Afr Health Sci. 2008
June; 8(2): 103–107.
Community understanding of pneumonia in Kenya
University of Nairobi, Department of Paediatrics and Child
Health, P. O. Box 19676-KNH, Nairobi, Kenya., University of Nairobi, Department
of Community Health
Author for correspondence: Grace W.
Irimu Department of Paediatrics and Child Health University of Nairobi P. O. Box
19676-KNH Nairobi, Kenya.
Copyright
© Makerere Medical School, Uganda 2008
This article has been
cited
by other articles in PMC.
Abstract
Background
Effective management of pneumonia demands active participation by
the caretaker to facilitate early seeking of appropriate health care and
adequate compliance to home care messages. This would only be possible if the
caretakers' perception of pneumonia is appropriate. This study aims to determine
community's perception of childhood pneumonia in a suburb of Nairobi.
Objectives
To determine community perception of childhood pneumonia.
Design
Cross sectional study utilizing qualitative ethnographic
methodology.
Participants
Six key informants for in-depth interview and eight groups for
focus group discussions from the study community.
Results
Pneumonia was perceived to be the most serious childhood illness.
There was a great deal of diversity of Kikuyu phrases for chest-in drawing.
There was no term for rapid breathing. Chest in-drawing, fever, difficult in
breathing, startling at night and convulsions were perceived as features of
pneumonia. Chest in-drawing, fever and convulsions were indicative of severe
disease.
Conclusion
The caretakers perceived severe pneumonia as outlined in the IMCI
guidelines. Non-severe pneumonia was not perceived for what it should be.
Inappropriate knowledge on causes of pneumonia and signs of non severe pneumonia
are likely to interfere with compliance with home care
messages.
Introduction
Pneumonia is a major public health problem in children aged less
than 5 years developing countries, with 150 million new clinical cases occurring
each year, between 11–20 million ( 7–13%) of the children require
hospitalization and two million die1.
The World Health Organization (WHO) and UNICEF initiated a strategy
for integrated management of childhood illnesses (IMCI) such as pneumonia at the
health facility and community level. The community component of IMCI consists of
education messages and programs in support of key family practices focused on
health promotion, development as well early care seeking and compliance with
health workers advice.
Effective management of pneumonia entails active participation by
the caretaker seeking appropriate health care and adequate adherence to home
care messages. Adequate participation is only possible if the caretakers'
perception of pneumonia is appropriate. Hitherto, the community perception of
childhood pneumonia in suburban Nairobi, Kenya, has not been described.
This study sought to establish the community's perception of the
signs, symptoms and treatment of childhood pneumonia.
Methods
We carried out the study in Waithaka location of Kiambu district
at the outskirts of Nairobi. Most families live in inadequate and overcrowded
houses. About 80% of the inhabitants were Kikuyus who lived on family
land.
This was a descriptive study, which utilized qualitative data
collection methods. These included indepth interviews with the key leaders in
the community and focus group discussions (FGDs) with the children's caretakers.
Interviews were conducted in Kikuyu language and were audio recorded
and later transcribed verbatim for analysis. Prior consent and permission to
record the interviews was sought and confidentiality assured to respondents. The
use of vernacular was aimed at gaining an understanding of the terminologies and
phrases that the community used to describe childhood respiratory tract
illnesses including the signs and symptoms. We therefore used terminologies
understood by the community in the FGDs as gathered from the key informants
interviews.
Two secondary school leavers who were residents of Waithaka
Location and were fluent in Kikuyu language were recruited to work as
field assistants. They received one day training on recording verbatim of
discussions and interviews.
Individual in depth
interviews
After consulting with the village elders, six key informants were
purposively selected one week before the study. The key informants were required
to be articulate, willing and interested in talking about childhood illnesses.
They included two community health workers (CHWs), one traditional birth
attendant (TBA), one church leader, one elderly mother and a village elder. Even
though the CHWs and TBA said they were not usually consulted on the care of sick
children, they were interviewed as members of the community interested in
childhood illnesses. The CHWs were involved in environmental sanitation and
visiting homes of the sick to ensure they sought medical help but were not
allowed to dispense any medication. The interview techniques used included free
listing, paired comparative methods and open-ended questions. A pre-designed
flexible topic guide was used for the key informant's indepth interview. A
pre-testing exercise of the study tools was used to assess their suitability and
comprehension among respondents. During this exercise we realized the need of
actual demonstration of the signs by the respondents to avoid misinterpretation.
Information was sought on common illnesses in the locality: the illnesses were
then ranked in order of severity. The informants were asked to list the
illnesses presenting with cough and for each of the illnesses, they were asked
to list the signs and symptoms. Precision of the description was confirmed by
asking the informants to demonstrate the signs where possible. The reasons for
categorizing one illness more severe than the other were explored. Paired
comparative technique was applied for the frequently listed illnesses. The key
informants explored terms and phrases used to describe the common illnesses in
the locality. The reasons for categorizing one illness a being more severe than
the other were probed.
Focus group discussions
Focus group discussions (FGDs) were carried out with mothers
selected randomly from the community. We randomly selected four villages out of
the nine villages in the study area. In each of the village, with the assistance
of the village elders and the community health workers, we listed the names of
the heads of the households with children aged less than 5 years on individual
pieces of paper which were then put in a basket and the households to be studied
were selected by the lottery method. Fifteen households were randomly selected
from each village. From each household we recruited one mother with a child aged
less than five years and in household with more than one eligible mother the
youngest one was recruited. The mothers were subsequently grouped into eight
groups. Each group had 6–8 participants. The participants in any given group
were not familiar with one another so that they could be to free to discuss in
the FGD. The principal investigator (PI) with the assistance of an
anthropologist conducted the FGDs using an interview guide. The discussions were
written verbatim and audio-taped. The discussions lasted 60–90 minutes per
group. The participants were presented with a hypothetical case scenario of sick
children followed by a series of questions to guide the discussion focusing on
diagnosis made in the community and the recommended treatment. The terminologies
and phrases used to describe signs and symptoms of pneumonia as revealed in the
key informants' interview were applied in the description of the case scenarios.
The PI demonstrated some of the signs to ensure they were understood precisely
by the participants. The scenarios described two weeks old neonate, six months
old infant and a two year old child with a cough for three days with varying
severity of ARI. An example of a case scenario is depicted below. (Box 1). Each
group was presented with three or four distinct scenarios.
Box 1. Case scenario of an infant with cough, no pneumonia.
You have visited your friend, Mumbi, a mother to six months old
Alice. Mumbi usually seeks advice from you. She tells you that Alice has been
running nose and coughing for the last two days. She does not feel hot on touch
and her breathing has not changed. She is worried and asks you what the baby is
likely to be suffering from. How and on what should she feed the baby on? What
else can she give Alice at home? (Probe) Would you recommend her to seek care
elsewhere? If the baby feels hot, what would you tell Mumbi the baby is likely
to be suffering from and what can she do or give the baby at home. How and on
what should she feed the baby? What else can she give Alice at home?
(Probe)Would you recommend her to seek care elsewhere?
Data analysis
Although the common trend nowadays is to use qualitative data
analysis software, this analysis was done manually. Recorded transcripts were
transcribed verbatim and read severally to gain an in depth understanding of the
key issues raised. These transcripts and the notes made during the interviews
were then shared with another researcher not privy to the study, who together
with the PI, independently identified the key themes which further informed the
final analysis and interpretation. Key themes were identified using the
terminologies and phrases used to describe pneumonia and the perceived signs and
symptoms and constant comparison techniques were applied. Themes identified by
the two researchers were then compared for consensus. During the initial
identification of the themes, methodological triangulation of data collected
using different techniques was done to obtain a consensus of the
interviews.
Results
In-depth key informants interview
Terms and phrases used to describe pneumonia
The key informants listed ‘diarrhoea and vomiting’ or cough as the
most common illnesses. ‘Diarrhoea and vomiting’ was mentioned as a single
entity. Others listed were measles and malaria. Pneumonia, malaria, measles,
asthma and common cold were illnesses perceived to present with cough. All the
informants ranked pneumonia as the most serious childhood illness in the
locality, measles was ranked second and ‘diarrhea and vomiting’ third.
The key informants used diverse terminologies and phrases to
describe signs and symptoms of pneumonia. ‘Rimunia’ is the Kikuyu word
used for severe pneumonia by all the informants. It was notable that fever,
difficult in breathing, chest in-drawing and convulsions were mentioned by all
the informants as features of pneumonia. The terminology commonly used to denote
chest in-drawing was ‘guteha’ . ‘Guteha’, literally means
grunting but in the study area it was used to denote chest indrawing. In fact in
this area, chest in-drawing (guteha) was synonymous with
rimunia or severe pneumonia.
Other terms used to describe chest indrawing were ‘guikania
mbaru’ and ‘kuhura ngoro muno’. The former literally translates to
‘pushing of the ribs’ while the latter translates to ‘very fast heart beat’.
Although ‘kuheha muno’ means ‘to breath fast’, it was not used to
describe fast breathing without chest in-drawing ().
There was no word used to describe fast breathing without chest in-drawing.
Terminologies used to describe illnesses
The key informants believed that fever was crucial for diagnosis
of severe pneumonia or rimunia. A child without fever was unlikely to
have rimunia except if rimunia was ‘hidden’ and in such cases
only the doctor could make the diagnosis. Chest in-drawing without fever was
also perceived as “hidden pneumonia”. Two of the informants said that if a child
with cough developed fever without chest in-drawing , that would be recognized
as ‘mild pneumonia’ while once the child had chest indrawing that would be
considered as severe pneumonia.
Five of the informants said chest pain in a child with cough was
also perceived as rimunia. The older child would complain of it but the
younger child would cry if held by the chest.
Pneumonia was also associated with startling at night in contrast
to malaria, which was associated with startling throughout the day and night.
One of the informants said pneumonia could present as grunting while all the
others said it was due to malaria.
Refusal to feed was also associated with pneumonia. Some
informants said that any serous illness could make a child unable to feed.
However if a child did not look sick that illness was generally perceived as
malaria.
Rimnia nini or ‘mild pneumonia’ in this community was
used to describe cough associated with fever with or without fast breathing so
long as there was no chest indrawing. This was not a taken seriously by the
community and was treated with an anti-malarial or antipyretics.
All key informants listed shedding of tears, running nose and
nasal blockage as features of common cold ‘homa’. The child would feed
well in most cases. Two of the informants said that if the children had fever
the illness would be perceived as ‘mild pneumonia’. If the child developed
convulsions then the child would be said to have ‘mburoko’. Convulsions
were described using different names indicating stiffening of the body
(kung'ang'athara, kwihanda, kumagara) and rolling of the eyes
(gukura maitho).
All the key informants perceived fever, grunting and startling all
the time as features of malaria. Grunting and startling all the time were
features that differentiated rimunia from malaria. Other signs and
symptoms for malaria listed by at least five of the informants included refusal
to feed, ‘diarrhoea and vomiting’, hallucination and chills.
Health seeking and causes of delayed care seeking
There was no known home treatment for rimunia and the
informants said a child had to be taken to hospital ‘immediately’. Other reasons
why a caretaker sought immediate health care for a child with a cough were high
fever and convulsions (‘mburoko’). The informants cited various reasons
for delay in seeking immediate care namely ignorance, financial, geographical,
social and religious ().
Reasons listed by the informants for delay in seeking appropriate
health care
Focus group discussions
Consensus of diagnosis made for the case scenarios
There was consensus that a child with cough, running nose or
blocked nose, but without fever, regardless of the age, had common cold in all
the groups. When fever was added to the scenario there was still consensus that
the neonate had ‘rimunia’ and the two year old child had common cold.
There was no consensus in any of the groups for the diagnosis of the scenario of
a febrile six months old infant with similar symptoms and signs; some of the
participants thought the infant had common cold or malaria.
Case scenarios of children with different ages with a cough, fast
breathing but no chest in-drawing were presented to the groups. For the two
weeks old neonate with fever there was consensus in all the groups that the
neonate had rimunia but few participants said the child could have
stomachache too. However there was no consensus on diagnosis in the scenario of
afebrile neonate. Participants felt the child could have pneumonia or
stomachache. Regarding the six months old infant and two year old child there
was consensus that the children had ‘mild pneumonia’. If fever was added to the
scenario there was no consensus with some participants making a diagnosis of
malaria or rimunia.
There was consensus in the case scenario of a child with cough and
chest in-drawing with or without fever that the child had rimunia.
However in the scenario for the neonate some participants felt the child could
have stomachache too.
Sugar salt solution (SSS) was recommended for treatment of
stomachache, antipyretic for mild pneumonia, and an antimalarial for malaria.
All the groups agreed there was no home treatment for “rimunia” and the
child should be taken to hospital. The participants also said a very young child
was not to be given drugs ‘just like that’.
The participants were asked how they would manage a child with
fever. There was consensus that a child with fever should be undressed, wiped
with luke-warm water and given antipyretics. But the participants thought that
the neonate was too young to be exposed and to receive home treatment with
antipyretics and all recommended that a neonate with body hotness should be
taken to the hospital.
Regarding feeding during illness there was consensus in all the
groups that the very young child should be fed on breast milk only. The older
child would continue with feeds but was denied some food stuffs namely fried
foods, cold foods, milk and fruits like avocadoes and bananas. These were
believed to be too strong for the sick child and that their consumption would
make pneumonia worse while eggs were believed to cause a child with a cough to
develop pneumonia.
Discussion
The study community was familiar with and used medical terms like
pneumonia, malaria and bronchopneumonia. However the signs, symptoms and
treatment for each of these differed considerably from the biomedical concept.
Health workers and the caretakers may be using the same words but their
understanding of these terminologies may be different. This qualitative research
provided an opportunity to elicit the differences and careful explanation of
what the terms used to describe pneumonia were understood by the community.
Terms for chest in drawing, labored breathing and convulsions were diverse and
yet specific. Other ethnographic studies in ARI have documented similar
diversity of terms 2,3. Chest in-drawing was synonymous to ‘rimunia’ or
severe pneumonia. Severe pneumonia was therefore easily recognized and
appreciated as the most severe childhood disease in the community. Inability to
differentiate severe pneumonia from stomachache in neonates in case scenarios
was noted in the FGDs. This could lead to inappropriately treating the neonate
with severe pneumonia with SSS at home.
The community had no term for rapid breathing; this is in contrast
with what has been found in a community in Western Uganda, although even in this
community it rarely prompted health care4. Even with description in the scenario in FGDs, caretakers
were unable to recognize the significance of rapid breathing. Fast breathing in
a child with cough is the key sign of pneumonia 5–7. In developing countries according to the IMCI case
management guidelines, pneumonia is presumed to be of bacterial origin,
antibiotic therapy should be instituted promptly. Many of the ARI deaths occur
within 3–5 days of disease onset 8. Failure to recognize fast breathing may result in delay in
seeking appropriate health care and hence delay treatment resulting into
avoidable deaths. Mild pneumonia, though it refers to an illness that requires
antibiotic treatment, in this community, it was regarded as a mild illness that
could be treated with antipyretics or anti-malarials. Early recognition of
pneumonia by the child's caretaker and appropriate health seeking are essential
for the reduction of mortality. Understanding how locally recognized signs and
symptoms relate to the clinical definition of pneumonia is important in
constructing messages that families can understand and which they are likely to
adhere to.
Caretakers continued giving a sick child feeds during an ARI event
but denied the child certain important foodstuffs like fried foods, eggs and
milk. This is detrimental in a country in which the prevalence of underweight in
the children aged less than 5 years is as high as 20% 9. Community health education is required to empower the
caretaker with an understanding to appreciate and recognize signs and symptoms
of pneumonia as well as understand the appropriate supportive care. This will
enable the caretaker to perceive pneumonia disease for what it should be, and
improve adherence to health care messages.
There were several reasons for delayed care seeking in this
community which should be addressed in the community IMCI. Financial constraints
and perception that an illness is not serious have similarly been described in a
city slum in Kenya to be main reasons given for failure to seek health care
outside home10.
The findings of this study cannot be generalized to the national
level but they do identify strengths and weaknesses in community perception of
pneumonia that will be of interest in the development and adaptation of the
training materials for community IMCI.
Acknowledgement
The authors are grateful to Prof. W. M. Macharia for having
reviewed the manuscript and for his useful comments.
References
1.
Rudan L, Tomaskovic L,
Pinto-Boschi C, Campbell H. Global estimate of the incidence of clinical
pneumonia among children under five years of age. Bull
World Health Organ. 2004;82(12):895–903. [PMC free
article] [PubMed]2.
Gove S, Pelto G. Focused
ethnographic studies in the WHO Programme for the Control of Acute Respiratory
Infections. Med Anthropol. 1994;15:409–424. [PubMed]3.
Rashid S, Hadi A, Afsana
K, Begum S. Acute respiratory infections in rural Bangladesh: cultural
understandings and practices and the role of mothers and community health
volunteers. Trop Med Int Health.
2001;6:249–255. [PubMed]4.
Källander K, Tomson G,
Nsabagasani X, Sabiiti JN, Pariyo G, Peterson S. Can community health workers
and caretakers recognize pneumonia in children? Experiences from Western Uganda.
Trans R Soc Trop Med Hyg. 2006
Oct>100(10):956–963. [PubMed]5.
Cherian T, John T, Simoes
E, Steinhoff M, John M. Evaluation of simple clinical sings for diagnosis of
acute lower respiratory infection. Lancet.
1988;2:125–128. [PubMed]6.
Shann F, Hart K, Thomas D.
Acute lower respiratory tract infections in children: Possible criteria for
selection of patients for antibiotic therapy and hospital admission. Bull World Health Organ. 1984;62(5):747–753. [PMC free
article] [PubMed]7.
Wafula E, Tindyebwa D,
Onyango F. The diagnostic value of the various features for acute infections
among the under fives. East Afr Med J.
1989;(66):678–684. [PubMed]8.
Mlango F, Neunans D. Acute
respiratory infections in children under 5 years. Control project in Bagamoyo
District, Tanzania. Trans R Soc Trop Med Hyg.
1986;80:851–858. [PubMed]9. Kenya demographic health survey. 2003.
10.
Taffa N, Chepngeno G.
Determinants of health care seeking for childhood illnesses in Nairobi slums.
Trop Med Int Health. 2005;10(3):240–245.
[PubMed]
