Delay in Care-Seeking for Respiratory Infections Among Children Under Five in Africa: A Systematic Review

Introduction Few illnesses take as heavy a toll on young children in low-income settings as acute respiratory infection, pneumonia chief among them. The children most exposed are also the most vulnerable: those who have not yet reached their fifth birthday (World Health Organization [WHO], 2022). Across the range of infectious disease, lower respiratory infections sit near the top of the list of killers at this age (GBD 2019 Lower Respiratory Infections Collaborators, 2022). The numbers are stark. Each year pneumonia accounts for roughly 740,000 deaths among under-fives, close to one in seven of all deaths in this age group (Villavicencio et al., 2024; WHO, 2022). This burden does not fall evenly. Most under-five deaths occur in sub-Saharan Africa and Southern Asia, and within that toll pneumonia recurs as a principal cause (Perin et al., 2022; UNICEF, 2025). In the African region especially, mortality from respiratory infection has stayed stubbornly high, and a sizeable share of these deaths traces back to care that arrived too late (Källander et al., 2008). Timeliness, then, is not a secondary matter. Whether a child recovers or deteriorates often turns on the time that passes between first symptoms and effective treatment (Perin et al., 2022). The difficulty is not a shortage of tools. Vaccines, antibiotics, and basic supportive care are all available, yet many children still reach services late (WHO, 2022). Once treatment is delayed, the infection has room to advance, and the risks of death and of lasting damage rise with it. Why caregivers wait is seldom a simple matter of choice: Colvin et al. (2013) show how economic pressure, cultural readings of illness, and the practical problem of distance all shape the decision. The timing of care-seeking therefore repays attention, since the moment a family turns to the health system does much to determine how severe the illness becomes. Acting early changes outcomes. When caregivers recognise the signs of pneumonia and seek treatment quickly, the illness is far less likely to progress to its severe forms, a pattern Onyango et al. (2012) documented in western Kenya. The reverse is equally well attested, with children treated late carrying a higher risk of death and of lasting respiratory harm (Källander et al., 2008). Early contact with a clinician can avert the most dangerous developments, including the falling oxygen levels that mark critical pneumonia (Hildenwall et al., 2009). Because the window between recognition and deterioration is so narrow, the speed of the caregiver’s response carries real weight. Several pressures push families toward delay. Money is often the first: poverty, out-of-pocket costs, and limited insurance cover all narrow the room a household has to act (Temsesgen et al., 2023; UNICEF, 2025). Distance adds a further layer, particularly for rural families whose nearest facility is far off and whose transport is unreliable (Colvin et al., 2013; Tesema & Seifu, 2023). These obstacles seldom appear one at a time. They overlap and reinforce one another, lengthening the interval before care is sought and raising the odds that a treatable infection turns dangerous. The scale of childhood respiratory infection, and the danger of treating it late, are by now well documented (Källander et al., 2008; Onyango et al., 2012). What remains less clear is why delay persists among under-fives in Africa. Existing work tends to map disease burden and broad care-seeking patterns (Colvin et al., 2013; WHO, 2026), while the specific barriers caregivers encounter stay scattered across studies, with rural and underserved communities thinly represented. The coverage gap is real: survey data suggest that only about six in ten children with respiratory symptoms reach an appropriate provider, and the figure is lower still across much of sub-Saharan Africa (UNICEF, 2025; WHO, 2026). This fragmentation carries practical costs. Without a consolidated, region-specific account of what delay does to children, health systems are poorly placed to design responses that fit their settings. Piecemeal evidence tends to yield piecemeal programmes, and progress against child mortality stalls as a result. A clear understanding of what drives delay, and of how it translates into worse outcomes, is needed before targeted, locally grounded interventions can be built. This review sets out to provide that understanding. It asks how often care-seeking for respiratory infection in African under-fives is delayed, what drives the delay, and what it costs children in clinical terms. The three-delay model frames the analysis (Thaddeus & Maine, 1994), separating the decision to seek care, the journey to a facility, and the treatment received on arrival. Each delay builds on the one before it, prolonging illness and pushing children closer to severe disease and death. By showing where and why these delays occur, the review aims to give policymakers and programme designers a firmer basis to act on, and to support Sustainable Development Goal 3.2 and its target of ending preventable under-five deaths by 2030