BackgroundTo plan for a community case management (CCM) program after the implementation of the Free Health Care Initiative (FHCI), we assessed health care seeking for children with diarrhoea, malaria and pneumonia in 4 poor rural districts in Sierra Leone.MethodsIn July 2010 we undertook a cross-sectional household cluster survey and qualitative research. Caregivers of children under five years of age were interviewed about healthcare seeking. We evaluated the association of various factors with not seeking health care by obtaining adjusted odds ratios and 95% confidence limits using a multivariable logistic regression model. Focus groups and in-depth interviews of young mothers, fathers and older caregivers in 12 villages explored household recognition and response to child morbidity.ResultsThe response rate was 93% (n=5951). Over 85% of children were brought for care for all conditions. However, 10.8% of those with diarrhoea, 36.5% of those with presumed pneumonia and 41.0% of those with fever did not receive recommended treatment. In the multivariable models, use of traditional treatments was significantly associated with not seeking outside care for all three conditions. Qualitative data showed that traditional treatments were used due to preferences for locally available treatments and barriers to facility care that remain even after FHCI.ConclusionWe found high healthcare seeking rates soon after the FHCI; however, many children do not receive recommended treatment, and some are given traditional treatment instead of seeking outside care. Facility care needs to be improved and the CCM program should target those few children still not accessing care.

Despite recent progress, Sierra Leone’s lifetime risk of maternal death remains high (1 in 21), as does neonatal mortality (35 per 1000 live births). We present findings on maternal and neonatal care practices from a mixed methods study conducted in four districts during July–August 2012. We conducted a household cluster survey with data on maternal and newborn care practices collected from women ages 15–49 years who had ever given birth. We also conducted focus group discussions and in-depth interviews in two communities in each of the four districts. Participants included pregnant women, mothers of young children, older caregivers, fathers, community health volunteers, traditional birth attendants (TBAs) and health workers. We explored personal experiences and understandings of pregnancy, childbirth, the newborn period and social norms. Data analysis was conducted using STATA (quantitative) and thematic analysis using Dedoose software (qualitative). Antenatal care was high (84.2%, 95% CI: 82.0–86.3%), but not timely due to distance, transport, and social norms to delay care-seeking until a pregnancy is visible, particularly in the poorer districts of Kambia and Pujehun. Skilled delivery rates were lower (68.9%, 95% CI: 64.8–72.9%), particularly in Kambia and Tonkolili where TBAs are considered effective. Clean cord care, delaying first baths and immediate breastfeeding were inadequate across all districts. Timely postnatal checks were common among women with facility deliveries (94.1%, 95% CI: 91.9–96.6%) and their newborns (94.5%, 95% CI: 92.5–96.5%). Fewer women with home births received postnatal checks (53.6%, 95% CI: 46.2–61.3%) as did their newborns (75.8%, 95% CI: 68.9–82.8%). TBAs and practitioners are well-respected providers, and traditional beliefs impact many behaviours. Challenges remain with respect to maternal and neonatal health in Sierra Leone; these were likely exacerbated by service interruptions during the 2014–2016 Ebola Virus Disease epidemic. The reasons behind existing practices must be examined to identify appropriate strategies to improve maternal and newborn survival.

Abstractobjective To examine whether community health volunteers induced significant changes in care seeking and treatment of ill children under five 2 years after their deployment in two underserved districts of Sierra Leone.methods A pre-test-post-test study with intervention and comparison groups was used. A household cluster survey was conducted among caregivers of 5643 children at baseline and of 5259 children at endline.results In the intervention districts, treatments provided by community health volunteers increased from 0 to 14.3% for all three conditions combined (P < 0.001). Care seeking from an appropriate provider was not statistically significant (OR = 1.50, 95% CI: 0.88-2.54) between intervention and comparison districts and coverage of appropriate treatment increased in both study groups for all three illnesses. However, the presence of community health volunteers was associated with a 105% increase in appropriate treatment for pneumonia (OR = 2.05, 95% CI: 1.22-3.42) and a 55% drop in traditional treatment for diarrhoea (OR = 0.45, 95% CI: 0.21-0.96). Community health volunteers were also associated with fewer facility treatments for malaria (OR = 0.21, 95% CI: 0.07-0.62).conclusion After implementing free care, coverage for treatment for all three illnesses in both study groups improved. Deployment of community health volunteers was associated with a reduced treatment burden at facilities and less reliance on traditional treatments.keywords community health workers/volunteers, community case management, health care seeking

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In 2010, at the same time as the national roll out of the Free Health Care Initiative (FHCI), which removed user fees for facility based health care, trained community health volunteers (CHVs) were deployed to provide integrated community case management of diarrhea, malaria and pneumonia to children under 5 years of age (U5) in Kambia and Pujehun districts, Sierra Leone. After 2 years of implementation and in the context of FHCI, CHV utilization rate was 14.0 %. In this study, we examine the factors associated with this level of CHV utilization. A cross-sectional household-cluster survey of 1590 caregivers of 2279 children U5 was conducted in 2012; with CHV utilization assessed using a multiple logistic regression model. Focus groups and in-depth interviews were also conducted to understand communities' experiences with CHVs. Children with diarrhea (OR = 3.17, 95 % CI: 1.17-8.60), from female-headed households (OR = 4.55, 95 % CI: 1.88-11.00), and whose caregivers reported poor quality of care as a barrier to facility care-seeking (OR = 8.53, 95 % CI: 3.13-23.16) were more likely to receive treatment from a CHV. Despite low utilization, caregivers were highly familiar and appreciative of CHVs, but were concerned about the lack of financial remuneration for CHVs. CHVs remained an important source of care for children from female-headed households and whose caregivers reported poor quality of care at health facilities. CHVs are an important strategy for certain populations even when facility utilization is high or when facility services are compromised, as has happened with the recent Ebola epidemic in Sierra Leone.