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Background In 2010, the government of Sierra Leone implemented the Free Health Care Initiative (FHCI) in the country with the objective of reducing the high maternal, infant, and child mortality rates and improving general health indicators. The objective of this study was to assess the trends in the prevalence of health care-seeking and to identify the determinants of healthcare service utilization by caregivers of children younger than five years. Methods The analysis of health-care-seeking behavior was done using data from four populationbased surveys in Sierra Leone before (2008) and after (2013, 2016, 2019) the FHCI was implemented. Care-seeking behavior was assessed with regard to caregivers seeking care for children under-five in the two weeks prior to each survey. We compared the percentages of healthcare-seeking behavior change and identify factors associated with healthcareseeking using a modified Poisson regression model with generalized estimating equations. Results In 2008, a total of 1208 children with fever were recorded, compared with 2823 children in 2013, 1633 in 2016, and 1464 in 2019. Care-seeking for children with fever was lowest in 2008 (51%; 95% CI (46.4-55.5)) than in 2013 (71.5%; 95% CI (68.4-74.5)), 2016 (70.3%; 95% CI (66.6-73.8)), and 2019 (74.6%; 95% CI (71.6-77.3)) (p < 0.001). Care-seeking in 2013, 2016 and 2019 was at least 1.4 time higher than in 2008 (p < 0.001) after adjusting for mother's age, wealth, religion, education level, household head and the child's age. Careseeking was lowest for children older than 12 months, mothers older than 35 years, children living in the poorest households, and in the northern region. A trend was observed for the sex of the household head. The level of care-seeking was lowest when the household head was a man. Conclusions The increase in healthcare-seeking for children under-five with fever followed the introduction of the FHCI in Sierra Leone. Care-seeking for fever varied by the child's age, caregiver's age, household wealth, the sex of the household head and region. Maintaining the FHCI with adequate strategies to address other barriers beyond financial ones is essential to reduce disparities between age groups, regions and, households.
This study used data from the Sierra Leone Demographic and Health Surveys (DHS) of 2008, 2013, and 2019 and the Malaria Indicator Survey (MIS) of 2016. These were nationally representative household surveys in which women aged 15 to 49 years were interviewed. The surveys used 3 questionnaires, a household questionnaire, a women’s (15–49 years old) questionnaire and a men’s (15–59 years old) questionnaire. Our study concerned children under the age of 5 years who had febrile episodes in the two last weeks preceding each survey in Sierra Leone. Sierra Leone is a country in West Africa with an area of 71,740 km2 and an estimated population in 2016 of 7,396,000 inhabitants [22]. The climate is tropical with vegetation ranging from savannah to forest. Sierra Leone is divided into 4 administrative regions: northern, eastern, southern, and western. The northern region was divided into North and North-west in 2019. These regions are subdivided into 14 districts, and into 16 from 2017. The health system is organized into 3 levels: The first is primary health care (PHC), with peripheral health units (PHUs): 233 community health centers (CHCs), 319 community health posts (CHPs), and 632 maternal and child health posts (MCHPs). The secondary level is made up of 21district hospitals [23]. The tertiary level includes regional and specialized hospitals. There are 6 hospitals in a teaching hospital complex established by an act of Parliament. There are several private clinics and hospitals spread across the 14 districts of the country. Wealth is not distributed equally within rural and urban areas. About 61% and 1.4% of the population are the richest respectively in the urban and in the rural areas, and about 3% and 28% of the population are the poorest respectively in the urban and in the rural areas [24]. The outcome variable was the proportion of children under-five years of age whose caregivers had sought care during a feverish illness in the 2 weeks preceding the survey. Independent variables included those describing sociodemographic data and those assessing the determinants of care-seeking for fever: respondent’s age (15−24, 25−34, and ≥35 years); level of education of the child’s mother (no formal education, primary, secondary, or higher level education); number of children ever born in the household (1−2, 3−4, and 5≥ children); the sex of the head of the child’s household; the age of the head of the household (15−24, 25–34, and ≥35 years); region (eastern, northern, southern, western, and northwestern in 2019); place of residence (urban or rural); religion (Christian, Muslim, traditional, or other); the sex of the child; the age of the child (<12, 12−35, and 36–59 months); and the place where health care is sought (public, private, traditional, or other). The wealth quintile (richest, richer, middle, poorer, and poorest) was used; its construction was based on survey data about the household’s ownership of consumer goods, dwelling characteristics, drinking water source, toilet facilities, and other characteristics that relate to a household’s socioeconomic status. The resulting combined wealth index has a mean of 0 and a standard deviation of 1. Once the index was computed, national-level wealth quintiles (from lowest to highest) were obtained by assigning household scores to each de jure household member, ranking each person in the population by their score, and then dividing the ranking into 5 equal categories, each comprising 20% of the population [24]. The four Sierra Leone population-based surveys used a 2-stage cluster sampling method. Enumeration areas (EAs) were constructed with complete coverage of the country. Each EA included several households. At the first stage, EAs were selected with stratified probability proportional to sample size. The place of residence (urban or rural) was used to stratify EAs. At the secondary stage, households were selected from the EAs using systematic random sampling. The frames were developed based on the 2004 census for the 2008 and 2013 surveys and the 2015 census for the 2016 and 2019 surveys [24–26]. Statistical analyses were performed using Stata version 15.0. The northern region was divided into North and North-west in 2019, for the comparison purpose with the 2008, 2013, and 2016 data, these 2 regions were combined during data analysis. We first described the characteristics of parents of children and those of children with fever during the two weeks preceding the survey. Chi-square test was used to assess differences between participants’ characteristics over the surveys. The descriptive analyses were weighted for probability sampling and considering stratification and clustering, as is standard in all DHS program surveys [24,25,27]. We compared the percentages of care-seeking between the four surveys adjusting for the participants’ characteristics using a multivariable modified Poisson regression model with generalized estimating equations. We also performed a modified Poisson regression model using a generalized estimating equations to identify the determinants of care-seeking under the FHCI (2013–2019). A two-sided P-value of 0.05 or less was considered to indicate statistical significance. The Sierra Leone National Ethics Committee and the International Review Board of International Coach Federation (ICF) approved the use of the surveys, and the participants’ written consent was obtained before data collection. We were authorized by the Demographic and Health Survey program to access data at https://dhsprogram.com/data.
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