“Where my pocket can afford is where I will take my child:” the influence of structural factors on health-seeking behaviour, Sierra Leone
Authors: Burtscher D , Maukner AC , Piatti M , Verschuere J , Aruna TM , Em O , Mahama G , Antierens A 
Published: July 2024

INTRODUCTION
In Sierra Leone, maternal and under-five mortality rates are among the highest in the world. In 2010, the government of Sierra Leone adopted the Free Healthcare Initiative (FHCI), aiming to provide free healthcare for children aged under five and pregnant and lactating women. However, the FHCI is seriously impeded by limited staffing, repeated gaps in medications and supplies, weak management, and entrenched corruption in the health sector. We present experiences and perceptions of people in the Gorama Mende/Wandor (GMW) chiefdoms navigating available options to seek care. We examined the different factors that influence health-seeking behaviour, examining accessibility, affordability, previous healthcare experience, and reception at the health facility.

METHODS
This anthropological study applied an exploratory qualitative research design and was conducted in rural GMW chiefdoms, within Kenema district, Sierra Leone, in February 2020. The study involved in-depth individual interviews (33), paired interviews (2), and group interviews (18). The study population comprised of different groups of respondents including women, male traditional healers, drug sellers, and healthcare professionals (including those working for the ministry of health and MSF, and community health workers and traditional birth assistants). Purposive and convenience sampling was applied. Participants were selected with the help of community intermediaries. All interviews were audio recorded and transcribed verbatim. Transcriptions were screened for relevant information, coded manually and with NVivo 11 (QSR International, Austria), and analysed using qualitative content analysis. Methodological triangulation enhanced interpretation.

ETHICS
This study was approved by the MSF Ethics Review Board and by the Sierra Leone Ethics and Scientific Review Committee.

RESULTS
Contrary to the assumption that traditional healers greatly influence health-seeking behaviour, our data suggest that people are influenced primarily by proximity, affordability, and reception at the health facility. Whereas healthcare providers felt that people would go to a traditional healer first, community members emphasised that their first choice for care would always be from peripheral health units (PHU) provided there were no barriers. Reported barriers included being in a hard-to-reach area, transportation, the need to pay unexpectedly for services, and fear of health staff because of distrust, violent communication, and unmet needs.

CONCLUSION
The study reveals the complex reality which people face in terms of access to healthcare, and a multitude of factors that influence health-seeking behaviour. One community member noted that if people could not afford a PHU, they would turn to alternative forms of healthcare such as self-treatment, local drug sellers, and traditional healers, saying “Where my pocket can afford is where I will take my child”.

CONFLICTS OF INTEREST
None declared.