STRENGTHS AND LIMITATIONS OF THIS STUDY
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The strength of this study lies in its methodology and theoretical contributions as the data sources and methods were triangulated, and quality assurance mechanisms were embedded in the planning, data collection, and analysis phases.
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Concerning the study’s limitations, first, the use of a snowball approach to identify participants could lead to some selection bias.
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Second, evidence was drawn from participants’ ability to recall treatment regimens over the past 24 months.
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Third, the study provides insights that are bounded by geographical and socio-cultural beliefs. Thus, the results are non-generalisable to populations and sub-groups not considered in this study.
Introduction
Febrile convulsion (FC) in children below age 5 is a common health condition especially in deprived/resource-limited areas.1 2 FC is defined as a seizure accompanied by fever (38°C by any method), without central nervous system infection, which occurs in infants and children 6–60 months of age.3 It occurs in about 5% of all children, making it the most common convulsive event in children younger than 60 months.3 The direct cause of FC is unknown.4 Nonetheless, it is associated with genetic, intrauterine, and metabolic abnormalities.5 Beyond this, FC is highly prevalent in malaria endemic regions, and therefore common in underdeveloped areas particularly in rural Africa.5–7 FC is usually benign and self-limiting with a favourable prognosis.6 Yet, complex FC (typically lasting over 15 minutes, focal, and recurrent) can lead to neurological, cognitive, and behavioural disorders,5 8 9 including seizure disorders,10 paralysis, speech, and hearing disabilities, as well as long-term adverse intellectual and behavioural outcomes if not properly managed.6 11 12 The consequences of FC transcend children to affect the psychosocial well-being of their caregivers.13
In Ghana, whereas FC is one of the most common emergency concerns received in hospitals and clinics, several cases are not reported.14 This is due to several socio-cultural norms, beliefs, and practices including community and/or household decision-making processes which influences folks perception and beliefs about the causes of ill-health.6 15 Consequently, FC is generally perceived as a non-hospital illness, and heavily managed at home by practitioners who are known to be bearers of indigenous knowledge.6 16 Against this backdrop, existing studies on FC are largely health facility-based and clinical,17 18 with few studies focusing on the home setting.6 19 Perhaps, this could be due to contexts where FC is highly managed in healthcare facilities, or limited research attention to the interplay of culture, indigenous knowledge, and health. This study, also underpinned by the household decision-making and pathways of care model (HDMPCM)15 20 sought to fill this research gap by drawing qualitative evidence from caregivers at home.
The HDMPCM is composed of four constructs which are: caregiver recognition and response; seeking advice and negotiating access; using the middle layer between home and clinic and accessing orthodox care.15 20 Concerning caregiver recognition and response, the ability of caregivers to timely recognise and act to prevent or lessen any risks to health (in the case of a dangerous environment) is critical. Standards for home response include caregiver calmness, airway obstruction circumvention, sideways child positioning, tepid sponging and avoidance of oral fluids and substances such as putting a spoon in the child’s mouth.21 22 As a condition generally perceived as ‘non-hospital’, caregiver use of non-hospital approaches to manage/treat FC among children needs to be studied due to its implications on childs health and well-being.6 16 The household decision-making model, thus, provides key theoretical constructs to aid our understanding of care seeking for ill-health, especially those that are deep-rooted in beliefs, and those whose management transcends individual to social/communal control (both typical of FC).
Undoubtedly, the healthcare setting guarantees optimum care and favourable outcomes for ill health. This is because orthodox care entails clinical attention that provides a 24-hour access to trained staff with expertise in resuscitation and lumber puncture for children younger than 18 months.23–25 Further, drugs such as diazepam 0.5 mg/kg intravenous can be safely administered, and prophylaxis may be considered for recurrent convulsion.26 27 There is research evidence in other developing countries to suggest that children who experience FC have delayed access to orthodox care until unfavourable treatment outcomes.28 29 Using qualitative approaches, this study sought to explore the home-managment of FC in communities which are closer to regional health faciltities in the Central region, Ghana.
Materials and methods
Study context and participants selection
Data were drawn from a qualitative study that explored the perceived causes and treatment of FC in rural contexts in the Cape Coast Metropolis, Ghana. The study was a descriptive and interpretive phenomenology. Phenomenology investigates people’s ‘pure’ experiences (descriptive) to interpret what’s ‘hidden’ in them—interpretive.30 Primary data were collected from 20 November 2020 to 13 December 2020 from 42 participants across 5 localities in the metropolis. The metropolis hosts the regional Cape Coast Teaching hospital and the University of Cape Coast Hospital. There are several community health planning centres, locally known as CHP zones. Data sources were triangulated across mothers, traditional health practitioners (THPs), herbalists, grandparents and faith healer’s resident in the area. They were purposively recruited using a maximum variation, and snowball sampling techniques (traditional healers who were the first point of call directed field officers to the homes of their FC clients). The field officers approached the traditional healers to inform and build a good rapport a day before the data collection. Using a screening form (see online supplemental file), the study employed the inclusion criteria below:
Supplemental material
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Participants must be a resident of the study area and either a parent or guardian of a child who has experienced FC. To reduce recall bias, FC management must have occurred within the past 24 months preceding the study.
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Participants must have treated/participated in the treatment of FC among children <age 5.
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THPs must be registered under the Ghana Federation of Traditional Medicine (GFTMP). This was because, according to an earlier report, traditional medicine remains in the hands of quack practitioners.31 The aim was to recruit practitioners with a good reputation in treatment.
Data collection procedure
Two semistructured interview guides (see online supplemental file) were developed for parents and folk healers (THPs, herbalists, faith healers) based on a thorough review of related literature and gaps in knowledge. The interview guides were pretested in a nearby locality, refined and used for the data collection. Data collection was assisted by two trained postgraduate field assistants who have in-depth experience in qualitative research. Research assistants had a one-to-one and a face-to-face interview with caregivers in their homes and treatment centres. An interview was conducted by each field assistant each day and transcribed. Interviewers had a face-to-face interaction with participants, allowing for several observations to be made. Interviews were conducted in a local dialect (Fanti or Twi) best understood and spoken by participants and were audio recorded. Each interview lasted between 45 and 120 min, and fieldnotes were taken. In all, seven participants were excluded from the study as they had not treated FC within the past 2 years. No new information related to the established objectives and criteria came forth after the 42nd interview where data saturation was judged. Voucher specimens of medicinal plants that were received from practitioners were preserved for later discussion with experts at the Herbarium Unit of UCC and with literature.
Patients and public involvement in the research
It was not appropriate or possible to involve patients or the public in the design, or conduct, or reporting, or dissemination plans of our research. This is because the patients were children. As such, caregivers were the participants who provided in-depth information about their care-seeking behaviour during episodes of FC.
Rigour
Quality assurance was based on Connelly classifications.32 Credibility measures entailed the presentation and interpretation of results based on participants’ experiences. Participants were interviewed in their homes/treatment centres, and medicinal plants were verified from the herbarium unit of UCC. Data sources and methods were triangulated, also to ensure that the results were confirmable. Independent checking of codes and generation of themes were done, and discrepant information was presented as well. The data presented represent a significant chunk of the study results and are, therefore, consistent with the findings. Reporting followed the Consolidated criteria for Reporting Qualitative research.33 The methods employed are reported for replication purposes.
Data analysis and presentation
The transcripts were imported into QSR NVivo V.14 for a computer-assisted qualitative data analysis. The analytical technique was thematic. It followed Colaizzi’s (1978) seven-staged thematic analysis structure including—familiarisation, coding, meaning-making, categories or theming, integrated exhaustive description and participant validation.34 Three themes which are treatment, prevention and referral were identified from the inductive data analysis. Three themes on treatment (tepid sponging, herbal medicine and spiritual healing), prevention (behavioural, herbal and spiritual) and two themes on referral (folk referral and orthodox care) were the subthemes identified. Specific significant statements were placed within the author’s sentence for thought coherence during the presentation of the data. Where appropriate, block quotes were employed to interview excerpts over 40 words. In vivo quotes were contextualised to maintain grammatical integrity while maintaining participants meaning.
Results
Background characteristics of participants
42 participants were interviewed in the Metropolis. They were mostly farmers, traders of farm produce and fishmongers. The communities were traditional, with residents living in deprived water, sanitation and hygiene conditions. Two of the communities had a poorly resourced community-based health planning service (CHPS) centre. In terms of sociodemographic characteristics, the parents were mostly in their middle ages (30–39 years), compared with the herbalists, THPs and faith healers who were over age 50 years, mostly with no formal education. Only 6/42 participants had attained a senior high school level of education. The THPs had undergone non-formalised training mostly from their older relatives and had stayed and practised folk medicine in the communities for over 4 decades. All parents, grandmothers and faith healers professed to be Christians (32) while herbalists and THPs were mostly traditionalists. Most of the participants were married or divorced, with three of the THPs being in polygamous marriages. The sociodemographic characteristics of the participants are presented in table 1.
Background characteristics of study participants
Themes
Three themes were identified from the data. These themes were treatment, prevention and case referral. These themes and subthemes are shown in figure 1.
Themes and subthemes on FC management practices in home settings. FC, febrile convulsion.
Among the dominant ethnic group (Akan’s), FC was locally referred to as ‘asram suro’. The ‘asram’ literally means the moon and ‘suro connotes the skies.
Treatment of FC
Tepid sponging
A common and palliative approach participants employed to treat FC was tepid sponging. Caregivers dipped, washed and bathed children who suffered FC in a bowl of lukewarm water, sometimes mixed with herbal products. For instance, a mother aged 30–40 years narrated that ‘When it (convulsion) came like that, I placed the child in a big bowl and we [together with grandmother] washed the child with cold water from the legs towards the head. The subsequent one [convulsion], I did it myself’. This was confirmed by a mother aged 40–50 years who shared that ‘I slowly lowered my child in a big bowl and washed him gently with cold water from the bottom up. After that I wrapped him in a big wet towel’. In some instances, herbal medicine was added to the water. For instance, a mother aged 30–40 years shared that ‘I mixed the Ocimum spp [3me] in a half-filled bucket with water and bathed my child with it.
Use of herbal antidotes
Herbal antidotes (HA) were heavily used in the treatment of FC. All participants’ categories, particularly the older ones employed HA or a preparation from it to treat FC. In explaining the use of HAs, this was what was said:
My mother said convulsion is treated at home with herbs. She said before the hospital came into existence; our ancestors had a way of treating convulsion with herbs. Herbs are very common, and the child could die on your way to the hospital’ (a 40-50-year-old mother).
The practice entailed forcing herbal products into the mouth, anus or nostrils of the child. For instance, ‘my friend rushed out and came with some herbs and garlic, she slopped and dropped its content into the nostrils of my child’ (a 50–60 year-old mother). This was confirmed by a 50–60 year-old THP who said, ‘I mix ‘kakapenpen (Rauvolfia vomitoria) ‘and ‘onyankomawa (Myrianthus arboreus)’ with local garlic to enema the children’. Table 2 summarises the common herbal medicine and other food products used to treat FC. The herbal medicines were believed to have spiritual potency. For instance, a mother aged 30–40 years had this to say:
The herbalist gave me some herbs to bath the child with it for a full month without soap and sponge. He then asked me to throw the residue on a crossroad deep in the night and come home and worry no more!
Common herbal medicines, food items and their use for FC treatment
Beyond science/spiritual approaches
As indicated earlier, the indigenous name of FC (asram suro) connotes a disease from the skies. As such, most participants perceive that FC was caused by evil spirits, and therefore, treated it in spiritual ways. They employed supernatural approaches such as incantation and mystical products, as well as allowing older women to urinate directly on the convulsing child. Some mothers who took their children who suffered FC to a THP demonstrated how the practice was done.
I rushed the child to his [THP) compound and he took two bunch of brooms. He placed one broom on the ground, placed the child’s head on the broom and used the other broom to hit him slightly for 3 times, the twitching receded, and he crashed herbs and dropped them into the child’s nostrils.
As indicated, THPs enabled a postmenopausal woman to urinate on the convulsing child to ward off evil spirits that were believed to have possessed the child. Several in vivo quotations, also from women aged 30–40 years, support this finding. ‘An older woman who had completed menstruation urinated directly on my child whilst the child was on the floor.
Prevention of FC
Participants shared that FC can be prevented and demonstrated three ways. These were behavioural including self-medication and good childcare practices, supernatural including the making of scarification and the use of herbal medicine.
Prevention of FC: behavioural approaches
Several approaches in the form of childcare practices including nutrition, periodic hospital reviews and self-medication were employed to prevent FC Concerning childcare practices and nutrition, a mother aged 20–30 years shared that ‘I take good care of them [two of her children had FC] in terms of providing them with a well-balanced diet. Also, a THP aged 50–60 years with 37 years of work experience narrated that ‘I don’t allow the children to eat pawpaw and coconut after treatment. These foods are usually stricken by thunder and convulsion destroys its victims as a thunder does to a coconut tree’. The practice of preventing children from eating pawpaw and coconut was only affirmed by this practitioner. Pawpaw and coconut trees were known to be stricken by thunderstorm in ways that children are ‘stricken’ by convulsion. Eating from them could mean making children vulnerable to convulsion strikes. At home, mothers gave medications to their children when they had a fever, a mother aged 40–50 years reported that ‘When the child is feverish, I give him paracetamol. Some mothers learnt to seek orthodox healthcare whenever they sense an increased child’s body temperature. For instance, a mother aged 30–40 years reported that ‘My mother told me that I should rush the child to the hospital when I sense that he has a fever,’.
Prevention of FC: spiritual approaches
Spiritual approaches to the prevention of FC were the making of scarification, tying of beads and amulets around the child’s wrist and prayers. The most common approach was the making of scarification either on the child’s face, ears, chest, hands or a combination of several parts. A mother aged 30–40 years stated that ‘after the incident, the THP made scarification around both of his ears, three at the back of both of his hands and three on his chest’. Others insisted that scarification was made. In the words of a mother aged 40–50 years, ‘I insisted that scarification’s were made on the child’s face because when my first child had convulsion, the THP did not make the scarification and the convulsion occurred again, so the second convulsion, I insisted that it was made’. Also, several local products such as amulets and beads were tied on the child’s wrist to prevent convulsion. For instance, a faith healer reported that ‘after treatment, I pray over a local bead fit together with a thread and put it on the child’s wrists’. Also, a mother aged 30–40 years stated that ‘a woman who was no more menstruating in the house took her underwear [‘3tam’ o ‘amoasin], tore a thread from it and tied it around the child’s wrist.
Prevention of FC: use of medicinal preparations
Participants applied herbal preparations to prevent FC after treatment. These were already prepared either by herbalists, grandmothers or THPs and periodically applied. For instance, a mother aged 30–40 years stated that ‘I prepare the herb and pour it in a small cup for him to drink. Since then, the child has not experienced convulsion in his life’. A THP aged 50–60 years stated that ‘I boil the concoction for the parents to keep, and then serve the child on a teaspoon three times a day continuously for three months. Also, a mother aged 30–40 years had this to say, ‘my mother has been applying local herbs to prevent subsequent convulsion.
FC case referral
Folk referral
Referrals were commonly done at the emergency phase of the convulsion. However, this was mostly done by mothers to herbalists, THPs and faith healers nearby rather than to a colleague folk healer. Thus, referrals from one practitioner to the other were uncommon. For instance, a faith healer aged 60–70 years reported that ‘I have never referred anyone to a different faith healer or pastor because my clients trust me’. In most instances, practitioners admitted FC cases for days. For instance, ‘all the rooms you see here are for sick people including FC that are brought here. Some take about 3 days, a week or even a month (a 70–80 year-old faith healer).
Referral for orthodox care
Orthodox care was sought after home care or folk care resulting in undesirable health outcomes. For instance, a THP aged 50–60 years shared that ‘I only refer children to the hospital when they found it difficult to breathe, or when they looked pale after treatment’. Similarly, parents referred FC cases for clinical attention when they were unable to adequately manage the convulsion at home. A woman aged 40–50 years reported that ‘after tepid sponging, he was still feverish, so I took him to the hospital’. This was confirmed by a father aged 40–50 years ‘the child was still not fit, so I sent her to the hospital.
Based on the decisions and practices regarding FC caregiving at home, a conceptual framework shown in figure 2 has been developed. In conceptual terms, caregivers characteristics including age, sex, type (parent/grandparent), and FC experiences influenced their recognition and response at the FC pre-attack, attack, and during the attack phases. For instance, early/first-time mothers could only identify FC during the attack/twitching phase compared with the grandparents who could pre-empt seizure following a child’s increased body temperature, but in most instances, misconstrued it to be malaria. During the attack/seizure phase, first-time mothers were very apprehensive regarding an immediate action, leading to older relatives/neighbours playing critical roles such as making decisions on actions and/or treatment to be provided. As indicated, FC cases were commonly managed at home and later referred for orthodox care when home management resulted in unfavourable treatment outcomes including shortness of breath and anaemia. Referral among traditional caregivers was reported to be uncommon. Upon their return from orthodox healthcare facilities, parents and home caregivers employed a combination of clinical knowledge (checking body temperature and tepid sponging), and indigenous knowledge and practices including scarification, herbal medicine, and prayer to manage/prevent FC reoccurrence (management pluralism).
A conceptual framework showing the pathway of febrile convulsion management in home settings. FC, febrile convulsion; THP, traditional health practitioner.
Discussion
This study explored the home management of FC in the Cape Coast metropolis in Ghana. The results show that caregivers managed FC by tepid sponging with lukewarm water, use of medicinal plants, and beyond-science/supernatural approaches including urine therapy. Similarly, they prevented FC through behavioural approaches such as good childcare practices, herbal medicine and supernatural approaches including making scarification and tying amulets and beads, particularly on the child’s face and wrists respectively. FC cases were referred for clinical attention after home care resulted in undesirable treatment outcomes.
Tepid sponging and use of herbal medicine were the common ways of managing FC at home, and this is confirmed in multiple studies.16 20 35–37 The practice of tepid sponging entailed pouring/dipping/sprinkling lukewarm water on the convulsing child to reduce the fever and/or induce consciousness. Similarly, several medicinal plants/preparations were used to manage FC. Herbal medicine used as anticonvulsion are widely reported in other studies.38 Plants such as A. sativum ‘local garlic’,39 40 Capsicum (pepper)41 and Elaeis guineensis were used in the treatment of convulsion among infants in South-western Nigeria, India and Malaysia.42–44 In other studies, parents applied a mixture of onion and honey, a residue of meals from a cooking pot on a child’s body, and put pepper in the fire as a means to treat FC.45
The role of supernatural beliefs in FC management is widely known. In Ghana, FC is commonly perceived as a non-hospital disease.6 16 Among the dominant Akan ethnic group in Ghana, FC is locally referred to as ‘asram suro’. The ‘asram’ literally means the moon, and ‘suro’ connotes the skies, indicating possibly that the condition emanates from a god of the moon. To exorcise the evil spirit that was believed to have possessed the child, caregivers used urine therapy, made scarification on the child’s face and wrists, and used herbal products. Making scarification was geared towards making the child dreadful for evil attacks due to a belief system that evil spirits attack adorable children. The practice of urinating directly on a convulsion child has been confirmed in other studies in Tanzania where mothers urinated on the convulsing child.46 In southern Nigeria, cow or human urine concoctions were used in the treatment of FC.47–50 The use of cow urine in Nigeria and human urine in Ghana could be due to cultural variations that exist in the beliefs and practices regarding childhood fever.51 Evidence suggests that, despite the popular use of urine therapy in deprived contexts, it can lead to several complications including hypoglycaemia, cortical blindness, and ironically, rather cause convulsion.47 Faith healing is a common treatment practice confirmed in related studies in Nigeria as well.47–50 Healers recited the Holy Quran as well as made incantations as ways of treating FC.47 Accepting the Bible/Quran as the literal truth, most religious groups including Christians and Traditional worshippers believe in the idea of divine healing. Consequently, faith healers are revered to have powers to exorcise evil spirits that are believed to have attacked children. Other management practices such as tying beads, and making scarification are also consistent with related studies.16 37 45 47
The use of herbal medicine and spiritual approaches to manage FC is widespread and consistent with related studies across Africa. One of the conundrums of people including researchers is whether herbal medicines such as those employed in treating FC work, are harmful, or useless. While acknowledging this general concern, these practices satisfied the needs of parents and practitioners alike despite limited scientific evidence, especially from clinical trials. Pessimists may argue that folk medicine is no more effective than a placebo.52 Whereas this study did not focus on the effectiveness of folk medicine, it has revealed that folk medicine is a common practice in FC management, and delayed access to orthodox care. In most instances, children were admitted at healing/treatment centres for days and later referred for clinical attention after home treatment resulted in undesirable outcomes including shortness of breath and anaemia. Late referral as reported in this study has been confirmed in related studies.28 53
Folk approaches have been related to adverse consequences including choking, pneumonitis, eye damage, contractures, bacterial infection, speech, walking, and hearing disabilities, and deaths.47 48 54 55 It is therefore critical to assess the realities of care delivery in traditional settings, and consider feasible options for improving childhood healthcare. For instance, the urgency of FC caregiving in the face of medical pluralism (Figure 2) implies that adequate treatment knowledge could offer better caregiving choices. This will require the need for the community health planning services (CHPS), working together with registered traditional medicine practitioners to educate caregivers about the optimal ways of managing FC at home, and feasible/practical linkages to orthodox healthcare. Such health education could demystify FC as a non-hospital disease, as well as discourage urine therapy and supernatural approaches as they seem to proffer no scientifically proven benefits for children. Further, socio-culturally adapting the recommendations by the consensus statements on the information to deliver after a febrile seizure during health education could enhance better treatment outcomes for children.56 The spiritual beliefs about the causes of FC could blur other possible behavioural and environmental factors, as such, non-pharmacological practices which directly or indirectly reduce the risk of seizures including breastfeeding, hygiene, and proper nutrition could be reinforced, believing that these are daily practices and would be better accepted in the community, and help with the child’s overall health.
Nonetheless, much can be learnt from the herbal preparations reported (table 2) as they have been applied to manage FC across different countries.39–43 In terms of policy, both local and global organisations including the WHO have a keen interest in documenting herbal medicine used in the treatment of human ailments.57 58 This research, therefore, echoes the feasibility of orthodox and non-orthodox healthcare integration. Similar recommendations for FC treatment have been put forth in Korea.44 It is essential in terms of research to scientifically evaluate the use of the medicinal plants reported in this study via pharmacological, toxicological and clinical studies for safety concerns and possible drug discovery.
Conclusion
FC is a common childhood illness commonly managed at home despite orthodox healthcare availability. FC caregivers at home were parents, older relatives, herbalists, traditional, and faith healers who provided first level of care, and subsequently supported in prevention modalities. They employed ad hoc treatment regimens, usually unwarranted by clinicians, visually frightening, and beyond science modalities which were not the best home management approaches. The management approaches, however, delayed orthodox care, and caregivers sought clinical attention after home management resulted in undesirable treatment outcomes including shortness of breath and anaemia. These results call for the need to educate caregivers about optimal FC management practices at home, as well as enhance appropriate and timely linkage to orthodox healthcare.
Data availability statement
Data are available on reasonable request. Data are available on reasonable request from the Department of Population and Health, University of Cape Coast. Email address: [email protected]
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and ethical clearance (Clearance ID: UCCIRB/CHLS/2020/42) was sought from the University of Cape Coast Ethical Review Board and the Department of Population and Health. Participants gave informed consent to participate in the study before taking part.
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