Caregivers in sub-Saharan Africa and Pakistan are less likely to seek formal healthcare when their infants show the most severe symptoms, according to a study by Henry D. Kalter and colleagues published in PLOS Global Public Health (2024). The counterintuitive finding reveals that severely ill neonates received formal care in only 8.4% to 41.8% of fatal cases, compared to 15.0% to 66.7% for mild illness cases.
Healthcare seeking decreases as infant illness severity increases
Percentage of caregivers seeking formal care by illness severity, neonates
Source: Kalter et al., PLOS Global Public Health, 2024 | Georgian Medical Journal News
Two-sign method reveals illness severity patterns
Researchers led by Henry D. Kalter from Johns Hopkins Bloomberg School of Public Health developed a novel two-sign assessment method focusing on activity level and feeding behavior to classify illness severity, according to the study published in PLOS Global Public Health. The study analyzed verbal and social autopsy data from fatal illness cases across six sub-Saharan African countries and Pakistan.
The research team examined careseeking patterns for 2,847 neonatal deaths and 2,156 deaths in infants aged 1-11 months, as reported in the study. Their findings challenge conventional assumptions about healthcare-seeking behavior, with implications for global health interventions designed to reduce infant mortality.
Age emerges as strongest predictor of healthcare seeking
Multivariate analysis revealed that infant age, rather than illness severity, was the most consistent predictor of formal careseeking, according to the Kalter et al. study. In all six African countries studied, older neonatal age was significantly associated with healthcare seeking, with adjusted odds ratios ranging from 1.10 to 1.11 per day of life.
For infants aged 1-11 months, the pattern held in three of five countries, with odds ratios of 1.10 to 1.26 per month of age, the study found. The study’s authors suggest this may reflect caregivers’ perception that very young infants are “too fragile” for transport to healthcare facilities, or cultural beliefs about newborn vulnerability. Additional analysis showed moderate illness severity predicted careseeking in three countries for neonates and one country for older infants, while severe illness showed no significant association after controlling for other factors.
Implications for child survival programs
The findings have direct relevance for programs designed to reduce under-5 mortality. Current integrated management of childhood illness protocols assume that severe symptoms will prompt immediate careseeking, but this study suggests the opposite may occur in many contexts.
Co-author Zulfiqar A. Bhutta is listed as an author on the study. The research builds on previous clinical studies showing that early recognition and treatment of severe illness can dramatically improve survival outcomes.
The study also found significant variation between countries, with some locations showing careseeking rates below 10% even for moderately ill neonates. This suggests that targeted, context-specific approaches may be more effective than universal protocols.
Careseeking was almost uniformly decreased for severely ill neonates, ranging from 8.4% to 41.8% compared to 15.0% to 66.7% for mild illness cases across all study sites.
— Kalter et al., PLOS Global Public Health, 2024
Key takeaways
- Severely ill neonates received formal healthcare in only 8.4%-41.8% of cases versus 15.0%-66.7% for mild illness (Kalter et al., 2024)
- Infant age was the strongest predictor of careseeking across all African countries studied (Kalter et al., 2024)
- A two-sign method based on activity and feeding effectively classified illness severity (Kalter et al., 2024)
Frequently asked questions
How was illness severity measured in this study?
Researchers developed a two-sign method focusing on activity level and feeding behavior, as well as a multiple sign method. Both effectively distinguished between mild, moderate, and severe illness in neonates and 1-11 month old infants based on verbal autopsy data, according to the Kalter et al. study.
Which countries were included in the research?
The study analyzed data from six sub-Saharan African countries and Pakistan, examining 2,847 neonatal deaths and 2,156 deaths in infants aged 1-11 months, as reported by Kalter et al. The research was part of broader verbal and social autopsy studies conducted across these regions.
These findings from the Kalter et al. study underscore the need for targeted educational interventions that specifically address careseeking behavior for severely ill infants. Understanding the complex relationship between perceived illness severity and healthcare decisions will be essential for reducing preventable infant deaths in resource-limited settings.
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Medically reviewed by Prof. Giorgi Pkhakadze, MD, MPH, PhD. Spotted an error? Contact the editorial team.
