Pluralistic coping and the impact–coping disconnect: how households in onchocerciasis-endemic communities of Bo District, Sierra Leone respond to disease — an explanatory sequential mixed-methods study

Abstract

Background How households living with onchocerciasis cope with the disease and whether their coping effort tracks the burden they bear is central to designing supportive interventions, yet it is rarely measured at scale in endemic African settings. We characterised the coping repertoire of communities in Bo District, Sierra Leone, tested whether coping is driven by disease impact, and examined how it varies across chiefdoms. Methods In an explanatory sequential mixed-methods design, 1,500 adults across five endemic chiefdoms were surveyed using multistage cluster sampling. Coping was measured at three levels and summarised by an individual-coping index (0–3), a community-coping index (0–3) and an economic-coping index (0–2); disease impact was summarised by composite socio-economic and psychological indices. Analyses in JASP used descriptive statistics, Spearman correlations, one-way ANOVA with Tukey post-hoc tests, and binary logistic regression. Eleven key informant interviews and eight focus group discussions were analysed thematically. Results Coping was active and pluralistic. Deliberate disease-management methods were used by 64.2% of respondents, lifestyle alterations by 57.1% and traditional or alternative therapies by 55.9%; about half affirmed each community-coping indicator, while economic-coping resources were scarcest (45–47%). Coping was strongest at the individual level (mean 1.77/3), then community (1.52/3), then economic (0.92/2). Crucially, none of the three coping indices was correlated with disease impact (all |ρ| ≤ .042, all p > .10). Individual and community coping were uniform across chiefdoms; only economic coping varied (F(4,1495) = 2.48, p = .042), driven by higher coping in Gbo than Tikonko (Tukey p = .021). Traditional-therapy use was not predicted by any socio-demographic variable (likelihood-ratio p = .598). Qualitative themes described livelihood diversification, concurrent traditional–biomedical pathways and indigenous osusu mutual-aid networks. Conclusions Communities in Bo District respond to onchocerciasis through a pluralistic, resource-dependent coping system in which coping effort is governed by what households can mobilise rather than by how severely the disease affects them. Because therapeutic pluralism is a population-wide norm and economic coping is the binding constraint, support should strengthen indigenous financing mechanisms and engage the whole pluralistic health system rather than target demographic subgroups.