Study design and procedures

We conducted a qualitative study using semi-structured in-depth interviews to explore beliefs and practices around sore throat diagnosis, care-seeking, and causes in children among Gambian caregivers and health professionals. Interviews explored understanding of sore throat causation, transmission, severity, and usual health-seeking patterns when children show signs of sore throat. The study was embedded within The Streptococcus Pyogenes Carriage Acquisition and Transmission prospective cohort study (SpyCATS–NCT05117528). SpyCATS cohort participants were initially selected via GPS randomisation. The methods utilized in the cohort study are described elsewhere [19].

Study setting

The study was carried out in the peri-urban area of Sukuta, in The Gambia which had a population of 47,048 and an average household size of 8.1 at the most recent census held in 2013 [20]. The main ethnic groups are Mandinka, Fula and Wolof, however, there are other minority groups. The most spoken languages are Mandinka and Wolof.

Research team

MSS conducted the semi-structured interviews and informal conversations. Three clinical research nurses (AB, IC, and MM) with prior experience in qualitative research, assisted the primary facilitator when translations from English to Mandinka (IC, MM) or Wolof (IC, AB) were required, and vice-versa. The nurses lived and worked in Sukuta and were fluent in the local languages and English.

Participant selection

A theoretical sampling approach was followed. Informants were purposefully and gradually selected based on emerging findings. The research team nurses and fieldworkers were identified as gatekeepers to the Sukuta community, knowledgeable regarding the pluralistic medical context, and informal conversations started. They were able to support identifying 13 households where children had been ‘recently’ (around six months before the study) affected by sore throats from the periodical visits they had to conduct as part of the cohort study. Informants from these interviews referred us to 2 other households they knew of not enrolled in the cohort (15 households in total), as well as a traditional healer and a drug shop vendor who were involved in treating the sore throat. Potential participants were approached by the field team, who would explain the study to them. Signed (or thumb-printed) informed consent was obtained after participants had read the study information document, or had the information translated line-by-line into a local language or their choice.

Adults of all ethnic groups and socioeconomic backgrounds were eligible. Interviewed individuals were adult (18 and over years old) caregivers, resident in Sukuta during the time of the fieldwork who had identified, experienced, or heard about an episode of sore throat in a household. Exclusion criteria included caregivers who declined to participate after informed consent and caregivers with cognitive impairment. Participant recruitment was conducted between the 29^th of July of 2022 and the 18^th of August 2022. Participants were not compensated for study involvement.

Interviews with households

Participants were interviewed by members of the study team in English, Mandinka, Wolof or Fula as appropriate. Interviews were audio-recorded and transcribed verbatim. All interviews were conducted in a quiet private area, elected by the participants, and lasted between 20 and 40 minutes. The semi-structured interview guideline included sections on socio-demographics, health-seeking behaviour in response to the most recent sore throat episode, health beliefs around sore throats, triggers and barriers to care-seeking and treatment, and knowledge of ARF and RHD (S1 Appendix). The first two interviews were used to validate the guideline, which was then adjusted, and some questions reworded.

Informal conversations and observations with providers

In addition to semi-structured interviews, non-audio recorded informal conversations were held opportunistically with three SpyCATS study nurses or fieldworkers and the pharmacy worker. The conversation with the healer was audio-recorded. Ethnographic observations were collected during routine procedures and visits to the pharmacy, traditional healer, and a herbalist stand in the Sandika herbs section of the Serrekunda Market. Notes were taken during the observations and the informal conversations, and aimed to generate hypotheses, complement the content of the interviews, and support the analysis process.

Data management and analysis

Sociodemographic characteristics of the participants included in this study are shown in Table 1.

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Table 1. Sociodemographic characteristics of participants at enrolment.

https://doi.org/10.1371/journal.pgph.0002257.t001

The analysis combined inductive (open coding) and deductive coding (based on themes previously identified during the interview guideline design stage and review of relevant literature) approaches. Open, axial (finding connections between codes) and selective (core category connects multiple codes) coding procedures were used.

Thematic saturation was defined as when new incoming data produced little to no new information on the topic under exploration [21]. For some themes, saturation was reached after eight interviews, and for all but the “societal change” domain, saturation was noticed after 14 interviews. The final matrix included 37 themes grouped into three great domains.

Data from the caregivers and traditional healer was analysed separately from the biomedical care providers and presented alongside one another in the sections below, being mindful that there is not always a clear distinction between ’biomedical’ and ’lay’ knowledge about diseases.

Illustrative quotes were included in the results section to exemplify and justify relevant themes, with viewpoints clearly labelled. To improve clarity and readability, minor grammatical changes were applied to some quotes in this report.

Ethics and consent

This study was approved by the joint The Gambia Government/MRC Joint Ethics Committee, the MRCG Scientific Coordinating committee, and the and the London School of Hygiene and Tropical Medicine Ethics Committee. Written informed consent was obtained from study participants prior to conducting interviews (S2 Appendix). This study follows the COnsolidated criteria for REporting Qualitative research (COREQ) [22]. A completed version of the COREQ checklist is included in the supporting information material of this publication (S1 Table).

Conceptualization of sore throats and its consequences

The local terms kankonoto dimo (Mandinka) and bat bumeti (Wolof) corresponded to “throat that is in pain”. No local language terms were identified to refer to ARF or RHD. The words balakando in Mandinka or yarambutouga in Wolof, which correspond to fever (“hot body”), were used together with other symptom descriptions characteristic of ARF, such as joint pain, to ask participants if they had ever known anyone suffering from it or heard about the condition. The Mandinka local term yusukusasa, meaning cardio pathology (“heart sickness”), was used with a description of other symptoms such as joint pain to ask whether participants had heard about the RHD or known anyone who had suffered it. The English terms were also used in case they heard about the medical term.

Case identification

Participants described sore throat as pain inside the throat that has a negative impact on eating and drinking, and sometimes swallowing saliva. Caregivers reported noticing sore throat episodes in children after they manifested their experience of pain through verbal complaints, sometimes involving crying. Some participants also described confirming the sore throat in a child upon observation of tonsillar exudates (referred to as the presence of “something white” inside the throat), or observation of lymphadenitis (“neck swallow” or “swollen glands”), which can be experienced before or simultaneously with fever (“hot body”), tiredness or otitis (“ear pain”) that initiates from the throat and “arrives” up to the ears:

“I see from her she can’t swallow, she feels tired, you know, she cried like ‘I cannot swallow, my neck is paining me’” (P008, mother).

Sore throat susceptibility was not perceived to be ubiquitously distributed, with a few participants stating that “children never get it” (generally referring to babies or young children who cannot speak) or something that only certain children get. Participants from many households identified one child in the family as the sole susceptible individual, reporting single or multiple (between one and four) sore throat episodes a year:

“Just I have only one girl who got sore throat problem, because my [other] children do not complain about sore throat. But her, only to her, sore throat, every year, two or three times” (P003, father).

If caregivers identified more than one child in the household as being susceptible to experiencing sore throat, only the child reporting multiple episodes would be regarded as the concerning case.

Perceived consequences and risks

Many participants reported being concerned about sore throat episodes in children. The most commonly emerging reason for concern was the inability to eat or drink. Unproductivity (“just lie down”), lymphadenitis, weight loss, difficulty speaking, and missing school due to sore throat, were also reported reasons for concern. Death as a perceived potential outcome of sore throat was reported twice and linked with not seeking appropriate healthcare in a health facility (“get medicines”).

“If you don’t remove it [the exudate] so that thing would come out, it can kill someone.” (P013, older sister).

Participants who reported no concern or very mild concern classified the sore throat episodes as “normal” and easy to resolve by the usage of traditional medicine.

Perceived causes

When it came to perceived causes of sore throat, most participants were unable to identify a causative agent for sore throat. The most widely discussed transmission model was based around the custom of members of the same compound eating with their hands from the same plate. The sore throat transmission event would specifically and consistently depend on the eaters’ hygiene-related practices after a meal-sharing event. There were variations regarding the specific hygiene-related acts identified as transmission triggers, the most common one was not washing your hands and “rubbing” them on the compound’s “wall” or “fence”.

“When you eat as a family you eat from one bowl. When you wash your hand here after that you make your hand like this [participant mimics rubbing her hands with a corner of a bucket] on the sides of the bucket, the top part. So after that, […] our belief is that some will have this thing [sore throat]” (P016, mother).

“If you eat with people in the same bowl and just wash your hand and wipe it on the fence or something then[afterwards], that can also cause sore throat” (P012, older sister).

Some participants also identified ingesting specific foods such as spicy chili peppers or palm oil as having the capacity to cause sore throat (in both adults and children) as well as smoking (adults only).

Healthcare workers perceptions

The causes of sore throat, as reported by healthcare workers, were attributed to a viral or a bacterial infection. According to the pharmacist, transmission events were associated with activities such as gatherings, eating and drinking with other people and “saying lots of things” (aerosols that caused person-to-person transmission). One of the nurses said sore throat infections were caused by improper food handling (not washing or peeling the food).

In terms of identification, healthcare workers indicated that a visual inspection for “tonsil swollen” was used to differentiate between “pharyngitis or tonsilitis”, which in this context referred to irritated throat caused by a viral infection or tonsils with exudates caused by a bacterial infection. The pharmacist mentioned that if exudates were present, he would dispense Penicillin V (phenoxyethylpenicillin) (250mg) and Ibuprofen to customers. However, he expressed concerns about the limited resources available to conduct specific diagnostic tests, which would help avoid the unnecessary use of broad-spectrum antibiotics.

Nurses and other healthcare workers’ knowledge regarding ARF and RHD causes, identification and management were limited. When initially probed, none mentioned ARF or RHD as sequelae related to sore throats. When specifically asked about ARF and RHD, one of the nurses said ARF involved high fever and incidence followed a seasonal pattern “just like malaria”. He acknowledged lots of heart problems among children under five, with RHD being a disease that started in 2020 and that could be diagnosed by using a heart scan. Another nurse said that paediatricians and cardiologists do know about the condition, but it is “briefly explained by external speakers” during nursing studies.

Health-seeking behaviour and care practices

A sore throat management episode would typically begin with the child experiencing it complaining to the primary caregiver (normally a mother or older sister) regarding their throat pain that is hampering their food or drink intake. After the caregiver identified the situation as a sore throat episode, they would initiate actions to manage the symptoms to resolve the episode. Biomedical and traditional approaches to healthcare were often viewed as complementary.

The most frequently narrated treatment itinerary corresponded to initial use of traditional remedies at home followed by health seeking at a pharmacy or health facility if home remedies did not treat the symptoms, e.g.,:

“we take black pepper, put it in hot water, and put it in the neck [throat]. But sometimes it doesn’t work, then we go to the hospital.” (P008, mother).

One young woman reported self-managing the condition by combining paracetamol with a safou, an amulet crafted by a marabout. Other participants indicated they never seek facility-based healthcare for a sore throat due to the perceived effectiveness of traditional remedies in solving recurrent sore throat episodes.

“I use hot water, use it two days, it stop, all gone, so she also I did that […] only hot water in two days, it stays and three days then it stop” (P007, -mother).

Within households, participants typically identified fathers as the one responsible for covering the healthcare-related expenditures, mothers and older sisters were commonly identified as chaperones to access the biomedical sector, and parents were most often identified as decision makers.

Traditional medicine use

The most common reported home remedy consisted of mixing black pepper (Piper nigrum) powder in hot water, which had to be drunk or gargled up to three times a day. Licking cooking mortars that had been used to grind black pepper and ginger was also described, as was using a teaspoon covered in black pepper to either straighten the inflamed uvula (after it “collapses”) to elicit the gagging reflex in the child. The latter was used to help exudate “come out”.

For babies and young children, the marabout described reciting a spell and massaging the child’s neck area where “the pain is”. For older children and adults, he reported making a paste of black pepper, salt, and leaves from the mango (Mangifera indica) or Gro trees, and putting the mixture on the tongue of the patient while they inhaled steam from a bowl of hot water under a blanket. This combination was used until “the exudates” come out.

Informal conversations suggested that some people go to the market to buy herbs to treat sore throats. During a visit to a Serrekunda market herbal stand, the herbalist recommended buying a sachet containing Banah tree leaves powder. The marabout also acknowledged Banah had curative properties for sore throat but used mango leaves more often because they were easier to find. The pharmacist reported that such traditional medicines could have negative effects on the kidneys and the liver due to their bitterness and unknown doses being taken.

Another treatment for sore throat mentioned by a few people involved spitting over the fence or wall delimitating your compound into a compound in which you had never eaten before. Only one nurse tried to provide a causal explanation for this, suggesting that the regurgitation that predeceases the spitting act would help to remove the exudates from the tonsils.

Biomedicine use

Following a consultation at formal healthcare facilities individuals would either receive treatment or a prescription to be taken to the pharmacy. Some participants referred to using antibiotics as superior, faster, or more appropriate for the sore throat condition. The pharmacy worker expressed concerns about antibiotic resistance and some caregiver accounts suggested they stopped giving antibiotics when symptoms resolved: “Before those medicines finish, then the sore throat goes away. She did not take medicine again [continue the medicine after the symptoms decreased]” (P011, mother).

Changing societal practices

Respondents reported how some care practices were changing, based on dynamics within both the traditional medicine and biomedical healthcare sectors. The most common practice change concerned the declining use of teaspoons covered in black pepper, usually executed by the elderly of the compound. This change was attributed to the discomfort elucidated by the method, compared with the simplicity of administration and perceived effectiveness of antibiotics. Another perceived cause for the subtle transition towards the preference of the biomedical sector is the death of marabouts with no apprentices to replace them. The practice of lymphadenectomy was also reported to be a procedure executed by marabouts in the past to cure and prevent future episodes of sore throats or “madness” caused by sleeping sickness which has been eliminated from this part of West Africa.

Perceived barriers to the biomedical sector

Although the overall perception of the biomedical sector was positive, several barriers were identified.

A repeatedly identified barrier in this study were the perceived direct and indirect costs involved in seeking healthcare in the biomedical sector. Participants described having to leave their “duties” and “chores” to go to the centre, implying loss of income (indirect cost), waiting for long hours to be seen by a health worker and then being deceived when treatment was needed but not available at the same facility (indirect cost), meaning they had to approach a pharmacy and pay for the treatment out-of-pocket (direct cost):

“Sometimes you leave everything, go with the sick there, from morning you’ll be in the queue until afternoon, then they will just tell you there is no medicine left, so you go and buy to the pharmacy, so then if you are there without money, how are you going to buy those medicine?” (P011, mother).

Some participants described delaying antibiotic treatment due to the need of obtaining the necessary resources to be able to buy them (direct cost). Having to go to the pharmacy after reaching the health centre was perceived as an additional burden. For example, one participant acknowledged never going to the pharmacy with the prescription received at the health centre because of the successful resolution of her sore throat after using traditional medicine.

When participants perceived they had insufficient time to visit a health centre on the day of illness, they sometimes reported directly attending pharmacies for investigation (“checkings”) and treatment, despite increased associated costs.

Another repeatedly expressed complaint was that health care workers were perceived to have a neglectful attitude towards the patients, regardless of the severity of their conditions:

“Sometimes these health centres, you can go there, then you see nurses there then they would refuse to attend you, they would be doing some other things. Sometimes you see a patient who is about to die and they will just be careless until the person die” (P006, father).