How should community health workers in fragile contexts be supported: qualitative evidence from Sierra Leone, Liberia and Democratic Republic of Congo

Background: Community Health Workers (CHWs) are critical players in fragile settings, where staff shortages are particularly acute, health indicators are poor and progress towards Universal Health Coverage is slow. Like other health workers, CHWs need support to contribute effectively to health programmes and promote health equity. Yet the evidence base of what kind of support works best is weak. We present evidence from three fragile settings - Sierra Leone, Liberia and Democratic Republic of Congo on managing CHWs, and synthesise recommendations for best approaches to support this critical cadre. Methods: We used a qualitative study design to explore how CHWs are managed, the challenges they face and potential solutions. We conducted interviews with decision makers and managers (n=37), life history interviews with CHWs (n=15) and reviewed policy documents. Results: Fragility disrupts education of community members so that they may not have the literacy levels required for the CHW role. This has implications for the selection, role, training and performance of CHWs. Policy preferences about selection need discussion at the community level, so that they reflect community realities. CHWs scope of work is varied and may change over time, requiring ongoing training. The modular, local, and mix of practical and classroom training approach worked well, helping to address gender and literacy challenges and developing a supportive cohort of CHWs. A package of supervision, community support, regular provision of supplies, performance rewards and regular remuneration is vital to retention and performance of CHWs. But there are challenges with supervision, scarcity of supplies, inadequate community recognition and unfulfilled promises about allowances. Clear communication about incentives with facility staff and communities is required as is their timely delivery. Conclusions: This is the first study that has explored the management of CHWs in fragile settings. CHWs interface role between communities and health systems is critical because of their embedded positionality and the trusting relationships they (often) have. Their challenges are aligned to those generally faced by CHWs but chronic fragility exacerbates them and requires innovative problem solving to ensure that countries and communities are not left behind in reforming the way that CHWs are supported. Keywords: Community Health Workers, management support, fragile settings

Behavioral surveillance during and after the 2014–2016 Ebola outbreak in Sierra Leone

Background: The first documented case of Ebola Virus Disease (Ebola) in Sierra Leone was confirmed in May 2014 in Kailahun district after cases had been reported in Guinea and Liberia. Ebola is transmitted through contact with infected blood, stool, and other bodily fluids. Transmission risk in West Africa was driven by traditional burials involving physical contact with corpses, caring for infected persons without adequate protection, and delaying medical care. Sexual transmission due to viral persistence in the semen of male survivors posed an additional risk. Experimental Ebola vaccine candidates were implemented to curb transmission among health workers and other high–risk individuals. Reporting of all deaths to a national toll–free line (1–1–7 system) was mandated so that burials could be handled by teams trained in infection prevention and control. Aim: To understand trends in population–level Ebola knowledge, attitudes and prevention practices throughout different stages of the outbreak, acceptability of experimental Ebola vaccines at the peak of the outbreak and reporting of deaths after the outbreak ended. Methods: Four cross–sectional household surveys (N=10,603) were conducted using multi– stage cluster sampling in August 2014, October 2014, December 2014, and July 2015 to measure trends in Ebola–related knowledge, attitudes, and prevention practices (KAP). In– depth interviews (N=31) and focus group discussions (N=35) were conducted with health workers, frontline workers, and community members between December 2014 and January 2014 to understand acceptability of Ebola vaccine. Population–level demand for Ebola vaccine was assessed in a national household survey in December 2014 (N=3,540). After the outbreak ended, in 2017, motivations and barriers related to death reporting were assessed through a national telephone survey (N=1,291) and in–depth interviews (N=32). Quantitative data were analyzed using multilevel and ordered logistic regression modeling to examine various associations. Content analysis was used to identify cross–cutting themes in the qualitative data. Results: Ebola–related knowledge, attitudes, and prevention practices improved throughout the outbreak, especially in high–transmission regions. For example, when comparing before and after the peak of the outbreak, avoidance of physical contact with suspected Ebola patients nearly doubled in high–transmission areas (adjusted odds ratio (aOR) 1.9 [95% confidence interval 1.4–2.5]). Acceptability of Ebola vaccine was discouraged by safety related concerns but encouraged by altruistic motivation to help end the outbreak. Nationally, 74% of the public expressed high demand for Ebola vaccine, which was associated with wanting to be the first to get the vaccine compared to wanting politicians to be the first to get the vaccine (aOR 13.0; [7.8–21.6]). The number of deaths reported to the 1–1–7 system nationally in 2017 after the outbreak had ended represented nearly 12% of the expected deaths in the country versus almost 34% in 2016 and as much as 100% in 2015; albeit not accounting for potential duplicate reporting. After the Ebola outbreak, motivation to report deaths was greater if the decedent experienced one or more Ebola–like symptoms compared to none (aOR 2.3 [1.8–2.9]. Barriers to reporting deaths after the outbreak were driven by the lack of awareness to report all deaths, lack of reciprocal benefits linked to reporting, and negative experiences from the outbreak. Conclusions: Ebola prevention practices improved nationally during the outbreak in Sierra Leone, but the magnitude of improvement was greater in high–transmission regions compared to low–transmission regions. Understanding the drivers of Ebola vaccine acceptability and demand was important to inform ethical and cultural considerations in the implementation of experimental Ebola vaccines. While the 1–1–7 system was ramped up to capture nearly all deaths during the outbreak, reporting substantially declined after the outbreak ended. Failure to report deaths after the outbreak was due to lack of awareness to report all deaths and lack of perceived benefits to report in the post–Ebola–outbreak setting. Nevertheless, knowledge and experiences from the Ebola outbreak increasingly motivated people to report deaths that exhibited Ebola–like symptoms. Post–Ebola–outbreak settings offer an opportunity to implement routine mortality surveillance, however, substantial social mobilization efforts may be required to optimize reporting

Exploring the use of health communication in health policy implementation : response to the Ebola outbreak in Sierra Leone

Background: During 2014 and 2015, Sierra Leone suffered the worst Ebola outbreak registered, which also affected Guinea and Liberia. The Government of Sierra Leone, supported by the World Health Organization, issued an accelerated response plan to reduce morbidity and mortality due to Ebola. This plan was initially built on previous experiences in Ebola outbreaks in other countries, albeit much less severe than this current outbreak. The response plan included Communication and Social Mobilization as one of its pillars. Aim: The aim of this degree project was to explore the use and contribution of health communication during the implementation of a health policy. This was achieved through identifying the health communications strategies used in Sierra Leone during the 2014-2015 Ebola outbreak, in the context of other implementation activities. Methods: This is a qualitative exploratory single case study covering a timeframe from April 2014 to April 2015 using thematic content analysis. Data from high-profile key informants was collected using semi-structured interviews. Documents from UNICEF and UNMEER were also analysed. Results: Health communication was used actively in the Ebola response in Sierra Leone, and its utilization changed over time in order to adapt to the outbreak situation and lessons learnt. The interviews highlighted moments and decision making during the response and jointly with the documents enabled identifying trends in strategies. It was possible to understand the rationale and context behind health communication decisions, studying communication styles changes over time and identifying particular lessons learned. Conclusion: Five main phases were identified in health communication usage during the Ebola response in Sierra Leone, each one characterized by a unique communication style, specific messages according to the outbreak situation or a different approach in the implementation of the response plan. Some best practices from the studied Ebola response in Sierra Leone were also highlighted.Undersöka användningen av hälsokommunikation i genomförandet hälso- och sjukvårdspolitik: svar på utbrottet Ebola i Sierra Leon

Bounce Forward Resilience Attributes: Information System Strengthening in Response to Crisis

Previous information system resilience studies have predominantly focused on analyzing bounce back, return to pre-shock state, resilience. This paper explores the phenomena of bounce forward information system resilience through longitudinal analysis of the COVID-19 responses in Sri Lanka and Sierra Leone. Both of these countries were able to significantly expand their information systems in terms of functionality, scale, and scope in response to the pandemic. The goal of this paper is to derive new bounce forward attributes that were present in the information system landscapes of these countries prior to the pandemic. Through the analysis of these cases against the previously identified resilience attributes found in the literature, we defined capacity for coordinated agility, configurable and extensible innovation platform infrastructure, and human resource action potential as unique information system attributes that can constitute bounce forward outcomes when systems face shocks or are under stress

Community Engagement in the International Emergency Response to Ebola, 2014-2016

An unsafe and illegal burial conducted in Port Loko, Sierra Leone during the Ebola epidemic of 2014-2016 exposed competing risk perspectives between emergency responders and the affected community, and called into question community engagement (CE) efforts in the response – particularly regarding strict, but culturally-problematic burial protocols. This work interrogates the effectiveness of CE through development of a novel, two-dimensional metric. The first dimension builds on the work of Davidson (1998) and others to parse CE efforts into four distinct domains: Information Provision, Consultation, Participation, and Community Empowerment. The second dimension builds on the work of Arnstein (1969) and others to create a semi-quantitative scale which assigns an Empowerment Score from zero to two, assessing the degree to which community feedback leads to material changes in interventions in each domain. The Empowerment Score methodology was applied to analyze CE efforts reported in literature and in the CE standards of international response organizations. The methodology was then used in a modified Delphi survey of responders and anthropologists with experience in the Ebola response in Sierra Leone, to characterize the successes and shortcomings of CE efforts, with a focus on burial of persons who had died of Ebola. Quantitative analysis of Delphi panelists’ numeric scores, combined with qualitative analysis of their textual comments, revealed substantial disagreement between diverse experts regarding the appropriateness or success of CE efforts in the response. However, there was general agreement among the experts that future epidemic responses should take into account cultural concerns in the negotiation of burial protocols or other interventions that may collide with cultural values. For future emergency responses, the incorporation of social scientists such as anthropologists into CE structures, as well as intentional involvement of community members in the planning and implementation of disease-control measures, is recommended. Additionally, the international emergency response community is called to a posture of humility, acknowledging that realities other than the medicalized and materialistic drive human behavior, including health-affecting behavior. Respectful engagement with risk as understood by a community, combined with a Harm Reduction philosophy to define interventions, may save more lives than biomedically pure, but coercive approaches

Geographic Variations in Antenatal Care Services in Sierra Leone

Despite antenatal care presenting opportunities to identify and monitor women at risk, use of recommended antenatal care services remains. Barriers preventing use of antenatal services vary between countries, and limited knowledge exists about the link between geographical settings and antenatal service use. The objective of this cross-sectional quantitative study was to explore geographical variations and investigate how social demographic characteristics affect use of antenatal care for women in Sierra Leone using the Andersen behavioral model. The data used were from the 2016 maternal death surveillance report of the whole counrty (N =706). Logistic regression analysis was used to determine the individual predictor effects on antenatal care, including geographical location, the age of women, marital status, parity, and institution of birth impact. Southern, Northern, and Eastern women had significantly lower odds of attending the recommended antenatal services compared to women in the Western region (OR = .517, p = .019; OR = .497, p = .021; OR = 0.014, p = .041, respectively). The odds of married women attending the recommended antenatal services was 7.3 times more than that of the single women (OR = 7.397). Also, significantly associated with less uptake of recommended antenatal visits was lower education level among women (OR = .517). This study will contribute to positive social change by highlighting inequities in antenatal care use among women, thus allowing for accurate targeting of health promotion programs and ultimately saving lives of mothers and children of Sierra Leone through more inclusive policies

An evaluation of COVID-19 surveillance system in New Juaben South Municipality of Ghana: a cross-sectional study

Introduction: among others, the objectives of Ghana’s COVID-19 surveillance system are to rapidly detect, test, isolate and manage cases, to monitor trends in COVID-19 deaths and to guide the implementation and adjustment of targeted control measures. We therefore aimed to examine the operations of the COVID-19 surveillance system in New Juaben South Municipality, describe its attributes and explore whether its objectives were being met. Methods: we utilized a mixed method descriptive study design to evaluate the COVID-19 surveillance system in the New Juaben South Municipality of the Eastern Region of Ghana. Desk review and key informant interviews were carried out from 1st February to 31st March 2021 to measure nine surveillance system attributes as an approximation of its performance using the CDC’s 2013 updated surveillance system guidelines. Results: while the COVID-19 surveillance system in New Juaben South (NJS) was highly representative of its population, it was rated ‘moderate’ for its stability, flexibility, sensitivity and acceptability. The system was however characterized by a low performance on data quality, simplicity, timeliness and predictive value positive. The sensitivity and predictive value positive (PVP) of the system were 55.6% and 31.3% respectfully. Conclusion: while the surveillance system is only partially meeting its objectives, it is useful in the COVID-19 response in New Juaben South Municipality. System performance could improve with stigma reduction especially among health care workers, timely testing and simplification of surveillance forms and software

Exploring the Factors Influencing the Performance of District Health Management Teams in Sierra Leone

Background: Decentralized district health system is the cornerstone of a country’s health sectors. The aim of the present study was to investigate the factors that influence the performance of the district health management team (DHMT) in Sierra Leone. The study was guided by a conceptual framework that is adapted from the World Health Organization leadership and management strengthening framework. Methods: The study used a qualitative method design and targeted both the District Medical Officers (DMO) and their subordinates in four DHMTs (Bo, Kailahun, Kenema and Kono). An interview guide was used to explore the perspectives of both the DMOs and their subordinates (n=27) on the perceived factors that influence the performance of the DHMTs. A thematic analysis, using the WHO framework was carried out in the analysis of the data. Results: The perceived factors that influence the performance of DHMTs are notably the inadequate and late disbursement of funds to the district. This affects the implementation of planned activities. Further, the lack of adequate and capable staff within the DHMTs was highlighted. Other concerns were the poor coordination between national and district level in health program implementation; and the poor working conditions such as poor office spaces, unreliable power supplies and internet connectivity. Conclusions: Addressing the human resource gap within DHMT, ensuring a better flow of funds to the district, and improved coordination in health program implementation between national and district are promising measures that will optimize the performance of the DHMTs in Sierra Leone. Keywords: health system, health system strengthening, health system performance, district health system, district health management, decentralization, devolution DOI: 10.7176/JHMN/76-03 Publication date:June 30th 202

The practice of evaluating epidemic response in humanitarian and low-income settings: a systematic review.

BACKGROUND: Epidemics of infectious disease occur frequently in low-income and humanitarian settings and pose a serious threat to populations. However, relatively little is known about responses to these epidemics. Robust evaluations can generate evidence on response efforts and inform future improvements. This systematic review aimed to (i) identify epidemics reported in low-income and crisis settings, (ii) determine the frequency with which evaluations of responses to these epidemics were conducted, (iii) describe the main typologies of evaluations undertaken and (iv) identify key gaps and strengths of recent evaluation practice. METHODS: Reported epidemics were extracted from the following sources: World Health Organization Disease Outbreak News (WHO DON), UNICEF Cholera platform, Reliefweb, PROMED and Global Incidence Map. A systematic review for evaluation reports was conducted using the MEDLINE, EMBASE, Global Health, Web of Science, WPRIM, Reliefweb, PDQ Evidence and CINAHL Plus databases, complemented by grey literature searches using Google and Google Scholar. Evaluation records were quality-scored and linked to epidemics based on time and place. The time period for the review was 2010-2019. RESULTS: A total of 429 epidemics were identified, primarily in sub-Saharan Africa, the Middle East and Central Asia. A total of 15,424 potential evaluations records were screened, 699 assessed for eligibility and 132 included for narrative synthesis. Only one tenth of epidemics had a corresponding response evaluation. Overall, there was wide variability in the quality, content as well as in the disease coverage of evaluation reports. CONCLUSION: The current state of evaluations of responses to these epidemics reveals large gaps in coverage and quality and bears important implications for health equity and accountability to affected populations. The limited availability of epidemic response evaluations prevents improvements to future public health response. The diversity of emphasis and methods of available evaluations limits comparison across responses and time. In order to improve future response and save lives, there is a pressing need to develop a standardized and practical approach as well as governance arrangements to ensure the systematic conduct of epidemic response evaluations in low-income and crisis settings

Vaccine

IntroductionExperimental Ebola vaccines were introduced during the 2014\u20132015 Ebola outbreak in West Africa. Planning for the Sierra Leone Trial to Introduce a Vaccine against Ebola (STRIVE) was underway in late 2014. We examined hypothetical acceptability and perceptions of experimental Ebola vaccines among health care workers (HCWs), frontline workers, and the general public to guide ethical communication of risks and benefits of any experimental Ebola vaccine.MethodsBetween December 2014 and January 2015, we conducted in-depth interviews with public health leaders (N=31), focus groups with HCWs and frontline workers (N=20), and focus groups with members of the general public (N=15) in Western Area Urban, Western Area Rural, Port Loko, Bombali, and Tonkolili districts. Themes were identified using qualitative content analysis.ResultsAcross all participant groups, not knowing the immediate and long-term effects of an experimental Ebola vaccine was the most serious concern. Some respondents feared that experimental vaccines may cause Ebola, lead to death, or result in other adverse events. Among HCWs, not knowing the level of protection provided by experimental Ebola vaccines was another concern. HCWs and frontline workers were motivated to help find a vaccine for Ebola to help end the outbreak. General public participants cited positive experiences with routine childhood immunization in Sierra Leone.DiscussionOur formative assessment prior to STRIVE\u2019s implementation in Sierra Leone helped identify concerns, motivations, and information gaps among potential participants of an experimental Ebola vaccine trial, at the time when an unprecedented outbreak was occurring in the country. The findings from this assessment were incorporated early in the process to guide ethical communication of risks and benefits when discussing informed consent for possible participation in the vaccine trial that was launched later in 2015.20192020-07-31T00:00:00ZCC999999/ImCDC/Intramural CDC HHS/United States30755367PMC7393388809