‘You have to do what is best’: The lived reality of having a child who is repeatedly hospitalized because of acute lower respiratory infection

Abstract Introduction Hospitalization of children is traumatic for children and their families. Little is known about the impact of repeated acute admissions on families, or of these experiences in Indigenous populations and ethnic minorities. This study explores the societal and health experiences for families who have a child under two years of age, admitted to hospitals more than twice for lower respiratory infections. Methods Underpinned by a reflective lifeworld research methodology, this article presents results from 14 in‐depth interviews in Aotearoa/New Zealand. Results Families learn to identify illness early and then navigate hospital systems. These families struggle to create safe spaces for their children at home or in society. Wider social and economic support are central to family resilience, without which they struggle. Conclusion This study reinforces the importance of bringing meaningful, culturally‐responsive care to the fore of treatment, particularly when managing vulnerable minorities. Formal referral and support processes are key to this responsiveness to lessen the burdens of acute admissions for families. Patient or Public Contribution Families chose to be involved in this study to highlight the importance of the topic and their experiences with accessing health care. The cultural advisors to the project provided feedback on the analysis and its applicability for the participant community.


| INTRODUCTION
Lower respiratory infections (LRIs) are a significant health burden for Aotearoa/New Zealand's paediatric population, 1 resulting in acute hospital readmissions, particularly for children in the first 2 years of life; 1,2 Indigenous Māori children and Pacific children (an underserved minority) have high hospitalization rates. 2 Limited research has been conducted in this area of high childhood morbidity and acute hospitalization. Yet, there is growing evidence linking LRIs in early childhood to recurrent respiratory conditions including chronic bronchitis and increasing rates of bronchiectasis, potentially leading to chronic lung disease in early and later life. 3,4 The impact of LRI can, therefore, be life-long from a social and health perspective.
Populations most likely to carry the burden of acute readmissions to hospitals during the first years of a child's life are generally lower socioeconomic status groups and ethnic minorities. Despite this, the experiences of these populations have received limited focus; researchers have explored, however, the experiences of parents whose children suffer chronic illnesses requiring frequent hospitalization.
Brown 5 reported on the coping mechanisms of Māori and Pacific families managing the continual re-entry of their children into the health system with life-threatening conditions. Her work suggests persistent barriers exist impacting on family engagement with the health system; at its core, the research indicates that family are critical resources for coping with these engagements.
Overseas, work in this area suggests that caregiver distress contributes directly to child health outcomes. 6 Kepreotes et al. 7 6 Beeton et al., 8 Nelson et al., 9 Resch et al., 10 Breen et al. 11 and Hudson et al. 12 ), while internalizing or pushing aside emotions around their child's illness. 13,14 Researchers have examined the impact on families of acute and unexpected intensive care unit (ICU) admissions of critically unwell children (see for example, Colville et al., 15 Abuqamar et al., 16 and Curtis et al. 17 ). In their earlier systematic review of these cases, Shudy et al. 18 emphasize how, during admission, parents and siblings are shocked and fearful, feelings hospitals intensify. Families stress the need for clear explanations of their child's treatment and better communication by ICU staff. 18 Shudy et al. 18 highlighted that in the long-term, critical admissions may permanently change family relationships, although of note, there is less literature exploring this concept, but it is supported in a more recent 2020 update to this systematic review, which suggests impacts begin within 24 hours of admission and last for years after discharge. 19 Similarly, environmental factors arising from childhood hospitalizations, including housing issues and parental financial or employment stressors arising due to their child's hospitalizations also negatively impact families. 20 Previous studies have focused on parental involvement and support during a child's hospitalization. 12,17,21,22 Burke et al. 23 and Kepreotes et al. 7 emphasize the need for parents to manage relationships with health professionals (HPs). This tenuous process involved parents reluctantly taking charge and directing care provision.
Parents discussed the fragility of their control over the situation, their need to be constantly attentive to their child's welfare and adopt a new sense of reality, which encompassed re-envisioning the future for their family.
Parents have highlighted that they want HPs to provide practical ways of caring for and supporting their chronically-ill child. 6,11,24,25 Such measures include nurses sharing parents' emotional burdens and supporting family coping strategies. 9,26 Assisting families in this way is important as positive health outcomes for chronically-ill children are associated with functional family relationships. 6 Similarly, support to navigate the health system and function within society (financially and through access to appropriate educational pathways), and to manage the immediate needs of ill children are also necessary if families are to function effectively whilst caring for their child. 6,11,12 There is a dearth of research addressing the systemic impact on families of repeat hospitalizations of children with acute illnesses.
Importantly, limited research has explored this phenomenon in minority populations who are more likely to experience societal and health problems leading to hospitalization. 27 This article lays out results from a qualitative study exploring the societal and health consequences for families who have a child under 2 years of age, admitted to hospital more than twice for acute respiratory illness. Understanding the lifeworlds of these families facilitates the meaningful tailoring of health care services and interventions.

| REFLECTIVE LIFEWORLD RESEARCH METHODOLOGY
This study follows the tenets of reflective lifeworld research. This methodology, explained extensively by Dahlberg et al., 28 involves seeking meaning from experiences. Applying this methodology enables researchers to see phenomenon afresh and readers to consider the material from their own perspectives knowing that there are multiple traditions, values, and beliefs influencing these perspectives.
Three principles inform this methodology: the hermeneutic circle, historicity, and openness.
The hermeneutic circle emerged from Schleiermacher's work on hermeneutics. [28][29][30] He posited that when engaged in the act of interpreting, it is important to consider the whole and the parts of a text, being consistently attentive to the minute, and the broader context to develop interpretations. 28,31 Emergent interpretations are never complete; they change as cultures and traditions advance. 31,32 Consequently, individuals are responsible for reinterpreting and en- held values; all future interpretations will emerge from this perspective or horizon. [31][32][33] While it is impossible to free oneself from previously held ideas completely, researchers constantly question their historicity and vigilantly assess how these issues affect emerging interpretations. 31 Through this position of 'openness', the researcher may then recognize the 'otherness' of a phenomenon. 31,32 Participants' lifeworlds are unique; understanding lived realities can inform meaningful dialogue around health care services and intervention, and therefore, is an appropriate methodology to underpin this study.

| MATERIALS AND METHODS
This study (ethics approval number: NTY/10/EXP/073) was con- children in this region. 2,36 Issues contributing to high LRI rates include overcrowded and under-heated housing. 36 Figure 1 outlines key aspects of the research protocol, including for data collection, recruitment, ethics, and analysis, developed based on a recognition of South Auckland's unique population.
All 14 participant groups self-nominated their ethnicity; most indicated they were of mixed ancestry. For example, participants stated they were of Māori and Niuean, Samoan and, or, Tongan, or Māori and European descent. Most participants resided in homes with their children and more than one adult and/or multigenerational households. Participants had two to six other children living in the family home (Table 1).
Participant recruitment and data collection were carried out by female research nurses (one Samoan and two of European descent), all had many years' experience working alongside South Auckland's population. To ensure consistency, before initiating data collection, the lead investigator provided training in qualitative interviewing.
Interviews were conducted in English in several ways; for example, an interview may have been conducted with one caregiver, two parents together or a parent and grandparent. One interview involved three family members, both the child's parents and a grandmother. All interviews were conducted while the child was in hospital. Interview

| RESULTS
Three major themes emerged from the analysis, these are 'coming-toknow', 'being in hospital' and 'navigating society' ( Table 2). Participants spoke of how, over time, they came to recognize and understand respiratory illness in their child, the factors causing illness, and how to protect their children from infection. They described coming to understand the hospital system but recognized they were considered outsiders, despite having expertize in caring for their child. Participants spoke at length on how they looked to improve housing situations to support their child's health. Across these themes, participants described the critical role extended families play in surviving readmissions.

| Coming-to-know
When participants spoke of their child's initial illness experience, they were often unable to recognize an illness trajectory. Gradually, participants came to know what respiratory illness was and the signs their child displayed. They were able to gauge illness severity and determine triggers in their child. The following narrative describes how one mother learnt to keep her child safe, and how she recognizes her son's repeat illnesses. Participants spoke about how they slowly acclimatized to hospital life, in the example above the mother referred to the hospital as a 'second mortgage', which may reflect, in part, the price of having an acutely unwell child. Participants highlighted that they gradually learnt to accept their child's hospitalization as necessary; they framed the hospital as a home away from home. This perspective on admissions allowed families to recast experiences as tools in caring for their child. That said, participants explained the need to navigate society to keep their child well and avoid future hospitalizations.

| Addressing housing issues
Participants discussed at length how poor-quality housing affected their child's health and how home environments were fundamental to keeping their children healthy. They worked to ensure homes were warm and free of airborne contaminants through remedies, such as opening windows when cooking, and addressing complex family-related factors. One example of managing the latter was the eviction of a partner, who smoked, from the home. One family spoke on the changes they engaged in to make their home function for their child; they offered the following narrative. Family support enabled participants to create wellbeing, despite the challenging context that these households found themselves.
Learning to use the hospital systems and manage their home to avoid future hospitalizations also presented challenges; however, family support enabled participants to manage their unwell child, other children and societal responsibilities.
One parent, a mother of three preschool children, had limited extended family support; she suffered significantly because of her child's repeat LRI admissions and was at the mercy of policies forcing her to place her young child alone in an ambulance, while trying to find care for her other children and when she was in the hospital caring for her unwell child. Financially, she struggled to feed her children and provide adequate housing. She also faced obstacles in managing relationships with others because of the situation with her child. Speaking at length about her experience, she described herself as being a bad mother and to blame for her child's sickness. She feared punishment and removal of her children by the State due to an insidious cycle of acute illness; this was a message reinforced by others she knew. She offered the following narrative. Multigenerational homes are sometimes viewed negatively. 42,43 Participants in this study, however, indicated that these types of homes offered invaluable support and strength. Extended family members were able to care for the sick child's siblings and these children did not have their daily lives or routines disrupted. Housing quality and overcrowding are significant issues in Aotearoa/New Zealand, with Māori and Pacific children suffering more because of a lack of suitable housing. 44 Public health initiatives to improve housing conditions will no doubt assist children living in substandard homes to stay well. However, initiatives aimed at reducing overcrowding, also need to encompass culturally-appropriate dwellings, so that extended families can reside in the same home if they choose; a call also made by others. 45,46 Where family support exists, issues with responding to childhood illness, managing the hospital system, and navigating society appear to be mitigated. Similar results within the context of chronic illness and health care access have been discussed; 47