Engaging the public in decisions about emergency vaccine deployment strategies: Lessons from scenario-based discussions in Sierra Leone.

ABSTRACTThe COVID-19 pandemic has amplified discussions on emergency vaccine deployment strategies, with current perspectives often neglecting extensive community involvement in ethical, logistical and political aspects. Existing social science literature predominantly delves into factors influencing trust, overlooking the untapped potential for community engagement.Our study examines community preparedness in Sierra Leone's Kambia District, exploring diverse viewpoints on vaccine deployment strategies, emphasising Ebola and COVID-19 vaccinations. Utilising extensive ethnographic research from the Ebola vaccine trials (EBOVAC Salone) conducted in Kambia District from 2015 to 2021, including participant observation and tailored focus group discussions, we investigated various deployment scenarios with community leaders and citizens.Our findings underscore the multifaceted contributions of social science research with communities in shaping emergency vaccination strategies. These contributions span logistical insights, aligning campaigns with local livelihoods and social structures, and grounded ethical concerns assessing social justice outcomes across epidemic scenarios. This study emphasises the imperative of integrating discussions on vaccine confidence and deployment. It highlights communities' proficiency in epidemiological reasoning and their ability to bring this in conversation with salient socio-cultural, economic and religious dimensions. We therefore promote the cultivation of public dialogue, collaborative creation of impactful vaccination initiatives alongside relevant communities in recognition of their invaluable perspectives .

Cannabis use and its psychosocial correlates among school-going adolescents in Sierra Leone.

BACKGROUND: In Sierra Leone, adolescents are increasingly engaging in risky activities, including cannabis use, which can lead to substance abuse, poor academic performance, and psychotic symptoms. This study aims to investigate the prevalence and associated factors of cannabis use among school-going adolescents in the country. METHOD: Data for the study was sourced from the 2017 Sierra Leone Global School-based Student Health Survey (GSHS), a nationally representative survey conducted among adolescents aged 10-19 years using a multistage sampling methodology. A weighted sample of 1,467 adolescents in Sierra Leone was included in the study. The study utilised bivariate and multivariable logistic regression analysis to identify factors linked to cannabis use, presenting results using adjusted odds ratios and 95% confidence intervals. RESULTS: The prevalence of cannabis use was 5.1% [3.0,8.6] among school-going adolescents in Sierra Leone. School-going adolescents who attempted suicide [aOR = 6.34, 95% CI = 1.71-23.45], used amphetamine [aOR = 15.84, 95% CI = 7.94-31.62] and were involved in sexual risk behaviour [aOR = 5.56, 95% CI = 2.18-14.20] were more likely to be associated with cannabis use. CONCLUSION: In Sierra Leone, a small but non-trivial minority of students use cannabis. Ever-used amphetamines or methamphetamines, suicidal attempts, and sexual risk behaviour were the factors associated with cannabis use in Sierra Leone. The development of school-based health intervention programmes is crucial to address the risk factors associated with cannabis use among school-going adolescents.

Alcohol use among in-school adolescents in Sierra Leone.

OBJECTIVE: To examine the prevalence of alcohol use and its associated factors among in-school adolescents in Sierra Leone. DESIGN: Data for the study was sourced from the 2017 Sierra Leone Global School-Based Student Health Survey, a nationally representative survey conducted among in-school adolescents aged 10-19 years using a multistage sampling methodology. Percentages were used to present the prevalence of alcohol use among in-school adolescents. Multivariable binary logistic regression analysis was performed to examine the factors associated with alcohol use among in-school adolescents. The results were presented using adjusted odds ratios (aOR) with their respective 95% confidence interval (CI). SETTING: Sierra Leone. PARTICIPANTS: A weighted sample of 1730 in-school adolescents in Sierra Leone. OUTCOME MEASURE: Current alcohol use. RESULTS: The prevalence of alcohol use among in-school adolescents was 10.7% (7.3, 15.3). In-school adolescents in senior secondary schools were more likely to use alcohol compared with those in junior secondary school (aOR=2.13; 95% CI 1.37, 3.30). The odds of alcohol use was higher among in-school adolescents who were truant at school relative to those who were not (aOR=2.24; 95% CI 1.54, 3.26). Also, in-school adolescents who were bullied (aOR=1.85; 95% CI 1.24, 2.76), ever engaged in sexual intercourse (aOR=2.06; 95% CI 1.39, 3.06), and used marijuana (aOR=3.36; 95% CI 1.72, 6.53) were more likely to use alcohol compared with those who were not. However, in-school adolescents who reported that their parents understood their problems (aOR=0.52; 95% CI 0.33, 0.82) had a lower likelihood of consuming alcohol. CONCLUSION: Our study has shown that alcohol use is prevalent among in-school adolescents in Sierra Leone. Grade level, experiences of being bullied, history of sexual intercourse, truancy at school, and previous use of marijuana were the factors influencing alcohol use among in-school adolescents. The findings emphasise the necessity of creating school-based health interventions in Sierra Leone that can effectively identify in-school adolescents potentially vulnerable to alcohol-related issues. Also, existing policies and programmes aimed at reducing alcohol use among in-school adolescents need to be strengthened.

Assessing geographical variation in ovulatory cycle knowledge among women of reproductive age in Sierra Leone: Analysis of the 2019 Demographic and Health Survey.

BACKGROUND: Sierra Leone has poor indicators of reproductive health and a high prevalence of unintended pregnancies. To date, no study has explored determinants of ovulatory cycle knowledge in Sierra Leone. We investigated geographic region to determine where the needs for improved ovulatory cycle knowledge are greatest in Sierra Leone. METHODS: This is a cross-sectional study of women of reproductive age (n = 15,574) based on the 2019 Sierra Leone Demographic and Health Survey. Geographic region and sociodemographic covariates were included in a multivariate logistic regression model predicting the odds that participants possessed accurate knowledge of when in the ovulatory cycle pregnancy initiation is most likely. RESULTS: In Sierra Leone, 39.8% (CI = 37.4-40.9) of 15-49-year-old women had accurate knowledge of the ovulatory cycle. Women in the Northern and Southern regions possessed the highest prevalence of correct knowledge (46.7%, CI = 43.1-50.3 and 45.1%, CI = 41.9-48.2, respectively). Women from the Northwestern (AOR = 0.29, CI = 0.22-0.38), Eastern (AOR = 0.55, CI = 0.41-0.72), and Western regions (AOR = 0.63, CI = 0.50-0.80) had significantly lower odds of accurate ovulatory cycle knowledge compared to others. Women aged 15-19, those with a primary school education, and participants with a parity of none all had the lowest odds of correct ovulatory cycle knowledge as well. CONCLUSION: Less than four in ten women in Sierra Leone had accurate knowledge of when in the ovulatory cycle pregnancy is most likely to occur. This suggests that family planning outreach programs should include education on the ovulatory cycle and the importance of understanding the implications of its timing. This can reduce the risk of unintended pregnancies throughout Sierra Leone, and can have an especially positive impact in the Northwestern, Eastern, and Western regions, where ovulatory cycle knowledge was significantly lower.

Geographic Disparities in Domestic Pig Population Exposure to Ebola Viruses, Guinea, 2017-2019.

Although pigs are naturally susceptible to Reston virus and experimentally to Ebola virus (EBOV), their role in Orthoebolavirus ecology remains unknown. We tested 888 serum samples collected from pigs in Guinea during 2017-2019 (between the 2013-16 epidemic and its resurgence in 2021) by indirect ELISA against the EBOV nucleoprotein. We identified 2 hotspots of possible pig exposure by IgG titer levels: the northern coast had 48.7% of positive serum samples (37/76), and Forest Guinea, bordering Sierra Leone and Liberia, where the virus emerged and reemerged, had 50% of positive serum samples (98/196). The multitarget Luminex approach confirms ELISA results against Ebola nucleoprotein and highlights cross-reactivities to glycoprotein of EBOV, Reston virus, and Bundibugyo virus. Those results are consistent with previous observations of the circulation of Orthoebolavirus species in pig farming regions in Sierra Leone and Ghana, suggesting potential risk for Ebola virus disease in humans, especially in Forest Guinea.

Human-animal entanglements in bushmeat trading in Sierra Leone: An ethnographic assessment of a potential zoonotic interface.

'Bushmeat' markets are often portrayed as chaotic spaces where exotic wild animals are sold. They are hypothesized to be important sites for zoonotic disease transmission, given the prolonged and intense nature of the cross-species encounters that occur within them. Whilst such markets have received some attention from researchers, rich qualitative descriptions of everyday practices in these markets are rare. Depictions of wild animal markets as sites for potential viral amplification often rely on exoticizing assumptions and narratives rather than actual evidence, and in some cases are based more on ideology than on science. We provide an in-depth ethnographic account of two bushmeat markets in Bo, Sierra Leone. Our analysis goes beyond common assumptions that zoonotic risk is located solely in the knowledge and behaviours of traders. Our account sheds light on the modes of touch, closeness and contact that shape this hypothesised zoonotic interface, outlining the possible risks to different people who use and spend time in the market. We found that inadequate infrastructure and sanitation facilities created risks of zoonotic disease transmission for diverse actors including traders, customers, children, and the wider public. Butchering and trading practices frequently resulted in people directly and indirectly encountering animal fluids. We also discuss how public health management of these markets focused on individual behaviours rather than on improving conditions. Urgent sanitary reform and infrastructure upgrades in these sites that support the economic needs of traders could encourage voluntary compliance with biosafety measures amongst traders seeking to balance responsibilities to family and public health. Our study reveals the value of moving beyond exoticized narratives about bushmeat markets to yield situated insights for reducing risk at this interface.

The feasibility, repeatability, validity and responsiveness of the EQ-5D-3L in Krio for patients with stroke in Sierra Leone.

OBJECTIVES: To assess the feasibility, repeatability, validity and responsiveness of the EQ-5D-3L in Krio for patients with stroke in Sierra Leone, the first psychometric assessment of the EQ-5D-3L to be conducted in patients with stroke in Sub Saharan Africa. METHODS: A prospective stroke register at two tertiary government hospitals recruited all patients with the WHO definition of stroke and followed patients up at seven days, 90 days and one year post stroke. The newly translated EQ-5D-3L, Barthel Index (BI), modified Rankin Scale (mRS) and National Institute of Health Stroke Scale (NIHSS), a measure of stroke severity, were collected by trained researchers, face to face during admission and via phone at follow up. Feasibility was assessed by completion rate and proportion of floor/ceiling effects. Internal consistency was assessed by inter item correlations (IIC) and Cronbach's alpha. Repeatability of the EQ-5D-3L was examined using test-retest, EQ-5D-3L utility scores at 90 days were compared to EQ-5D-3L utility scores at one year in the same individuals, whose Barthel Index had remained within the minimally clinical important difference. Known group validity was assessed by stroke severity. Convergent validity was assessed against the BI, using Spearman's rho. Responsiveness was assessed in patients whose BI improved or deteriorated from seven to 90 days. Sensitivity analyses were conducted using the UK and Zimbabwe value sets, to evaluate the effect of value set, in a subgroup of patients with no formal education to evaluate the influence of patient educational attainment, and using the mRS instead of the BI to evaluate the influence of utilising an alternative functional scale. RESULTS: The EQ-5D-3L was completed in 373/460 (81.1%), 360/367 (98.1%) and 299/308 (97.1%) eligible patients at seven days, 90 days and one year post stroke. Missing item data was low overall, but was highest in the anxiety/depression dimension 1.3% (5/373). Alpha was 0.81, 0.88 and 0.86 at seven days, 90 days and one year post stroke and IIC were within pre-specified ranges. Repeatability of the EQ-5D-3L was moderate to poor, weighted Kappa 0.23-0.49. EQ-5D-3L utility was significantly associated with stroke severity at all timepoints. Convergent validity with BI was strong overall and for shared subscales. EQ-5D-3L was moderately responsive to both improvement Cohen's D 0.55 (95% CI:0.15-0.94) and deterioration 0.92 (95% CI:0.29-1.55). Completion rates were similar in patients with no formal education 148/185 (80.0%) vs those with any formal education 225/275 (81.8%), and known group validity for stroke severity in patients with no formal education was strong. Using the Zimbabwe value set instead of the UK value set, and using the mRS instead of the BI did not change the direction or significance of results. CONCLUSIONS: The EQ-5D-3L for stroke in Sierra Leone was feasible, and responsive including in patients with no formal education. However, repeatability was moderate to poor, which may be due to the study design, but should add a degree of caution in the analysis of repeated measures of EQ-5D-3L over time in this population. Known group validity and convergent validity with BI and mRS were strong. Further research should assess the EQ-5D in the general population, examine test-retest reliability over a shorter time period and assess the acceptability and validity of the anxiety/depression dimension against other validated mental health instruments. Development of an EQ-5D value set for West Africa should be a research priority.

Last-mile delivery increases vaccine uptake in Sierra Leone.

Less than 30% of people in Africa received a dose of the COVID-19 vaccine even 18 months after vaccine development1. Here, motivated by the observation that residents of remote, rural areas of Sierra Leone faced severe access difficulties2, we conducted an intervention with last-mile delivery of doses and health professionals to the most inaccessible areas, along with community mobilization. A cluster randomized controlled trial in 150 communities showed that this intervention with mobile vaccination teams increased the immunization rate by about 26 percentage points within 48-72 h. Moreover, auxiliary populations visited our community vaccination points, which more than doubled the number of inoculations administered. The additional people vaccinated per intervention site translated to an implementation cost of US $33 per person vaccinated. Transportation to reach remote villages accounted for a large share of total intervention costs. Therefore, bundling multiple maternal and child health interventions in the same visit would further reduce costs per person treated. Current research on vaccine delivery maintains a large focus on individual behavioural issues such as hesitancy. Our study demonstrates that prioritizing mobile services to overcome access difficulties faced by remote populations in developing countries can generate increased returns in terms of uptake of health services3.

A community-based mentoring scheme for pregnant and parenting adolescents in Sierra Leone: Protocol for a hybrid pilot cluster randomised controlled trial.

BACKGROUND: Sierra Leone has a very high maternal mortality rate, and this burden falls heavily on adolescents, a particularly vulnerable group; this is usually driven by poverty, lack of education and employment opportunities. In 2017, a local grassroots organisation, Lifeline Nehemiah Projects, developed a community-based mentoring intervention '2YoungLives' (2YLs) for adolescent girls in Eastern Freetown. We aim to formally assess the feasibility and implementation of the 2YL mentorship scheme in new communities in Sierra Leone. METHODS: A hybrid type 2 pilot cluster randomised controlled trial of the 2YL mentoring scheme in urban and rural communities living around twelve peripheral health units (PHU) across five districts in Sierra Leone. Clusters will be matched into pairs and randomisation will be determined by computer-generated random numbers via a secure web-based system hosted by MedSciNet. All under-eighteen adolescents identified as pregnant in the community and/or the PHU are included. Feasibility (recruitment, retention, and attrition rates; data collection and completeness; sample calculation) and primary clinical outcome data (composite of maternal deaths, stillbirths, neonatal deaths) will be collected. A mixed-methods process evaluation will explore implementation outcomes, mechanisms of change, contextual factors, experiences of care, and health and wellbeing. A concurrent cost-consequence analysis will be undertaken. Main trial analysis will be pragmatic, by intention to treat, and a complementary per protocol analysis will also be included. DISCUSSION: Improving health and wellbeing for adolescent girls (including sexual and reproductive health) remains a top priority in Sierra Leone indicated by several government policies targeted to this group, in which maternal and infant mortality are still persistently high. Supporting these girls and facilitating their wellbeing is imperative, along with sensitisation of communities, strengthening of youth friendly services and collaboration with stakeholders at all levels (government, regional, community, family). We believe 2YL supports the global holistic agenda to integrate and implement interventions across health, education, and social systems in order to protect, nurture, and support the health and development potential of every adolescent girl, and thus become a model of good practice for adolescent pregnancy, to be adopted more widely in Sierra Leone and elsewhere. TRIAL REGISTRATION: ISRCTN registry ISRCTN32414369. Prospectively registered on 14/03/2022.

Impact assessment of onchocerciasis through lymphatic filariasis transmission assessment surveys using Ov-16 rapid diagnostic tests in Sierra Leone.

BACKGROUND: Onchocerciasis is endemic in 14 of Sierra Leone's 16 districts with high prevalence (47-88.5%) according to skin snips at baseline. After 11 rounds of mass treatment with ivermectin with good coverage, an impact assessment was conducted in 2017 to assess the progress towards eliminating onchocerciasis in the country. METHODS: A cluster survey was conducted, either integrated with lymphatic filariasis (LF) transmission assessment survey (TAS) or standalone with the LF TAS sampling strategy in 12 (now 14) endemic districts. Finger prick blood samples of randomly selected children in Grades 1-4 were tested in the field using SD Bioline Onchocerciasis IgG4 rapid tests. RESULTS: In total, 17,402 children aged 4-19 years in 177 schools were tested, and data from 17,364 children aged 4-14 years (14,230 children aged 5-9 years) were analyzed. Three hundred forty-six children were confirmed positive for Ov-16 IgG4 antibodies, a prevalence of 2.0% (95% CI 1.8-2.2%) in children aged 4-14 years with prevalence increasing with age. Prevalence in boys (2.4%; 95% CI 2.1-2.7%) was higher than in girls (1.6%; 95% CI 1.4-1.9%). There was a trend of continued reduction from baseline to 2010. Using data from children aged 5-9 years, overall prevalence was 1.7% (95% CI 1.5-1.9%). The site prevalence ranged from 0 to 33.3% (median prevalence = 0.0%): < 2% in 127 schools, 2 to < 5% in 34 schools and ≥ 5% in 16 schools. There was a significant difference in average prevalence between districts. Using spatial analysis, the Ov-16 IgG4 antibody prevalence was predicted to be < 2% in coastal areas and in large parts of Koinadugu, Bombali and Tonkolili Districts, while high prevalence (> 5%) was predicted in some focal areas, centered in Karene, Kailahun and Moyamba/Tonkolili. CONCLUSIONS: Low Ov-16 IgG4 antibody prevalence was shown in most areas across Sierra Leone. In particular, low seroprevalence in children aged 5-9 years suggests that the infection was reduced to a low level after 11 rounds of treatment intervention. Sierra Leone has made major progress towards elimination of onchocerciasis. However, attention must be paid to those high prevalence focal areas.

Prevalence and predictors of lifetime amphetamine use among in-school adolescents in Sierra Leone.

OBJECTIVE: This study examined the prevalence of amphetamine use and its associated factors among in-school adolescents in Sierra Leone. DESIGN: Data for the study was sourced from the 2017 Sierra Leone Global School-based Health Survey. Percentages with confidence intervals (CIs) were used to present the prevalence of amphetamine use among in-school adolescents. A multivariable binary logistic regression analysis was employed to examine the factors associated with amphetamine use. The results were presented using adjusted odds ratios (aORs) with 95% CIs. SETTING: Sierra Leone. PARTICIPANTS: A weighted sample of 1,314 in-school adolescents in Sierra Leone. OUTCOME MEASURE: Lifetime amphetamine use. RESULTS: The prevalence of amphetamine use was 6.1% (3.9%-9.5%). In-school adolescents who planned suicide were more likely to use amphetamine compared with those who did not (aOR 2.54; 95% CI 1.02 to 6.31). Also, the odds of amphetamine use were higher among in-school adolescents who received support from their peers (aOR 3.19, 95% CI 1.71 to 5.96), consumed alcohol (aOR 4.85, 95% CI 2.61 to 9.03), and those who had previously used marijuana (aOR 13.31, 95% CI 6.61 to 28.78) compared with those who did not receive any support, never consumed alcohol, and never used marijuana, respectively. CONCLUSION: Amphetamine use is prevalent among in-school adolescents in Sierra Leone. There is a need to implement comprehensive public health policies that extend beyond school-based psychobehavioural therapies. These policies should specifically address the considerable risk factors associated with amphetamine use among in-school adolescents in Sierra Leone.

Prevalence of hypertension, diabetes mellitus, and their risk factors in an informal settlement in Freetown, Sierra Leone: a cross-sectional study.

BACKGROUND: Noncommunicable diseases (NCDs), especially hypertension and diabetes mellitus are on the increase in sub-Saharan Africa (SSA). Informal settlement dwellers exhibit a high prevalence of behavioural risk factors and are highly vulnerable to hypertension and diabetes. However, no study has assessed the prevalence of hypertension, diabetes, and NCDrisk factors among informal settlement dwellers in Sierra Leone. We conducted a study in June 2019 to determine the prevalence of hypertension, diabetes, and NCD risk factors among adults living in the largest Sierra Leonean informal settlement (KrooBay). METHODS AND MATERIALS: We conducted a community-based cross-sectional survey among adults aged ≥ 35 years in the KrooBay community. Trained healthcare workers collected data on socio-demographic characteristics and self-reported health behaviours using the World Health Organization STEPwise surveillance questionnaire for chronic disease risk factors. Anthropometric, blood glucose, and blood pressure measurements were performed following standard procedures. Logistics regression was used for analysis and adjusted odd ratios with 95% confidence intervals were calculated to identify risk factors associated with hypertension. RESULTS: Of the 418 participants, 242 (57%) were females and those below the age of 45 years accounted for over half (55.3%) of the participants. The prevalence of smoking was 18.2%, alcohol consumption was 18.8%, overweight was 28.2%, obesity was 17.9%, physical inactivity was 81.5%, and inadequate consumption of fruits and vegetables was 99%. The overall prevalence of hypertension was 45.7% (95% CI 41.0-50.5%), systolic hypertension was 34.2% (95% CI 29.6-38.8%), diastolic blood pressure was 39.9% (95% CI 35.2-44.6), and participants with diabetes were 2.2% (95% CI 0.7-3.6%). Being aged ≥ 55 years (AOR = 7.35, 95% CI 1.49-36.39) and > 60 years (AOR 8.05; 95% CI 2.22-29.12), separated (AOR = 1.34; 95% 1.02-7.00), cohabitating (AOR = 6.68; 95% CL1.03-14.35), vocational (AOR = 3.65; 95% CI 1.81-7.39 ) and having a university education (AOR = 4.62; 95% CI 3.09-6.91) were found to be independently associated with hypertension. CONCLUSION: The prevalence of hypertension,and NCD risk factors was high among the residents of the Kroobay informal settlement. We also noted a low prevalence of diabetes. There is an urgent need for the implementation of health education, promotion, and screening initiatives to reduce health risks so that these conditions will not overwhelm health services.

The economic burden of Ebola virus disease: a review and recommendations for analysis.

BACKGROUND: Ebola virus disease (EVD) continues to be a major public health threat globally, particularly in the low-and-middle-income countries (LMICs) of Africa. The social and economic burdens of EVD are substantial and have triggered extensive research into prevention and control. We aim to highlight the impact and economic implications, identify research gaps, and offer recommendations for future economic studies pertaining to EVD. METHOD: We conducted a comprehensive librarian-led search in PubMed/Medline, Embase, Google Scholar, EconLit and Scopus for economic evaluations of EVD. After study selection and data extraction, findings on the impact and economics of EVD were synthesized using a narrative approach, while identifying gaps, and recommending critical areas for future EVD economic studies. RESULTS: The economic evaluations focused on the burden of illness, vaccine cost-effectiveness, willingness-to-pay for a vaccine, EVD funding, and preparedness costs. The estimated economic impact of the 2014 EVD outbreak in Guinea, Liberia, and Sierra Leone across studies ranged from $30 billion to $50 billion. Facility construction and modification emerged as significant cost drivers for preparedness. The EVD vaccine demonstrated cost-effectiveness in a dynamic transmission model; resulting in an incremental cost-effectiveness ratio of about $96 per additional disability adjusted life year averted. Individuals exhibited greater willingness to be vaccinated if it incurred no personal cost, with a minority willing to pay about $1 for the vaccine. CONCLUSIONS: The severe impact of EVD puts pressure on governments and the international community for better resource utilization and re-allocation. Several technical and methodological issues related to economic evaluation of EVD remain to be addressed, especially for LMICs. We recommend conducting cost-of-sequelae and cost-of-distribution analyses in addition to adapting existing economic analytical methods to EVD. Characteristics of the affected regions should be considered to provide evidence-based economic plans and economic-evaluation of mitigations that enhance resource allocation for prevention and treatment.

Ebola virus disease (EVD) is a serious health problem, not only in Africa where there have been outbreaks but in other parts of the world as well. In addition to its severe health implications and resultant death, EVD also poses significant impact across several sectors, including food and agriculture, transportation, education, among others, ultimately impacting the economies of affected countries. While some studies have estimated the economic burden of EVD, there remains questions that need addressing. We conducted a review of published studies to estimate what is known about the economic burden of EVD, identified research gaps. Studies looked at how much money EVD costs in terms of prevention and treatment, while others reported on people's willingness to pay for a vaccine. The estimated economic impact of the 2014 EVD outbreak in Guinea, Liberia, and Sierra Leone ranged from approximately $30 billion to $50 billion across studies. Healthcare facility construction and modification were significant cost factors for response preparedness for EVD outbreaks. While the EVD vaccine showed cost-effectiveness, surveys of people across various regions revealed that more individuals were willing to get vaccinated if it was free, with a minority willing to pay a median of about $1 for the vaccine. The severe impact of EVD puts pressure on governments and the international community to use resources more efficiently. We recommend conducting analyses on the costs of long-term effects of EVD and costs of vaccine and treatment distribution, as well as adapting existing economic methods to the specific characteristics of affected regions. This would help create evidence-based economic plans and evaluations of strategies to enhance resource allocation for EVD prevention and treatment.

A qualitative study examining the health system's response to COVID-19 in Sierra Leone.

The paper examines the health system's response to COVID-19 in Sierra Leone. It aims to explore how the pandemic affected service delivery, health workers, patient access to services, leadership, and governance. It also examines to what extent the legacy of the 2013-16 Ebola outbreak influenced the COVID-19 response and public perception. Using the WHO Health System Building Blocks Framework, we conducted a qualitative study in Sierra Leone where semi-structured interviews were conducted with health workers, policymakers, and patients between Oct-Dec 2020. We applied thematic analysis using both deductive and inductive approaches. Twelve themes emerged from the analysis: nine on the WHO building blocks, two on patients' experiences, and one on Ebola. We found that routine services were impacted by enhanced infection prevention control measures. Health workers faced additional responsibilities and training needs. Communication and decision-making within facilities were reported to be coordinated and effective, although updates cascading from the national level to facilities were lacking. In contrast with previous health emergencies which were heavily influenced by international organisations, we found that the COVID-19 response was led by the national leadership. Experiences of Ebola resulted in less fear of COVID-19 and a greater understanding of public health measures. However, these measures also negatively affected patients' livelihoods and their willingness to visit facilities. We conclude, it is important to address existing challenges in the health system such as resources that affect the capacity of health systems to respond to emergencies. Prioritising the well-being of health workers and the continued provision of essential routine health services is important. The socio-economic impact of public health measures on the population needs to be considered before measures are implemented.

Non-communicable disease care in Sierra Leone: a mixed-methods study of the drivers and barriers to retention in care for hypertension.

OBJECTIVE: To retrospectively analyse routinely collected data on the drivers and barriers to retention in chronic care for patients with hypertension in the Kono District of Sierra Leone. DESIGN: Convergent mixed-methods study. SETTING: Koidu Government Hospital, a secondary-level hospital in Kono District. PARTICIPANTS: We conducted a descriptive analysis of key variables for 1628 patients with hypertension attending the non-communicable disease (NCD) clinic between February 2018 and August 2019 and qualitative interviews with 21 patients and 7 staff to assess factors shaping patients' retention in care at the clinic. OUTCOMES: Three mutually exclusive outcomes were defined for the study period: adherence to the treatment protocol (attending >80% of scheduled visits); loss-to-follow-up (LTFU) (consecutive 6 months of missed appointments) and engaged in (but not fully adherent) with treatment (<80% attendance). RESULTS: 57% of patients were adherent, 20% were engaged in treatment and 22% were LTFU. At enrolment, in the unadjusted variables, patients with higher systolic and diastolic blood pressures had better adherence than those with lower blood pressures (OR 1.005, 95% CI 1.002 to 1.009, p=0.004 and OR 1.008, 95% CI 1.004 to 1.012, p<0.001, respectively). After adjustment, there were 14% lower odds of adherence to appointments associated with a 1 month increase in duration in care (OR 0.862, 95% CI 0.801 to 0.927, p<0.001). Qualitative findings highlighted the following drivers for retention in care: high-quality education sessions, free medications and good interpersonal interactions. Challenges to seeking care included long wait times, transport costs and misunderstanding of the long-term requirement for hypertension care. CONCLUSION: Free medications, high-quality services and health education may be effective ways of helping NCD patients stay engaged in care. Facility and socioeconomic factors can pose challenges to retention in care.

Advancing sustainable implementation of an evidence-based mental health intervention in Sierra Leone's schools: protocol for a hybrid type 3 implementation-effectiveness trial.

BACKGROUND: Mental health disorders among youth contribute substantially to the global burden of disease, which is exacerbated in low- and middle-income countries (LMICs) due to large mental health treatment gaps. In Sierra Leone, a West African country with a long history of complex adversity, the mental health treatment gap is estimated at 98%. Implementing innovative mental health interventions that can be sustained at scale is a priority. The Youth Readiness Intervention (YRI) is an evidence-based mental health intervention for youth that can be delivered feasibly by lay health workers/nonspecialists. Using mobile-based technologies to assist implementation could improve the reach and sustainability of the YRI in Sierra Leone. This study aims to train teachers to deliver the YRI in Sierra Leone's secondary schools and test the feasibility, acceptability, cost, and fidelity to the YRI of a mobile-based supervision model compared with standard, in-person supervision. METHODS: We will conduct a hybrid type 3 implementation-effectiveness cluster randomized trial to assess the feasibility, acceptability, costs and fidelity to the YRI implemented by teachers receiving mobile-based supervision vs. standard supervision. Enrolled schools (N = 50) will be randomized to YRI + mobile supervision (N = 20), YRI + standard supervision (N = 20) or waitlist control (N = 10). We will recruit and enroll four teachers per intervention-condition school (N = 160) and 1200 youth. We will collect data on implementation outcomes among teachers, principals and youth via a mixed methods approach at baseline and post-intervention. We will also collect quantitative data on youth mental health and functioning as secondary outcomes at baseline and post-intervention, as well as cost-effectiveness data at 12-month follow-up. DISCUSSION: Study findings have the potential to expand the reach of mental health services among youth in low-resource settings via a teacher workforce. The use of mobile tools, if successful, could support further scale out and sustainment of the YRI to other regions of Sierra Leone and West Africa more broadly, which could help address the mental health treatment gap. TRIAL REGISTRATION: Clinical Trial Network: NCT05737667.

The role of constraints and information gaps in driving risky medicine purchasing practices in four African countries.

Substandard and falsified (SF) medical products pose a major threat to public health and socioeconomic development, particularly in low- and middle-income countries. In response, public education campaigns have been developed to alert consumers about the risks of SF medicines and provide guidance on 'safer' practices, along with other demand- and supply-side measures. However, little is currently known about the potential effectiveness of such campaigns while structural constraints to accessing quality-assured medicines persist. This paper analyses survey data on medicine purchasing practices, information and constraints from four African countries (Ghana, Nigeria, Sierra Leone and Uganda; n > 1000 per country). Using multivariate regression and structural equation modelling, we present what we believe to be the first attempt to tease apart, statistically, the effects of an information gap vs structural constraints in driving potential public exposure to SF medicines. The analysis confirms that less privileged groups (including, variously, those in rural settlements, with low levels of formal education, not in paid employment, often women and households with a disability or long-term sickness) are disproportionately potentially exposed to SF medicines; these same demographic groups also tend to have lower levels of awareness and experience greater levels of constraint. Despite the constraints, our models suggest that public health education may have an important role to play in modifying some (but not all) risky practices. Appropriately targeted public messaging can thus be a useful part of the toolbox in the fight against SF medicines, but it can only work effectively in combination with wider-reaching reforms to address higher-level vulnerabilities in pharmaceutical supply chains in Africa and expand access to quality-assured public-sector health services.