Why Do Parents Take Their Children to Informal Healthcare Providers? Insights from Bangladesh

TL;DR

This study explores why parents in Bangladesh take their children to informal healthcare providers, finding that accessibility and trust are key factors.

Contribution

The study provides new qualitative insights into parental motivations for using informal healthcare providers in low-resource settings.

Findings

Parents choose informal providers due to geographic and financial accessibility.

Lack of knowledge about evidence-based treatment for pediatric diarrhea was observed.

Informal providers may hinder formal healthcare follow-ups, affecting long-term child health.

Abstract

In low- and middle-income countries, informal healthcare providers are often the first point of contact for pediatric care. The present qualitative study, conducted in Bangladesh, was designed to explore why parents seek pediatric care from informal providers. Through in-depth interviews with 12 parents of children under 5 years of age, key drivers for visiting informal providers were identified, including geographic and financial accessibility, as well as trust and familiarity. Parents expected informal providers to offer them informed and effective treatment but did not have a clear understanding of evidence-based treatment of pediatric diarrhea. Although informal providers may meet families’ immediate needs, they can also undermine formal healthcare visits and follow-ups that are essential to supporting children’s long-term health. The study findings highlight the need for targeted health education to improve parents’ knowledge, awareness, and informed decision-making. Strengthening trust in formal providers and addressing accessibility barriers is essential to improving pediatric health outcomes in low-resource settings.

Full text

Introduction

In many low- and middle-income countries (LMICs), access to formal healthcare services remains limited^1^. In these environments, informal healthcare providers, including drug vendors, traditional healers, and untrained allopathic providers, play a central role in delivering healthcare services, offering medical advice and treatment, and meeting other healthcare needs for the population, especially the rural poor^2^.

While informal providers bridge critical gaps in healthcare access, it does not replace the value of regular and consistent engagement with formally trained healthcare practitioners, who are equipped to provide evidence-based prevention and treatment for acute and chronic ailments^3^. This is especially true for pediatric populations, where early prevention is key and where both short- and long-term impacts of diseases can be life-threatening and often require longitudinal management^4,5^.

In Bangladesh, informal providers known as “village doctors” practice allopathic medicine mostly without formal medical training and play an important role in providing healthcare services, consultations, and medications^6^. In many parts of the country, village doctors are the first and most accessible point of care for the rural population. However, their clinical decisions are frequently influenced by external pressures, including financial incentives, the need to retain clientele, and the demands and expectations of patients and their families^7^.

Because village doctors operate in a competitive, profit-driven marketplace, their clinical decisions and behaviors are influenced by the expectations of the patient population. Recent studies have revealed that external pressure from patients and their families can lead to inappropriate treatment practices by informal providers, including unnecessary antibiotic use^8,9^ and delays in referring patients to higher level healthcare facilities^10^. Additionally, families of pediatric patients often lack awareness of the importance of formal pediatric healthcare, resulting in poor follow-up even when referrals are provided^10^.

Given the critical role and well-established benefits of regular contact with formal practitioners in improving pediatric health outcomes^11^, there is an urgent need to understand the motivations of parents and other caregivers who take their child to informal providers. At the same time, formal healthcare systems also face challenges including accessibility barriers and financial incentives that may influence pediatric care decisions. This study aims to qualitatively explore the motivations and expectations of parents when taking their child to a village doctor in Bangladesh, offering insights into the types of care that matter most to families and how parents make decisions about their child’s health while navigating the complex healthcare landscape shaped by formal and informal systems.

Methods

The study was undertaken collaboratively by members of the research team at the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) and The University of Utah. All data were collected in the Sitakunda Upazila (subdistrict) of the Chattogram District in southeastern Bangladesh. The Sitakunda Upazila is about 500 square kilometers, and its population consists of approximately 383,000 people^12^. Through a community-based mapping exercise, we identified 411 village doctor practices in the Sitakunda Upazila^13^.

In June and July 2023, we purposefully selected 8 village doctor practices from the original 411 practices; from these 8 practices, we recruited 12 caregivers of pediatric patients. Individuals were eligible if they were an adult (≥18 years old), responsible for a child under 5 years of age, and had taken their child to the village doctor with the primary complaint of diarrhea. Recruitment was conducted until data saturation was reached, at which point additional interviews no longer provided new insights.

Individual in-depth interviews (IDIs) were conducted at the village doctor practices by a member of the qualitative research team at icddr,b. IDIs were conducted in Bangla and ranged in duration from 20 to 30 minutes. A semi-structured interview guide (Supplement 1) included open-ended questions and follow-up probes, and covered topics such as motivation for seeking village doctor care, past experiences with village doctors, and expectations during visits with village doctors. All IDIs were audio-recorded, transcribed verbatim, and translated into English to facilitate coding and thematic analysis by the international collaborative team.

Analysis was conducted in NVivo (version 12) following an applied thematic analysis framework^14^. The analysis involved several stages: familiarization with the raw data, coding, analytic memo writing, identification of emerging themes, and interpretation of the data. We developed a codebook to identify emerging themes across two domains: 1) parents’ motivations for seeking village doctor care, and 2) parents’ expectations of village doctors. The coding output was used to write analytic memos, which allowed for comprehensive understanding of the data and synthesis of themes.

Results

The 12 participants included 9 mothers and 3 fathers. The average age of parents was 29 years (range: 18–40 years). Household income ranged from 6,000–25,000 Tk (approximately 50 to 200 USD), and few parents had beyond an 8^th^ grade education.

Parents’ Motivations for Seeking Village Doctor Care

Three themes characterized parents’ motivations for seeking care for pediatric diarrhea from a village doctor: 1) geographic accessibility, 2) financial accessibility, and 3) trust and familiarity (Table 1).

Participants expressed preference for village doctors due to their proximity from their residence, especially with limited transportation options. Although some acknowledged that formal healthcare facilities may offer higher quality of care, participants consistently reported that they only went to formal healthcare facilities if the initial treatment from the village doctor was ineffective. Village doctors were seen as preferential because of their community locations and ability to provide house calls, eliminating transportation barriers. Village doctors were also seen as more affordable, as they offered similar treatments at a lower cost. Finally, participants noted that they had longstanding relationships with the village doctors in their community, which fostered feelings of trust and familiarity.

Parents’ Expectations of Care from Village Doctors

Two themes characterized parents’ expectations during a visit to a village doctor: 1) informed treatment decisions, and 2) quick and effective treatment (Table 1).

Participants said that they expected a village doctor would consider the patient’s medical history and symptoms when determining the cause of illness and deciding on treatment. Additionally, they expected to receive treatment that provides a timely resolution of symptoms with minimal side effects. While some parents specifically stated that they expected antibiotics, the majority expressed a more general expectation for effective medication, seemingly lacking knowledge on specific medication types or other evidence-based treatment options for diarrhea management. No participants mentioned expectations for receiving rehydration therapy or guidance on non-pharmaceutical approaches for symptom management.

Discussion

Consistent access to the formal healthcare system is essential to ensure positive and long-term health outcomes for children^11^. This access is often limited in LMICs like Bangladesh, where informal practitioners provide the majority of health-related services, including care for pediatric patients in rural areas^2^. While informal providers fill a critical gap, their limited medical knowledge can lead to inappropriate clinical decisions, potentially compromising children’s health^7^. This study aimed to qualitatively explore parents’ motivations and expectations when seeking pediatric care from a village doctor and identify opportunities for interventions to improve pediatric health.

We found that geographic and financial accessibility were primary factors driving parents to seek pediatric care from village doctors rather than formal healthcare facilities. This finding is consistent with existing literature showing that less than 50% of the population in low resource settings are able to reach a registered healthcare facility within 60 minutes of walking^15,16^. Although some studies suggest that patients may be willing to accept higher costs and travel times to access formal healthcare facilities^17^, there is a preference for local informal providers due to geographic and financial constraints^18^. Our findings add to this body of evidence and reinforce the need for targeted interventions to make healthcare more accessible and reduce family burden in low resource areas. Given the importance of geographic location and proximity, interventions could also consider integrating village doctors into the formal healthcare system through structured training strategies to ensure adherence to appropriate clinical guidelines for pediatric care and encouraging timely referrals to formal health care facilities.

Trust and familiarity emerged as a significant motivator for seeking care from a village doctor. A systematic review examining the role of informal providers offered similar insights, with informal providers in LMICs having high rates of trust and respect within the community^2^. Community members in LMICs appreciate providers who understand cultural norms and context-specific factors^19^. Building trust in formal providers requires systems-level interventions to create a facility culture of patient-centered care^20^.

While parents commonly expected quick and effective remedies for their child’s condition, there was a gap in parents’ understanding and knowledge about what an appropriate treatment plan might entail. This presents the opportunity for health education interventions aimed at improving caregivers’ understanding of available and evidence-based treatment options for pediatric care, in turn promoting shared decision making between providers and parents.

It is important to consider some limitations associated with this study. Our sample of parents was small and centralized to a specific area in Bangladesh. The interviews were conducted with parents in the context of questioning them about their motivations and expectations of care related to pediatric diarrhea, which may limit the generalizability of our findings to other pediatric ailments. Conducting the interviews at village doctor practices may have increased social desirability bias in favor of village doctors.

In conclusion, this study identifies important barriers and expectations that influence pediatric care-seeking behavior in Bangladesh. These findings can be used to inform targeted approaches to address barriers to formal healthcare and encourage caregivers of pediatric patients to make informed decisions related to their child’s health. Our findings also highlight the need for broader health system reform that recognizes the roles of both informal and formal healthcare providers. Strengthening collaboration between these systems is essential to promote effective treatment options and enhance pediatric care in low resource settings.

Supplementary Material

Supplement 1