Disability-related care trajectories in a pluralistic health system: a qualitative study in urban Sierra Leone

People living with disabilities (PLWD) often require long-term and repeated engagement with healthcare services. In pluralistic health systems, where biomedical, traditional, spiritual and NGO-based services coexist, care seeking is rarely linear and is shaped by multiple social, cultural and structural factors. Little is known about how disability-related care trajectories unfold over time and which factors shape access at different stages.

This qualitative study is based on six focus group discussions (N = 42) with PLWD and caregivers of children living with disabilities, conducted in urban Freetown. Care trajectories were reconstructed from participants' accounts and differentiated between early care seeking at symptom onset and long-term care. Qualitative content analysis was conducted, conceptualising access as shaped by people's abilities to perceive care options, seek, reach, afford and engage with care.

Early care seeking was characterised by frequent movement between care domains, particularly biomedical, traditional and spiritual care, driven by uncertainty, trial-and-error processes and dissatisfaction with outcomes. Long-term care trajectories tended to focus on biomedical and NGO-based services, while traditional care was largely abandoned. Adult PLWD often disengaged from long-term care altogether. Access to biomedical care was shaped by substantial barriers, including physical inaccessibility, transport difficulties, informal payments, and experiences of discrimination. NGO services were perceived as more accessible, especially for long-term care yet were often unknown during early care seeking.

The findings illustrate how disability-related care seeking in a pluralistic health system is dynamic and shaped by evolving interpretations of disability, prior care experiences and structural constraints. A central tension emerged: biomedical care was perceived as more reliable for diagnosis, yet associated with the highest access barriers. NGO-based services, while experienced as more accessible, remained largely unknown during early care seeking.

Improving access to disability-related care in pluralistic health systems requires attention to the full range of care domains that people navigate and to the structural and relational barriers shaping access over time. Strengthening accessible, respectful and coordinated care within public health systems, and increasing the visibility of NGO-based services at earlier stages of care seeking, are essential to support sustained engagement for PLWD and their families.

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