Introduction. Gains to ensure global healthcare access are at risk of stalling because some old resilient challenges require new solutions. Our objective was to identify determinants of intended versus actual care-seeking behaviors in a pluralistic healthcare system that is reliant on both conventional and non-conventional providers and discover opportunities to catalyze improved healthcare access.

Methods. A cross-sectional study was conducted among households with children less than 5 years of age in Haiti. Households were randomly sampled geographically with stratifications for population density. Household questionnaires with standardized cases (intentions) were compared to self-recall of health events (behaviors). The connectedness of households and their providers was determined by network analysis.

Results. A total of 568 households (incorporating 2900 members) and 65 providers were enrolled. Households reported 636 health events in the prior month. Households sought care for 35% (n=220) and treated with home remedies for 44% (n=277). The odds of seeking care increased 217% for severe events (aOR=3.17; 95%CI 1.99-5.05; p< 0.001). The odds of seeking care from a conventional provider increased by 37% with increasing distance (aOR=1.37; 95%CI 1.06-1.79; p=0.016). Despite stating an intention to seek care from conventional providers, there was a lack of congruence in practice that favored non-conventional providers (McNemar’s Chi-squared Test p<0.001). Care was sought from primary providers for 68% (n=150) of cases within a three-tiered network; 25% (n=38/150) were non-conventional.

Conclusion. Addressing geographic barriers, possibly with technology solutions, should be prioritized to meet healthcare seeking intentions while developing approaches to connect non-conventional providers into healthcare networks when geographic barriers cannot be overcome.

Data Collection. Data were collected by one enumerator and one nurse. Survey instruments included two thirty-minute in-person questionnaires administered with REDCap mobile version 9.1.1 and were piloted with non-participant households. A household questionnaire collected demographic and socio-economic data, and healthcare seeking behavior for standardized cases and health events. A health event was defined as any illness a household member experienced in the previous month, regardless of whether care was sought. The standardized respiratory and diarrhoeal cases consisted of hypothetical scenarios involving an ill child at 10 PM with typical symptoms of acute respiratory infection or diarrhoea. A provider questionnaire captured details about the facility/business, personnel qualifications and resources available. Conventional providers were licensed persons who worked at a licensed facility. For large facilities with greater than 200 patients per month, the facility itself was defined as a ‘provider’. Non-conventional providers were licensed or non-licensed providers at non-licensed facilities, or mobile non-licensed providers. The dataset was deidentified in a manner that allows for the connectedness of households and providers to be preserved.

Lists of variables and codes are attached for questionnaire data and provider network data.