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payday loans A strong informal network of health providers, dominated by traditional healers, already exists within the country,18 and available evidence suggests that approximately 30% of persons have visited a traditional healer in Sierra Leone at least once.19 20 This is in line with wider evidence, which suggests that over 50% of persons in sub Saharan Africa have sought care from traditional, complementary and complementary medicine providers.21Communities play a key role in shaping not only health seeking behaviours22 23 but also the lifestyle decisions that drive chronic illness onset and continuation, and people’s interpretations of the responses to pain and suffering. Culture and values play significant roles in decision making: cultural values influence patient preferences, and the status and reputation of providers in communities and trust in informal providers are all factors that influence whom people approach for medical care.24 Community level norms and practices shape whether or not people will make best use of medical services when these are available, in terms of appropriate access and optimal adherence to medical advice.25 In addition, community networks mediate the diffusion of health related knowledge from health professionals to vulnerable individuals.26 However, there is a dearth of evidence on this in the context of Sierra Leone.We use a method called participatory systems dynamics to understand how chronic conditions are perceived and experienced and how they drive health seeking practices, and to explore how they fit in a previously described framework (see box 1).Box 1 Illness practices described in de Graft Aikins 2005Biomedical management is marked as follows:Explanations on causes of diseases and solutions are predominantly biomedical.Doctors are recognised as diagnostic and pharmacological experts offering superior knowledge and practices over ethnomedical and faith healing systems, which are viewed as inept.Spiritual action is marked as follows:Explanations of causes of disease predominantly refer to spiritual issues (eg, witchcraft and sorcery) and demand intervention from religious specialists.Persons may distinguish between legitimate (formal religious) versus illegitimate (traditional healing and traditional religious) practices as part of health seeking.Cure seeking refers to how people practise the above mentioned two practices:Active cure seeking refers to the continued need of persons to pursue a cure for their chronic condition, for example, by continuously seeing a multitude of biomedical and spiritual practitioners in the hope that a cure would materialise.MethodsStudy designGiven the increased recognition that health and community systems operate as complex adaptive systems,27 28 we conducted participatory group model building sessions with both health system actors (national policy makers and district health representatives and urban and rural healthcare providers) and communities (urban and rural community leaders and members). We focus here only on community related work and present all work pertaining to health system elements elsewhere16).payday loans

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