Using traditional healers to treat child malnutrition: a qualitative study of health-seeking behaviour in eastern Ethiopia | BMC Public Health

Setting

This study was conducted in the Kersa Health and Demographic Surveillance System (HDSS) site in the Oromia region of eastern Ethiopia. The Kersa district has 38 Kebeles (the smallest administrative unit in Ethiopia), of which 24 were included in the HDSS (three are urban and 21 are rural). The total population of the district is estimated to be 172,626 of whom 6.9% are urban dwellers people [12].

93.8% of the study population practice agriculture as their primary means of livelihood and the remaining 6.2% are urban dwellers. The cereal crops most commonly grown are sorghum, maize, wheat, barley and pulses in their order of importance. Khat and vegetables are the main cash crops. Cattle, goat and sheep are common in the community. The main economic activities are food crop production, cash crop (Khat) production and livestock production.

Design

The Child Health and Mortality Prevention Surveillance (CHAMPS) network, with seven sites in Africa and South Asia, aims to identify and track definitive causes of under-five child mortality in regions where it is highest, and to generate and share high-quality data to inform policy and public health action. CHAMPS began work in Ethiopia in August 2017, conducting formative research and community engagement activities. While assessing community perceptions on maternal and child health problems, malnutrition was identified as a top priority. As a result of this study new local views of malnutrition was explained by participants.

The CHAMPS Social-Behavioral Science conceptual framework is based on ethnographic method. Ethnography is an approach seeking to understand how a group of people give a meaning for particular topics. which result in an understanding of certain cultural behaviour and practices [13] and this approach allows opportunities to explore people’s day to day lives and understand local meanings of malnutrition. Ethnographic principles were used to develop interview guidelines and data collection procedures. First, the researchers established relationships with study participants and then developed interview guides based on the research questions. Second, face to face interview was used, then probing was also used to further understand vague answers and to know more details.

Finally, the study used an iterative approach to make the analysis ongoing based on fieldwork observation and emerging themes, resembling a spiral process rather than a circular or linear process [14]. Thus, the topic areas in the guideline included local views related to malnutrition treatment, conditions in which traditional healers are consulted, and categories of malnutrition and health seeking towards them.

Participants and data collection

Before actual data collection, the team in CHAMPS Ethiopia received training on qualitative research, data collection tools, participant selection, interaction with participants and how to be reflective, and minimize subjectivity [15]. This in turn supported to control the quality of the study. The study was part of broader objectives of CHAMPS program and the main aim is to understand local views of childhood malnutrition. From the preliminary findings of the mortality surveillance, malnutrition is one of the major causes of child death and local views are not addressed well. The study used this initial assumption to conduct the study.

In order to choose the study participants the team followed Participatory Inquiry Into Community Knowledge of Child Health and Mortality Prevention (PICK-CHAMP), a framework to select participants from diverse groups who were representative of community groups, activities, and/or individuals [16]. The study used purposive theoretical sampling techniques and participants were selected based on their prior knowledge of the research questions and the majority of the mothers who were interviewed received care either from traditional healers or healthcare.

For this study, in order to select the participants for interviews and Focus Group Discussions, researchers worked closely with local Health Demographic Surveillance data collectors who live in the community and they helped facilitate the recruitment process. Data collectors recruited participants who had experience in local treatment of child malnutrition and mothers admitted at children nutrition rehabilitation center. Moreover, to triangulate the data people who could affect or influence community members’ perceptions and practices around child health also participated in the study. The researcher met the study participant in person, asked for written consent and conducted data collection. Moreover, the study data collection has been conducted by the authors at participants homes and health facilities.

The one-to-one interviews were conducted in a private locations preferred by the respondents, such as their homes. Key informant interviews (total n = 12) were conducted with religious leaders (n = 2), a traditional birth attendant (n = 1) and health extension workers (Health extension workers are people who have received basic training to support the primary health care unit at the health post level or grassroots level) (n = 2). Children and women affairs experts (n = 2), and mothers of children admitted to the nutrition rehabilitation unit at Kersa and Water health centre (n = 5) were participated in the study. The interview participants were limited to 12 people due availability of the participants who had experience with child malnutrition healing practice and the sensitivity of the topic.

Four Focus Group Discussions (FGD) with 8–10 participants were held with pregnant women (n = 1), religious leaders (n = 1), and mothers of children under five years old (n = 2). FGDs conducted in Health Demographic Surveillance offices. With regard to time, the interviews took 35–40 min on average, while the FGDs lasted from 45 to 65 min.

In addition, the study conducted participant observation in multiple settings at community over a two year period level to understand the local views of malnutrition and the healing process. The observation target included; mothers who providing care for malnourished children at rehabilitation center, nutrition screening campaigns at community level and families home who have under five children. Therefore, the participant observation was done to see what people say and actually do. In addition this, data was used to triangulate interviews and FGDs data.

During the data collection process, the researchers who collected data spoke the local language and this contributed to clearly understanding the conversation with participants and probing for further questions. In addition, this supported the data analysis process. However, knowing the local language does not guarantee against bias. It is clear that most of the time mothers are the ones who look after their children and they are often too busy to give interviews and shy to talk about sensitive information like childhood malnutrition. Moreover, gender differences between the researcher and the participants also create obstacles for knowing why traditional healers are preferred to modern medicine. In order to reduce this bias at the time of data collection and analysis, multiple people participated to address reliability, reduce bias and quality control.

Data analysis and interpretation

In this study grounded theory is used to understand what are local views of child malnutrition in children under five years and how people view under-five malnutrition and their health-seeking behaviour. Grounded theory, which enables researchers to develop theory from data [17], guided the research and the analysis of the data. It is a holistic and flexible approach to construct theory through analyzing qualitative data. It starts using inductive data, relies on comparative analysis, involves simultaneous data collection and analysis, and includes strategies for refining the emerging analytic themes [18].

Therefore, the value of grounded theory is to explore basic social processes and to understand the multiplicity of interactions that produces variation in research findings. In this regard, the constructive grounded theory is applied as an inductive approach with an ongoing process of simultaneous data collection and data analysis.

The study included constructivist grounded theory strategies. It allows to explore multiple standpoints related to childhood malnutrition treatment. The study used several strategies as part of grounded theory; collecting data in iterative stages, using theoretical sampling, coding the data, data interpretations to link with the theoretical foundation of the study, constructivist ground theory [19]. Furthermore, the study used grounded theory in order to see the difference and communalities of themes in data analysis process, and allows new and unexpected themes to arise from the data. In addition, it helps reduce researchers’ assumptions. After data was collected, themes were generated based on the views of the participants towards child malnutrition including local concepts of malnutrition and health seeking behaviour.

Data was organized, edited, and analyzed using the NVivo, version 11 software package. To address reliability and reduce bias in analytical interpretation, different researchers were involved in data interpretation and quality control. An iterative process has been used to sort and analyze interviews, focus group discussions and observations data. Moreover, the observation report was also uploaded in the NVivo project and coded and go through an iterative approach and analysed continuously until the end of data collection.

Ethical considerations

This protocol was approved by the institutional ethics committee of the College of Health and Medical Sciences, Haramaya University and by the National Committee at the Ministry of Sciences and Higher Education (30.10/70/2018). Written informed consent was obtained in the local language from the participants by signing (or thumb-printing in case they were illiterate) on the consent form. The study participants were informed that there was no risk of participating in this study, that there would not be any direct payment for participating and that the information they share would be protected. All participant names are pseudonyms.

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