Care pathways for critically ill children aged 0-5 years arriving at district hospitals in Burkina Faso, Guinea, Mali, and Niger (2022): a cross-sectional study.

Care pathways for critically ill children aged 0-5 years arriving at district hospitals in Burkina Faso, Guinea, Mali, and Niger (2022): a cross-sectional study. | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Care pathways for critically ill children aged 0-5 years arriving at district hospitals in Burkina Faso, Guinea, Mali, and Niger (2022): a cross-sectional study. Emelyne GRES, Sarah Louart, Bertrand Méda, Lucie Peters-Bokol, and 8 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4693196/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 13 Nov, 2025 Read the published version in BMC Public Health → Version 1 posted 4 You are reading this latest preprint version Abstract Background . Under-five mortality remains high in West Africa, where sick children are expected to first attend the primary health care before being referred to a hospital if necessary. However, little is known about how families navigate between home and higher levels of care to meet their children’s health needs, despite multiple known barriers (including social, financial, and geographical accessibility). We analysed the care pathways of children aged 0-5 years before they presented to the district hospital with a serious illness and the determinants of these care pathways in four West African countries. Methods . From May to August 2022, we conducted a cross-sectional study over a one-month data collection in seven district hospitals participating in the AIRE project aimed to introduce pulse oximetry at primary health care level in Burkina Faso, Guinea, Mali, and Niger. All children aged 0-5 years, classified as severe or priority cases by clinicians at referral district hospitals were included after parental consent. Data about care pathways since the onset of their disease were collected from caregivers, and the Levesque framework was used to analyse the accessibility issues. Results . A total of 861 severely ill children were included, with 33% being neonates: 20.3% in Burkina Faso, 9.2% in Guinea, 9.5% in Mali, and 61% in Niger. In Burkina Faso and Niger, most children followed the recommended care pathway and first visited a primary health centre before arriving at the hospital, with 81.1% and 73.3% of children, respectively. However, they were only 51.2% in Mali and 13.9% in Guinea. Using alternative pathways was common, particularly in Guinea, where 30.4% of children first consulted a pharmacist, and Mali, where 25.6% consulted a traditional medicine practitioner. Overall, primary care was perceived to be more geographically accessible and less expensive, but parents were much less convinced that it could improve their child's health compared to hospital care. Conclusion . The recommended pathway is largely adhered to, yet parallel pathways require attention, notably in Guinea and Mali. A better understanding of healthcare-seeking behaviours can help remove barriers to care, improving the likelihood that a sick child will receive optimal care. Child health Pathway of care primary health care referral to hospital Burkina Faso Guinea Mali Niger Figures Figure 1 Figure 2 Figure 3 What is already known on this topic In West Africa, public health services are planned hierarchically: sick children are expected to attend first the first level of primary health care before being referred to upper levels, if necessary... The health system in this part of the world generally consists of a combination of public and private care, alongside a traditional system that includes traditional medicine and alternative practitioners. Access to appropriate care for children under the age of five is often not guaranteed due to several barriers (transport, cost, quality of care, etc). What this study adds: There has been relatively little research exploring how barriers to access to care differ between facilities and influence care pathways. This study illustrates the diversity of family care pathways in four West African countries with different health policies and varying barriers to care. How this study might affect research, practice, or policy: Understanding the behaviour of families when seeking care makes it possible to act on the main obstacles to access to care Free-of-charge healthcare policies appear to significantly impact on access to health centres and the use of recommended pathways. It is therefore important to maintain and ensure these policies where they exist, and to extend them where they do not yet exist. It is also crucial to improve the quality of primary care, which is more accessible and less expensive, but in which parents have much less confidence in improving their children's care INTRODUCTION Under-five mortality remains high in West Africa, despite significant progress over the past thirty years. In 2018, three West African countries had some of the highest child mortality rates worldwide, above 100 per 1000 live births: Nigeria, Mali, and Sierra Leone ( 1 , 2 ). The main causes of these deaths are pneumonia, complications of preterm birth, childbirth-related events, diarrhoea, and malaria ( 1 ). These causes are exacerbated by malnutrition, which affected nearly 6.9% of children under 5 in West Africa by 2020 ( 3 ). Most of these causes are treatable and preventable. Morbidity and mortality from these diseases could therefore be considerably reduced if families had access to appropriate health prevention and care. Ensuring children under five have access to appropriate care is crucial for rapid diagnosis, timely and proper treatment, and the prevention of complications. ( 4 ). To address these access issues and bring healthcare services closer to the populations, WHO developed the “Global Strategy for Health for All by the Year 2000” ( 4 ). Despite the inherent limitations of a pyramidal organizational approach ( 5 ), the focus has been on developing primary health care and structuring the public health system accordingly ( 6 , 7 ). Healthcare facilities range from small, decentralised primary healthcare centres (PHCs) to intermediate structures, such as district hospitals or regional hospitals, then national reference hospitals where specialised, highly technical care is provided ( 7 ). The various structures are linked by a referral system organized according to the severity of the illness and the care capacities of the healthcare facilities. The private sector (e.g. approved or unapproved pharmacies, and private clinics) and traditional care complete the picture of the health system. Despite these efforts to bring healthcare closer to the population, many accessibility problems remain highly impacting vulnerable populations, such as children. Several health reforms, in particular the introduction of free health care, aim to increase families' access to healthcare ( 8 , 9 ). However, there is limited information on how families navigate the health system, including the care pathways they use before hospitalization—whether they adhere to the recommended route from community or primary care to hospitals, or choose alternatives pathways. Families' perceptions of PHC, their reasons for choosing specific health services for their ill children, and the accessibility issues influencing their decisions of healthcare are key elements to consider. This study is part of the AIRE project which aimed to enhance the detection of respiratory distress in children under five by introducing a pulse oximeter (PO) during the Integrated Management of Childhood Illness consultations at PHC ( 10 ). Early observations revealed a low incidence of severe cases at PHCs with variations across countries, suggesting that families might use alternative care pathways that bypass the PHC ( 11 ). Thus, this study aims to describe and measure the determinants of the care pathways of children aged 0–5 years presenting with severe illness at district hospitals in the four countries participating in the AIRE project (Burkina Faso, Guinea, Mali, and Niger). METHODS Study design and sites The ITINER’AIRE study is part of the AIRE research project carried out between 2020 and 2022, in Burkina Faso, Guinea, Mali, and Niger. The AIRE research protocol and details about the study locations have been previously published ( 10 ) (SF1). We conducted a descriptive cross-sectional study in seven district hospitals of the AIRE project, two per country, except for Guinea where only one hospital contributed ( 12 ). Inclusion process The study was implemented over one month (23 May − 23 June 2022 in Burkina Faso, Guinea, and Mali, and 13 July – 12 August 2022 in Niger). All the children aged 0–5 years presenting at one of the seven district hospitals and classified by clinicians as severe cases were included after written parental consent. Children were classified by clinicians at the triage level upon hospital admission (Emergency or Paediatric ward, depending on the country) based on the emergency triage form into three categories: urgent, priority, and ordinary ( 13 ). We define as severe cases, children classified as urgent or priority. The triage form had previously been used by clinicians, except in Guinea, where it has been specifically introduced for the study. Inclusion in the study was proposed to the families when the children were stabilised. After parental consent, an interview was conducted by the trained nurses already involved in the AIRE project to collect data. Data collection and main outcome All quantitative and qualitative data were collected using a tablet-based electronic case report form (CRF) (SF2) and stored on REDCap® software, with restricted access to guarantee data confidentiality. Any child visiting the hospital more than once during the month of data collection was considered as an independent event. We collected socio-demographic characteristics of children and their caregivers to understand the family context in which children live (financial means available, caregivers' literacy, etc.). Moreover, we collected clinical data that highlighted the reasons why families sought care. The fever described in our study represents the threshold used by clinicians to identify children requiring urgent or priority attention. This criterion is met when the child's temperature exceeds 39.5°C in Burkina Faso and Niger, or 38.5°C in Guinea and Mali. The mid-upper arm circumference (MUAC), using WHO thresholds, estimated the prevalence of severe acute malnutrition (MUAC < 115 mm) and moderate acute malnutrition (MUAC between 115 and 125 mm) ( 14 ). Care pathway since the onset of child’ disease was collected: we asked caregivers whether they had previously visited a traditional practitioner, a pharmacist, a community health worker, a health post, a private health centre, a primary health centre, a maternity ward (neonates), or a hospital. Pharmacist and private health centre regrouped under private care. We recorded the order of visits to the different facilities and the time elapsed since each visit to accurately reconstruct care pathways. Information regarding obstacles to healthcare access and caregivers' perspectives on various health facilities was gathered to comprehend their care pathways. We used the framework of Levesque et al, presenting five dimensions of access to care, each of which has a demand side (patients) and a supply side (care system) ( 15 ). These five dimensions are: 1) Approachability/ability to perceive 2) Acceptability/ability to seek 3) Availability and accommodation/ability to reach 4) Affordability/ability to pay 5) Appropriateness/ability to engage. We asked several questions on each of the five dimensions, using a Likert scale with five possible answers ranging from "strongly disagree" to "strongly agree" ( 16 ). A few open-ended questions were also asked to understand care pathways, and the responses were exploited using a thematic analysis. In West Africa, the healthcare system follows a hierarchical structure known as the health pyramid, which outlines the recommended path for efficiently managing ill children. According to this pyramid, sick children typically begin their care pathway at a primary health centre, either referred by a community health worker or from a health post. If a child's condition is severe, they are then referred to a district hospital. Should additional care be necessary, they may be further referred to a regional, national or, university hospital level. In our study, “recommended" care pathways are those in compliance with this health pyramid. All children who consult other structures, such as pharmacists or traditional practitioners, are considered to be following an alternative pathway. Data analysis Due to the varying contexts in each country regarding health services, the availability of health facilities, and health policies, we will present the outcomes for each country separately. In Niger, where one hospital was in a rural area, and the other in an urban area, the significant differences in pathway choice between these contexts have led to separate analyses. We conducted descriptive analyses of the socio-demographic and clinical characteristics of children by country. We present the mean (standard deviation) and median (interquartile range) for quantitative variables, as well as frequencies and percentages for qualitative variables. A description of the care pathways followed by the children was done using Sankey diagrams ( 17 ). We also described the delay of care according to whether the patient went to the PHC and according to the pathways recommended by the national health system. Spatial analysis produced a link map representing the relationships between the children's village of residence and the hospital. The relationships are also characterized by the average number of steps in a health system before reaching the hospital. This processing was carried out using the QGIS (3.24 Tisler version) geographic information system (GIS) and the thematic cartography tools for processing extension to draw the links connecting the locations. To determine the barriers and facilitators to access care according to Levesque's framework, we report the percentages of carers who agree or totally agree with the propositions. We used appropriate statistical tests to compare the responses relating to the health centre and the hospital. Percentages were compared using Chi-2 tests or a Fisher exact test if appropriate. The significance level was set at 0.05 and all tests were two-tailed. All analyses were performed using R software, version 4.3.2 ( 18 ). Ethical considerations The four national ethics committees (Burkina Faso n°2022/089/MS/MESRI/CERS, Guinea n°51/CNERS/22, Mali n°2022-068-MSDS-CNESS and Niger n° 038/2022/CNERS), the WHO Ethics Committee (n° ERC.0003788) have approved the protocol. The study has been conducted within the framework of the agreements signed with each hospital. All children were registered with written parental consent and were assigned a unique identifier associated with the data collected to guarantee confidentiality. RESULTS Flowchart and population description Over the study period, 1902 children under 5 years reached one of the seven district hospitals, of whom 1098 (57.7%) were defined as severe cases (Fig. 1 ). Among them, 861 children (78.4%) were included in this study: 175 (20.3%) in Burkina Faso, 79 (9.2%) in Guinea, 82 (9.5%) in Mali, and 525 (61.0%) in Niger (225 children in Dosso and 300 in Niamey). The sociodemographic data of children and caregivers are outlined in Table 1 . Overall, 52.4% of enrolled children were males, and 67.1% were aged between 2 and 59 months (Table 1 ). Mothers were the primary caregivers for the children, accounting for 92.7% in Niamey (Niger) and 68.0% in Burkina Faso. Regarding the education level of caregivers, 66.3% in Burkina Faso, 60.0% in Niger, 54.9% in Mali, and 49.4% in Guinea had no formal school education. Clinically, children primarily presented on admission with respiratory symptoms (28.0%) or dehydration (25.7%) in Burkina Faso, dehydration and circulatory disorders (29.1% and 25.3%, respectively) in Guinea, and nutritional problems in Mali (31.7%). In Niger, 58.7% and 32.9% of children were seen with dehydration in Niamey and Dosso, respectively. Care pathway for severe cases In Burkina Faso, most children (81.1%), sought care initially at a PHC before being admitted to the district hospital (Fig. 2 ). The median duration between the onset of symptoms and the visit to the PHC was estimated at one day (SF 3). Only 3.4% of children went directly to the district hospital. Nearly 20.0% of children mentioned consulting a private structure before visiting the district hospital, including pharmacists, private health centres, or traditional medicine practitioners. Most children (> 70.0%) reported a traveling time of more than 30 minutes to reach the district hospital, and 72.5% reported traveling by private vehicle (motorbike or car) (Table 2 ). In contrast, in Guinea, a greater part of children (57.0%) came directly to the district hospital (Table 2 and Fig. 2 ), mainly on the advice of the head of the family (86.1%). Two-thirds of these children lived within 30 minutes of the district hospital. We observed that 13.9% of children sought consultation at a PHC, with a median delay of 5 days between the onset of symptoms and the PHC visit. At least 30.0% of children also consulted pharmacies (licensed or not), and more than 63% had taken medication before arriving at the hospital. Taxis were the most common means of getting to hospital for consultations (83.5%). In Mali, 51.2% of children consulted first a PHC (Fig. 2 , Table 2 ) with a median delay of 0 days between the onset of symptoms and the PHC visit (SF 3). One-fourth of the children (24.4%) bypassed PHC and went directly to the hospital, with 55.0% of them residing within a 30-minute distance from the hospital. Multiple hospital visits were also observed: 26.8% of the children had already been to the hospital for the same symptoms (Table 2 ). Other healthcare workers were consulted more extensively compared to other countries, notably traditional medicine practitioners (25.6%), community health workers (12.2%), and private healthcare services (12.2%, including pharmacists and private health centres). In Niger, most children sought consultation at PHCs before reaching the district hospital (73.3%). Besides examining care pathways, our selected sites allowed us to explore differences between urban (Niamey) and rural (Dosso) areas. Firstly, a higher proportion of children visited PHCs in urban areas compared to rural areas (81.3% vs. 62.7%, p-value < 0.001) (Fig. 2 and Table 2 ). Secondly, the analysis revealed that private healthcare workers (traditional medicine practitioners or private health centres) were more commonly utilized in urban areas than in rural areas (p-value < 0.05). Conversely, the use of community services was more prevalent in rural areas (p-value < 0.01). Lastly, in Niamey, accompanying mothers reported receiving more advice regarding the care pathway compared to Dosso (< 0.001), with the advice primarily coming from healthcare workers. Figure 3 illustrates, for each country, a link between the children's village of residence and the hospital. Each link represents, by its length, the distance to the hospital, and by its thickness, the average number of steps taken in the health system before reaching the hospital. In most countries, the thickest links are as frequent as the thinnest, and there seems to be no link between the thickness of the line and the distance from the hospital. Determinants of care pathways During the interviews, we found that the level of health literacy of families regarding the signs of simple and serious illnesses that they were aware of, varied considerably from one country to another. In Burkina Faso, for example, parents seem much better informed about how to distinguish a serious illness from a simple one. We also found that the power of the decision to seek care for a child depended very much on their father or the head of household. In Mali, for example, only 31.7% of the mothers could decide alone to bring their child to a health facility, compared to 92.6% for fathers. In Burkina Faso, Guinea, and Niger-Dosso, caregivers tended to visit PHC more for mild illnesses over severe ones (SF 4). Mali and Niger-Niamey show no significant difference. Seeking directly hospital increased for serious illnesses in all countries, but the extent varies. In Burkina Faso, there was a notable disparity, with only 5% visiting hospitals for simple illnesses versus 96% for severe ones. In Guinea, most parents were likely to go to the hospital regardless of the illness severity (84% for simple and 100% for severe). In Mali, many opted for traditional practitioners (29%), or community health workers (23%) for simple issues, but primarily used PHC for severe conditions (66%), with a high resort to hospitals in the end (95%). In Niger's Niamey, PHC were popular for both simple and severe illnesses, with less use of hospitals for serious cases than in other health districts (74%). In Dosso, caregivers primarily used PHC for mild illnesses (96%), rarely hospitals (3%), and sometimes health posts (12%). For severe illnesses, they were least likely to use PHCs (32%) compared to other districts. Levesque's framework enabled us to analyse the various dimensions of access to care for the different health structures and to compare caregivers’ perceptions of access between the PHC and the hospital (Table 3 ). Regarding the first dimension, respondents in Guinea expressed more confidence in hospitals than in PHC regarding improving their child's health (20% vs. 100%, p-value < 0.001). Across all countries, hospitals are preferred for serious illnesses (it’s particularly the case in Guinea where only 3% in PHC were confident that the care provided will improve their child's health if they are severely ill, vs 98% for the hospital, p-value < 0.001) and perceived to better meet health needs. According to the second dimension, few cultural or social barriers (discrimination, relationship problems, etc.) or barriers related to the acceptability of healthcare services were reported overall, but when differences between PHC and hospitals existed, hospitals were favoured. For dimension three, while PHCs were considered more accessible geographically (for example, 91% found the PHC easy to access from home vs. 39% for the hospital in Niamey, p-value < 0.001), hospitals were perceived to have better staff availability and opening hours in Mali and Niger. Except in Burkina Faso and in Guinea's hospital, waiting times for care are quite short. According to the respondents, medicines were perceived to be more available in hospitals, but, in dimension four, care was considered more affordable at PHC facilities, except in Mali where it was roughly equivalent. This was particularly the case in Guinea, where caregivers were much less able to pay for healthcare costs in the hospital than in the PHC (87 vs. 12, p-value < 0.001). At the PHC, opportunity costs (travel time and impact on daily activities) were also considered to be lower than at hospitals in all countries. Finally, for dimension five, overall satisfaction and perceived quality of care favoured hospitals across all countries. Communication with health workers was generally good, with no significant differences between PHC and hospitals, except in Niger, where it seemed to be slightly better in hospitals. DISCUSSION To our knowledge, our study is the first to analyse care pathways for critically unwell under-5 children in four West African countries with diverse contexts. We examined including a spatial analysis the care pathways of 861 critically ill children admitted to district hospitals with the recommended public pathways. This study illustrates the wide range of care pathways that families follow before arriving at the district hospital. These are mostly a combination of structures recommended by the public health system (health post, PHC, and then district hospital) and parallel care (traditional practitioner, private health centre, pharmacist...). In Burkina Faso and Niger, going to a PHC before going to hospital seems to be respected, in contrast to Guinea, where only 15% of children seeked a PHC before going to hospital. In addition, traditional healers are an important step in the healthcare pathway in Mali. On the other hand, private facilities, such as pharmacies or private clinics are consulted more in Guinea than in other countries. In Niger, we also observe different consultation practices between the urban environment of Niamey and the rural environment of Dosso, mainly due to the different care services available. Levesque's framework provided a solid conceptual basis for developing our data collection tools and analysing barriers to access to healthcare. Factors such as the availability of facilities, care services, geographical distance, affordability, and the child's clinical data were carefully studied. Results have enabled us to better understand how parents make decisions about specific care pathways. We will discuss the primary determinants of the identified care pathways and seek to explain them. The different care pathways followed by the families in this study can be explained by many factors, such as the contexts in which children's illnesses are managed and the services available in each country, the barriers to accessing care… Burkina Faso and Niger are the two countries with the highest proportions of direct pathways to PHC. These findings are supported by a 2021 study in Burkina Faso, where more than 80% of respondents who were ill in the 15 days before the survey reported visiting PHC, and similar patterns were also observed in Niger ( 19 , 20 ). In contrast to Guinea and Mali, since 2006 in Niger and 2016 in Burkina Faso, the respective governments have implemented free health care programs for children under five and pregnant women in order to promote access to care and usage of health services ( 9 , 21 ). By improving financial accessibility, these reforms encourage families to visit health centres, particularly the PHC where most procedures are free of charge, and to seek care earlier. In Guinea and Mali, where the free policy is only partial for specific diseases (HIV, tuberculosis, malaria, malnutrition), consulting at alternative structures (such as traditional medicine practitioners/pharmacists/drug vendors) may be less costly. In West Africa, several studies have demonstrated the benefits of these policies in increasing the use of health services for children ( 21 – 24 ). However, the financial barrier still plays a discriminatory role, despite the total or partial exemption policies implemented in each country. Its impact on care pathways can be manifold. Limited finances may prompt families to bypass intermediary structures and head directly to hospitals, particularly when distances are shorter, to minimize costs and steps. In addition, even though some treatments are free at the PHC level, frequent drug shortages still force families to spend significant amounts of money at private pharmacies. In Niger, only 52% of essential child health medicines are available and not expired in healthcare facilities nationally in November 2019 ( 25 ). Hospital fees, which are typically higher than primary level fees, may deter some people from using hospital facilities. Research conducted in Zimbabwe by Zeng et al. suggests that wealthier households tend to use hospitals more often, while others often use primary facilities ( 26 ). The cost of care, influenced by exemption policies and additional expenses incurred by families (such as indirect costs and multiple charges from visits to various healthcare facilities), also documented in the AIRE project, significantly impacts care pathways in diverse ways ( 27 ). While the cost of care is a crucial factor in access, it does not solely account for the utilization of various healthcare facilities. Numerous non-financial barriers also play a significant role. The observed variations in care pathways can be attributed to differences in the availability of healthcare services depending on the context. A study of care-seeking behaviour for pneumonia in six high-mortality countries shows considerable variation in care pathways between the countries studied ( 28 ). In addition to national disparities, there are intranational disparities, particularly between urban areas, which have a wider range of nearby health services, and remote rural areas. In urban areas, such as the city of Télimélé in Guinea or the Niamey district in Niger, there is a higher use of private facilities such as pharmacies and private PHCs. Conversely, in rural areas such as the Dosso (Niger), health posts and community health workers play a key role in improving access to care for isolated populations ( 29 ). We also note that traditional medicine is sometimes viewed as the sole healthcare option for households with limited access to modern medical services. This is particularly evident among families residing in rural areas of Mali in our study but similar trends were also observed in Burkina Faso and Sierra Leone ( 30 – 34 ). Other factors, such as the perceived severity of the condition, influence decisions about care pathways. Despite recommended pathways, parents choose facilities based on their perception of their child's condition. In all countries, they indicate a preference for direct hospital attendance in severe cases. This highlights the challenge of recognising the severity of illness, which may delay care or change care pathways. These findings are supported by the systematic review carried out by Geldsetzeret et al, in 2014, which showed that the recognition of diarrhoea, malaria, and pneumonia by families is generally poor ( 33 ). Our study also revealed variations in knowledge levels regarding illness severity across different countries, notably high levels in Burkina Faso, suggesting successful community health initiatives in recent years. However, according to the literature, the link between education level and care pathway adherence appears unclear ( 20 ). Geographical access is also a key factor in the choice of pathway. In Burkina Faso, for example, the 2018 SARA survey showed that the average theoretical distance travelled by the population to reach a basic healthcare facility was 1.6 km in the central region where the capital is located, compared to 6.4 km in the Boucle du Mouhoun, where our study was conducted ( 35 ). In Guinea, about two-thirds of families living within 30 minutes of the hospital chose to go directly to the hospital instead of using nearby PHCs. This preference for direct hospital visits, despite the availability of local PHCs, mirrors findings from other contexts such as Nigeria and Sierra Leone ( 34 , 36 ). We also observed that in all districts except the urban district of Niamey, approximately one-third of families reported traveling more than an hour to reach the hospital. Given the situation of the districts in terms of geographical access (poor road conditions, few means of transport, etc.) and population distribution, this means that some people are trying to optimise their journeys, while others simply do not have access to certain structures and consult to nearby facilities (Fig. 3 ). The Malian study conducted by Treleaven et al. also highlights the significant impact of distance. Children living less than 2 km from the nearest health centre were twice as likely to consult a qualified provider within 24 hours compared to those living between 2 and 5 km away ( 32 ). Gender dynamics significantly impact access to child healthcare services, with many mothers reliant on their husbands for financial resources and transportation, resulting in limited autonomy in decision-making regarding their children's treatment and care pathways. This phenomenon is extensively documented in the literature ( 36 – 38 ). Finally, another factor is the variation in how each country implements the care pyramid. In Burkina Faso, compliance with the pyramid is enforced by requiring written proof of referral from the primary healthcare centre upon arrival at the hospital. In contrast, the care pyramid may be less familiar in other countries, and non-compliance may not necessarily result in reprimand. Despite barriers to accessing certain facilities, families naturally opt for the solution they believe best suits their child's needs, based on their resources. Across all surveyed countries, families perceive hospitals as providing superior care compared to PHCs. This preference stems from the perceived higher quality of care, trust in institutional capabilities, and better availability of equipment, qualified staff, and treatment options at hospitals. Similar findings from studies in Sierra Leone echo concerns about PHC challenges, including staff shortages, long wait times, medicine shortages, and perceived inadequate care ( 34 ). It is also confirmed by national surveys which show that hospitals are much better supplied in terms of equipment and human resources ( 25 , 35 ). These factors create a trend where families, despite potentially higher costs and longer travel distances, often choose hospital care, aiming to secure optimal outcomes for their children. This highlights the necessity for enhancing primary healthcare facilities to instil trust and ensure that high-quality, accessible care is universally available throughout the healthcare system. In the end, while representations of care pathways are often linear, this is rarely the case. Care pathways are non-linear, with families combining care opportunities for their children as best as they can, depending on the assessment of the type of sickness, the course of the sickness, and their available means to invest in treatment ( 39 ). Thus, they navigate the healthcare system between their capabilities, barriers to accessing care, and their child's condition. Pathways can be concomitant (use of several types of care and treatment at the same time), interrupted (if the child's condition improves or if financial resources are insufficient to go further, for example), and evolving. Our study has several limitations. Initially, we aimed to collect comprehensive data collection to accurately represent care pathways for critically ill children under 5 presenting at hospital. However, the sample's adequacy in representing the region and country is uncertain, as we included only two health districts per country, mainly rural (except in Niger). As the data was collected during a single month of the year, this does not allow us to illustrate the variations in care pathways according to seasonal factors (seasonal pathologies, rainy seasons, etc.). Despite exhaustive data collection efforts, few children may have been missed or data may not have been found despite thorough searches of medical registers. Some of the data, especially clinical information, relied on hospital medical registers, which are contingent on thorough completion by healthcare personnel, a practice that may not always be consistent. Our sample does not represent the situation of all serious cases in the district. As we have already mentioned, there may be many children critically ill censored who have never reached the hospital because of a lack of resources. Also, although the chosen hospitals function as district referral hospitals, sometimes hospitals in neighbouring districts are closer to certain areas on the outskirts. Thus, families facing health problems may prefer to go to these neighbouring hospitals rather than to the district referral hospital. This situation is notable in certain regions of Guinea and Mali. These factors may affect the representativeness of our sample. Finally, certain elements, such as the classification of severe cases, vary slightly between countries in terms of definitions, and remain sensitive to clinician judgment. We utilized Levesque's framework to identify barriers to healthcare access; however, qualitative interviews would have been valuable for further refining our analyses. Analysing longitudinal data (not available here) would enable us to describe the influence of healthcare pathways on disease progression, particularly due to therapeutic missteps (delayed treatment initiation, seeking consultation outside recommended facilities). Moreover, interviewing caregivers at hospital may have influenced their answers due to social desirability bias and concern that their responses might affect their child's care. For example, they may have been reluctant to report frequenting informal structures or to give negative opinions of hospitals. Lastly, interviewing caregivers of seriously ill children potentially affected their mental state and focus, as they were understandably preoccupied with their child's health while awaiting stabilisation. CONCLUSION Our study aimed to explore and assess the factors influencing the care pathways of children aged 0-5 years with severe illness in four West African countries. In countries where free healthcare policies are implemented, most children follow the recommended care pathway by initially seeking care at PHCs before hospital admission. Furthermore, our findings suggest the need for interventions aimed at improving geographical, equitable, and financial accessibility, as well as enhancing caregivers' trust in healthcare facilities, particularly PHCs. Enhancing the quality of care and reception at PHCs, along with improving perceptions of these facilities, can encourage families to seek care closer to home, and at an earlier stage, thereby reducing the burden of childhood illnesses. Declarations ACKNOWLEDGMENTS We would like to thank all the children and their families who took part in the study, as well as the healthcare staff at the study hospitals. We also would like to thank the field project team, the AIRE Research Study Group, the Ministries of Health of the four countries for their support, and UNITAID for funding the AIRE project. Contributors: EG, SL, VL, LPB, conceptualised the study design,with contributions from BM, DK, AS, JSK, GBH and VR. EG, SL, LPB, GBH, BM, DK, AS and JSK conducted training, data collection and management. EG and SL with contributions from ZZ conducted the data analysis. EB conducted geographical analysis. EG and SL wrote the first draft of this article. All authors were involved in data interpretation and review of the final manuscript. VL is the guarantor. Funding: The ITINER’AIRE Study is part of the AIRE project, funded by UNITAID, with in-kind support from Inserm and the French National Research Institute for Sustainable Development (IRD). UNITAID was not involved in the design of the study, the collection, analysis and interpretation of the data, nor in the writing of the manuscript. ITINER’AIRE study was conducted with no additional cost. AIRE Research Study Group is composed as follows: Country investigators: Burkina Faso: S. Yugbaré Ouédraogo (PI), V. M. Sanon Zombré (CoPI), Guinea: M. Sama Cherif (CoPI), I. S. Diallo (CoPI), D. F. Kaba, (PI). Mali: A. A. Diakité (PI), A. Sidibé, (CoPI).Niger: H. Abarry Souleymane (CoPI), F. T. Issagana Dikouma (PI). Research coordinators & data centers: CERPOP, Inserm, Toulouse 3 University, France: H. Agbeci (Int Health Economist), L. Catala (Research associate), D. L. Dahourou (Research associate), S. Desmonde (Research associate), E.Gres (PhD Student), G. B. Hedible (Int research project manager), V. Leroy (Research coordinator), L. Peters Bokol (Int clinical research monitor), J. Tavarez (Research project assistant), Z. Zair (Statistician). CEPED, IRD, Paris, France: S. Louart (process manager), V. Ridde (process coordination). Inserm U1137, Paris, France : A. Cousien (Research associate). Inserm U1219, EMR271 IRD, Bordeaux University, France : R. Becquet (Research associate), V.Briand (Research associate), V. Journot (Research associate). PACCI, CHU Treichville, Abidjan, Côte d’Ivoire : S. Lenaud (Int data manager), B. Seri (Supervisor IT), C. Yao (data manager supervisor). Consortium NGOs partners: Alima-HQ (consortium lead), Dakar, Sénégal: G. Anago (Int Monitoring Evaluation Accountability And Learning Officer), D. Badiane (Supply chain manager), M. Kinda (Director), D. Neboua (Medical officer), P. S. Dia (Supply chainmanager), S. Shepherd (referent NGO), N. di Mauro (Operations support officer), G. Noël (Knowledge broker), K. Nyoka (Communication and advocacy officer), W. Taokreo (Finance manager), O. B. Coulidiati Lompo (Finance manager), M. Vignon (Project Manager). Alima, Conakry, Guinea: P. Aba (clinical supervisor), N. Diallo (clinical supervisor), M. Ngaradoum (Medical Team Leader), S. Léno (data collector), A. T. Sow (data collector), A. Baldé (data collector), A. Soumah (data collector), B. Baldé (data collector), F. Bah (data collector), K. C. Millimouno (data collector), M. Haba (data collector), M. Bah (data collector), M. Soumah (data collector), M. Guilavogui (data collector), M. N. Sylla (data collector), S. Diallo (data collector), S. F. Dounfangadouno (data collector), T. I. Bah (data collector), S. Sani (data collector), C. Gnongoue (Monitoring Evaluation Accountability And Learning Officer), S. Gaye (Monitoring Evaluation Accountability And Learning Officer), J. P. Y. Guilavogui (Clinical Research Assistant), A. O. Touré (Country health economist), J. S. Kolié (Country clinical research monitor), A. S. Savadogo (country project manager). Alima, Bamako, Mali: F. Sangala (Medical Team Leader), M. Traore (Clinical supervisor), T. Konare (Clinical supervisor), A.Coulibaly (Country health economist), A. Keita (data collector), D. Diarra (data collector), H. Traoré (data collector), I.Sangaré (data collector), I. Koné (data collector), M. Traoré (data collector), S. Diarra (data collector), V. Opoue (Monitoring Evaluation Accountability And Learning Officer), F. K. Keita (medical coordinator), M. Dougabka (Clinical research assistant then Monitoring Evaluation Accountability And Learning Officer), B. Dembélé (data collector then Clinical research assistant), M. S. Doumbia (country health economist), G. D. Kargougou (country clinical research monitor), S. Keita (country project manager). Solthis-HQ, Paris: S. Bouille (NGO referent), S. Calmettes (NGO referent), F. Lamontagne (NGO referent). Solthis, Niamey: K. H. Harouna (clinical supervisor), B. Moutari (clinical supervisor), I. Issaka (clinical supervisor), S. O. Assoumane (clinical supervisor), S. Dioiri (Medical Team Leader), M. Sidi (data collector), K. Sani Alio (Country supply chain officer), S. Amina (data collector), R. Agbokou (Clinical research assistant), M. G. Hamidou (Clinical Research Assistant), S. M. Sani (Country health economist), A. Mahamane, Aboubacar Abdou (data collector), B. Ousmane (data collector), I Kabirou (data collector), I. Mahaman (data collector), I Mamoudou (data collector), M. Baguido (data collector), R. Abdoul (data collector), A. Sahabi (data collector), F. Seini (data collector), Z. Hamani (data collector), L-Y B Meda (Country clinical research monitor), Mactar Niome (country project manager), X. Toviho (Monitoring Evaluation Accountability And Learning Officer), I. Sanouna (Monitoring Evaluation Accountability And Learning Officer), P. Kouam (program officer). Roubanatou Abdoulaye-Mamadou (director Solthis, Niger) Terre des hommes-HQ, Lausanne: S. Busière (NGO referent), F. Triclin (NGO referent). Terre des hommes, BF: A. Hema (country project manager), M. Bayala (IeDA IT), L. Tapsoba (Monitoring Evaluation Accountability And Learning Officer), J. B. Yaro (Clinical reearch assistant), S. Sougue (Clinical reearch assistant), R. Bakyono (Country health economist), A. G. Sawadogo (Country clinical research monitor), A. Soumah (data collector), Y. A. Lompo (data collector), B. Malgoubri (data collector), F. Douamba (data collector), G. Sore (data collector), L. Wangraoua (data collector), S. Yamponi (data collector), S. I. Bayala (data collector), S. Tiegna (data collector), S. Kam (data collector), S. Yoda (data collector), M. Karantao (data collector), D. F. Barry (Clinical supervisor), O. Sanou (clinical supervisor), N.Nacoulma (Medical Team Leader), N. Semde (clinical supervisor), I. Ouattara (Clinical supervisor), F. Wango (clinical supervisor), Z. Gneissien (clinical supervisor), H. Congo (clinical supervisor). Terre des hommes, Mali: Y. Diarra (clinical supervisor), B. Ouattara (clinical supervisor), A. Maiga (data collector), F. Diabate (data collector), O. Goita (data collector), S. Gana (data collector), S. Diallo (data collector), S. Sylla (data collector), D. Coulibaly (Tdh project manager), N. Sakho (NGO referent). Country SHS team: Burkina Faso: K. Kadio (consultant and research associate), J. Yougbaré (data collector), D. Zongo (data collector), S. Tougouma (data collector), A. Dicko (data collector), Z. Nanema (data collector), I. Balima (data collector), A. Ouedraogo (data collector), A. Ouattara (data collector), S. E. Coulibaly (data collector). Guinea: H. Baldé (consultant and research associate), L. Barry (data collector), E. Duparc Haba (data collector). Mali: A. Coulibaly (consultant and research associate), T. Sidibe (data collector), Y. Sangare (data collector), B. Traore (data collector), Y. Diarra (data collector). Niger: A. E. Dagobi (consultant and research associate), S. Salifou (data collector), B. Gana Moustapha Chétima (data collector), I. H. Abdou (data collector). Competing interest: All authors have declared no conflict of interest. Ethics approval and consent to participate: The four national ethics committees (Burkina Faso n°2022/089/MS/MESRI/CERS, Guinea n°51/CNERS/22, Mali n°2022-068-MSDS-CNESS and Niger n° 038/2022/CNERS), the WHO Ethics Committee (n° ERC.0003788) have approved the protocol. The study has been conducted within the framework of the agreements signed with each hospital. All children were registered with written parental consent and were assigned a unique identifier associated with the data collected to guarantee confidentiality. Data Availability Statement: The datasets generated and analysed during the current study are not publicly available. Access to processed deidentified participant data will be made available to any third Party after the publication of the main AIRE results stated in the Pan African Clinical Trial Registry Study statement (PACTR202206525204526, registered on 06/15/2022), upon a motivated request (concept sheet), and after the written consent of the AIRE research coordinator (Valeriane Leroy, [email protected] , Inserm U1295 Toulouse, France, orcid.org/0000-0003-3542-8616) obtained after the approval of the AIRE publication committee, if still active. References UNICEF, Organisation Mondiale de la Santé (OMS), Groupe de la banque mondiale, Nations Unies. Levels and trends in child mortality - Report 2020 [Internet]. 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Minitère de la santé, Secrétariat général, Direction générale des études et des statistiques sectorielles. Enquête nationale sur la disponibilité, la capacité opérationnelle et la qualité des soins dans les services de santé au Burkina Faso (SARA - 2018). 2018; Dougherty L, Gilroy K, Olayemi A, Ogesanmola O, Ogaga F, Nweze C, et al. Understanding factors influencing care seeking for sick children in Ebonyi and Kogi States, Nigeria. BMC Public Health. 2020 May 24;20(1):746. Akinyemi JO, Banda P, De Wet N, Akosile AE, Odimegwu CO. Household relationships and healthcare seeking behaviour for common childhood illnesses in sub-Saharan Africa: a cross-national mixed effects analysis. BMC Health Serv Res. 2019 May 14;19(1):308. James PB, Gyasi RM, Kasilo OMJ, Wardle J, Bah AJ, Yendewa GA, et al. The use of traditional medicine practitioner services for childhood illnesses among childbearing women: a multilevel analysis of demographic and health surveys in 32 sub-Saharan African countries. BMC Complement Med Ther. 2023 Apr 29;23(1):137. Østergaard LR, Bjertrup PJ, Samuelsen H. “Children get sick all the time”: A qualitative study of socio-cultural and health system factors contributing to recurrent child illnesses in rural Burkina Faso. BMC Public Health. 2016 May 10;16(1):384. Tables Tables 1 to 3 are available in the Supplementary Files section Additional Declarations No competing interests reported. Supplementary Files 20240628ITINERAIRESF.docx SUPPLEMMENTARY DATA Supplementary file 1: Main characteristics of the district hospitals Supplementary file 2: ITINER'AIRE survey 2022 Supplementary file 3: Time (in days) between first symptoms and arrival at the hospital according to visit or not to a PHC (A) and according to the recommendations of the healthcare system (B) (N = 861). Supplementary file 4: Structures visited by children according to whether the illness is perceived by parents as simple or severe (N = 861) Tables.docx Cite Share Download PDF Status: Published Journal Publication published 13 Nov, 2025 Read the published version in BMC Public Health → Version 1 posted Editorial decision: Revision requested 08 Jul, 2024 Editor assigned by journal 08 Jul, 2024 Submission checks completed at journal 06 Jul, 2024 First submitted to journal 05 Jul, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4693196","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":324168499,"identity":"d6d47aae-b91f-4e41-91fc-99f1d3f1737a","order_by":0,"name":"Emelyne GRES","email":"data:image/png;base64,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","orcid":"","institution":"BPH, UMR 1219, Inserm-Université de Bordeaux, IRD","correspondingAuthor":true,"prefix":"","firstName":"Emelyne","middleName":"","lastName":"GRES","suffix":""},{"id":324168500,"identity":"7450bfec-df28-46c9-a212-4798a580306e","order_by":1,"name":"Sarah Louart","email":"","orcid":"","institution":"Univ. Lille, CNRS, UMR 8019 - CLERSE - Centre Lillois d’Études et de Recherches Sociologiques et Économiques","correspondingAuthor":false,"prefix":"","firstName":"Sarah","middleName":"","lastName":"Louart","suffix":""},{"id":324168501,"identity":"a615dcdc-6f32-421a-9a2d-24fbcf7bbab2","order_by":2,"name":"Bertrand Méda","email":"","orcid":"","institution":"Solthis","correspondingAuthor":false,"prefix":"","firstName":"Bertrand","middleName":"","lastName":"Méda","suffix":""},{"id":324168502,"identity":"9b0457bb-4d7f-44a4-ad43-06821c95025a","order_by":3,"name":"Lucie Peters-Bokol","email":"","orcid":"","institution":"CERPOP, UMR 1295, Inserm, University of Toulouse 3","correspondingAuthor":false,"prefix":"","firstName":"Lucie","middleName":"","lastName":"Peters-Bokol","suffix":""},{"id":324168503,"identity":"1aa4b872-da26-4105-a758-8a4dffe4181c","order_by":4,"name":"Désiré Kargougou G","email":"","orcid":"","institution":"ALIMA","correspondingAuthor":false,"prefix":"","firstName":"Désiré","middleName":"Kargougou","lastName":"G","suffix":""},{"id":324168504,"identity":"31bdbd04-c50c-4604-858d-3bc2831a8a7c","order_by":5,"name":"Gildas Boris Hedible","email":"","orcid":"","institution":"CERPOP, UMR 1295, Inserm, University of Toulouse 3","correspondingAuthor":false,"prefix":"","firstName":"Gildas","middleName":"Boris","lastName":"Hedible","suffix":""},{"id":324168505,"identity":"4e9855d4-3528-4c2f-a877-919ff925c48c","order_by":6,"name":"Abdoul Guaniyi Sawadogo","email":"","orcid":"","institution":"Terre des Hommes","correspondingAuthor":false,"prefix":"","firstName":"Abdoul","middleName":"Guaniyi","lastName":"Sawadogo","suffix":""},{"id":324168506,"identity":"62a42276-0501-4bbc-a12a-74fcd43c670d","order_by":7,"name":"Zineb Zair","email":"","orcid":"","institution":"CERPOP, UMR 1295, Inserm, University of Toulouse 3","correspondingAuthor":false,"prefix":"","firstName":"Zineb","middleName":"","lastName":"Zair","suffix":""},{"id":324168507,"identity":"b4f36edb-720b-447d-be6e-4eca4fdfd933","order_by":8,"name":"Jacques Séraphin Kolié","email":"","orcid":"","institution":"ALIMA","correspondingAuthor":false,"prefix":"","firstName":"Jacques","middleName":"Séraphin","lastName":"Kolié","suffix":""},{"id":324168508,"identity":"20d00160-35f1-4204-b246-95caeff870c0","order_by":9,"name":"Emmanuel Bonnet","email":"","orcid":"","institution":"UMR 215 PRODIG, IRD, CNRS, Université Paris 1 Panthéon-Sorbonne","correspondingAuthor":false,"prefix":"","firstName":"Emmanuel","middleName":"","lastName":"Bonnet","suffix":""},{"id":324168509,"identity":"e568f151-55bc-4571-9001-7bfc030b3d5d","order_by":10,"name":"Valéry Ridde","email":"","orcid":"","institution":"Université Paris Cité, IRD, Inserm","correspondingAuthor":false,"prefix":"","firstName":"Valéry","middleName":"","lastName":"Ridde","suffix":""},{"id":324168510,"identity":"385fc31c-a34e-4160-8ae8-b401523d8dd4","order_by":11,"name":"Valériane Leroy","email":"","orcid":"","institution":"CERPOP, UMR 1295, Inserm, University of Toulouse 3","correspondingAuthor":false,"prefix":"","firstName":"Valériane","middleName":"","lastName":"Leroy","suffix":""}],"badges":[],"createdAt":"2024-07-05 15:21:58","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4693196/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4693196/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12889-025-24835-1","type":"published","date":"2025-11-13T15:57:43+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":61346494,"identity":"4d0c63b9-dea3-44f3-bc51-418eb6e2092c","added_by":"auto","created_at":"2024-07-29 18:08:24","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":66743,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eFlow chart of the ITINER’AIRE Study (Burkina Faso, Guinea, Mali, and Niger) (N = 861)\u003c/em\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4693196/v1/14896e4a51ef89077feff000.png"},{"id":61346498,"identity":"2ef30f7e-6b68-4c21-bfc7-6f6973fbf417","added_by":"auto","created_at":"2024-07-29 18:08:24","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":140545,"visible":true,"origin":"","legend":"\u003cp\u003eSankey diagram illustrating the care pathways from domicile to the district hospital (N = 861). Legend: PC: Private care (pharmacist and private health centre), TMP: Traditional Medicine Practitioner, PHC: Primary Health Centre, CC: Community Care (community agent or health post). The numbers associated with the facilities have no meaning, solely for the construction of the graph. The \"green\" pathways align with the health system's recommendations.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4693196/v1/b1ae3a7546f1910bc8aeced5.png"},{"id":61346497,"identity":"91a62852-22de-4136-8c0d-b5f89257ae11","added_by":"auto","created_at":"2024-07-29 18:08:24","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1167738,"visible":true,"origin":"","legend":"\u003cp\u003eGeographic illustration of the origin of the patients and the average number of interactions with healthcare services.\u003c/p\u003e\n\u003cp\u003eMade by children from each village before reaching the district hospital. The thickness of the lines indicates the number of steps taken. (ITINER'AIRE study, 2022; N = 861).\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-4693196/v1/b97f754857f76583fa3e75ae.png"},{"id":96105326,"identity":"442db0ea-e397-4b23-85c6-702c4a240b28","added_by":"auto","created_at":"2025-11-17 16:11:09","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1943112,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4693196/v1/7196c760-592a-41b8-ac3c-719a49cf8173.pdf"},{"id":61346499,"identity":"53d53906-fe45-40d8-975d-e4971051aeab","added_by":"auto","created_at":"2024-07-29 18:08:24","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":211509,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSUPPLEMMENTARY DATA\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSupplementary file 1: Main characteristics of the district hospitals\u003c/p\u003e\n\u003cp\u003eSupplementary file 2: ITINER'AIRE survey 2022\u003c/p\u003e\n\u003cp\u003eSupplementary file 3: Time (in days) between first symptoms and arrival at the hospital according to visit or not to a PHC (A) and according to the recommendations of the healthcare system (B) (N = 861).\u003c/p\u003e\n\u003cp\u003eSupplementary file 4: Structures visited by children according to whether the illness is perceived by parents as simple or severe (N = 861)\u003c/p\u003e","description":"","filename":"20240628ITINERAIRESF.docx","url":"https://assets-eu.researchsquare.com/files/rs-4693196/v1/84f137e8ede2e14e7468e8ee.docx"},{"id":61346495,"identity":"74a19e18-0209-4128-8913-e764e0de2a48","added_by":"auto","created_at":"2024-07-29 18:08:24","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":57628,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-4693196/v1/85c0dc6f077ee4e242f61e78.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Care pathways for critically ill children aged 0-5 years arriving at district hospitals in Burkina Faso, Guinea, Mali, and Niger (2022): a cross-sectional study.","fulltext":[{"header":"What is already known on this topic","content":"\u003cul\u003e\n \u003cli\u003eIn West Africa, public health services are planned hierarchically: sick children are expected to attend first the first level of primary health care before being referred to upper levels, if necessary...\u003c/li\u003e\n \u003cli\u003eThe health system in this part of the world generally consists of a combination of public and private care, alongside a traditional system that includes traditional medicine and alternative practitioners.\u003c/li\u003e\n \u003cli\u003eAccess to appropriate care for children under the age of five is often not guaranteed due to several barriers (transport, cost, quality of care, etc).\u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eWhat this study adds:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eThere has been relatively little research exploring how barriers to access to care differ between facilities and influence care pathways.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eThis study illustrates the diversity of family care pathways in four West African countries with different health policies and varying barriers to care.\u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eHow this study might affect research, practice, or policy:\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eUnderstanding the behaviour of families when seeking care makes it possible to act on the main obstacles to access to care\u003c/li\u003e\n \u003cli\u003eFree-of-charge healthcare policies appear to significantly impact on access to health centres and the use of recommended pathways. It is therefore important to maintain and ensure these policies where they exist, and to extend them where they do not yet exist.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eIt is also crucial to improve the quality of primary care, which is more accessible and less expensive, but in which parents have much less confidence in improving their children\u0026apos;s care\u003c/p\u003e"},{"header":"INTRODUCTION","content":"\u003cp\u003eUnder-five mortality remains high in West Africa, despite significant progress over the past thirty years. In 2018, three West African countries had some of the highest child mortality rates worldwide, above 100 per 1000 live births: Nigeria, Mali, and Sierra Leone (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). The main causes of these deaths are pneumonia, complications of preterm birth, childbirth-related events, diarrhoea, and malaria (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). These causes are exacerbated by malnutrition, which affected nearly 6.9% of children under 5 in West Africa by 2020 (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Most of these causes are treatable and preventable. Morbidity and mortality from these diseases could therefore be considerably reduced if families had access to appropriate health prevention and care. Ensuring children under five have access to appropriate care is crucial for rapid diagnosis, timely and proper treatment, and the prevention of complications. (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTo address these access issues and bring healthcare services closer to the populations, WHO developed the \u0026ldquo;Global Strategy for Health for All by the Year 2000\u0026rdquo; (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Despite the inherent limitations of a pyramidal organizational approach (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), the focus has been on developing primary health care and structuring the public health system accordingly (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Healthcare facilities range from small, decentralised primary healthcare centres (PHCs) to intermediate structures, such as district hospitals or regional hospitals, then national reference hospitals where specialised, highly technical care is provided (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). The various structures are linked by a referral system organized according to the severity of the illness and the care capacities of the healthcare facilities. The private sector (e.g. approved or unapproved pharmacies, and private clinics) and traditional care complete the picture of the health system.\u003c/p\u003e \u003cp\u003eDespite these efforts to bring healthcare closer to the population, many accessibility problems remain highly impacting vulnerable populations, such as children. Several health reforms, in particular the introduction of free health care, aim to increase families' access to healthcare (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). However, there is limited information on how families navigate the health system, including the care pathways they use before hospitalization\u0026mdash;whether they adhere to the recommended route from community or primary care to hospitals, or choose alternatives pathways. Families' perceptions of PHC, their reasons for choosing specific health services for their ill children, and the accessibility issues influencing their decisions of healthcare are key elements to consider.\u003c/p\u003e \u003cp\u003eThis study is part of the AIRE project which aimed to enhance the detection of respiratory distress in children under five by introducing a pulse oximeter (PO) during the Integrated Management of Childhood Illness consultations at PHC (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Early observations revealed a low incidence of severe cases at PHCs with variations across countries, suggesting that families might use alternative care pathways that bypass the PHC (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Thus, this study aims to describe and measure the determinants of the care pathways of children aged 0\u0026ndash;5 years presenting with severe illness at district hospitals in the four countries participating in the AIRE project (Burkina Faso, Guinea, Mali, and Niger).\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and sites\u003c/h2\u003e \u003cp\u003eThe ITINER\u0026rsquo;AIRE study is part of the AIRE research project carried out between 2020 and 2022, in Burkina Faso, Guinea, Mali, and Niger. The AIRE research protocol and details about the study locations have been previously published (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) (SF1). We conducted a descriptive cross-sectional study in seven district hospitals of the AIRE project, two per country, except for Guinea where only one hospital contributed (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eInclusion process\u003c/h2\u003e \u003cp\u003eThe study was implemented over one month (23 May \u0026minus;\u0026thinsp;23 June 2022 in Burkina Faso, Guinea, and Mali, and 13 July \u0026ndash; 12 August 2022 in Niger). All the children aged 0\u0026ndash;5 years presenting at one of the seven district hospitals and classified by clinicians as severe cases were included after written parental consent.\u003c/p\u003e \u003cp\u003eChildren were classified by clinicians at the triage level upon hospital admission (Emergency or Paediatric ward, depending on the country) based on the emergency triage form into three categories: urgent, priority, and ordinary (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). We define as severe cases, children classified as urgent or priority. The triage form had previously been used by clinicians, except in Guinea, where it has been specifically introduced for the study.\u003c/p\u003e \u003cp\u003eInclusion in the study was proposed to the families when the children were stabilised. After parental consent, an interview was conducted by the trained nurses already involved in the AIRE project to collect data.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eData collection and main outcome\u003c/h2\u003e \u003cp\u003eAll quantitative and qualitative data were collected using a tablet-based electronic case report form (CRF) (SF2) and stored on REDCap\u0026reg; software, with restricted access to guarantee data confidentiality. Any child visiting the hospital more than once during the month of data collection was considered as an independent event.\u003c/p\u003e \u003cp\u003e We collected socio-demographic characteristics of children and their caregivers to understand the family context in which children live (financial means available, caregivers' literacy, etc.). Moreover, we collected clinical data that highlighted the reasons why families sought care. The fever described in our study represents the threshold used by clinicians to identify children requiring urgent or priority attention. This criterion is met when the child's temperature exceeds 39.5\u0026deg;C in Burkina Faso and Niger, or 38.5\u0026deg;C in Guinea and Mali. The mid-upper arm circumference (MUAC), using WHO thresholds, estimated the prevalence of severe acute malnutrition (MUAC\u0026thinsp;\u0026lt;\u0026thinsp;115 mm) and moderate acute malnutrition (MUAC between 115 and 125 mm) (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eCare pathway since the onset of child\u0026rsquo; disease was collected: we asked caregivers whether they had previously visited a traditional practitioner, a pharmacist, a community health worker, a health post, a private health centre, a primary health centre, a maternity ward (neonates), or a hospital. Pharmacist and private health centre regrouped under private care. We recorded the order of visits to the different facilities and the time elapsed since each visit to accurately reconstruct care pathways.\u003c/p\u003e \u003cp\u003eInformation regarding obstacles to healthcare access and caregivers' perspectives on various health facilities was gathered to comprehend their care pathways. We used the framework of Levesque et al, presenting five dimensions of access to care, each of which has a demand side (patients) and a supply side (care system) (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). These five dimensions are: 1) Approachability/ability to perceive 2) Acceptability/ability to seek 3) Availability and accommodation/ability to reach 4) Affordability/ability to pay 5) Appropriateness/ability to engage. We asked several questions on each of the five dimensions, using a Likert scale with five possible answers ranging from \"strongly disagree\" to \"strongly agree\" (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). A few open-ended questions were also asked to understand care pathways, and the responses were exploited using a thematic analysis.\u003c/p\u003e \u003cp\u003eIn West Africa, the healthcare system follows a hierarchical structure known as the health pyramid, which outlines the recommended path for efficiently managing ill children. According to this pyramid, sick children typically begin their care pathway at a primary health centre, either referred by a community health worker or from a health post. If a child's condition is severe, they are then referred to a district hospital. Should additional care be necessary, they may be further referred to a regional, national or, university hospital level. In our study, \u0026ldquo;recommended\" care pathways are those in compliance with this health pyramid. All children who consult other structures, such as pharmacists or traditional practitioners, are considered to be following an alternative pathway.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eDue to the varying contexts in each country regarding health services, the availability of health facilities, and health policies, we will present the outcomes for each country separately. In Niger, where one hospital was in a rural area, and the other in an urban area, the significant differences in pathway choice between these contexts have led to separate analyses.\u003c/p\u003e \u003cp\u003eWe conducted descriptive analyses of the socio-demographic and clinical characteristics of children by country. We present the mean (standard deviation) and median (interquartile range) for quantitative variables, as well as frequencies and percentages for qualitative variables. A description of the care pathways followed by the children was done using Sankey diagrams (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). We also described the delay of care according to whether the patient went to the PHC and according to the pathways recommended by the national health system. Spatial analysis produced a link map representing the relationships between the children's village of residence and the hospital. The relationships are also characterized by the average number of steps in a health system before reaching the hospital. This processing was carried out using the QGIS (3.24 Tisler version) geographic information system (GIS) and the thematic cartography tools for processing extension to draw the links connecting the locations.\u003c/p\u003e \u003cp\u003eTo determine the barriers and facilitators to access care according to Levesque's framework, we report the percentages of carers who agree or totally agree with the propositions. We used appropriate statistical tests to compare the responses relating to the health centre and the hospital. Percentages were compared using Chi-2 tests or a Fisher exact test if appropriate. The significance level was set at 0.05 and all tests were two-tailed.\u003c/p\u003e \u003cp\u003eAll analyses were performed using R software, version 4.3.2 (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eEthical considerations\u003c/h2\u003e \u003cp\u003e The four national ethics committees (Burkina Faso n\u0026deg;2022/089/MS/MESRI/CERS, Guinea n\u0026deg;51/CNERS/22, Mali n\u0026deg;2022-068-MSDS-CNESS and Niger n\u0026deg; 038/2022/CNERS), the WHO Ethics Committee (n\u0026deg; ERC.0003788) have approved the protocol. The study has been conducted within the framework of the agreements signed with each hospital. All children were registered with written parental consent and were assigned a unique identifier associated with the data collected to guarantee confidentiality.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eFlowchart and population description\u003c/h2\u003e \u003cp\u003eOver the study period, 1902 children under 5 years reached one of the seven district hospitals, of whom 1098 (57.7%) were defined as severe cases (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Among them, 861 children (78.4%) were included in this study: 175 (20.3%) in Burkina Faso, 79 (9.2%) in Guinea, 82 (9.5%) in Mali, and 525 (61.0%) in Niger (225 children in Dosso and 300 in Niamey).\u003c/p\u003e \u003cp\u003eThe sociodemographic data of children and caregivers are outlined in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Overall, 52.4% of enrolled children were males, and 67.1% were aged between 2 and 59 months (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Mothers were the primary caregivers for the children, accounting for 92.7% in Niamey (Niger) and 68.0% in Burkina Faso. Regarding the education level of caregivers, 66.3% in Burkina Faso, 60.0% in Niger, 54.9% in Mali, and 49.4% in Guinea had no formal school education. Clinically, children primarily presented on admission with respiratory symptoms (28.0%) or dehydration (25.7%) in Burkina Faso, dehydration and circulatory disorders (29.1% and 25.3%, respectively) in Guinea, and nutritional problems in Mali (31.7%). In Niger, 58.7% and 32.9% of children were seen with dehydration in Niamey and Dosso, respectively.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eCare pathway for severe cases\u003c/h2\u003e \u003cp\u003eIn Burkina Faso, most children (81.1%), sought care initially at a PHC before being admitted to the district hospital (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The median duration between the onset of symptoms and the visit to the PHC was estimated at one day (SF 3). Only 3.4% of children went directly to the district hospital. Nearly 20.0% of children mentioned consulting a private structure before visiting the district hospital, including pharmacists, private health centres, or traditional medicine practitioners. Most children (\u0026gt;\u0026thinsp;70.0%) reported a traveling time of more than 30 minutes to reach the district hospital, and 72.5% reported traveling by private vehicle (motorbike or car) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn contrast, in Guinea, a greater part of children (57.0%) came directly to the district hospital (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), mainly on the advice of the head of the family (86.1%). Two-thirds of these children lived within 30 minutes of the district hospital. We observed that 13.9% of children sought consultation at a PHC, with a median delay of 5 days between the onset of symptoms and the PHC visit. At least 30.0% of children also consulted pharmacies (licensed or not), and more than 63% had taken medication before arriving at the hospital. Taxis were the most common means of getting to hospital for consultations (83.5%).\u003c/p\u003e \u003cp\u003eIn Mali, 51.2% of children consulted first a PHC (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) with a median delay of 0 days between the onset of symptoms and the PHC visit (SF 3). One-fourth of the children (24.4%) bypassed PHC and went directly to the hospital, with 55.0% of them residing within a 30-minute distance from the hospital. Multiple hospital visits were also observed: 26.8% of the children had already been to the hospital for the same symptoms (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Other healthcare workers were consulted more extensively compared to other countries, notably traditional medicine practitioners (25.6%), community health workers (12.2%), and private healthcare services (12.2%, including pharmacists and private health centres).\u003c/p\u003e \u003cp\u003eIn Niger, most children sought consultation at PHCs before reaching the district hospital (73.3%). Besides examining care pathways, our selected sites allowed us to explore differences between urban (Niamey) and rural (Dosso) areas. Firstly, a higher proportion of children visited PHCs in urban areas compared to rural areas (81.3% vs. 62.7%, p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Secondly, the analysis revealed that private healthcare workers (traditional medicine practitioners or private health centres) were more commonly utilized in urban areas than in rural areas (p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Conversely, the use of community services was more prevalent in rural areas (p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.01). Lastly, in Niamey, accompanying mothers reported receiving more advice regarding the care pathway compared to Dosso (\u0026lt;\u0026thinsp;0.001), with the advice primarily coming from healthcare workers.\u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e illustrates, for each country, a link between the children's village of residence and the hospital. Each link represents, by its length, the distance to the hospital, and by its thickness, the average number of steps taken in the health system before reaching the hospital. In most countries, the thickest links are as frequent as the thinnest, and there seems to be no link between the thickness of the line and the distance from the hospital.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eDeterminants of care pathways\u003c/h2\u003e \u003cp\u003eDuring the interviews, we found that the level of health literacy of families regarding the signs of simple and serious illnesses that they were aware of, varied considerably from one country to another. In Burkina Faso, for example, parents seem much better informed about how to distinguish a serious illness from a simple one. We also found that the power of the decision to seek care for a child depended very much on their father or the head of household. In Mali, for example, only 31.7% of the mothers could decide alone to bring their child to a health facility, compared to 92.6% for fathers.\u003c/p\u003e \u003cp\u003eIn Burkina Faso, Guinea, and Niger-Dosso, caregivers tended to visit PHC more for mild illnesses over severe ones (SF 4). Mali and Niger-Niamey show no significant difference. Seeking directly hospital increased for serious illnesses in all countries, but the extent varies. In Burkina Faso, there was a notable disparity, with only 5% visiting hospitals for simple illnesses versus 96% for severe ones. In Guinea, most parents were likely to go to the hospital regardless of the illness severity (84% for simple and 100% for severe). In Mali, many opted for traditional practitioners (29%), or community health workers (23%) for simple issues, but primarily used PHC for severe conditions (66%), with a high resort to hospitals in the end (95%). In Niger's Niamey, PHC were popular for both simple and severe illnesses, with less use of hospitals for serious cases than in other health districts (74%). In Dosso, caregivers primarily used PHC for mild illnesses (96%), rarely hospitals (3%), and sometimes health posts (12%). For severe illnesses, they were least likely to use PHCs (32%) compared to other districts.\u003c/p\u003e \u003cp\u003eLevesque's framework enabled us to analyse the various dimensions of access to care for the different health structures and to compare caregivers\u0026rsquo; perceptions of access between the PHC and the hospital (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Regarding the first dimension, respondents in Guinea expressed more confidence in hospitals than in PHC regarding improving their child's health (20% vs. 100%, p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Across all countries, hospitals are preferred for serious illnesses (it\u0026rsquo;s particularly the case in Guinea where only 3% in PHC were confident that the care provided will improve their child's health if they are severely ill, vs 98% for the hospital, p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and perceived to better meet health needs. According to the second dimension, few cultural or social barriers (discrimination, relationship problems, etc.) or barriers related to the acceptability of healthcare services were reported overall, but when differences between PHC and hospitals existed, hospitals were favoured. For dimension three, while PHCs were considered more accessible geographically (for example, 91% found the PHC easy to access from home vs. 39% for the hospital in Niamey, p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.001), hospitals were perceived to have better staff availability and opening hours in Mali and Niger. Except in Burkina Faso and in Guinea's hospital, waiting times for care are quite short. According to the respondents, medicines were perceived to be more available in hospitals, but, in dimension four, care was considered more affordable at PHC facilities, except in Mali where it was roughly equivalent. This was particularly the case in Guinea, where caregivers were much less able to pay for healthcare costs in the hospital than in the PHC (87 vs. 12, p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.001). At the PHC, opportunity costs (travel time and impact on daily activities) were also considered to be lower than at hospitals in all countries. Finally, for dimension five, overall satisfaction and perceived quality of care favoured hospitals across all countries. Communication with health workers was generally good, with no significant differences between PHC and hospitals, except in Niger, where it seemed to be slightly better in hospitals.\u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eTo our knowledge, our study is the first to analyse care pathways for critically unwell under-5 children in four West African countries with diverse contexts. We examined including a spatial analysis the care pathways of 861 critically ill children admitted to district hospitals with the recommended public pathways. This study illustrates the wide range of care pathways that families follow before arriving at the district hospital. These are mostly a combination of structures recommended by the public health system (health post, PHC, and then district hospital) and parallel care (traditional practitioner, private health centre, pharmacist...). In Burkina Faso and Niger, going to a PHC before going to hospital seems to be respected, in contrast to Guinea, where only 15% of children seeked a PHC before going to hospital. In addition, traditional healers are an important step in the healthcare pathway in Mali. On the other hand, private facilities, such as pharmacies or private clinics are consulted more in Guinea than in other countries. In Niger, we also observe different consultation practices between the urban environment of Niamey and the rural environment of Dosso, mainly due to the different care services available.\u003c/p\u003e \u003cp\u003e Levesque's framework provided a solid conceptual basis for developing our data collection tools and analysing barriers to access to healthcare. Factors such as the availability of facilities, care services, geographical distance, affordability, and the child's clinical data were carefully studied. Results have enabled us to better understand how parents make decisions about specific care pathways.\u003c/p\u003e \u003cp\u003eWe will discuss the primary determinants of the identified care pathways and seek to explain them. The different care pathways followed by the families in this study can be explained by many factors, such as the contexts in which children's illnesses are managed and the services available in each country, the barriers to accessing care\u0026hellip;\u003c/p\u003e \u003cp\u003eBurkina Faso and Niger are the two countries with the highest proportions of direct pathways to PHC. These findings are supported by a 2021 study in Burkina Faso, where more than 80% of respondents who were ill in the 15 days before the survey reported visiting PHC, and similar patterns were also observed in Niger (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). In contrast to Guinea and Mali, since 2006 in Niger and 2016 in Burkina Faso, the respective governments have implemented free health care programs for children under five and pregnant women in order to promote access to care and usage of health services (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). By improving financial accessibility, these reforms encourage families to visit health centres, particularly the PHC where most procedures are free of charge, and to seek care earlier. In Guinea and Mali, where the free policy is only partial for specific diseases (HIV, tuberculosis, malaria, malnutrition), consulting at alternative structures (such as traditional medicine practitioners/pharmacists/drug vendors) may be less costly. In West Africa, several studies have demonstrated the benefits of these policies in increasing the use of health services for children (\u003cspan additionalcitationids=\"CR22 CR23\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHowever, the financial barrier still plays a discriminatory role, despite the total or partial exemption policies implemented in each country. Its impact on care pathways can be manifold. Limited finances may prompt families to bypass intermediary structures and head directly to hospitals, particularly when distances are shorter, to minimize costs and steps. In addition, even though some treatments are free at the PHC level, frequent drug shortages still force families to spend significant amounts of money at private pharmacies. In Niger, only 52% of essential child health medicines are available and not expired in healthcare facilities nationally in November 2019 (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Hospital fees, which are typically higher than primary level fees, may deter some people from using hospital facilities. Research conducted in Zimbabwe by Zeng et al. suggests that wealthier households tend to use hospitals more often, while others often use primary facilities (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). The cost of care, influenced by exemption policies and additional expenses incurred by families (such as indirect costs and multiple charges from visits to various healthcare facilities), also documented in the AIRE project, significantly impacts care pathways in diverse ways (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWhile the cost of care is a crucial factor in access, it does not solely account for the utilization of various healthcare facilities. Numerous non-financial barriers also play a significant role.\u003c/p\u003e \u003cp\u003eThe observed variations in care pathways can be attributed to differences in the availability of healthcare services depending on the context. A study of care-seeking behaviour for pneumonia in six high-mortality countries shows considerable variation in care pathways between the countries studied (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). In addition to national disparities, there are intranational disparities, particularly between urban areas, which have a wider range of nearby health services, and remote rural areas. In urban areas, such as the city of T\u0026eacute;lim\u0026eacute;l\u0026eacute; in Guinea or the Niamey district in Niger, there is a higher use of private facilities such as pharmacies and private PHCs. Conversely, in rural areas such as the Dosso (Niger), health posts and community health workers play a key role in improving access to care for isolated populations (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). We also note that traditional medicine is sometimes viewed as the sole healthcare option for households with limited access to modern medical services. This is particularly evident among families residing in rural areas of Mali in our study but similar trends were also observed in Burkina Faso and Sierra Leone (\u003cspan additionalcitationids=\"CR31 CR32 CR33\" citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOther factors, such as the perceived severity of the condition, influence decisions about care pathways. Despite recommended pathways, parents choose facilities based on their perception of their child's condition. In all countries, they indicate a preference for direct hospital attendance in severe cases. This highlights the challenge of recognising the severity of illness, which may delay care or change care pathways. These findings are supported by the systematic review carried out by Geldsetzeret et al, in 2014, which showed that the recognition of diarrhoea, malaria, and pneumonia by families is generally poor (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). Our study also revealed variations in knowledge levels regarding illness severity across different countries, notably high levels in Burkina Faso, suggesting successful community health initiatives in recent years. However, according to the literature, the link between education level and care pathway adherence appears unclear (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eGeographical access is also a key factor in the choice of pathway. In Burkina Faso, for example, the 2018 SARA survey showed that the average theoretical distance travelled by the population to reach a basic healthcare facility was 1.6 km in the central region where the capital is located, compared to 6.4 km in the Boucle du Mouhoun, where our study was conducted (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). In Guinea, about two-thirds of families living within 30 minutes of the hospital chose to go directly to the hospital instead of using nearby PHCs. This preference for direct hospital visits, despite the availability of local PHCs, mirrors findings from other contexts such as Nigeria and Sierra Leone (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). We also observed that in all districts except the urban district of Niamey, approximately one-third of families reported traveling more than an hour to reach the hospital. Given the situation of the districts in terms of geographical access (poor road conditions, few means of transport, etc.) and population distribution, this means that some people are trying to optimise their journeys, while others simply do not have access to certain structures and consult to nearby facilities (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The Malian study conducted by Treleaven et al. also highlights the significant impact of distance. Children living less than 2 km from the nearest health centre were twice as likely to consult a qualified provider within 24 hours compared to those living between 2 and 5 km away (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eGender dynamics significantly impact access to child healthcare services, with many mothers reliant on their husbands for financial resources and transportation, resulting in limited autonomy in decision-making regarding their children's treatment and care pathways. This phenomenon is extensively documented in the literature (\u003cspan additionalcitationids=\"CR37\" citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFinally, another factor is the variation in how each country implements the care pyramid. In Burkina Faso, compliance with the pyramid is enforced by requiring written proof of referral from the primary healthcare centre upon arrival at the hospital. In contrast, the care pyramid may be less familiar in other countries, and non-compliance may not necessarily result in reprimand.\u003c/p\u003e \u003cp\u003eDespite barriers to accessing certain facilities, families naturally opt for the solution they believe best suits their child's needs, based on their resources. Across all surveyed countries, families perceive hospitals as providing superior care compared to PHCs. This preference stems from the perceived higher quality of care, trust in institutional capabilities, and better availability of equipment, qualified staff, and treatment options at hospitals. Similar findings from studies in Sierra Leone echo concerns about PHC challenges, including staff shortages, long wait times, medicine shortages, and perceived inadequate care (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). It is also confirmed by national surveys which show that hospitals are much better supplied in terms of equipment and human resources (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). These factors create a trend where families, despite potentially higher costs and longer travel distances, often choose hospital care, aiming to secure optimal outcomes for their children. This highlights the necessity for enhancing primary healthcare facilities to instil trust and ensure that high-quality, accessible care is universally available throughout the healthcare system.\u003c/p\u003e \u003cp\u003eIn the end, while representations of care pathways are often linear, this is rarely the case. Care pathways are non-linear, with families combining care opportunities for their children as best as they can, depending on the assessment of the type of sickness, the course of the sickness, and their available means to invest in treatment (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). Thus, they navigate the healthcare system between their capabilities, barriers to accessing care, and their child's condition. Pathways can be concomitant (use of several types of care and treatment at the same time), interrupted (if the child's condition improves or if financial resources are insufficient to go further, for example), and evolving.\u003c/p\u003e \u003cp\u003eOur study has several limitations. Initially, we aimed to collect comprehensive data collection to accurately represent care pathways for critically ill children under 5 presenting at hospital. However, the sample's adequacy in representing the region and country is uncertain, as we included only two health districts per country, mainly rural (except in Niger). As the data was collected during a single month of the year, this does not allow us to illustrate the variations in care pathways according to seasonal factors (seasonal pathologies, rainy seasons, etc.). Despite exhaustive data collection efforts, few children may have been missed or data may not have been found despite thorough searches of medical registers. Some of the data, especially clinical information, relied on hospital medical registers, which are contingent on thorough completion by healthcare personnel, a practice that may not always be consistent.\u003c/p\u003e \u003cp\u003eOur sample does not represent the situation of all serious cases in the district. As we have already mentioned, there may be many children critically ill censored who have never reached the hospital because of a lack of resources. Also, although the chosen hospitals function as district referral hospitals, sometimes hospitals in neighbouring districts are closer to certain areas on the outskirts. Thus, families facing health problems may prefer to go to these neighbouring hospitals rather than to the district referral hospital. This situation is notable in certain regions of Guinea and Mali. These factors may affect the representativeness of our sample.\u003c/p\u003e \u003cp\u003eFinally, certain elements, such as the classification of severe cases, vary slightly between countries in terms of definitions, and remain sensitive to clinician judgment. We utilized Levesque's framework to identify barriers to healthcare access; however, qualitative interviews would have been valuable for further refining our analyses. Analysing longitudinal data (not available here) would enable us to describe the influence of healthcare pathways on disease progression, particularly due to therapeutic missteps (delayed treatment initiation, seeking consultation outside recommended facilities). Moreover, interviewing caregivers at hospital may have influenced their answers due to social desirability bias and concern that their responses might affect their child's care. For example, they may have been reluctant to report frequenting informal structures or to give negative opinions of hospitals. Lastly, interviewing caregivers of seriously ill children potentially affected their mental state and focus, as they were understandably preoccupied with their child's health while awaiting stabilisation.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eOur study aimed to explore and assess the factors influencing the care pathways of children aged 0-5 years with severe illness in four West African countries. In countries where free healthcare policies are implemented, most children follow the recommended care pathway by initially seeking care at PHCs before hospital admission. Furthermore, our findings suggest the need for interventions aimed at improving geographical, equitable, and financial accessibility, as well as enhancing caregivers\u0026apos; trust in healthcare facilities, particularly PHCs. Enhancing the quality of care and reception at PHCs, along with improving perceptions of these facilities, can encourage families to seek care closer to home, and at an earlier stage, thereby reducing the burden of childhood illnesses.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eACKNOWLEDGMENTS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank all the children and their families who took part in the study, as well as the healthcare staff at the study hospitals. We also would like to thank the field project team, the AIRE Research Study Group, the Ministries of Health of the four countries for their support, and UNITAID for funding the AIRE project.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eContributors:\u0026nbsp;\u003c/strong\u003eEG, SL, VL, LPB, conceptualised the study design,with contributions from BM, DK, AS, JSK, GBH and VR. \u0026nbsp;EG, SL, LPB, GBH, BM, DK, AS and JSK conducted training, data collection and management. EG and SL with contributions from ZZ conducted the data analysis. EB conducted geographical analysis. EG and SL wrote the first draft of this article. All authors were involved in data interpretation and review of the final manuscript. VL is the guarantor.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e The ITINER’AIRE Study is part of the AIRE project, funded by UNITAID, with in-kind support from Inserm and the French National Research Institute for Sustainable Development (IRD). UNITAID was not involved in the design of the study, the collection, analysis and interpretation of the data, nor in the writing of the manuscript. ITINER’AIRE study was conducted with no additional cost.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAIRE Research Study Group is composed as follows:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCountry investigators: Burkina Faso: S. Yugbaré Ouédraogo (PI), V. M. Sanon Zombré (CoPI), Guinea: M. Sama Cherif (CoPI), I. S. Diallo (CoPI), D. F. Kaba, (PI).\u0026nbsp;Mali: A. A. Diakité (PI), A. Sidibé, (CoPI).Niger: H. Abarry Souleymane (CoPI), F. T. Issagana Dikouma (PI).\u0026nbsp;Research coordinators \u0026amp; data centers: CERPOP, Inserm, Toulouse 3 University, France: H. Agbeci (Int Health Economist), L. Catala (Research associate), D. L. Dahourou (Research associate), S. Desmonde (Research associate), E.Gres (PhD Student), G. B. Hedible (Int research project manager), V. Leroy (Research coordinator), L. Peters Bokol (Int clinical research monitor), J. Tavarez (Research project assistant), Z. Zair (Statistician). CEPED, IRD, Paris, France: S. Louart (process manager), V. Ridde (process coordination). Inserm U1137, Paris, France : A. Cousien (Research associate). Inserm U1219, EMR271 IRD, Bordeaux University, France : R. Becquet (Research associate), V.Briand (Research associate), V. Journot (Research associate). PACCI, CHU Treichville, Abidjan, Côte d’Ivoire : S. Lenaud (Int data manager), B. Seri (Supervisor IT), C. Yao (data manager supervisor). Consortium NGOs partners: Alima-HQ (consortium lead), Dakar, Sénégal: G. Anago (Int Monitoring Evaluation Accountability And Learning Officer), D. Badiane (Supply chain manager), M. Kinda (Director), D. Neboua (Medical officer), P. S. Dia (Supply chainmanager), S. Shepherd (referent NGO), N. di Mauro (Operations support officer), G. Noël (Knowledge broker), K. Nyoka (Communication and advocacy officer), W. Taokreo (Finance manager), O. B. Coulidiati Lompo (Finance manager), M. Vignon (Project Manager). Alima, Conakry, Guinea: P. Aba (clinical supervisor), N. Diallo (clinical supervisor), M. Ngaradoum (Medical Team Leader), S. Léno (data collector), A. T. Sow (data collector), A. Baldé (data collector), A. Soumah (data collector), B. Baldé (data collector), F. Bah (data collector), K. C. Millimouno (data collector), M. Haba (data collector), M. Bah (data collector), M. Soumah (data collector), M. Guilavogui (data collector), M. N. Sylla (data collector), S. Diallo (data collector), S. F. Dounfangadouno (data collector), T. I. Bah (data collector), S. Sani (data collector), C. Gnongoue (Monitoring Evaluation Accountability And Learning Officer), S. Gaye (Monitoring Evaluation Accountability And Learning Officer), J. P. Y. Guilavogui (Clinical Research Assistant), A. O. Touré (Country health economist), J. S. Kolié (Country clinical research monitor), A. S. Savadogo (country project manager). Alima, Bamako, Mali: F. Sangala (Medical Team Leader), M. Traore (Clinical supervisor), T. Konare (Clinical supervisor), A.Coulibaly (Country health economist), A. Keita (data collector), D. Diarra (data collector), H. Traoré (data collector), I.Sangaré (data collector), I. Koné (data collector), M. Traoré (data collector), S. Diarra (data collector), V. Opoue (Monitoring Evaluation Accountability And Learning Officer), F. K. Keita (medical coordinator), M. Dougabka (Clinical research assistant then Monitoring Evaluation Accountability And Learning Officer), B. Dembélé (data collector then Clinical research assistant), M. S. Doumbia (country health economist), G. D. Kargougou (country clinical research monitor), S. Keita (country project manager). Solthis-HQ, Paris: S. Bouille (NGO referent), S. Calmettes (NGO referent), F. Lamontagne (NGO referent). Solthis, Niamey: K. H. Harouna (clinical supervisor), B. Moutari (clinical supervisor), I. Issaka (clinical supervisor), S. O. Assoumane (clinical supervisor), S. Dioiri (Medical Team Leader), M. Sidi (data collector), K. Sani Alio (Country supply chain officer), S. Amina (data collector), R. Agbokou (Clinical research assistant), M. G. Hamidou (Clinical Research Assistant), S. M. Sani (Country health economist), A. Mahamane, Aboubacar Abdou (data collector), B. Ousmane (data collector), I Kabirou (data collector), I. Mahaman (data collector), I Mamoudou (data collector), M. Baguido (data collector), R. Abdoul (data collector), A. Sahabi (data collector), F. Seini (data collector), Z. Hamani (data collector), L-Y B Meda (Country clinical research monitor), Mactar Niome (country project manager), X. Toviho (Monitoring Evaluation Accountability And Learning Officer), I. Sanouna (Monitoring Evaluation Accountability And Learning Officer), P. Kouam (program officer). Roubanatou Abdoulaye-Mamadou (director Solthis, Niger) Terre des hommes-HQ, Lausanne: S. Busière (NGO referent), F. Triclin (NGO referent). Terre des hommes, BF: A. Hema (country project manager), M. Bayala (IeDA IT), L. Tapsoba (Monitoring Evaluation Accountability And Learning Officer), J. B. Yaro (Clinical reearch assistant), S. Sougue (Clinical reearch assistant), R. Bakyono (Country health economist), A. G. Sawadogo (Country clinical research monitor), A. Soumah (data collector), Y. A. Lompo (data collector), B. Malgoubri (data collector), F. Douamba (data collector), G. Sore (data collector), L. Wangraoua (data collector), S. Yamponi (data collector), S. I. Bayala (data collector), S. Tiegna (data collector), S. Kam (data collector), S. Yoda (data collector), M. Karantao (data collector), D. F. Barry (Clinical supervisor), O. Sanou (clinical supervisor), N.Nacoulma (Medical Team Leader), N. Semde (clinical supervisor), I. Ouattara (Clinical supervisor), F. Wango (clinical supervisor), Z. Gneissien (clinical supervisor), H. Congo (clinical supervisor). Terre des hommes, Mali: Y. Diarra (clinical supervisor), B. Ouattara (clinical supervisor), A. Maiga (data collector), F. Diabate (data collector), O. Goita (data collector), S. Gana (data collector), S. Diallo (data collector), S. Sylla (data collector), D. Coulibaly (Tdh project manager), N. Sakho (NGO referent). Country SHS team: Burkina Faso: K. Kadio (consultant and research associate), J. Yougbaré (data collector), D. Zongo (data collector), S. Tougouma (data collector), A. Dicko (data collector), Z. Nanema (data collector), I. Balima (data collector), A. Ouedraogo (data collector), A. Ouattara (data collector), S. E. Coulibaly (data collector). Guinea: H. Baldé (consultant and research associate), L. Barry (data collector), E. Duparc Haba (data collector). Mali: A. Coulibaly (consultant and research associate), T. Sidibe (data collector), Y. Sangare (data collector), B. Traore (data collector), Y. Diarra (data collector). Niger: A. E. Dagobi (consultant and research associate), S. Salifou (data collector), B. Gana Moustapha Chétima (data collector), I. H. Abdou (data\u0026nbsp;collector).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interest:\u003c/strong\u003e All authors have declared no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe four national ethics committees (Burkina\u0026nbsp;Faso\u0026nbsp;n°2022/089/MS/MESRI/CERS, Guinea\u0026nbsp;n°51/CNERS/22, Mali\u0026nbsp;n°2022-068-MSDS-CNESS and Niger\u0026nbsp;n°\u0026nbsp;038/2022/CNERS), the WHO Ethics Committee (n°\u0026nbsp;ERC.0003788) have approved the protocol. The study has been conducted within the framework of the agreements signed with each hospital.\u0026nbsp;All children were registered with written parental consent and were assigned a unique identifier associated with the data collected to guarantee confidentiality.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement:\u0026nbsp;\u003c/strong\u003eThe datasets generated and analysed during the current study are not publicly available. \u0026nbsp;Access to processed deidentified participant data will be made available to any third Party after the publication of the main AIRE results stated in the Pan African Clinical Trial Registry Study statement (PACTR202206525204526, registered on 06/15/2022), upon a motivated request (concept sheet), and after the written consent of the AIRE research coordinator (Valeriane Leroy, [email protected], Inserm U1295 Toulouse, France, orcid.org/0000-0003-3542-8616) obtained after the approval of the AIRE publication committee, if still active.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eUNICEF, Organisation Mondiale de la Sant\u0026eacute; (OMS), Groupe de la banque mondiale, Nations Unies. 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Household roles and care-seeking behaviours in response to severe childhood illness in Mali. J Biosoc Sci. 2013 Nov;45(6):743\u0026ndash;59. \u003c/li\u003e\n\u003cli\u003ePouliot M. Relying on nature\u0026rsquo;s pharmacy in rural Burkina Faso: empirical evidence of the determinants of traditional medicine consumption. Soc Sci Med 1982. 2011 Nov;73(10):1498\u0026ndash;507. \u003c/li\u003e\n\u003cli\u003eTreleaven E, Whidden C, Cole F, Kayentao K, Traor\u0026eacute; MB, Diakit\u0026eacute; D, et al. Relationship between symptoms, barriers to care and healthcare utilisation among children under five in rural Mali. Trop Med Int Health. 2021 Aug;26(8):943\u0026ndash;52. \u003c/li\u003e\n\u003cli\u003eGeldsetzer P, Williams TC, Kirolos A, Mitchell S, Ratcliffe LA, Kohli-Lynch MK, et al. The Recognition of and Care Seeking Behaviour for Childhood Illness in Developing Countries: A Systematic Review. PLOS ONE. 2014 Apr 9;9(4):e93427. \u003c/li\u003e\n\u003cli\u003eScott K, McMahon S, Yumkella F, Diaz T, George A. Navigating multiple options and social relationships in plural health systems: a qualitative study exploring healthcare seeking for sick children in Sierra Leone. Health Policy Plan. 2014 May;29(3):292\u0026ndash;301. \u003c/li\u003e\n\u003cli\u003eMinit\u0026egrave;re de la sant\u0026eacute;, Secr\u0026eacute;tariat g\u0026eacute;n\u0026eacute;ral, Direction g\u0026eacute;n\u0026eacute;rale des \u0026eacute;tudes et des statistiques sectorielles. Enqu\u0026ecirc;te nationale sur la disponibilit\u0026eacute;, la capacit\u0026eacute; op\u0026eacute;rationnelle et la qualit\u0026eacute; des soins dans les services de sant\u0026eacute; au Burkina Faso (SARA - 2018). 2018; \u003c/li\u003e\n\u003cli\u003eDougherty L, Gilroy K, Olayemi A, Ogesanmola O, Ogaga F, Nweze C, et al. Understanding factors influencing care seeking for sick children in Ebonyi and Kogi States, Nigeria. BMC Public Health. 2020 May 24;20(1):746. \u003c/li\u003e\n\u003cli\u003eAkinyemi JO, Banda P, De Wet N, Akosile AE, Odimegwu CO. Household relationships and healthcare seeking behaviour for common childhood illnesses in sub-Saharan Africa: a cross-national mixed effects analysis. BMC Health Serv Res. 2019 May 14;19(1):308. \u003c/li\u003e\n\u003cli\u003eJames PB, Gyasi RM, Kasilo OMJ, Wardle J, Bah AJ, Yendewa GA, et al. The use of traditional medicine practitioner services for childhood illnesses among childbearing women: a multilevel analysis of demographic and health surveys in 32 sub-Saharan African countries. BMC Complement Med Ther. 2023 Apr 29;23(1):137. \u003c/li\u003e\n\u003cli\u003e\u0026Oslash;stergaard LR, Bjertrup PJ, Samuelsen H. \u0026ldquo;Children get sick all the time\u0026rdquo;: A qualitative study of socio-cultural and health system factors contributing to recurrent child illnesses in rural Burkina Faso. BMC Public Health. 2016 May 10;16(1):384. \u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 3 are available in the Supplementary Files section\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Child health, Pathway of care, primary health care, referral to hospital, Burkina Faso, Guinea, Mali, Niger","lastPublishedDoi":"10.21203/rs.3.rs-4693196/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4693196/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cem\u003eBackground\u003c/em\u003e.\u003c/p\u003e\n\u003cp\u003eUnder-five mortality remains high in West Africa, where sick children are expected to first attend the primary health care before being referred to a hospital if necessary. However, little is known about how families navigate between home and higher levels of care to meet their children’s health needs, despite multiple known barriers (including social, financial, and geographical accessibility). We analysed the care pathways of children aged 0-5 years before they presented to the district hospital with a serious illness and the determinants of these care pathways in four West African countries.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eMethods\u003c/em\u003e.\u003c/p\u003e\n\u003cp\u003eFrom May to August 2022, we conducted a cross-sectional study over a one-month data collection in seven district hospitals participating in the AIRE project aimed to introduce pulse oximetry at primary health care level in Burkina Faso, Guinea, Mali, and Niger. All children aged 0-5 years, classified as severe or priority cases by clinicians at referral district hospitals were included after parental consent. Data about care pathways since the onset of their disease were collected from caregivers, and the Levesque framework was used to analyse the accessibility issues.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eResults\u003c/em\u003e.\u003c/p\u003e\n\u003cp\u003eA total of 861 severely ill children were included, with 33% being neonates: 20.3% in Burkina Faso, 9.2% in Guinea, 9.5% in Mali, and 61% in Niger. In Burkina Faso and Niger, most children followed the recommended care pathway and first visited a primary health centre before arriving at the hospital, with 81.1% and 73.3% of children, respectively. However, they were only 51.2% in Mali and 13.9% in Guinea. Using alternative pathways was common, particularly in Guinea, where 30.4% of children first consulted a pharmacist, and Mali, where 25.6% consulted a traditional medicine practitioner. Overall, primary care was perceived to be more geographically accessible and less expensive, but parents were much less convinced that it could improve their child's health compared to hospital care.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConclusion\u003c/em\u003e.\u003c/p\u003e\n\u003cp\u003eThe recommended pathway is largely adhered to, yet parallel pathways require attention, notably in Guinea and Mali. A better understanding of healthcare-seeking behaviours can help remove barriers to care, improving the likelihood that a sick child will receive optimal care.\u003c/p\u003e","manuscriptTitle":"Care pathways for critically ill children aged 0-5 years arriving at district hospitals in Burkina Faso, Guinea, Mali, and Niger (2022): a cross-sectional study.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-29 18:08:19","doi":"10.21203/rs.3.rs-4693196/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-07-08T12:44:14+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-07-08T12:17:25+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-07-06T13:58:12+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2024-07-05T15:20:31+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7f0a5cd7-9855-474c-9b9c-bb2d2f3f5abb","owner":[],"postedDate":"July 29th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-11-17T16:07:39+00:00","versionOfRecord":{"articleIdentity":"rs-4693196","link":"https://doi.org/10.1186/s12889-025-24835-1","journal":{"identity":"bmc-public-health","isVorOnly":false,"title":"BMC Public Health"},"publishedOn":"2025-11-13 15:57:43","publishedOnDateReadable":"November 13th, 2025"},"versionCreatedAt":"2024-07-29 18:08:19","video":"","vorDoi":"10.1186/s12889-025-24835-1","vorDoiUrl":"https://doi.org/10.1186/s12889-025-24835-1","workflowStages":[]},"version":"v1","identity":"rs-4693196","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4693196","identity":"rs-4693196","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}