The results are presented in the order of the aggregate number of coding references in each theme, starting with the nodes with the highest to the lowest. Consequently, the themes are presented in the following order: Traditional medicine (183 references), biomedicine (119 references), spiritual causation (105 references), syncretism (63 references), and fatalism (56 references).
Traditional medicine
Belief in the efficacy of traditional medicine
The study documented belief in the efficacy of traditional medicine and preference for it over other ways of seeking care for children across zones. The belief that traditional medicine is equally or more efficacious than biomedicine was documented in the South West (FGD #41–43, 45–47, 82, 84, 87, 90, 92), South South (Akwa Ibom in particular) (FGD #33, Interview #66, 70–72), the South East (FGD #29, Interview #50, 52, 56, 61, 64, 75), and the North East (FGD #15, Interview #24, 28, 30). While the study shows that caregivers in the North West also believe in the efficacy of traditional medicine (Interview #36, 37, 41), participants explained that the belief was not common and it has reduced significantly over the years (Interview #40). In the North Central zone, belief in the efficacy of traditional medicine is not widespread although it does exist (Interview #7, 16). Sometimes, this belief is illness-specific. Caregivers believe that traditional medicine is more efficacious for specific health conditions in children (FGD #29, 41) such as convulsion (FGD #29, Interview #61, 62).
In some communities in the South South and South West, people routinely administer traditional medicine prepared from roots, tree bark, and leaves (locally called agbo), to children to produce immunity to diseases even when they show no signs of illness (Interview #75, 90). A caregiver said: “I just gave it to the baby so that the baby can be strong.” (Interview 75, Caregiver, Rivers).
Based on this belief in the efficacy of traditional medicine, a study participant made a case for the inclusion of traditional medicine into the country’s formal health system:
Traditional medicine should be included in PHC [primary health care]. We cannot survive without our culture. There are concoctions in every culture that can help our children survive more. We have killed our culture with foreign culture (FGD 45, Male, Osun).
Women frequently use TBAs for delivery in the South South (Akwa Ibom especially) and the South East, regardless of whether they have accessed antenatal care in health facilities (FGD #34–36, Interview #49, 71).
When traditional medicine fails, caregivers turn to biomedicine (FGD #7, Interview #61, 71, 92). A traditional medicine practitioner said: “If it passes our power and must be treated in the hospital, we’ll say it is not ours. Then, we’ll send them to the hospital” (FGD 7, Male, Plateau).
Traditional medicine only
The belief that certain illnesses in children can only be cured with traditional medicine is common in the South East and South West zones and in parts of the South South. The belief is less common in the northern zones. Illnesses which caregivers in Ebonyi cited as being treatable only through traditional medicine (and which would prove fatal if treated with biomedicine) include ihe eghirigha [multiple illnesses at once], oke ejo onwo [very big boil], jadi-jadi/eriri isi/eku efor/efia [convulsion] (FGD #25, 26, 27, 28). In Imo, participants also mentioned nra onu, jedi-jedi, ogburo afo, nwaobro afo [splenomegaly], and epilepsy (FGD #29, 30). In the South South, participants mentioned convulsion, akpa, ikpakip [stomach ulcer], and jedi-jedi as illnesses that can be cured only with traditional medicine (FGD #36, 39). In the South West, illnesses that participants believe can be cured only with traditional medicine include kolobo [which turns the tongue black], measles, eela alapaadi [big black rashes] (FGD #45), olo inu [colic], and oka ori [sutural diastasis] (Interview #87). In the North Central, ciwon daji [shingles] was identified as an illness that can be cured only with traditional medicine (FGD #5).
A study participant said:
… there is a sickness that is called ihe eghirigha. If you use an English medicine on any child suffering from it, the child will die… (FGD 25, Female, Ebonyi).
In many communities, traditional medicine involves the use of herbs as well as spiritual powers and rituals for healing (FGD #7, 8, 16, Interview #90). If children are believed to be possessed by a demon or attacked spiritually by witches, they are treated with traditional medicine (FGD #7, 8, 10, 13, 16, Interview #16, 29). The treatment in such cases typically involves the use of incense, spiritual perfumes, and/or some rituals including the use of incisions (FGD #7, 16, Interview #90).
Use of traditional medicine for other reasons
The study found that many caregivers use traditional medicine not necessarily because of their belief in its efficacy, but for other reasons, the most common being its affordability and availability. Participants stated that accessing traditional medicine is cheaper in comparison with care in health facilities (FGD #1, 2, 15, 16, 26, 32, 34, 36, 37, 45, 46, Interview #29, 39, 50, 55, 56, 59, 64, 66, 71, 77, 79, 92). The traditional healers may also accept delaying payment until treatment proves effective (FGD #46), an option that health facilities do not offer. Some caregivers use traditional medicine because there are no alternatives (FGD #5, 8, 35, 41, Interview #28, 30, 40). In many communities, there are no health facilities or health facilities are too far (Interview #40, 41). This reason for using traditional medicine featured prominently in interviews and discussion in the North West and the North Central zones. A study participant in a North Central community said:
Lack of hospitals in the village is what makes us seek traditional medicine. It’s not that we reject hospitals. No. We have none that is close to us. That is why we help ourselves with the traditional medicines. After all, since we were born, that has been the only alternative here. It is actually the lack of hospital[s] that makes us to do that. It’s not that we choose traditional over orthodox medicine (FGD 5, Male, Plateau).
Caregivers may use traditional medicine because those around them believe it is the right choice. For instance, caregivers often feel they should take the counsel of mothers-in-law and neighbors who recommend it (FGD #29, Interview #30, 58), notably in the South East and the North East. Sometimes, the counsel comes from healthcare workers (Interview #54). At other times, other community members influence their decisions (Interview #51, 61, 66, 76). This last observation was found more in the South East and South South zones, where neighbors often tell caregivers that their children’s illnesses are only curable with traditional medicine and encourage them to seek traditional care:
I didn’t take her to the hospital... not for lack of money but because the sickness is what people will tell you that traditional medicine will treat. People around told me it is not a hospital issue. They suggested that traditional medicine is the best and they started doing that and the child became okay and I was very happy that she was okay, it was in the morning that it [the convulsion] started again and I decided to take her to the hospital but she died on the way (Interview 61, Caregiver, Imo).
Another study participant explained:
The other people in the house will tell you to use palm kernel oil and shea butter, [and] other things, sometimes onions. They believe that you can treat it with that and the child will be okay and it is working (FGD 29, Male, Imo).
In other situations, caregivers use traditional medicine because there are no health workers in the facilities to attend to them (FGD #33–35). This was found in all the regions, but especially in the South South. Additional reasons cited for using traditional medicine included hostility and disrespect of healthcare providers toward caregivers (FGD #45), most commonly in the South West; and in unsafe communities in the South South, the fear of being attacked while traveling to reach a health facility, when traditional healers and TBAs are closer to them (Interview #78, 79).
Education is also a barrier for some who cannot read and may not be able to follow prescribed instructions, or they may not feel comfortable in the formal health facility setting (FGD #25, 47), as participants in the South East and South West suggested.
Belief in biomedicine
The study found acceptance of biomedicine as an efficacious healthcare option for children across all geo-political zones. Many participants expressed confidence in its reliability in diagnosing illnesses in children through expert medical examination and laboratory tests (FGD #9, 12, Interview #91) and in the procedural administration of drugs in a measurable way (Interview #53). Study participants also said that biomedicine reduces the chances of complications that commonly result from attempts to treat children using other (nonbiomedical) methods (FGD #14, 25, Interview #75). Some participants generally consider biomedicine to be the most efficacious treatment option (FGD #20, 29, Interview #30, 34, 35), and believe that drugs provided in health facilities produce faster results than other methods of healthcare for children (FGD #14).
In this community, we prefer to go to the hospital because that is where proper diagnosis will be carried out to know the cause of the illness. One cannot just stay at home and say he is using herbs without going for [medical] examination. That’s why we go to the hospital (FGD 43, Male, Ekiti State).
Many caregivers who believe in the efficacy of biomedicine may not use it for their under-five children because they cannot afford it (FGD #46, Interview #2, 4, 6); there are no well-equipped health facilities in their communities (Interview #1, 28, 46), or the health facilities lack personnel or drugs (FGD #4). One caregiver explained:
We like going to the hospital [but] there are people who like visiting boka [herbalist] and it is because there is no money to pay hospital bills. If there was money they would prefer to go to the hospital. The herbalist will mix plants and powers for you and sometimes they [the children] get better and many times they don’t (Interview 2, Caregiver, Niger State).
Biomedical care outside health facilities
For many caregivers, a visit to a chemist/PPMV is the first-line treatment. They take their under-five children to those managing the medicine stores to “mix drugs” at the first sign of illness (FGD #26, 30, 31, Interview #51, 52, 58, 69). This practice is common in the South East but was also observed in the other zones. When drugs are mixed, the chemist sells a combination of drugs to the caregiver, depending on the amount he or she is willing to pay (Interview #61). Caregivers explained that they choose PPMVs when the illness is considered not severe (Interview #61, 70). Participants said:
We will buy drugs from the chemist before we take the child to the hospital, especially infants. However, from the advert of the drugs, it is often said that if symptoms persist for two days we should see the doctor (FGD 43, Male, Ekiti State).
Some take children to PPMVs on the advice of their “mother-in-law doctors,” an expression an FGD participant used to describe mothers-in-law who exercise greater power than mothers over child healthcare (FGD #32). Another reason for the choice of PPMVs is that sometimes, caregivers visit health facilities but there are no healthcare providers to attend to their children (FGD #33, 39). They therefore sometimes seek out healthcare providers at home or go to PPMVs for treatment (Interview #74–76). The practice of seeking care for children in the homes of healthcare providers is most common in the South East and South South. Another motivation for this option is the lower cost and flexible payment options of accessing care from PPMVs or at the homes of nurses (FGD #33, Interview #62, 63, 77). In a group discussion, a participant said:
If they know the type of drugs that will cure the children, they will rather go to buy from the chemist for self-treatment, because they’ll say, the money that they would pay in the hospital will be a lot (FGD 33, Male, Akwa Ibom State).
Study participants noted that some of the PPMVs providing medical care to children in these contexts may not have the needed training to save children’s lives, they are often not licensed to offer these services, and they sometimes sell substandard, adulterated, or expired drugs (FGD #33, 44). The study found that there is no clear demarcation between nurses and midwives providing care in their homes and PPMVs. Some have some medical training while others do not. Some registered nurses and midwives operate drug shops where they examine sick children; and other PPMVs with little or no medical education are operating drug stores where they also examine children and administer drugs and injections. Some study participants referred to them as “quacks” and expressed fear about the quality of their services (FGD #38, Interview #88, 92). Yet they may still access their medical services, even if they trust the efficacy of biomedicine, because these providers are available during night hours when health facilities are not open (Interview FGD #38, Interview #88).
The use of PPMVs and healthcare providers who practice out of their homes is most common in the South East (Imo and Ebonyi), South South (Akwa Ibom and Rivers), and South West (especially in Ekiti). It was also observed in the northern zones, but not as common as in the Southern zones.
Exceptions to acceptance of biomedicine
Though the study found that most people trust biomedicine, there were some caveats in some zones. Participants mentioned illnesses for which injections must not be administered, saying that injection would result in their death (FGD #5, Interview #8). Examples include
ciwon daji [shingles] (FGD #5), diarrhea, and sunken fontanel (Interview #16). Some caregivers also consider blood transfusion a taboo and will refuse this treatment for their children (Interview #7). This belief is common in the North Central zone. In the South South and South West zones, some participants who agreed to the efficacy of biomedicine objected to immunization in children because they believed it worsens the health condition of children or might kill them (FGD #35, Interview #93). One said:
You’ll give your child immunization and it will make you waste your money…. It makes them worse…. then you will now spend more money to buy more medication (FGD 35, Male, Akwa Ibom).
Another participant said:
Some people don’t believe in the uptake of the immunization, they claim it kills their children (Interview 93, Female, Key informant, Osun State).
These objections to biomedicine are widespread in Plateau and Niger States in the North Central zone, but also were documented in Imo (South East) and Osun (South South).
Spiritual causation
The study documented widespread belief in illnesses caused by spirit possession in all the zones. Participants believe that children may fall ill because they are possessed by some spirits (FGD #2, 13, 20, 25, 44, Interview #26, 41, 60, 69) or attacked spiritually by witches (FGD #3, 7, 8, 33, 34, 36, 42, Interview #3, 15, 16, 25, 26, 29, 37, 47, 50, 53–57, 59, 61, 66–68), in which case the preferred treatment option is traditional medicine or faith healing in a church. In Akwa Ibom where this theme featured prominently in interviews and discussions, spiritual attack is referred to as eka satan, which is believed to be used to charm and kill children. The belief is also common in the South East. A study participant’s words sum up how this belief influences healthcare seeking behavior:
Yes, spiritual attack happens, because there are some babies that after one applied every form of treatment, nothing good comes from the treatment until you take the baby to the traditional medicine doctor, because laboratory equipment don’t detect that kind of sickness (FGD 32, Female, Imo State).
Another caregiver gives insight into how the belief affects timely use of health facilities.
In the beginning, I thought the deceased was involved in spiritual attack, and this delayed us from going to the health center (Interview 25, Caregiver, Female, Gombe State).
Some participants believe that illness may be caused by a deity that wants the child dedicated to them (FGD #25). Some children are believed to be reincarnated. In such a situation, it is believed that the child chooses their own name spiritually, and if given other names, they become ill and may die. This is why caregivers consult spiritual healers and not health facilities (FGD #26, 32). Some believe that illness occurs because the child is an ogbanje child (an evil child that dies and is reborn into the same household in a cycle) (Interview #51, 52, 63). This belief was documented in the South South. In some situations, caregivers’ health-seeking decisions are guided by prophecies that they would die if they used health facilities, especially for delivery (FGD #34–36, Interview #77, 85). This was found to be common in the South South.
These beliefs explain why pregnant women choose to give birth in the church or take children to church for care or consult traditional healers rather than a health facility (FGD #25, 33, Interview #51, 52, 63). Some religious sects also discourage the use of biomedicine (FGD #30). They teach their followers about miraculous healing independent of use of medicines and immunization for children (FGD #33–35, 41, 46, 47, Interview #63, 72, 78, 85). Some register with health facilities but choose the prayer house as the preferred place of delivery because there, they can be scanned spiritually with solutions proffered to manage their spiritual problems (Interview #69, 70). Belief about a deity or ogbanje spirit causing fatal illness in a child is common in Ebonyi in the South East. Belief in spiritual attacks by witches is common in Ebonyi, Akwa Ibom, and Imo. The belief was also documented in the South West, Gombe, Plateau, and Jigawa but was not common in Kebbi, Bauchi, Niger, and Rivers (FGD #18, 21, 22, 23, 24, Interview #58). Where people hold these beliefs, the health facility is usually the last resort, sought only when the traditional healer’s efforts have proven futile (FGD #7). Overall, belief in spiritual causation is common in the South South, South East and South West.
Syncretism
The beliefs caregivers, and those who may influence them, hold about efficacious treatment options are not mutually exclusive and often, individuals believe in combining treatment options. Caregivers commonly combine traditional medicine with biomedicine, often starting with the former and using the latter only as a last resort (FGD #6, 10, 14, 15, 25, 48, Interview #28, 41, 71). Conversely, caregivers may also revert to traditional medicine if they try biomedicine and find that it is not effective (FGD #14, 16, 43, Interview #26, 34, 44, 46). A female participant said: Well, the mothers, you see, if they’ve tried the healthcare center and there is no improvement, they turn to traditional medicine” (FGD 16, Female, Gombe). In Ebonyi, the study documented a syncretic belief that traditional medicine is useful for diagnosis while biomedicine is useful for treating the identified diseases. This explains why treatment often starts with traditional medicine and progresses to biomedicine (FGD #25, 26):
You must use the native medicine first to ascertain what the child is suffering from (FGD 26, Male, Ebonyi).
What I know is that it is wrong to start the treatment of any illness with orthodox medicine because it can make the child to die. I have had an experience when I started treating a baby with orthodox medicine without knowing that orthodox medicine was not the right medicine for that particular sickness, then the child died (Interview 50, Caregiver, Female, Ebonyi).
Showing how traditional medicine and biomedicine are combined in treating children, a caregiver said:
You must start the treatment with traditional medicine before you know whether to use the English medicine or not…. If the child has so much sickness in the body, the traditional medicine will bring out all the sickness in the person’s body, then you will use the English medicine to treat all the sicknesses (Interview 52, Caregiver, Female, Ebonyi).
Some caregivers also believe in a combination of spiritual rituals and biomedicine (Interview #60, 61). A caregiver held the belief that a child in need of treatment should first be taken to the church for prayers before going to a health facility (Interview #68, 69). Sometimes, caregivers use both traditional medicine and biomedicine simultaneously (FGD #10, Interview #22, 25–27, 29, 30, 41, 50, 84, 90); and for pregnant women, a common practice is to register for and attend antenatal clinic but choose to use TBAs for delivery (FGD #34, Interview #49). While simultaneous use of traditional medicine and biomedicine cuts across the geo-political zones of Nigeria, the belief that traditional medicine is most suitable for diagnosis and biomedicine is most suitable for treatment was documented in the South East zone only.
Fatalism
The study shows that sometimes, caregivers believe that their actions cannot alter the outcome of illness in children because the fate of the child has been predetermined by forces beyond their control (FGD #34, Interview #3, 4, 29, 37, 43, 45, 52). Such children will continue to be ill until they die. A caregiver explained that she never accessed facility-based care for her sick child in the one-year period of illness because she believed that the child’s fate was determined (Interview #37). Another caregiver discontinued treatment in a health facility because she perceived that the child was meant to die. The two-year-old child had been in the hospital for 4 days when the parents decided to leave. The mother explained:
It was already her time to die. We came back in the afternoon, and in the night around 2:00 am at night, she passed away (Interview 17, Caregiver, Female, Bauchi).
A similar fatalistic behavior was captured in the words of a caregiver who said:
I told them to come and remove the thing [intravenous needle], let me take her home or “is it when she dies that I will take her home?” They refused and we kept dragging [debating] until they said I should go and pay since I felt like taking her home. I went round to look for money and paid them and took her away. As we were coming back, we had not passed XX [name of town] when she died (Interview 59, Caregiver, Female, Imo).
Another caregiver said:
He was not getting better because it is only Allah who makes things better, even when I took him to the hospital for the malnutrition, I went three times and from then he refused taking the food supplement and from then I did not go again and accepted my fate (Interview 37, Caregiver, Jigawa).
Fatalism is most common in the North West, North East, and South East zones. Belief in
ogbanje also leads to fatalism in the South East. Although both belief in spiritual causation and fatalism may be connected, with the former sometimes leading to the latter, they differ because while belief in spiritual causation may lead to the use of traditional medicine, fatalism often leads to inaction or a feeble attempt at seeking care. In a typical example of how belief in spiritual causation leads to fatalism, a caregiver expressed her fatalistic views because, according to her, her son had died three times because he is
ogbanje (Interview #52). Another mother’s fatalism was reflected in her belief that her child was charmed (Interview #68). Experience of child death reinforces fatalism in caregivers when they feel they have done everything they could possibly do to prevent the death (Interview #10, 32, 58) as evidence shows in the North Central, North East and South East.