddy season. If I go through that road one day, I would sleep for at least 2 days due to the difficulty of the trip. They might bring a sick child with great suffering; otherwise, they would let them die on their hand. The road is too difficult. (man aged 45–49 years old, group discussion)

Lack of money was reported to be another barrier to bringing sick children to a health facility. Community health insurance alleviated the financial burden of healthcare for the majority of the community, but there were some households that did not enter into this system. Such parents might not have the money to obtain treatment for their sick child. Participants recalled that community members might wait for days, thinking the child will recover soon without any treatment, or that the illness is not a serious risk to the child. Sometimes, such individuals might not have enough money, so they wait until they could obtain money; otherwise, those who used community health insurance were more likely to bring their sick children to the health facility immediately. Participants reported that some fathers hesitated to pay for their child’s medical bills; they did so not because they had no money on hand, but rather, they hesitated to pay for other reasons. However, there were some women who saved money from their household allowance for expenditure when such difficult situations arose.

Individuals who do not have a community health insurance prefer to buy drugs from the pharmacy, rather than paying for related services like getting examination card, waiting for long queue and passing through other steps. Moreover, they might not be able to bring sick children to the health facility, so they can buy from private clinics without any physical examination and investigation. I met a man whose child was sick and when he went to a private clinic to buy medications, I asked him why he brings the child with him; he said since it is a busy working day in the community, he can access no one to bring his sick child to a health facility, so his only option is to buy medication from the private clinic by telling them his symptoms. (woman aged 20–24 years old, interview)

Participants reported that beliefs around traditional practices were a factor in decision-making. For example, if a family had only one child, and they believed they received this child as a miracle from God, and they may get this child by performing cultural rituals like giving promise for the witch, the witch might perform magical and spiritual things to let couples have a baby. A child who is delivered through such a process would not be taken to the health facility when they are sick, since the mother believes that the witch is the one who can protect and save the child from all the risks the child might experience through their entire life. As such, the mother would prefer to take care of the child at home as per the recommendation of the witch; similarly, the mother would not agree to take her child for vaccination. The mother would even cut the child’s hair in such a way that would expose the child as her only child; such children could thus be easily identified by the community. This indicates that there are harmful traditional practices and norms that prevent children from accessing healthcare.

When I tried to convince the woman to take her child to a health centre, she said, ‘I get this child by pledging to a witch, if I take him to health centre he might die. I would never take him for any medical care’. (health professional aged 20–24 years old)

I fear their diseases might adapt the medication through time if I bring them to a health facility for each sickness. It is not a good practice to provide medicines for sick children frequently, since they might develop resistance. Therefore, I observe their progress at home in 2 or 3 days; if they do not show improvement, I would bring them to the health centre. (man aged 40–44 years old, group discussion)

Decision-making to seek care

A caregiver’s decision to seek care was influenced by a caregiver’s partner and family. Husbands were the decision-makers for seeking care in any circumstance. Most mothers in Ethiopia were dependent on their husbands, specifically in resources. Additionally, elders and religious leaders had a strong influence on the decision-making of caregivers. Though an individual’s perception varied, participants reported that the majority of elders did not recommend taking sick children to health facilities. Instead, they preferred to perform a coffee ceremony for sick individuals. A participant recalled that in her community, caregivers believed that if a child was exposed to mich, then her mother-in-law would suggest providing a local plant known as aregessa. They could provide this for the child to drink and to apply locally to their body. For example, a caregiver might want to take a sick child to the health centre, and her husband partially supports his wife’s opinion. However, the grandmother of the ill child never goes to the health facility for medical care; the religious leader also recommends the community bring sick children to church for religious and spiritual services rather than taking them to the health centre. Religious leaders believe that a sick child can be better cured by taking them to holy water and through other religious practices.

I do not bring my child to the health centre unless I communicate with my husband. My husband prefers to take children once we observe their situation at home, thinking that the illness might be cured by itself. If I bring the child, opposing my husband’s opinion, and something wrong happen to our child, he will make me accountable for that. So I need to wait for his present or recommendation before I bring sick children to the health centre. (woman aged 40–44 years old, group discussion with caregivers)