An exploratory qualitative case study design was conducted in Iringa and Sumbawanga DCs in Tanzania. A purposive sampling technique was used to select the study districts’ DCs based on the number of the population served by trained healthcare providers in the study settings (Table 1). Iringa DC was selected for having the highest number of people served by the trained healthcare providers, while Sumbawanga DC was chosen for having the lowest number. In-depth interviews (IDIs) were conducted among healthcare workers (HCWs) to get a comprehensive understanding of the challenges and opportunities for adopting a comprehensive PHC-HSBs in the selected two DCs. The case study design was deemed appropriate to study a comprehensive PHC-HSB, which is a complex and non-linear phenomenon involving social processes.¹⁹

The study was conducted in two councils (Iringa and Sumbawanga DCs) from two regions out of 26 regions in Tanzania. Iringa DC is among the five councils of the Iringa Region. This council is situated in the Southern highland of Tanzania between latitudes 6.540 and 100 and longitudes 33 and 370–000. Administratively, the council is divided into six divisions and 25 wards with a total of 123 villages and 718 hamlets distributed unevenly. According to the 2022 Census, the district had a population of 315 354 of which 153 556 are males and 161 798 females. The economic activities are agriculture, fishing and livestock keeping in this district. Additionally, the district has about 77 health facilities (HFs) (8 health centres, 68 dispensaries). Tanzania has a hierarchical health system with the dispensaries at the bottom, found in every village, followed by health centres found at the ward level. District hospitals are found at the district level, and at the regional level we have regional referral hospitals. The tertiary level is comprised with the zone hospitals, and at a national level, there is a national hospital, and 1 district hospital served by 318 skilled HCWs.

Sumbawanga DC is one of the three councils of Rukwa region situated in the South-west highlands of Tanzania on latitudes 7.8 and 9 South, longitudes 31 and 32.3 to the East. Administratively, the council has seven (n = 7) divisions, 23 wards, and 167 villages. According to the 2022 Census, the district had a population of 303 986 of which 144 657 are males and 159 329 females. The economic activities are agriculture, livestock keeping, tourism, beekeeping and fishing. The total number of HFs available is 76 comprising two (n = 2) hospitals, eight (n = 8) health centres and 66 dispensaries. These facilities are served by 260 skilled HCWs.

The study population included community health workers (CHWs) and the HCWs at the selected facilities (dispensaries, health centres and district hospitals). Overall, the study included 15 participants: six CHWs and nine HCWs from the sampled primary HFs. Data were collected from two DCs of Iringa and Sumbawanga. The study was designed as a PHC facility-based since most of the information was obtained from healthcare providers at the facility. A multistage sampling strategy was employed during the sampling process. In the first stage, a purposive sampling technique was applied to select two regions among 26 regions. In the second stage, two DCs were purposively selected based on the number of people served by trained healthcare providers and by considering the rural characteristics of councils. In the third stage, from each DC, we purposively selected a DC hospital, health centres and dispensaries as primary HFs. At the fourth stage, purposive sampling was used to select individual participants for IDIs. Healthcare workers were eligible if they were facility in-charges or frontline HCWs (e.g. clinicians or nurses) with at least 1 year of experience at the selected facility. Community health workers were selected based on their active role in community-level health activities linked to the facility and their experience supporting service delivery in the facility’s catchment area. Efforts were made to include participants from different facility levels (dispensary, health centres and district hospital) and cadres to capture diverse perspectives on HSB within PHC settings. In total, 15 participants (6 CHWs and 9 HCWs) were interviewed across the selected facilities.

The study employed IDIs qualitative data collection methods to explore challenges and opportunities in adopting comprehensive PHC-HSB. Participants included CHWs and trained HCWs from selected HFs in Iringa and Sumbawanga districts. Interviews were conducted in a facility-based setting, focusing on individual and community health-seeking behaviours. The qualitative approach allowed for an in-depth understanding of the complex and non-linear social processes influencing PHC-HSB.

The interview guide consisted of questions on participants’ views and perceptions regarding HSB in their area of work, as well as opportunities and challenges with adopting health-seeking behaviour. We interviewed one to two HCWs from each selected HF. In each DC, interviews were conducted with seven HCWs who were purposely selected. Each interview was conducted by two researchers, where one facilitated the interview and another one facilitated note taking, audio recording, and probing. All interviews were conducted in Swahili language, which is widely understood in Tanzania. All interviews were audio-recorded using a digital voice recorder, and the duration of the interview ranged from 30 min to 45 min. Debriefings were conducted after every interview to ensure consistency, quality control, and to capture new emerging issues.

To ensure trustworthiness of the findings, we included participants from different cadres (HCWs and CHWs), which supported credibility through triangulation of perspectives. Transferability was strengthened by providing a detailed description of the study setting. Dependability was enhanced by documenting the data collection procedures and analysis process in detail, thereby supporting the reliability of the findings.

Data analysis began with reading and re-reading the interview transcripts to achieve familiarity with the data. The transcripts were then systematically coded by identifying meaningful units and extracting key statements related to health-seeking behaviours. Codes were compared and grouped into categories, which were subsequently organised into sub-themes and overarching themes based on patterns across participants’ responses. The analysis followed an inductive thematic approach, allowing themes to emerge from the data rather than being predetermined. NVivo 14 software was used to support coding and data management. The case study design facilitated an in-depth exploration of contextual factors influencing health-seeking behaviours, thereby providing a comprehensive understanding of the phenomenon. Thematic saturation was considered achieved when no new codes or themes emerged from successive interviews, hence strengthening the robustness of the findings.

Ethical clearance to conduct this study was obtained from the Muhimbili University of Health and Allied Sciences Ethical Review Board with ethical clearance number: MUHAS-REC-04-2022-1121. Permission to conduct the study in two districts (Iringa and Sumbawanga DCs) was requested from the Regional Administrative Secretary (RAS) of the respective region, then District Administrative Secretaries (DAS) and District Medical Officer (DMOs) of the two districts after submitting an introduction letter and the ethical approval from Muhimbili University of Health and Allied Sciences (MUHAS).

The study comprised 15 participants, of which 10 were male and 5 were female. The participants had a mixture of different cadres including nurses, clinical officers, medical doctors and CHWs. Out of the 10 sampled facilities, two were district hospitals, three were health centres and five were dispensaries. The respondents come a small group of healthcare workers who can easily be identified, thus, no additional participant identifiers are provided.

The summary of the study findings is presented in Table 2. The findings are structured into two themes, namely, evidence of opportunities (enablers) for adopting comprehensive PHC-HSBs and evidence of challenges (barriers) for adopting PHC-HSBs.

This theme was based on the evidence of the available opportunities in the PHC systems for adopting comprehensive health-seeking behaviour, which had seven sub-themes namely: existence of exemptions and waiver, presence of special clinics, benefits of early health-seeking behaviour, availability of outreach services, community’s interest in health issues, presence of CHWs and health education provided at the household level. These sub-themes are described as follows.

The participants indicated some challenges for the community to adapt comprehensive HSB with the following sub-themes: frequent stockout of drugs, overburdened HFs as a result of large catchment areas, cultural and behavioural barriers to timely health-seeking, unreliable and inadequate transport systems, poor continuity of preventive health-seeking after campaign and low health insurance coverage.

Exemptions and waivers for vulnerable groups (e.g. pregnant women, under-five children, elderly and disabled individuals) are the financial interventions put in place to facilitate healthcare access, reducing financial barriers and hence protecting the vulnerable group from experiencing catastrophic health expenditure (CHE). Key informants for this study acknowledged the existence of such intervention and its role in facilitating HSB among the community members who receive services at the selected facilities in Tanzania. Possible explanation for this is that people who belong to the exemption groups do not pay cash for health services like consultation fees, laboratory tests and drugs. This attracts the community members to increase HSB for the early detection of different diseases.^20,21 Similar findings were reported in Ghana, where fee exemptions improved maternal and child health service utilization.²² However, to the contrary, Chuma et al. found that exemptions and waivers are ineffective in protecting the poor and hence hinder the accessibility of health services.²³ This could be explained by challenges such as reimbursement delays, poor quality of care received by the exempted groups and health providers not giving exemptions to those eligible for it and ending up paying out of their pockets.

The presence of special clinics for chronic diseases (e.g. diabetes, hypertension) was identified as an opportunity to enhance HSB. Interviewed HCWs suggested that such clinics can attract individuals to HFs for the management of specific conditions, which may, over time, foster a habit of regular attendance and encourage early detection of other health problems. This aligns with studies from South Africa and Uganda, where the presence of chronic disease clinics improved patient follow-up and early detection.^24,25 However, unlike in urban settings where such clinics are well-established, rural areas in Tanzania face staffing and resource shortages, limiting their effectiveness.^26,27

Implementation of outreach services provides various health services including vaccinations, screening and counselling for Non Communicable Diseases (NCD) and HIV patients, maternal and child health, as well as caring for elderly people. During the interview with CHWs and CHWs, outreach service was found to be an opportunity in ensuring HSBs among members in the local communities of the selected districts in Tanzania. The outreach services are normally provided to those communities residing far from the HFs and reduce the distance covered by clients to access health services. Different health systems in the world, especially in low-resource settings, have introduced different guidelines and strategies on how outreach services can be conducted. A report by World Health Organization (WHO) and United Nations Children’s Fund (UNCEF) stipulates different types of outreach services covered and how they should be conducted.^28,29 Additionally, a report by Health Outreach Partners (HOP),³⁰ highlights the importance of clinical outreach such that outreach services bring primary health care close to communities, families and individuals who may face barriers in seeking and accessing care if they visited the health centre sites. Clinical outreach reduces financial barriers and serves time that could be spent by individuals and communities to access care at the HFs. Our findings concur with other studies, which explain the importance of outreach programmes which may increase access to health services among people, especially in rural areas, hence increasing HSB among the community members and also providing key professional support to those HCWs who are posted in hard to reach areas.^28,30,31

The presence of CHWs in the community was found to be an opportunity for community members to develop HSB. This may be because of the efforts made by CHWs in conducting follow-ups with members of all households regarding health matters in their streets or villages. This finding is similar to findings reported by Ndambo et al. which explains that CHWs can build personal resources of trust, gratitude and hope within the communities, fostering positive interpersonal relationships between themselves, communities and HF staff, which may increase HSB.³² Additionally, Geldsetzer et al. found that home-based CHW intervention in urban Tanzania significantly increased the proportion of women delivering at the facility.³³ In contrast, a randomised controlled trial by Nance et al. in Tanzania assessed whether a community-level CHW intervention could improve short-term retention in care and adherence to antiretroviral therapy (ART) among pregnant women living with HIV. Although the intervention was reported to be feasible and acceptable, it did not demonstrate strong effects on most Preventions of Mother to Child Transmission (PMTCT) indicators; however, it may have contributed to improved ART adherence among postpartum women living with HIV.³⁴ However, a report by WHO highlights the important roles of CHWs, which may serve as an opportunity for adopting comprehensive health-seeking behaviour. Such roles include: delivering diagnostic, treatment or clinical care, encouraging uptake of health services, providing health education and behaviour change motivation, data collection and record-keeping, improving relationships between health system functionaries and community members and providing psychological support to the community, family and individuals.³⁵

Health education provided at the household level by HCWs and CHWs was seen as a facilitator for HSB. This suggests that for attaining comprehensive HSB, health education is crucial, as recommended by Mulikuza.³⁶ This is similar to the findings reported by Adongo and Asaarik in the study conducted in rural settings,³⁷ which emphasised the necessity of increasing investment in public consultation, household education and other related health education methods, which may play an effective role in the spread of health education to improve the HSB among community members. Furthermore, another study from Ghana, which aimed at assessing the health-seeking behaviours of rural dwellers in under- resourced communities, found a significant association between education status and HSB. They concluded that health promotion and education policies for the community should be emphasised to bring about improvement in health-seeking among rural dwellers.³⁸ Similarly, a study by Mulikuza et al., found that women with formal education were more likely to seek maternal care compared to those without.¹² The study emphasised that countries in the sub-Saharan region need to adapt best practices for promoting healthcare education in the community so as to increase healthcare utilisation for under-five children and their mothers.

Additionally, this finding indicates that many community members were interested in receiving health-related information within their localities. Participants described that when HCWs or CHWs visit the communities, they are generally met with positive cooperation and engagement on health matters. This receptiveness suggests that communities are willing and ready to participate in health education activities and other outreach services, which may facilitate the adoption of HSB through improved awareness and stronger community–provider interactions. Healthcare providers also receive support and cooperation from the community leaders who facilitate the meeting between the community and the health providers by passing on information to the community and assisting in gathering people at the meeting points. Findings from a study done in Rwanda by Uwizeye in 2022 show that regular audience surveillance assists in determining whether messages are reaching target audiences and are being accepted and adopted. In addition, the study also found that CHWs are an important means of relaying messages, especially in the hardest to reach communities.³⁹

Frequent stockouts of essential medicines at HFs emerged as a key challenge from the key informant interviews. Participants explained that medicine unavailability discouraged community members from seeking care at HFs, as they perceived visits to be unhelpful if prescribed drugs are not available. As a result, stockouts are viewed as a major deterrent to timely health-seeking, potentially contributing to delays in care and reduced trust in the health system. Similar findings were observed by Kuwawenaruwa in his study, which assessed the effects of medicine availability and stockouts on healthcare utilisation in the Dodoma region, Tanzania. He found that the household’s healthcare utilisation was positively and significantly associated with continuous availability of all essential medicines for the surveyed HFs.⁴⁰ The findings were also consistent with studies in Kenya and Zambia^41,42 as well as a study by Twaweza in Tanzania.⁴³ Unlike in Rwanda, where supply chain improvements reduced stockouts, Tanzania’s decentralised procurement system still faces logistical challenges.⁴⁴

Overburdened HFs as a result of large catchment areas emerged as a major barrier to adopting comprehensive HSB. The findings indicate that a limited number of HFs were serving multiple and widely dispersed villages, resulting in large catchment populations and increased pressure on available services. This imbalance between service demand and facility availability constrained timely access to care and discouraged routine and preventive health-seeking among community members. In addition to large catchment areas, physical access was further complicated by unreliable means of transport and inadequate transport infrastructure. As a result, most patients in the study districts relied on motorcycles, bicycles, or walking to reach HFs. Similar findings have been reported in rural Ghana, where Adongo et al. found that motorcycles, bicycles and walking were the most common means of transport used to access HFs.³⁸ Evidence from rural Ghana and Kenya also highlights that limited transport options restrict access to care and contribute to delayed health-seeking.^45,46 Furthermore, studies from Kenya and Nigeria have shown that distance to HFs is associated with frequency of clinic attendance, choice of HF, cost of care, and delays in receiving services.^45,47 Therefore, taking health services closer to the community could improve HSB and address the barriers associated with distance and transportation issues.

The study revealed that delayed healthcare-seeking behaviour, influenced by cultural and behavioural barriers to timely health-seeking, poses a significant challenge to the adoption of comprehensive HSB. Healthcare providers reported that many community members do not proactively visit HFs for early checkups, often waiting until their conditions become severe before seeking medical attention. This delay is further worsened by a deeply rooted culture of not seeking care early by majority of the community members, which sometimes discourages timely healthcare utilisation or leads individuals to seek alternative treatments. These findings align with a 2021 Tanzanian study by Mulikuza et al., and Bad and Maliganya 2024 which highlighted how cultural and religious practices shape health-seeking behaviour.^12,48

Additionally, research from sub-Saharan Africa by Latunji and Akinyemi found that traditional beliefs, particularly regarding childhood illnesses, often lead parents to prioritise traditional healers over formal healthcare services, resulting in treatment delays.⁴⁹ These cultural barriers highlight the need for community sensitisation programmes to promote early healthcare-seeking and integrate culturally appropriate health interventions.

The study further found that limited health insurance coverage restricts healthcare access and discourages HSB among community members. Healthcare providers reported encountering many uninsured patients during facility visits and outreach sessions, with a number of households lacking insurance coverage, especially in rural areas. These findings align with multiple Tanzanian and African studies that have found a positive association between health insurance and healthcare utilisation.^50,51,52 Health insurance serves as a financial risk protection against catastrophic health expenditures and is important for achieving Universal Health Coverage, ensuring equitable access to care without financial hardship^13,53,54,55 However, the study revealed that many rural residents are uninsured, hence limiting their ability to afford healthcare services and reducing formal care-seeking. This suggests that expanding health insurance coverage could enhance health-seeking behaviour, as evidenced by findings from Tabora, where insured elderly individuals utilised healthcare more than their uninsured counterparts.⁵⁶ However, this contrasts with other studies in which insurance did not significantly influence help-seeking behaviour,^17,57 indicating contextual variations in insurance impact.

The study also identified personal risk behaviours as a key factor influencing health-seeking practices. Participants noted that individuals engaging in high-risk behaviours, such as excessive alcohol consumption or unhealthy lifestyles, were less likely to seek timely healthcare. This finding is supported by Tungu et al., who found that individuals with chronic disease risks or unhealthy behaviours exhibited different health-seeking patterns compared to their healthier counterparts.⁵⁶ Such behaviours contribute to delayed care-seeking, as individuals often wait until symptoms become severe before visiting HFs. Addressing these risk factors through targeted behavioural interventions could improve early healthcare utilisation and overall community health outcomes.

This qualitative study has several limitations that should be considered when interpreting the findings. Firstly, the small sample size (15 participants) and purposive sampling may limit the generalizability of the results to broader populations. Secondly, the study was conducted in only two districts (Iringa and Sumbawanga), which may not fully represent the diverse healthcare challenges and opportunities across Tanzania. Thirdly, as a qualitative study, the findings are based on participants’ subjective perspectives, which could introduce social desirability bias, particularly among HCWs reporting on service delivery challenges. Finally, the PHC facility-based design may have overlooked community-level factors influencing health-seeking behaviours among individuals who do not frequently access formal healthcare facilities. These limitations suggest the need for further mixed-methods or multi-site studies to validate and expand on these findings.