Open Access Open Badges Research article

Healthcare seeking for diarrhoea, malaria and pneumonia among children in four poor rural districts in Sierra Leone in the context of free health care: results of a cross-sectional survey

Theresa Diaz1*, Asha S George12, Sowmya R Rao34, Peter S Bangura5, John B Baimba6, Shannon A McMahon2 and Augustin Kabano6

Author Affiliations

1 Knowledge Management and Implementation Research Unit, Health Section, Programme Division, United Nations Children’s Fund (UNICEF), NY, New York, USA

2 Department of International Health, Bloomberg School of Public Health, John Hopkins University, Baltimore, MD, USA

3 Statisticians without Borders, American Statistical Society, Department of Quantitative Health Sciences, University of Massachusetts Medical School, MA, Worcester, USA

4 Center for Health Quality, Outcomes, and Economics Research, Bedford VA Medical Center, Bedford, MA, USA

5 Statistics Sierra Leone, Freetown, Sierra Leone

6 United Nations Children Fund (UNICEF), Freetown, Sierra Leone

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BMC Public Health 2013, 13:157  doi:10.1186/1471-2458-13-157

Published: 20 February 2013



To 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.


In 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.


The 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.


We 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.