Exploring Household Vulnerabilities and Agency in Healthcare Pathways

All formal interviews were audio-recorded, transcribed verbatim and later translated into English. All notes from the field and post-interview debrief were typed up and reviewed for issues to follow up in later interviews.
We worked as a team to adopt two complementary approaches to analyse the data: a narrative approach [28 (link), 29 (link)] and a thematic coding approach [30 ]. The narrative approach involved the construction of a detailed overall summary for each household, drawing on all available data, and a shorter narrative, or story. We worked with these summaries and stories to explore the overall picture of households’ pathways through care, examining household/community and health service/system influences pre- and post-admission. We investigated changes over time, and patterns of similarity and difference across households, facilitated by the construction of charts (see Table 1 for an excerpt). The thematic coding supplemented and enriched the narrative analysis. All transcriptions were coded in NVivo 10 using a coding framework based on our initial and emerging themes of interest, including treatment-seeking patterns and influences on those patterns. To support the trustworthiness of the coding process, at least two people coded each transcript, comparing results and resolving any discrepancies.
Table 1

Example of Household Charts comparing themes

PID	Length of illness	Length of treatment-seeking	Patterns of treatment-seeking	Influences on treatment-seeking				Other influences	Infor/advice on discharge & adherence
				Nature of illness and perceptions of it	Levels of access to cash	Social support	Health systems issues/referrals
Hh3 Male, with SWK, 21 months old & unknown birth weight.	Approx. 3 months pre, 2 weeks admission, 4 months post.	About 8 months: Child occasionally gets convulsions, but the cause not clearly understood.	PRE Health centre-Health centre-Private clinic-Private clinic-(both retirees living in the village) -Public dispensary-duka POST Supp Public Dispensary-Private clinic-illness continues (child still not well), duka, Public dispensary, Private clinic.	Believed uvula was causing vomiting, diarrhoea and loss of appetite. Symptoms persisted after it was traditionally cut. Afterwards, diviner diagnosed possession by some evil spirits. Later, suspecting kwashiorkor, neighbours advised mother to seek care from local health facility.	Used to walk long distances to seek care, so as to reduce costs. Missed meals or reduced intake to help cover expenses for the child during treatment seeking. Siblings stopped schooling during the child’s admission. Post Could not sustain providing nourishing food as prescribed at discharge.	Received support from relatives, neighbours and friends in different forms: advice, loans or foodstuff. Neighbours convinced the child’s father to accept biomedical care and send funds for the same.	Took long to diagnose the problem despite several visits to local health practitioners and health facilities. Some levels of mistrust (local hws) regarding post treatment therapy. Couldn’t access care when needed during a health worker strike. Sometimes had to self-medicate due to regular drug stock-outs at local facility.	Had initially been referred to a different subcounty hospital. But chose to go to KCH as was unfamiliar with that facility and town in which it is located.	Ensure child fed on nutritious food: fruits, high protein content foods-eggs, milk though couldn’t sustain. Also, asked to observe and maintain hygiene around the child- limited water sources around her area.

We drew on both the narrative and coded data to identity forms of vulnerability of (re) admission, prolonged illness or death (intrapersonal, interpersonal, environmental and structural), and agency, observed at household/community levels and in health service interactions.