Health-seeking behaviour, health service delivery and its perceived impact among stroke survivors in Sierra Leone: a longitudinal qualitative study embedded in the SISLE project

Stroke is a leading cause of disability and mortality globally. Despite growing awareness of the stroke epidemic, there is limited understanding of the lived experiences and perspectives of stroke care within resource-constrained health systems. This study explored the experiences and perspectives of stroke survivors, primary caregivers and healthcare providers on stroke care in Sierra Leone. This qualitative descriptive study involved face-to-face semi-structured interviews with stroke survivors, informal caregivers, and healthcare providers between December 2020 and August 2021 in Sierra Leone. We purposively sampled participants to capture diverse experiences across the care continuum. Data were analysed thematically using a constant comparative approach and interpretative phenomenological analysis, triangulating perspectives across participant groups. Five interconnected themes emerged and are grouped into three categories: (1) Health-seeking behaviour: delayed hospital presentation, financial burden and out-of-pocket costs; (2) Health service delivery: hospital care experiences, access to and continuity of physiotherapy and; (3) Perceived impact and recommendation: recommendations for systemic improvements. Stroke survivors and caregivers reported a lack of knowledge of stroke symptoms, considering traditional treatment or religious consultation as the first point of contact, resulted in considerable delay in seeking hospitalisation. Other major barriers were related to challenges in accessing physiotherapy services and the financial hardship associated with stroke care. The dependence of stroke survivors on their caregivers as a result of staffing shortages and frequent communication breakdowns was frequently reported during hospitalisation. National health policies on stroke care, dedicated stroke units, community physiotherapy programmes and funding support were recommended. Stroke care in Sierra Leone is limited by systemic barriers that include infrastructure, cost, and accessibility. To bridge these gaps, community-based stroke education, health insurance schemes, workforce stroke-care training, and organised stroke-care delivery are needed. These results offer actionable recommendations for improving stroke care and service delivery in resource-constrained settings.