title: Navigating multiple options and social relationships in plural health systems: a qualitative study exploring healthcare seeking for sick children in Sierra Leone.
abstract: 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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, USA. E-mail: asgeorge@jhsph.edu.
authors.forename: Kerry
authors.initials: K
authors.lastname: Scott
authors.forename: Shannon
authors.initials: S
authors.lastname: McMahon
authors.forename: Fatu
authors.initials: F
authors.lastname: Yumkella
authors.forename: Theresa
authors.initials: T
authors.lastname: Diaz
authors.forename: Asha
authors.initials: A
authors.lastname: George
mesh_terms: D000884:Anthropology, Cultural; D002648:Child; D003695:Delivery of Health Care / Q000458:organization & administration* / Q000706:statistics & numerical data; D017144:Focus Groups; D006801:Humans; D007407:Interviews as Topic; D016488:Medicine, African Traditional / Q000706:statistics & numerical data; D010342:Patient Acceptance of Health Care; D062526:Patient Navigation; D036301:Qualitative Research; D012807:Sierra Leone / Q000453:epidemiology; D012944:Social Support
keywords: Acute respiratory infection; Sierra Leone; child health; diarrhoea; healthcare seeking behaviour; malaria