Integrated Strategies Addressing Predisposing, Enabling, and Illness-Level Factors Influencing Healthcare-Seeking Behavior among Pregnant Women and Newborn Mothers: Insights from Sierra Leone

Integrated Strategies Addressing Predisposing, Enabling, and Illness-Level Factors Influencing Healthcare-Seeking Behavior among Pregnant Women and Newborn Mothers: Insights from Sierra Leone | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Integrated Strategies Addressing Predisposing, Enabling, and Illness-Level Factors Influencing Healthcare-Seeking Behavior among Pregnant Women and Newborn Mothers: Insights from Sierra Leone Rennie Viah, Ansumana Rashid This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6618062/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 12 You are reading this latest preprint version Abstract Background Maternal and newborn health outcomes in Sierra Leone remain among the poorest globally, driven by a complex interplay of socio-demographic, systemic, and behavioral factors. Understanding how integrated strategies influence healthcare-seeking behavior is critical for tailoring interventions that reduce delays and improve maternal outcomes. This study aimed to identify high-impact strategies addressing predisposing, enabling, and illness-level factors that affect maternal and newborn healthcare-seeking behavior in Bo District, Sierra Leone. Methods A descriptive cross-sectional study was conducted at Bo Government Hospital (urban) and Tikonko Maternity Home (rural) between January – May 2024. Using simple random sampling, 500 participants (294 pregnant women and 206 mothers of children under five) were selected from facility attendance lists. Quantitative data was collected through structured interviews using a digital questionnaire administered via the ONA platform. Descriptive analysis was performed using SPSS version 26 to identify patterns in healthcare-seeking preferences and perceived effectiveness of integrated health strategies. Results The mean age of pregnant participants was 24.83 years (SD = 4.74), and the average household income showed substantial disparity (Mean = 335.03 NLE; SD = 668.49). Regarding predisposing factors, the preferred strategies included prenatal education (25.91%) and community outreach for early antenatal care (24.12%). Enabling factors were most influenced by transportation support (24.6%) and access to affordable care (24.21%). Illness-level strategies prioritized by participants included strengthening maternal health surveillance systems (27.55%) and prenatal screening services (23.08%). Education level, income, and parity were key determinants of healthcare-seeking behavior. Conclusion Integrated strategies that combine health education, community outreach, logistical and financial support, and health system strengthening are the most effective in influencing maternal and newborn healthcare-seeking behavior. Culturally tailored, equitable, and evidence-informed approaches help improve maternal health service utilization in low-resource settings like Sierra Leone. Healthcare-seeking behavior Integrated strategies Predisposing Factors Enabling Factors Illness-Level Factors Figures Figure 1 Figure 2 Figure 3 Figure 4 INTRODUCTION Despite considerable progress in maternal and newborn health across sub-Saharan Africa, Sierra Leone continues to confront persistent and alarming disparities in healthcare access, particularly for pregnant women and mothers of newborns. In 2023, the country reported a maternal mortality rate of 443 deaths per 100,000 live births, one of the highest globally [ 1 , 2 ]. This sobering statistic reflects deep-rooted systemic challenges, including inadequate healthcare infrastructure, a shortage of skilled healthcare personnel, and wide socio-economic inequalities between urban and rural communities. Understanding the multifaceted nature of healthcare services utilization is crucial for comprehending the factors influencing pregnant women's and newborn mothers’ health-seeking behavior. The Andersen Behavioral Model, a widely accepted framework, proposes a comprehensive understanding of healthcare utilization through three main levels: Predisposing, Enabling, and Illness. This model has been instrumental in analyzing disparities in maternal health service utilization, particularly in low- and middle-income countries, as in the case of Sierra Leone, where factors such as socioeconomic status, education, and access to healthcare facilities significantly influence maternal health outcomes [ 3 – 6 ] Examining the various factors that influence maternal healthcare-seeking behavior becomes essential in the complex landscape of Sierra Leone. The factors are categorized into predisposing factors (education, beliefs, and age), enabling factors (income, transport, and healthcare access), and illness-level factors (perceived severity of health issues or pregnancy complications). A nuanced understanding of how these dimensions shape healthcare-seeking behaviors is key to designing effective maternal and child health interventions. The study identified and investigated integrated strategies that can effectively influence or mitigate the barriers at each level. These strategies include community health education, mobile clinics, financial support systems, culturally sensitive care, improved maternal surveillance, and early diagnostic services. By exploring the priorities, experiences, and perspectives of 500 pregnant women and newborn mothers in Bo District, this research provides context-specific insights into the design of holistic, equitable, and impactful maternal health programs. The findings have implications not only for national policy but also for broader regional efforts to reduce maternal mortality and improve maternal and newborn outcomes in low-resource settings. MATERIALS AND METHODS Study Design A descriptive cross-sectional study design was used to assess how integrated strategies influence healthcare-seeking behavior. This design allowed for quantitative data collection within a defined period, facilitating the analysis of patterns, barriers, and the effectiveness of specific health system interventions across diverse socio-demographic groups. Study Setting and Population The research was conducted in Bo District, Southern Sierra Leone, at two contrasting healthcare facilities: Bo Government Hospital (urban, tertiary-level) and Tikonko Maternity Home (rural, primary-level). These sites were strategically selected to capture variations in access and healthcare-seeking behavior across urban and rural contexts. The study population included pregnant women and mothers of children under five who had accessed antenatal, postnatal, or child health services at the selected facilities during the study period. Eligibility Criteria and Sampling Inclusion criteria required participants to be residents of Bo District for at least six months and to have accessed healthcare services at either of the two selected facilities. Exclusion criteria included inability to provide informed consent or lack of service utilization at the time of data collection. A simple random sampling technique was employed using daily service attendance lists to select participants. This approach ensured broad representation across geographic and socio-demographic groups. Sample Size Determination The sample size was calculated using Cochran’s formula for cross-sectional studies: n₀ = (Z² × p (1 - p)) / e² Where: Z = 1.96 (standard normal deviate for 95% confidence level) p = 0.5 (maximum variability assumption) e = 0.05 (desired margin of error) Based on this formula, a minimum sample size of 370 was determined. To address potential non-responses and incomplete data, a 26% buffer was added, yielding a final sample of 500 participants (294 pregnant women and 206 mothers of young children). Data Collection Procedures Data was collected through face-to-face interviews using a structured digital questionnaire administered via the ONA platform. The questionnaire was pre-tested and translated into local languages. Interviews were conducted by trained research assistants in private settings to ensure confidentiality and reduce response bias. Data collection protocols adhered to ethical standards, and quality assurance was maintained through supervisory oversight. Ethical Considerations The Njala University Institutional Ethics Review Board granted ethical approval for the study. Written informed consent was obtained from all participants before participation. The study complied with the ethical standards outlined in the Declaration of Helsinki. Participation was voluntary, and respondents were informed of their right to withdraw without repercussion. The manuscript is original, not under consideration elsewhere, and does not involve any animal experimentation. There are no known financial or non-financial conflicts of interest to disclose. Data Analysis Data was exported from the ONA platform and analyzed using SPSS version 26. Descriptive statistics, including frequencies, percentages, means, and standard deviations, were used to summarize participant demographics and responses. No inferential statistical tests were performed, as the study focused on descriptive analysis to illustrate patterns in healthcare-seeking behavior. RESULTS This section presents the descriptive analysis of the study participants' predisposing and enabling socio-demographic characteristics, which are central to understanding healthcare decision-making patterns among pregnant women and newborn mothers in Sierra Leone. Table 1 summarizes key demographic and socio-economic factors. Among the 500 participants, the mean age of pregnant women was 24.83 years (SE = 0.28, SD = 4.74), with the median and mode at 25 years. The age of mothers with newborns or children was slightly lower, with a mean of 24.07 years (SE = 0.30, SD = 4.34), a median of 23 years, and a mode of 20 years. This relatively young population indicates a critical need for early and sustained reproductive health interventions. Education levels varied, with most respondents (53.6%) attaining secondary education, 28.4% having primary education, and only 8% having tertiary education. A notable 10% had no formal education, signaling potential barriers to healthcare literacy and informed decision-making. Monthly household income showed wide disparities, with a mean income of 335.03 New Leones (NLE), a high standard deviation of 668.49, and a range from 0 to 10,000 NLE. This substantial income variability reflects significant economic inequalities that may affect access to healthcare services. The average number of pregnancies reported was 1.83 (SE = 0.05, SD = 1.05), with values ranging from one to over seven pregnancies. These highlights differing levels of maternal experience, which may influence risk perception and health-seeking behavior. These findings provide a foundational understanding of the predisposing and enabling factors relevant to healthcare utilization decisions, which are further explored in the discussion through integrated strategies (see Table 1 ). Table 1 Predisposing and Enabling Socio-Demographic Factors of Participants Category Sub-Category Frequency (n = 500) Percent (%) Statistical Summary Age of Pregnant Women Mean — — Mean = 24.83 (SE = 0.28, SD = 4.74, Range: 16–45, 95% CI = ± 0.54) Median — — Median = 25 Mode — — Mode = 25 Age of Newborn Mothers Mean — — Mean = 24.07 (SE = 0.30, SD = 4.34, Range: 17–45, 95% CI = ± 0.60) Median — — Median = 23 Mode — — Mode = 20 Education Level No Formal Education 50 10.00 Primary Education 142 28.40 Secondary Education 268 53.60 Tertiary Education 40 8.00 Monthly Income (NLE) Mean — — Mean = 335.03 (SE = 29.90, SD = 668.49, Range: 0–10,000, 95% CI = ± 58.74) Pregnancies Experienced Mean — — Mean = 1.83 (SE = 0.05, SD = 1.05, Range: 1–7+, 95% CI = ± 0.09) INTEGRATED APPROACHES TO STRENGTHEN PREDISPOSING FACTORS Figure 1 presents responses from participants regarding which integrated approaches most effectively strengthen predisposing factors that influence healthcare-seeking decisions. The responses were recorded across five intervention strategies, providing insight into maternal preferences and perceived impact. High-Impact Strategies The most frequently cited strategy was increasing access to prenatal education programs (25.91%), reflecting a strong demand for knowledge-based empowerment. This approach equips women with essential information on pregnancy, childbirth, and newborn care, helping them make timely and informed decisions. Closely following, community outreach programs to promote early antenatal care (24.12%) were also highly emphasized. These initiatives foster early engagement with healthcare services, particularly in rural or marginalized communities, where delayed first contact often leads to adverse outcomes. Moderate-Impact Strategy Culturally sensitive prenatal counseling (21.53%) emerged as a valued approach for improving the patient-provider relationship. By tailoring services to the cultural norms and beliefs of expectant mothers, this strategy helps reduce stigma, builds trust, and enhances service acceptability. Although not as prioritized as education or outreach, its importance lies in creating a respectful and responsive care environment. Low-Impact Strategy Financial incentives for regular check-ups (16.61%) were noted as useful in reducing economic barriers. While incentives can increase attendance at health facilities, the relatively lower frequency suggests that women may value knowledge and supportive outreach more than direct monetary support when deciding to seek care. Least-Impact Strategy Improving access to family planning services (11.83%) was the least prioritized intervention. Despite its preventive potential in reducing high-risk and unintended pregnancies, this approach may receive less attention in the context of immediate maternal care. The result signals a need for better integration of family planning into antenatal and postnatal education programs. INTEGRATED APPROACHES TO STRENGTHEN ENABLING FACTORS Figure 2 summarizes the responses, with strategies categorized according to their frequency of selection. High-Impact Strategies Responses were recorded across five enabling factor categories. The most cited initiative was the enhancement of transportation options for pregnant women and mothers, which accounted for 24.6% of responses. This finding indicates a high prioritization of logistical support to facilitate timely access to healthcare services. The second most emphasized strategy was the expansion of access to affordable maternal healthcare services, receiving 24.21% of total responses. This underscores the relevance of cost-related barriers in shaping maternal healthcare-seeking behavior and suggests that affordability remains a central concern for women across different socio-economic backgrounds. Moderate-Impact Strategies Closely following were strategies focused on community-level engagement and financial protection. Specifically, 22.76% of respondents highlighted the importance of establishing community-based support groups, while 22.16% favored the provision of subsidies for maternal and child health insurance coverage. These approaches reflect the perceived value of both social and financial support systems in promoting consistent and equitable maternal health access. Low-Impact Strategies Finally, a smaller proportion of participants (6.27%) suggested offering flexible work arrangements to enable pregnant women to attend antenatal appointments. While acknowledged, this strategy received comparatively less emphasis, possibly due to limited applicability in informal employment settings or a lack of awareness regarding its benefits. INTEGRATED APPROACHES TO STRENGTHEN ILLNESS FACTORS INFLUENCING Healthcare-Seeking Behavior Figure 3 presents participants’ perceptions of the most impactful strategies for strengthening illness-level factors within maternal and newborn healthcare settings. These strategies are foundational to addressing complications, improving outcomes, and reducing preventable morbidity and mortality. High-Impact Strategies The most frequently cited approach was to strengthen maternal and child health surveillance systems (27.55%). Respondents emphasized the importance of systematic tracking and data collection to monitor pregnancy outcomes, identify risk factors early, and implement timely clinical interventions. Robust surveillance enables targeted responses in high-risk groups and supports evidence-based resource allocation, aligning with global maternal health monitoring recommendations. The second most prioritized strategy was improving access to prenatal screening and diagnostic services for high-risk pregnancies (23.08%). This reflects growing awareness of the role early detection plays in reducing maternal and perinatal complications. Access to quality diagnostic tools can facilitate timely referral, better birth preparedness, and tailored clinical care, particularly for women at elevated risk. Moderate-Impact Strategies A substantial portion of participants (21.69%) highlighted the need to increase the availability of skilled birth attendants and emergency obstetric care facilities. While this intervention is well-recognized globally, its moderate ranking suggests ongoing disparities in availability, particularly in rural or underserved areas. The presence of skilled attendants during childbirth is a proven factor in preventing maternal and neonatal deaths, especially when supported by functional emergency services. In addition, enhancing postnatal care services to detect and manage complications in newborns received 18.16% of responses. While less emphasized than antenatal care or childbirth interventions, postnatal care remains essential for managing neonatal complications, promoting healthy development, and offering maternal support in the critical weeks following delivery. Low-Impact Strategies The implementation of breastfeeding promotion campaigns and lactation support services was the least frequently cited strategy (9.52%). Although breastfeeding is vital for child survival, nutrition, and immunity, its relatively low prioritization may reflect a gap in public understanding or program availability. Strengthening lactation support could improve infant outcomes and should be viewed as an integral part of comprehensive maternal and child health programming. Figure 4 reveals that Community-Based Education (14%) and Maternal and Child Health Clinics (10%) were identified as the most impactful strategies in addressing predisposing factors by enhancing awareness, knowledge, and early facility contact. Early Antenatal Care (9.4%) also supports predisposing factors , emphasizing the importance of timely engagement and risk identification. Strategies targeting enabling factors , such as Financial Support Programs (8%), Community Health Workers (7.6%), and Incentive Programs (7.3%), were moderately impactful, highlighting the relevance of economic and logistical support in improving service uptake. Meanwhile, illness-level factors were addressed through moderate support for Mental Health Services (7.9%) and Telehealth Services (6.7%), while strategies like Emergency Preparedness (4.1%) and Transportation Facilities (4.2%) were perceived as least impactful, indicating potential areas for increased investment and awareness. DISCUSSION EMPOWERING WOMEN THROUGH EDUCATION AND COMMUNITY ENGAGEMENT Prenatal education programs (25.91%) and community outreach for early ANC (24.12%) were identified as the most effective strategies for strengthening predisposing factors that would influence maternal healthcare-seeking behavior. These findings suggest that knowledge-based interventions and early engagement empower women to make timely, informed decisions about their health and that of their newborns. This aligns with evidence from cross-sectional studies conducted in sub-Saharan Africa, which emphasize the role of community health education in increasing service uptake and reducing maternal mortality. For example, a community-based study in rural Sierra Leone demonstrated that structured prenatal education sessions improved women’s decision-making autonomy and increased antenatal care attendance [ 7 ]. Similarly, outreach programs supported by community health workers have been shown to increase ANC utilization and trust in facility-based services [ 8 , 9 ]. Culturally sensitive prenatal counseling (21.53%) reinforces the importance of respectful care. Evidence from qualitative research confirms that alignment with cultural norms enhances the acceptability of maternal services and reduces delays in seeking care [ 10 ]. ADDRESSING FINANCIAL AND LOGISTICAL BARRIERS TO CARE For enabling factors, respondents prioritized enhancing transportation (24.6%) and expanding access to affordable maternal services (24.21%). These results underline the ongoing burden of distance and cost, particularly in rural and underserved areas of the Bo District. This is well-supported by findings from health systems reviews and policy evaluations, which document that transportation delays and high out-of-pocket costs are leading contributors to maternal deaths in low-resource settings [ 11 , 12 ]. Systematic reviews have consistently shown that reducing transport barriers through community emergency transport schemes and improving affordability via fee exemptions or insurance schemes significantly increase ANC attendance and reduce obstetric complications [ 13 , 14 ]. Community-level strategies, such as support groups (22.76%) and subsidies for maternal health insurance (22.16%), were also valued, aligning with mixed-methods implementation research showing that social and financial protection mechanisms reduce inequality and improve care continuity. STRENGTHENING HEALTH SYSTEMS FOR IMPROVED OUTCOMES Concerning illness-level factors, the top strategy was strengthening maternal and child health surveillance systems (27.55%), followed by improving access to prenatal screening and diagnostic services (23.08%). These findings reflect strong support for early detection and clinical monitoring as core components of maternal and newborn safety. These results are consistent with findings from longitudinal cohort studies and implementation research emphasizing the importance of robust surveillance and diagnostic systems. For instance, longitudinal maternal tracking in Ghana and Sierra Leone has been associated with early referral and lower maternal complications [ 15 , 16 ]. Strengthening surveillance systems allows healthcare providers to proactively identify high-risk cases, allocate resources, and ensure follow-up care, all of which are essential for improving outcomes in fragile health systems. Skilled birth attendance and emergency obstetric care (21.69%) and enhanced postnatal services (18.16%) also ranked moderately. These align with global evidence-based guidelines indicating that the presence of skilled personnel and postnatal continuity of care is critical to reducing neonatal deaths [ 11 ]. Breastfeeding support and lactation services (9.52%) were the least prioritized strategy, signaling potential under-recognition despite their well-documented benefits in newborn nutrition and immunity. This gap highlights the need for integrated postnatal counseling and education on infant feeding. CONCLUSION The study reveals that an integrated strategy approach, centered on education, culturally sensitive engagement, financial protection, transportation, surveillance, and diagnostics, is key to addressing the multi-level factors influencing maternal healthcare-seeking behavior in Bo District, Sierra Leone. These findings are consistent with a growing body of recent evidence underscoring that health system responsiveness, cultural alignment, and structural access are all essential to improving maternal and newborn outcomes in low-income contexts. Declarations FUNDING DECLARATION The study was a self-initiative that formed part of the requirements for the Degree of Doctor of Philosophy in Public Health. The study was self-funded and didn’t receive any funding from other sources. Author Contribution R.V. (Rennie Viah) conceptualized the study, developed the research design, conducted the fieldwork, performed the data analysis, and wrote the main manuscript text. He also prepared all figures (1–4) and Table 1. R.A. (Rashid Ansumana) supervised the research process, provided guidance throughout the study, and reviewed the manuscript for intellectual content. All authors read and approved the final version of the manuscript. Acknowledgement I sincerely thank Mr. Emmanuel Finoh for his key role in training and supervising the data collection team. I also appreciate the nine senior public health students and the graduate community health officer from Njala University who served as enumerators. Gratitude is extended to the nursing and midwifery staff at Tikonko Village Health Center and Bo Government Hospital for their valuable support. Special thanks to the College of Health and Medical Sciences at Njala University for reviewing and approving this research. Lastly, I am grateful to all participants whose involvement made this study possible. Data Availability All data pertaining to the study are provided within the manuscript. References Ministry of Health and Sanitation. (2024). National Health Sector Strategic Plan 2021–2025 . https://mohs.gov.sl UNICEF. (2023). Maternal, Neonatal, Child and Adolescent Health in Sierra Leone . https://www.unicef.org/sierraleone/maternal-neonatal-child-and-adolescent-health Bobo FT, Yesuf EA, Woldie M. Inequities in utilization of reproductive and maternal health services in Ethiopia. Int J Equity Health. 2017;16:105. https://doi.org/10.1186/s12939-017-0602-2 . Baten A, Biswas RK, Kendal E, Bhowmik J. Utilization of maternal healthcare services in low- and middle-income countries: a systematic review and meta-analysis. Syst Reviews. 2025;14:88. https://doi.org/10.1186/s13643-025-02123-4 . Mebratie AD. Receipt of core antenatal care components and associated factors in Ethiopia: a multilevel analysis. Front Global Women's Health. 2024;4:1169347. https://doi.org/10.3389/fgwh.2024.1169347 . Bulcha G, Gutema H, Amenu D, Birhanu Z. Maternal health service utilization in the Jimma Zone, Ethiopia: results from a baseline study for mobile phone messaging interventions. BMC Pregnancy Childbirth. 2024;24:485. https://doi.org/10.1186/s12884-024-06683-w . Bangura S, Bah AJ, Kanu R. Impact of maternal health education on ANC uptake in rural Sierra Leone: A cross-sectional study. BMC Pregnancy Childbirth. 2023;23:119. https://doi.org/10.1186/s12884-023-05564-7 . ICAP at Columbia University. (2024). Community in Sierra Leone shows zero maternal deaths after three years of successful maternal health program. https://icap.columbia.edu/news-events/community-in-sierra-leone-shows-zero-maternal-deaths-after-three-years-of-successful-maternal-health-program/ El Ayadi AM, et al. Community engagement for maternal health equity: A realist review. Global Health Res Policy. 2021;6:5. https://doi.org/10.1186/s41256-021-00187-y . Olayo R, et al. Cultural factors influencing maternal health-seeking in rural Kenya: A qualitative study. Reproductive Health. 2022;19:165. https://doi.org/10.1186/s12978-022-01475-3 . World Health Organization (WHO). (2022). Strategies toward ending preventable maternal mortality (EPMM). https://www.who.int/publications/i/item/9789240068395 Médecins Sans Frontières (MSF). (2019). Reducing maternal and child morbidity and mortality in Sierra Leone. https://mohs2017.files.wordpress.com/2017/10/msf_reducing-maternal-and-child-morbidity-and-mortality-in-sierra-leone_web.pdf Balde MD, et al. Transport-related barriers to maternal health services in sub-Saharan Africa: A systematic review. Tropical Med Int Health. 2021;26(3):221–31. https://doi.org/10.1111/tmi.13523 . Kazanga I, et al. The effects of removing user fees for maternal care in sub-Saharan Africa: A systematic review. Int J Equity Health. 2022;21:135. https://doi.org/10.1186/s12939-022-01729-1 . Elston JWT, et al. Integrating public health approaches in the management of maternal health: Lessons from Sierra Leone. BMJ Global Health. 2022;7:e009234. https://doi.org/10.1136/bmjgh-2021-009234 . UNICEF Sierra Leone. (2021). Scaling up quality of care for maternal and newborn health in Sierra Leone. https://www.unicef.org/stories/making-strides-maternal-health-worst-place-to-be-mother Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6618062","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":503138818,"identity":"db68685b-d183-491d-a9f4-55e95caed613","order_by":0,"name":"Rennie Viah","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA20lEQVRIiWNgGAWjYLCCBAYGHgYJ5gNApoQMKVrYEkBaeEiwSoLHAEQR1mLe3nvswYOKwzL8s3s+v7pRY8HDwH746AZ8WmTOnEs3SDhzmEfiztlt1jnHgA7jSUu7gdc5EjlmEoltaTwMN3K3GeewAbVI8Jjh1yL/BqjlXxqP/I2cZ8Y5/4jRAlQgkdhgw2NwI4f5cW4bMVp4gA5LOGbDY3gjzYw5t0+Ch42gX9jPmEn+qJGwl7uR/Phzzrc6OX72w8fwakEGbBJgkljlIMD8gRTVo2AUjIJRMHIAALgaQJJPKi3zAAAAAElFTkSuQmCC","orcid":"","institution":"Njala University","correspondingAuthor":true,"prefix":"","firstName":"Rennie","middleName":"","lastName":"Viah","suffix":""},{"id":503138819,"identity":"dffd6fa5-aca2-4c7a-bf30-4cc05f10a5ee","order_by":1,"name":"Ansumana Rashid","email":"","orcid":"","institution":"Njala University","correspondingAuthor":false,"prefix":"","firstName":"Ansumana","middleName":"","lastName":"Rashid","suffix":""}],"badges":[],"createdAt":"2025-05-08 07:53:26","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6618062/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6618062/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":89986724,"identity":"4771425a-8558-40aa-8e6f-cdd65847029d","added_by":"auto","created_at":"2025-08-27 06:55:57","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":82758,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eIntegrated approaches to strengthen predisposing factors\u003c/em\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6618062/v1/dccb2f720397361d1a46ac52.png"},{"id":89986721,"identity":"f34242bf-0da6-4b50-a388-7baad6ad69a1","added_by":"auto","created_at":"2025-08-27 06:55:57","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":68577,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eIntegrated Approaches to Strengthen Enabling Factors\u003c/em\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6618062/v1/93f3b5a394521c0cdcc9bf9d.png"},{"id":89988376,"identity":"4ccb3156-d1f1-4de1-b671-bb0f0d054fdc","added_by":"auto","created_at":"2025-08-27 07:03:57","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":64882,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eIntegrated Approaches to Strengthen Illness Factors Among Pregnant Women and Newborn Mothers\u003c/em\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-6618062/v1/172970302c6ab47f5d143cd8.png"},{"id":89986732,"identity":"eb43de2a-c11c-4e03-90fb-064843f78b98","added_by":"auto","created_at":"2025-08-27 06:55:57","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":76414,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eIntegrated Strategies that Effectively Address Predisposing, Enabling, and Illness-Level Factors Influencing Healthcare Services Decision-Making Process of Pregnant Women and Newborn Mothers\u003c/em\u003e\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-6618062/v1/2f418dab70acb6a6b0b10b09.png"},{"id":89990410,"identity":"6275ea6b-e69b-4d2d-9259-6289bee09523","added_by":"auto","created_at":"2025-08-27 07:11:57","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1083796,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6618062/v1/3f819a25-1cbf-4244-9f93-28c27835fcf0.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eIntegrated Strategies Addressing Predisposing, Enabling, and Illness-Level Factors Influencing Healthcare-Seeking Behavior among Pregnant Women and Newborn Mothers: Insights from Sierra Leone\u003c/p\u003e","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eDespite considerable progress in maternal and newborn health across sub-Saharan Africa, Sierra Leone continues to confront persistent and alarming disparities in healthcare access, particularly for pregnant women and mothers of newborns. In 2023, the country reported a maternal mortality rate of 443 deaths per 100,000 live births, one of the highest globally [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. This sobering statistic reflects deep-rooted systemic challenges, including inadequate healthcare infrastructure, a shortage of skilled healthcare personnel, and wide socio-economic inequalities between urban and rural communities.\u003c/p\u003e\u003cp\u003eUnderstanding the multifaceted nature of healthcare services utilization is crucial for comprehending the factors influencing pregnant women's and newborn mothers\u0026rsquo; health-seeking behavior. The Andersen Behavioral Model, a widely accepted framework, proposes a comprehensive understanding of healthcare utilization through three main levels: Predisposing, Enabling, and Illness. This model has been instrumental in analyzing disparities in maternal health service utilization, particularly in low- and middle-income countries, as in the case of Sierra Leone, where factors such as socioeconomic status, education, and access to healthcare facilities significantly influence maternal health outcomes [\u003cspan additionalcitationids=\"CR4 CR5\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eExamining the various factors that influence maternal healthcare-seeking behavior becomes essential in the complex landscape of Sierra Leone. The factors are categorized into predisposing factors (education, beliefs, and age), enabling factors (income, transport, and healthcare access), and illness-level factors (perceived severity of health issues or pregnancy complications). A nuanced understanding of how these dimensions shape healthcare-seeking behaviors is key to designing effective maternal and child health interventions.\u003c/p\u003e\u003cp\u003eThe study identified and investigated integrated strategies that can effectively influence or mitigate the barriers at each level. These strategies include community health education, mobile clinics, financial support systems, culturally sensitive care, improved maternal surveillance, and early diagnostic services.\u003c/p\u003e\u003cp\u003eBy exploring the priorities, experiences, and perspectives of 500 pregnant women and newborn mothers in Bo District, this research provides context-specific insights into the design of holistic, equitable, and impactful maternal health programs. The findings have implications not only for national policy but also for broader regional efforts to reduce maternal mortality and improve maternal and newborn outcomes in low-resource settings.\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy Design\u003c/h2\u003e\u003cp\u003eA descriptive cross-sectional study design was used to assess how integrated strategies influence healthcare-seeking behavior. This design allowed for quantitative data collection within a defined period, facilitating the analysis of patterns, barriers, and the effectiveness of specific health system interventions across diverse socio-demographic groups.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eStudy Setting and Population\u003c/h3\u003e\n\u003cp\u003eThe research was conducted in Bo District, Southern Sierra Leone, at two contrasting healthcare facilities: Bo Government Hospital (urban, tertiary-level) and Tikonko Maternity Home (rural, primary-level). These sites were strategically selected to capture variations in access and healthcare-seeking behavior across urban and rural contexts. The study population included pregnant women and mothers of children under five who had accessed antenatal, postnatal, or child health services at the selected facilities during the study period.\u003c/p\u003e\n\u003ch3\u003eEligibility Criteria and Sampling\u003c/h3\u003e\n\u003cp\u003eInclusion criteria required participants to be residents of Bo District for at least six months and to have accessed healthcare services at either of the two selected facilities. Exclusion criteria included inability to provide informed consent or lack of service utilization at the time of data collection. A simple random sampling technique was employed using daily service attendance lists to select participants. This approach ensured broad representation across geographic and socio-demographic groups.\u003c/p\u003e\n\u003ch3\u003eSample Size Determination\u003c/h3\u003e\n\u003cp\u003eThe sample size was calculated using Cochran\u0026rsquo;s formula for cross-sectional studies:\u003c/p\u003e\u003cp\u003en₀ = (Z\u0026sup2; \u0026times; p (1 - p)) / e\u0026sup2;\u003c/p\u003e\u003cp\u003eWhere:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eZ\u0026thinsp;=\u0026thinsp;1.96 (standard normal deviate for 95% confidence level)\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.5 (maximum variability assumption)\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003ee\u0026thinsp;=\u0026thinsp;0.05 (desired margin of error)\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eBased on this formula, a minimum sample size of 370 was determined. To address potential non-responses and incomplete data, a 26% buffer was added, yielding a final sample of 500 participants (294 pregnant women and 206 mothers of young children).\u003c/p\u003e\n\u003ch3\u003eData Collection Procedures\u003c/h3\u003e\n\u003cp\u003eData was collected through face-to-face interviews using a structured digital questionnaire administered via the ONA platform. The questionnaire was pre-tested and translated into local languages. Interviews were conducted by trained research assistants in private settings to ensure confidentiality and reduce response bias. Data collection protocols adhered to ethical standards, and quality assurance was maintained through supervisory oversight.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eEthical Considerations\u003c/h2\u003e\u003cp\u003e The Njala University Institutional Ethics Review Board granted ethical approval for the study. Written informed consent was obtained from all participants before participation. The study complied with the ethical standards outlined in the Declaration of Helsinki. Participation was voluntary, and respondents were informed of their right to withdraw without repercussion. The manuscript is original, not under consideration elsewhere, and does not involve any animal experimentation. There are no known financial or non-financial conflicts of interest to disclose.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003eData Analysis\u003c/h2\u003e\u003cp\u003eData was exported from the ONA platform and analyzed using SPSS version 26. Descriptive statistics, including frequencies, percentages, means, and standard deviations, were used to summarize participant demographics and responses. No inferential statistical tests were performed, as the study focused on descriptive analysis to illustrate patterns in healthcare-seeking behavior.\u003c/p\u003e\u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eThis section presents the descriptive analysis of the study participants' predisposing and enabling socio-demographic characteristics, which are central to understanding healthcare decision-making patterns among pregnant women and newborn mothers in Sierra Leone.\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e summarizes key demographic and socio-economic factors. Among the 500 participants, the mean age of pregnant women was 24.83 years (SE\u0026thinsp;=\u0026thinsp;0.28, SD\u0026thinsp;=\u0026thinsp;4.74), with the median and mode at 25 years. The age of mothers with newborns or children was slightly lower, with a mean of 24.07 years (SE\u0026thinsp;=\u0026thinsp;0.30, SD\u0026thinsp;=\u0026thinsp;4.34), a median of 23 years, and a mode of 20 years. This relatively young population indicates a critical need for early and sustained reproductive health interventions.\u003c/p\u003e\u003cp\u003eEducation levels varied, with most respondents (53.6%) attaining secondary education, 28.4% having primary education, and only 8% having tertiary education. A notable 10% had no formal education, signaling potential barriers to healthcare literacy and informed decision-making.\u003c/p\u003e\u003cp\u003eMonthly household income showed wide disparities, with a mean income of 335.03 New Leones (NLE), a high standard deviation of 668.49, and a range from 0 to 10,000 NLE. This substantial income variability reflects significant economic inequalities that may affect access to healthcare services.\u003c/p\u003e\u003cp\u003eThe average number of pregnancies reported was 1.83 (SE\u0026thinsp;=\u0026thinsp;0.05, SD\u0026thinsp;=\u0026thinsp;1.05), with values ranging from one to over seven pregnancies. These highlights differing levels of maternal experience, which may influence risk perception and health-seeking behavior.\u003c/p\u003e\u003cp\u003eThese findings provide a foundational understanding of the predisposing and enabling factors relevant to healthcare utilization decisions, which are further explored in the discussion through integrated strategies (see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePredisposing and Enabling Socio-Demographic Factors of Participants\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCategory\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSub-Category\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFrequency (n\u0026thinsp;=\u0026thinsp;500)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePercent (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eStatistical Summary\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge of Pregnant Women\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMean\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMean\u0026thinsp;=\u0026thinsp;24.83 (SE\u0026thinsp;=\u0026thinsp;0.28, SD\u0026thinsp;=\u0026thinsp;4.74, Range: 16\u0026ndash;45, 95% CI\u0026thinsp;=\u0026thinsp;\u0026plusmn;\u0026thinsp;0.54)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMedian\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMedian\u0026thinsp;=\u0026thinsp;25\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMode\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMode\u0026thinsp;=\u0026thinsp;25\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge of Newborn Mothers\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMean\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMean\u0026thinsp;=\u0026thinsp;24.07 (SE\u0026thinsp;=\u0026thinsp;0.30, SD\u0026thinsp;=\u0026thinsp;4.34, Range: 17\u0026ndash;45, 95% CI\u0026thinsp;=\u0026thinsp;\u0026plusmn;\u0026thinsp;0.60)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMedian\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMedian\u0026thinsp;=\u0026thinsp;23\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMode\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMode\u0026thinsp;=\u0026thinsp;20\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eEducation Level\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo Formal Education\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePrimary Education\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e142\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e28.40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSecondary Education\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e268\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e53.60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTertiary Education\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMonthly Income (NLE)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMean\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMean\u0026thinsp;=\u0026thinsp;335.03 (SE\u0026thinsp;=\u0026thinsp;29.90, SD\u0026thinsp;=\u0026thinsp;668.49, Range: 0\u0026ndash;10,000, 95% CI\u0026thinsp;=\u0026thinsp;\u0026plusmn;\u0026thinsp;58.74)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePregnancies Experienced\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMean\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMean\u0026thinsp;=\u0026thinsp;1.83 (SE\u0026thinsp;=\u0026thinsp;0.05, SD\u0026thinsp;=\u0026thinsp;1.05, Range: 1\u0026ndash;7+, 95% CI\u0026thinsp;=\u0026thinsp;\u0026plusmn;\u0026thinsp;0.09)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eINTEGRATED APPROACHES TO STRENGTHEN PREDISPOSING FACTORS\u003c/h2\u003e\u003cp\u003eFigure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e presents responses from participants regarding which integrated approaches most effectively strengthen predisposing factors that influence healthcare-seeking decisions. The responses were recorded across five intervention strategies, providing insight into maternal preferences and perceived impact.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eHigh-Impact Strategies\u003c/h2\u003e\u003cp\u003eThe most frequently cited strategy was increasing access to prenatal education programs (25.91%), reflecting a strong demand for knowledge-based empowerment. This approach equips women with essential information on pregnancy, childbirth, and newborn care, helping them make timely and informed decisions. Closely following, community outreach programs to promote early antenatal care (24.12%) were also highly emphasized. These initiatives foster early engagement with healthcare services, particularly in rural or marginalized communities, where delayed first contact often leads to adverse outcomes.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eModerate-Impact Strategy\u003c/h2\u003e\u003cp\u003eCulturally sensitive prenatal counseling (21.53%) emerged as a valued approach for improving the patient-provider relationship. By tailoring services to the cultural norms and beliefs of expectant mothers, this strategy helps reduce stigma, builds trust, and enhances service acceptability. Although not as prioritized as education or outreach, its importance lies in creating a respectful and responsive care environment.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eLow-Impact Strategy\u003c/h2\u003e\u003cp\u003eFinancial incentives for regular check-ups (16.61%) were noted as useful in reducing economic barriers. While incentives can increase attendance at health facilities, the relatively lower frequency suggests that women may value knowledge and supportive outreach more than direct monetary support when deciding to seek care.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eLeast-Impact Strategy\u003c/h2\u003e\u003cp\u003eImproving access to family planning services (11.83%) was the least prioritized intervention. Despite its preventive potential in reducing high-risk and unintended pregnancies, this approach may receive less attention in the context of immediate maternal care. The result signals a need for better integration of family planning into antenatal and postnatal education programs.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eINTEGRATED APPROACHES TO STRENGTHEN ENABLING FACTORS\u003c/h2\u003e\u003cp\u003eFigure \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e summarizes the responses, with strategies categorized according to their frequency of selection.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eHigh-Impact Strategies\u003c/h2\u003e\u003cp\u003eResponses were recorded across five enabling factor categories. The most cited initiative was the enhancement of transportation options for pregnant women and mothers, which accounted for 24.6% of responses. This finding indicates a high prioritization of logistical support to facilitate timely access to healthcare services.\u003c/p\u003e\u003cp\u003eThe second most emphasized strategy was the expansion of access to affordable maternal healthcare services, receiving 24.21% of total responses. This underscores the relevance of cost-related barriers in shaping maternal healthcare-seeking behavior and suggests that affordability remains a central concern for women across different socio-economic backgrounds.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003eModerate-Impact Strategies\u003c/h2\u003e\u003cp\u003eClosely following were strategies focused on community-level engagement and financial protection. Specifically, 22.76% of respondents highlighted the importance of establishing community-based support groups, while 22.16% favored the provision of subsidies for maternal and child health insurance coverage. These approaches reflect the perceived value of both social and financial support systems in promoting consistent and equitable maternal health access.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003eLow-Impact Strategies\u003c/h2\u003e\u003cp\u003eFinally, a smaller proportion of participants (6.27%) suggested offering flexible work arrangements to enable pregnant women to attend antenatal appointments. While acknowledged, this strategy received comparatively less emphasis, possibly due to limited applicability in informal employment settings or a lack of awareness regarding its benefits.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003eINTEGRATED APPROACHES TO STRENGTHEN ILLNESS FACTORS INFLUENCING\u003c/h2\u003e\u003cdiv id=\"Sec21\" class=\"Section3\"\u003e\u003ch2\u003eHealthcare-Seeking Behavior\u003c/h2\u003e\u003cp\u003eFigure \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e presents participants\u0026rsquo; perceptions of the most impactful strategies for strengthening illness-level factors within maternal and newborn healthcare settings. These strategies are foundational to addressing complications, improving outcomes, and reducing preventable morbidity and mortality.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\u003ch2\u003eHigh-Impact Strategies\u003c/h2\u003e\u003cp\u003eThe most frequently cited approach was to strengthen maternal and child health surveillance systems (27.55%). Respondents emphasized the importance of systematic tracking and data collection to monitor pregnancy outcomes, identify risk factors early, and implement timely clinical interventions. Robust surveillance enables targeted responses in high-risk groups and supports evidence-based resource allocation, aligning with global maternal health monitoring recommendations.\u003c/p\u003e\u003cp\u003eThe second most prioritized strategy was improving access to prenatal screening and diagnostic services for high-risk pregnancies (23.08%). This reflects growing awareness of the role early detection plays in reducing maternal and perinatal complications. Access to quality diagnostic tools can facilitate timely referral, better birth preparedness, and tailored clinical care, particularly for women at elevated risk.\u003c/p\u003e\u003cdiv id=\"Sec23\" class=\"Section3\"\u003e\u003ch2\u003eModerate-Impact Strategies\u003c/h2\u003e\u003cp\u003eA substantial portion of participants (21.69%) highlighted the need to increase the availability of skilled birth attendants and emergency obstetric care facilities. While this intervention is well-recognized globally, its moderate ranking suggests ongoing disparities in availability, particularly in rural or underserved areas. The presence of skilled attendants during childbirth is a proven factor in preventing maternal and neonatal deaths, especially when supported by functional emergency services.\u003c/p\u003e\u003cp\u003eIn addition, enhancing postnatal care services to detect and manage complications in newborns received 18.16% of responses. While less emphasized than antenatal care or childbirth interventions, postnatal care remains essential for managing neonatal complications, promoting healthy development, and offering maternal support in the critical weeks following delivery.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec24\" class=\"Section2\"\u003e\u003ch2\u003eLow-Impact Strategies\u003c/h2\u003e\u003cp\u003eThe implementation of breastfeeding promotion campaigns and lactation support services was the least frequently cited strategy (9.52%). Although breastfeeding is vital for child survival, nutrition, and immunity, its relatively low prioritization may reflect a gap in public understanding or program availability. Strengthening lactation support could improve infant outcomes and should be viewed as an integral part of comprehensive maternal and child health programming.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eFigure \u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e reveals that Community-Based Education (14%) and Maternal and Child Health Clinics (10%) were identified as the most impactful strategies in addressing \u003cem\u003epredisposing factors\u003c/em\u003e by enhancing awareness, knowledge, and early facility contact. Early Antenatal Care (9.4%) also supports \u003cem\u003epredisposing factors\u003c/em\u003e, emphasizing the importance of timely engagement and risk identification. Strategies targeting \u003cem\u003eenabling factors\u003c/em\u003e, such as Financial Support Programs (8%), Community Health Workers (7.6%), and Incentive Programs (7.3%), were moderately impactful, highlighting the relevance of economic and logistical support in improving service uptake. Meanwhile, \u003cem\u003eillness-level factors\u003c/em\u003e were addressed through moderate support for Mental Health Services (7.9%) and Telehealth Services (6.7%), while strategies like Emergency Preparedness (4.1%) and Transportation Facilities (4.2%) were perceived as least impactful, indicating potential areas for increased investment and awareness.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cdiv id=\"Sec26\" class=\"Section2\"\u003e\u003ch2\u003eEMPOWERING WOMEN THROUGH EDUCATION AND COMMUNITY ENGAGEMENT\u003c/h2\u003e\u003cp\u003ePrenatal education programs (25.91%) and community outreach for early ANC (24.12%) were identified as the most effective strategies for strengthening predisposing factors that would influence maternal healthcare-seeking behavior. These findings suggest that knowledge-based interventions and early engagement empower women to make timely, informed decisions about their health and that of their newborns.\u003c/p\u003e\u003cp\u003eThis aligns with evidence from cross-sectional studies conducted in sub-Saharan Africa, which emphasize the role of community health education in increasing service uptake and reducing maternal mortality. For example, a community-based study in rural Sierra Leone demonstrated that structured prenatal education sessions improved women\u0026rsquo;s decision-making autonomy and increased antenatal care attendance [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Similarly, outreach programs supported by community health workers have been shown to increase ANC utilization and trust in facility-based services [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eCulturally sensitive prenatal counseling (21.53%) reinforces the importance of respectful care. Evidence from qualitative research confirms that alignment with cultural norms enhances the acceptability of maternal services and reduces delays in seeking care [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\u003cdiv id=\"Sec27\" class=\"Section3\"\u003e\u003ch2\u003eADDRESSING FINANCIAL AND LOGISTICAL BARRIERS TO CARE\u003c/h2\u003e\u003cp\u003eFor enabling factors, respondents prioritized enhancing transportation (24.6%) and expanding access to affordable maternal services (24.21%). These results underline the ongoing burden of distance and cost, particularly in rural and underserved areas of the Bo District.\u003c/p\u003e\u003cp\u003eThis is well-supported by findings from health systems reviews and policy evaluations, which document that transportation delays and high out-of-pocket costs are leading contributors to maternal deaths in low-resource settings [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Systematic reviews have consistently shown that reducing transport barriers through community emergency transport schemes and improving affordability via fee exemptions or insurance schemes significantly increase ANC attendance and reduce obstetric complications [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e Community-level strategies, such as support groups (22.76%) and subsidies for maternal health insurance (22.16%), were also valued, aligning with mixed-methods implementation research showing that social and financial protection mechanisms reduce inequality and improve care continuity.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec28\" class=\"Section2\"\u003e\u003ch2\u003eSTRENGTHENING HEALTH SYSTEMS FOR IMPROVED OUTCOMES\u003c/h2\u003e\u003cp\u003e Concerning illness-level factors, the top strategy was strengthening maternal and child health surveillance systems (27.55%), followed by improving access to prenatal screening and diagnostic services (23.08%). These findings reflect strong support for early detection and clinical monitoring as core components of maternal and newborn safety.\u003c/p\u003e\u003cp\u003eThese results are consistent with findings from longitudinal cohort studies and implementation research emphasizing the importance of robust surveillance and diagnostic systems. For instance, longitudinal maternal tracking in Ghana and Sierra Leone has been associated with early referral and lower maternal complications [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Strengthening surveillance systems allows healthcare providers to proactively identify high-risk cases, allocate resources, and ensure follow-up care, all of which are essential for improving outcomes in fragile health systems.\u003c/p\u003e\u003cp\u003eSkilled birth attendance and emergency obstetric care (21.69%) and enhanced postnatal services (18.16%) also ranked moderately. These align with global evidence-based guidelines indicating that the presence of skilled personnel and postnatal continuity of care is critical to reducing neonatal deaths [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eBreastfeeding support and lactation services (9.52%) were the least prioritized strategy, signaling potential under-recognition despite their well-documented benefits in newborn nutrition and immunity. This gap highlights the need for integrated postnatal counseling and education on infant feeding.\u003c/p\u003e\u003c/div\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThe study reveals that an integrated strategy approach, centered on education, culturally sensitive engagement, financial protection, transportation, surveillance, and diagnostics, is key to addressing the multi-level factors influencing maternal healthcare-seeking behavior in Bo District, Sierra Leone. These findings are consistent with a growing body of recent evidence underscoring that health system responsiveness, cultural alignment, and structural access are all essential to improving maternal and newborn outcomes in low-income contexts.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eFUNDING DECLARATION\u003c/h2\u003e\n\u003cp\u003eThe study was a self-initiative that formed part of the requirements for the Degree of Doctor of Philosophy in Public Health. The study was self-funded and didn\u0026rsquo;t receive any funding from other sources.\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eR.V. (Rennie Viah) conceptualized the study, developed the research design, conducted the fieldwork, performed the data analysis, and wrote the main manuscript text. He also prepared all figures (1\u0026ndash;4) and Table 1. R.A. (Rashid Ansumana) supervised the research process, provided guidance throughout the study, and reviewed the manuscript for intellectual content. All authors read and approved the final version of the manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eI sincerely thank Mr. Emmanuel Finoh for his key role in training and supervising the data collection team. I also appreciate the nine senior public health students and the graduate community health officer from Njala University who served as enumerators. Gratitude is extended to the nursing and midwifery staff at Tikonko Village Health Center and Bo Government Hospital for their valuable support. Special thanks to the College of Health and Medical Sciences at Njala University for reviewing and approving this research. Lastly, I am grateful to all participants whose involvement made this study possible.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eAll data pertaining to the study are provided within the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMinistry of Health and Sanitation. 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BMC Pregnancy Childbirth. 2024;24:485. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12884-024-06683-w\u003c/span\u003e\u003cspan address=\"10.1186/s12884-024-06683-w\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBangura S, Bah AJ, Kanu R. Impact of maternal health education on ANC uptake in rural Sierra Leone: A cross-sectional study. BMC Pregnancy Childbirth. 2023;23:119. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12884-023-05564-7\u003c/span\u003e\u003cspan address=\"10.1186/s12884-023-05564-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eICAP at Columbia University. (2024). Community in Sierra Leone shows zero maternal deaths after three years of successful maternal health program. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://icap.columbia.edu/news-events/community-in-sierra-leone-shows-zero-maternal-deaths-after-three-years-of-successful-maternal-health-program/\u003c/span\u003e\u003cspan address=\"https://icap.columbia.edu/news-events/community-in-sierra-leone-shows-zero-maternal-deaths-after-three-years-of-successful-maternal-health-program/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEl Ayadi AM, et al. Community engagement for maternal health equity: A realist review. 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Tropical Med Int Health. 2021;26(3):221\u0026ndash;31. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/tmi.13523\u003c/span\u003e\u003cspan address=\"10.1111/tmi.13523\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKazanga I, et al. The effects of removing user fees for maternal care in sub-Saharan Africa: A systematic review. Int J Equity Health. 2022;21:135. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12939-022-01729-1\u003c/span\u003e\u003cspan address=\"10.1186/s12939-022-01729-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eElston JWT, et al. Integrating public health approaches in the management of maternal health: Lessons from Sierra Leone. BMJ Global Health. 2022;7:e009234. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1136/bmjgh-2021-009234\u003c/span\u003e\u003cspan address=\"10.1136/bmjgh-2021-009234\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eUNICEF Sierra Leone. (2021). Scaling up quality of care for maternal and newborn health in Sierra Leone. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.unicef.org/stories/making-strides-maternal-health-worst-place-to-be-mother\u003c/span\u003e\u003cspan address=\"https://www.unicef.org/stories/making-strides-maternal-health-worst-place-to-be-mother\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"reproductive-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"reph","sideBox":"Learn more about [Reproductive Health](http://reproductive-health-journal.biomedcentral.com)","snPcode":"12978","submissionUrl":"https://submission.nature.com/new-submission/12978/3","title":"Reproductive Health","twitterHandle":"@Reprod_Health","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Healthcare-seeking behavior, Integrated strategies, Predisposing Factors, Enabling Factors, Illness-Level Factors","lastPublishedDoi":"10.21203/rs.3.rs-6618062/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6618062/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMaternal and newborn health outcomes in Sierra Leone remain among the poorest globally, driven by a complex interplay of socio-demographic, systemic, and behavioral factors. Understanding how integrated strategies influence healthcare-seeking behavior is critical for tailoring interventions that reduce delays and improve maternal outcomes. This study aimed to identify high-impact strategies addressing predisposing, enabling, and illness-level factors that affect maternal and newborn healthcare-seeking behavior in Bo District, Sierra Leone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA descriptive cross-sectional study was conducted at Bo Government Hospital (urban) and Tikonko Maternity Home (rural) between January – May 2024. Using simple random sampling, 500 participants (294 pregnant women and 206 mothers of children under five) were selected from facility attendance lists. Quantitative data was collected through structured interviews using a digital questionnaire administered via the ONA platform. Descriptive analysis was performed using SPSS version 26 to identify patterns in healthcare-seeking preferences and perceived effectiveness of integrated health strategies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe mean age of pregnant participants was 24.83 years (SD = 4.74), and the average household income showed substantial disparity (Mean = 335.03 NLE; SD = 668.49). Regarding predisposing factors, the preferred strategies included prenatal education (25.91%) and community outreach for early antenatal care (24.12%). Enabling factors were most influenced by transportation support (24.6%) and access to affordable care (24.21%). Illness-level strategies prioritized by participants included strengthening maternal health surveillance systems (27.55%) and prenatal screening services (23.08%). Education level, income, and parity were key determinants of healthcare-seeking behavior.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIntegrated strategies that combine health education, community outreach, logistical and financial support, and health system strengthening are the most effective in influencing maternal and newborn healthcare-seeking behavior. Culturally tailored, equitable, and evidence-informed approaches help improve maternal health service utilization in low-resource settings like Sierra Leone.\u003c/p\u003e","manuscriptTitle":"Integrated Strategies Addressing Predisposing, Enabling, and Illness-Level Factors Influencing Healthcare-Seeking Behavior among Pregnant Women and Newborn Mothers: Insights from Sierra Leone","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-27 06:55:52","doi":"10.21203/rs.3.rs-6618062/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-07T18:45:03+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-07T18:19:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"153005604155140255823659691890354410803","date":"2026-04-07T17:45:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"286271142968867098334672098972641289254","date":"2026-02-09T14:34:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"100484890580309187670347627499979140602","date":"2026-01-01T09:01:57+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-22T02:33:47+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"196117793608256365067818594457238268466","date":"2025-10-22T20:30:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"183522115532589616383712523003599838235","date":"2025-10-02T05:50:09+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-18T12:48:19+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-12T01:47:11+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-12T01:46:28+00:00","index":"","fulltext":""},{"type":"submitted","content":"Reproductive Health","date":"2025-05-08T07:47:13+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"reproductive-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"reph","sideBox":"Learn more about [Reproductive Health](http://reproductive-health-journal.biomedcentral.com)","snPcode":"12978","submissionUrl":"https://submission.nature.com/new-submission/12978/3","title":"Reproductive Health","twitterHandle":"@Reprod_Health","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c14b6b0e-8cc0-469a-8a46-5fd7851080f0","owner":[],"postedDate":"August 27th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-20T11:53:46+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-27 06:55:52","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6618062","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6618062","identity":"rs-6618062","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}