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Background: From 2014 to 2016, the largest Ebola outbreak in history threatened Sierra Leone and its neighbouring countries, Guinea and Liberia. The Ebola outbreak impacted pregnant adolescent girl’s access to prenatal care during the pandemic. The aim of this study is to understand health-seeking behaviour among adolescent mothers who were pregnant during the Ebola epidemic in Waterloo, Sierra Leone. Methods: The present qualitative study uses the “Three Delay” model, as a theoretical framework to understand and explore adolescent mother’s health-seeking behaviour through four focus group discussions with five participants in each discussion group. The data were analysed using thematic analysis. Results: A multitude of challenges were identified following the Ebola epidemic. The fear of contracting Ebola was a common reason for not seeking care or utilising services. This notion was perpetuated by perceptions in the community and participants personal experiences. Quarantines, national lockdowns, roadblocks, loss of income and extreme poverty were also identified as barriers to accessing health facilities during Ebola. The different encounters with health workers and the challenges that arose at the health facilities were subsequently additional discouraging factors influencing participant’s decision not to seek health care. Conclusion: Many of the pre-existing maternal health, societal and social-economic challenges were exacerbated during the Ebola. The epidemic also contributed new challenges such as public fear, mistrust towards health professionals and the health system. Greater emphasis needs to be placed on improving maternal care in general, but also improving preparedness for maternal care in case of future outbreaks, especially for the most vulnerable groups such as adolescent mothers.
Sierra Leone has 4 provinces and 14 districts. The Western Area province is divided into an urban and rural district. The study was conducted in Waterloo, which is the capital in the Western Rural Area. The Western Rural Area has a population of 444,270, with (48.1%) of the population living in the Waterloo. The ethnic composition is predominantly Temne (48.7%) followed by a large minority of Mende (12.8%) and Limba (11.3%); and the majority of the population are Muslim (72%). Waterloo is one of five chiefdoms in the rural district [17]. The District Health Management Team (DHMT) has a total of 317 registered staff medical and non-medical staff working in health facilities in the District. The facilities available in Western Rural Area: 12 Community Health Centres (CHC), 20 Community Health Posts (CHP), 21 Maternal Child Health Post s (MCHP) and 1 hospital. Traditional medicine is also considered a part of the primary health care system in Sierra Leone. Western Rural Area reported the last two EVD cases on 20 April 2015. During the EVD, this area was considered an epicentre of the outbreak. The cumulative number of confirmed cases is 1164 for the area [18]. This study was a descriptive study design employing qualitative methods of data collection to explore attitudes and perceptions from adolescent mothers. This data was obtained in June 2016 and was guided by the framework of the “Three Delays” model to understand maternal outcome and how the EDV has influenced health-seeking behaviour and the utilisation of health services according to each delay: (1) deciding to seek appropriate medical help for an obstetric emergency; (2) reaching an appropriate obstetric facility; and (3) receiving adequate care when a facility is reached [19]. This study targeted adolescent mothers aged 15 to 24 who have been pregnant during the EVD outbreak from September 2014 to April 2015 and had been in contact with maternal health care services during their pregnancy or after childbirth. All participants were recruited through homogeneous sampling. With assistance from the local NGO coordinators in Waterloo who helped identify eligible participants. Twenty adolescent mothers were approached and recruited as participants. In a study with a relatively homogeneous population, using a semi-structured guide three Focus Group Discussions (FGDs) will likely capture 80% of the most broadly shared themes and topics [20]. The point of saturation was reached after 4 FGDs. Four FGDs with five participants in each group were employed as a primary mode of data collection to understand social norms, expectations, and experience and how community members form perceptions and attitudes to influence behaviour. The FGDs also aimed to produce group interactions and stimulate discussions based on shared experiences, realities, attitudes and perceptions toward health-seeking behaviour [20]. The duration of the FGDs was approximately 40–60 min. The principal researcher moderated all of the FGDs in the local language Krio which is a mixture of English and indigenous- and afro-descent language. The discussions were conducted in a local school building in a private office. All participants were recruited through in collaboration with ‘Health Alert’, an NGO known for its routine involvement and work with vulnerable girls and young women in Urban and Rural Western District Area. A focus group discussion guide was developed for the study to guide the conversations and provide prompts as attached in Additional file 1. Participants were also asked to comment on a short summary of the VSO report “Exploring the impact of the Ebola outbreak on routine maternal health services in Sierra Leone” [8]. The questions from the guide was also inspired by each delay in the Three Delay Model to help determine where improvements could best be made to reduce the risk of maternal mortality [19]. The guide was tested during a pilot semi-structured interview in order to help modify the questions. Data from the pilot interview was not included in the data set. The questions in the FGD guide included both broad open-ended questions regarding general perceptions on health care and specific questions regarding challenges relating to health care access. All the FGDs were audio-recorded and notes were taken during the FGDs to supplement the audio recording. The FGDs were transcribed verbatim, and translated from Krio to English by the first author. The transcripts were analysed in depth after re-reading the transcripts. Thematic analysis, as described by Braun and Clarke was found to be an appropriate framework for analysis due to the explorative nature of the study, the emergent design of the data collection, and the aim and objectives of the study [21]. Codes and themes were found manually by highlighting the transcript in sections and identifying the codes generated through the FGDs. The data were then rearranged according to the identified patterns. Furthermore, codes were then combined with more abstract sub-themes and themes. An inductive approach was used to find the correlation between codes, sub-theme, theme and the framework. Lastly, the dataset was re-read to ensure that themes correlated to the full dataset and that important data had not been missed.
