Parent and Provider Perspectives on Factors Influencing Treatment-Seeking and Recovery After Hospital Discharge Among Undernourished Children Aged 2-23 Months in Bangladesh
Authors: Uddin Md. Fakhar , Molyneux Sassy , Muraya Kui , Jemutai Julie , Berkley James A. , Walson Judd L. , Hossain Md. Alamgir , Islam Md. Aminul , Zakayo Scholastica M. , Njeru Rita Wanjuki , Ahmed Tahmeed , Chisti Mohammod Jobayer , Sarma Haribondhu 
Published: September 2020

Abstract
Background: Post-hospital discharge mortality is high among undernourished children in many low and middle-income countries; often exceeding in-patient mortality rates. Although a number of studies have highlighted a range of potential socio-cultural, economic and health system factors influencing paediatric post-discharge treatment-seeking and recovery, including in Bangladesh, few studies have explored parent and provider perspectives.Methods: As part of a large, multi-country prospective cohort study - the Childhood Acute Illness and Nutrition (CHAIN) Network - we conducted a qualitative study to understand the post-discharge treatment-seeking and recovery experiences of families of undernourished children aged 2-23 months admitted in two icddr,b (International Centre for Diarrhoeal Disease Research, Bangladesh) hospitals. To gather parent perspectives, we gathered in-depth qualitative data from family members of 17 purposively selected undernourished children from a rural and urban hospital. These data were supplemented by observations in hospitals and homes and from health worker interviews. We interviewed family members on discharge and again in their homes after discharge over several visits. Results: 13 of the 17 purposively selected children were reported by family members to have fully recovered by the time we completed our interviews; four had died. Important perceived drivers of treatment-seeking and recovery included advice provided while in hospital, media campaigns on hygiene practice, positive social and financial support from family members, relatives and neighbours, and the availability of free treatment. Key challenges included low household incomes, mothers having to juggle multiple responsibilities in addition to caring for the child, lack of support - and in some cases violence - from the child’s father, and family members’ preference for relatively accessible drug shops, physicians or healers over (re)admission to hospital. For most families, a range of challenges interplayed to contribute to early discharge from hospital against medical advice and to non-adherence to follow-up advice. Providers were primarily concerned about an inappropriately high use of antibiotics among families.Conclusion: Development of interventions that address the range of vulnerabilities that many families face is essential to support post-discharge adherence to medical advice and ensure recovery. These data suggest that potential interventions could include strengthening information giving during hospitalization on what post-discharge care is needed and why, reducing direct and indirect costs associated with hospital visits, engaging fathers and other ‘significant others’ in post-discharge advice, and building mobile phone-based support for follow-up care.