Navigating multiple options and social relationships in plural health systems: a qualitative study exploring healthcare seeking for sick children in Sierra Leone.

BACKGROUND Sierra Leone has emerged from civil war but remains in the lowest tier of the human development index. While significant health reforms, such as the removal of user fees, aim to increase access to services, little is known about how families navigate a plural health system in seeking health care for sick children. This research aims to build on recent care-seeking literature that emphasizes a shift from static supply-and-demand paradigms towards more nuanced understandings, which account for the role of household agency and social support in navigating a landscape of options. METHODS A rapid ethnographic assessment was conducted in villages near and far from facilities across four districts: Kambia, Kailahun, Pujehun and Tonkolili. In total, 36 focus group discussions and 64 in-depth interviews were completed in 12 villages. Structured observation in each village detailed sources of health care. RESULTS When a child becomes sick, households work within their geographic, social and financial context to seek care from sources including home treatment, herbalists, religious healers, drug peddlers and facility-based providers. Pathways vary, but respondents living closer to facilities emphasized facility care compared with those living further away, who take multi-pronged approaches. Beyond factors linked to the location and type of healthcare provision, social networks and collaboration within and across families determine how best to care for a sick child and can contribute to (or hinder) the mobilization of resources necessary to access care. Husbands play a particularly critical role in mobilizing funds and facilitating transport to facilities. CONCLUSION Caregivers in Sierra Leone have endured in the absence of adequate health care for decades: their resourcefulness in devising multiple strategies for care must be recognized and integrated into the service delivery reforms that are making health care increasingly available.

[1]  A. George,et al.  Understanding careseeking for child illness in sub-Saharan Africa: a systematic review and conceptual framework based on qualitative research of household recognition and response to child diarrhoea, pneumonia and malaria. , 2013, Social science & medicine.

[2]  K. Jacobsen,et al.  Considerations in the selection of healthcare providers for mothers and children in Bo, Sierra Leone: reputation, cost and location. , 2012, International health.

[3]  Jamie Perin,et al.  Global, regional, and national causes of child mortality: an updated systematic analysis for 2010 with time trends since 2000 , 2012, The Lancet.

[4]  B. Meessen,et al.  Composition of pluralistic health systems: how much can we learn from household surveys? An exploration in Cambodia. , 2011, Health policy and planning.

[5]  L. Nyabola,et al.  Who is to blame? Perspectives of caregivers on barriers to accessing healthcare for the under-fives in Butere District, Western Kenya , 2011, BMC public health.

[6]  J. Donnelly.  How did Sierra Leone provide free health care? , 2011, The Lancet.

[7]  Romy Steenbeek,et al.  The development of instruments to measure the work disability assessment behaviour of insurance physicians , 2011, BMC public health.

[8]  L. Otieno,et al.  Impact of Plasmodium falciparum infection on haematological parameters in children living in Western Kenya , 2010, Malaria Journal.

[9]  D. Nyato,et al.  Community response to artemisinin-based combination therapy for childhood malaria: a case study from Dar es Salaam, Tanzania , 2010, Malaria Journal.

[10]  Sándor Bereczky,et al.  Genetic diversity among Plasmodium falciparum field isolates in Pakistan measured with PCR genotyping of the merozoite surface protein 1 and 2 , 2010, Malaria Journal.

[11]  Icf Macro.  Sierra Leone Demographic and Health Survey 2008 , 2009 .

[12]  D. Peters,et al.  Poverty and Access to Health Care in Developing Countries , 2008, Annals of the New York Academy of Sciences.

[13]  G. Bloom,et al.  Future health systems: Why future? Why now? , 2008, Social science & medicine.

[14]  V. Kamat.  Dying under the bird's shadow: narrative representations of degedege and child survival among the Zaramo of Tanzania. , 2008, Medical anthropology quarterly.

[15]  T. Ensor,et al.  REVIEW OF FINANCING OF HEALTH IN SIERRA LEONE AND THE DEVELOPMENT OF POLICY OPTIONS , 2008 .

[16]  M. Dixon-Woods,et al.  Conducting a critical interpretive synthesis of the literature on access to healthcare by vulnerable groups , 2006 .

[17]  V. Kamat.  "I thought it was only ordinary fever!" cultural knowledge and the micropolitics of therapy seeking for childhood febrile illness in Tanzania. , 2006, Social science & medicine.

[18]  T. Ricketts,et al.  Access in health services research: the battle of the frameworks. , 2005, Nursing outlook.

[19]  Caroline O H Jones,et al.  A critical review of behavioral issues related to malaria control in sub-Saharan Africa: what contributions have social scientists made? , 2004, Social Science & Medicine (1967).

[20]  S. Mackian,et al.  Up the garden path and over the edge: where might health-seeking behaviour take us? , 2004, Health policy and planning.

[21]  T. Ensor,et al.  Overcoming barriers to health service access: influencing the demand side. , 2004, Health policy and planning.

[22]  G. Campbell.  Blood Diamonds: Tracing the Deadly Path of the World's Most Precious Stones , 2002 .

[23]  N. Abrahams,et al.  Why do nurses abuse patients? Reflections from South African obstetric services. , 1998, Social science & medicine.

[24]  P. Pelto,et al.  Studying knowledge, culture, and behavior in applied medical anthropology. , 1997, Medical anthropology quarterly.

[25]  C. Kendall,et al.  The household production of health: integrating social science perspectives on micro-level health determinants. , 1994, Social science & medicine.

[26]  Jimmy D. Kandeh.  Politicization of Ethnic Identities in Sierra Leone , 1992, African Studies Review.

[27]  M. Nichter.  Use of social science research to improve epidemiologic studies of and interventions for diarrhea and dysentery. , 1991, Reviews of infectious diseases.

[28]  J. Trostle.  Medical compliance as an ideology. , 1988, Social science & medicine.