Navigating the Lay Referral System for Treatment-Seeking Decisions During Illness in the Digital Age: A Qualitative Study of Adults Living in Slums in Nigeria.

Interaction with a lay referral system (informal networks that provide health advice during illness) influences the treatment-seeking decisions of individuals with perceived healthcare needs. We examined how this occurred in urban slums in Nigeria with scarce formal healthcare and unstable social networks. Using existing theories of social networks and lay referral, we examined the use of these systems for treatment-seeking decisions in slums, including the use of digital technologies. We interviewed 30 adults (aged 18-64) of diverse age, gender, network size and use of digital technologies for health advice in two Nigerian slums. We analysed the data using a thematic inductive-deductive approach. Lay referral was multidimensional: discussion of illness during daily bonding, social demonstration of self and purposeful exchange of support. People limited lay referrals to a few family members and friends, avoiding wider interactions due to mistrust. Use of online sources was scarce due to limited access to smart devices and low digital health literacy. Lay referral motivated timely care seeking but also facilitated unhelpful advice. Slum residents were agentic in their use of their lay referral system. The effectiveness of their agency may be improved if trusted and reliable health advice sources are available in addition to their social network.