Identifying barriers to care and child mortality in urban and rural areas: a mixed method study in Sierra Leone.

BackgroundReducing mortality of children <5 years in Sierra Leone is a priority. Despite an enabling policy environment, health indicators have remained poor. Evidence on barriers to care is limited. ObjectivesThis study describes barriers to care, health-seeking behaviour, and health outcomes of children <5 years. MethodsFrom October 2016 to January 2017, we conducted a sequential mixed-methods study in urban and rural areas of Tonkolili District comprising: household survey targeting carers of children <5 years; and in-depth interviews (IDIs) targeting community leaders and healthcare workers (HCWs). We chose 30 clusters in urban and 30 clusters in rural areas. Topics that were identified during the survey were examined further through IDIs. ResultsWe surveyed 643 carers of 1092 children <5 years and conducted 72 IDIs. Of children <5 years, 62% had experienced febrile illness in the 2 weeks prior, and mortality was higher rurally (1.55/10,000/day vs urban 0.26/10,000/day). Barriers, including costs and physical inaccessibility of healthcare facilities, delayed or prevented 90% (287/318; 95%CI: 80-96) rural and 48% (155/325; 95%CI: 37-58) urban carers from accessing care for a febrile child. Mistrust of HCWs was frequent, primarily due to their requests for payment. HCWs described lack of pay and holistic support precluding provision of quality care. ConclusionsChildren <5 faced important barriers to healthcare, particularly in rural areas, contributing to high preventable mortality near to the emergency threshold. Access to healthcare was important to carers, however available services were costly and unreachable. Equally, HCWs experienced structural barriers to provide quality care. Key messagesO_LIChild <5years mortality near to the humanitarian emergency threshold and substantially high among rural children. C_LIO_LIInequity in healthcare access and inequality in health between urban and rural areas. C_LIO_LIBarriers, including costs of healthcare and physical inaccessibility of healthcare facilities, delayed or prevented 90% of rural and 48% of urban carers from accessing care for a febrile child. C_LIO_LIJust 8% of rural children <5 years used Long-Lasting Insecticide-Treated bednets. C_LIO_LIMistrust of healthcare workers was widely expressed primarily due to payment demanded for "free" healthcare. Healthcare workers described lack of pay and poor conditions precluding provision of quality care. C_LI