Unpacking the impact of integrating the neglected tropical disease supply chain into the national supply chain system: illustrative evidence from Liberia.

Effective supply chain management is a critical pillar of well-functioning health systems ensuring that medical commodities reach those in need. In Liberia, the national neglected tropical disease (NTD) programme supports health systems strengthening for case management of NTDs. Integration of NTD commodities into the national health system supply chain is central to the integrated approach; however, there is minimal evidence on enablers and barriers. Drawing on qualitative evaluation data, we illustrate that perceived benefits and strengths to integrating NTD commodities into the supply chain include leveraged storage and management capacities capitalized at lower system levels; the political will to integrate based on cost-saving and capacity strengthening potential and positive progress integrating paper-based reporting tools. Challenges remain, specifically the risk of reliance on donor funding; difficulty in accessing commodities due to bureaucratic bottlenecks; lack of inclusion of NTD commodities within electronic data tools and poor coordination leading to an inability to meet demand. Collectively, the negative consequences of ineffective integration of NTD commodities into the supply chain has a detrimental impact on health workers (including community health workers) unable to deliver the quality of care to patients. Trust between affected populations and the health system is compromised when treatments are unavailable.

The lasting influence of Ebola: a qualitative study of community-level behaviors, trust, and perceptions three years after the 2014-16 Ebola epidemic in Liberia.

The majority of disease transmission during the 2014-16 West Africa Ebola epidemic was driven by community-based behaviors that proved difficult to change in a social paradigm of misinformation, denial, and deep-seated distrust of government representatives and institutions. In Liberia, perceptions and beliefs about Ebola during and since the epidemic can provide insights useful to public health strategies aimed at improving community preparedness. In this 2018 study, we conducted nine focus groups with Liberians from three communities who experienced Ebola differently, to evaluate behaviors, attitudes, and trust during and after the epidemic. Focus group participants reported that some behaviors adopted during Ebola have persisted (e.g. handwashing and caretaking practices), while others have reverted (e.g. physical proximity and funeral customs); and reported ongoing distrust of the government and denial of the Ebola epidemic. These findings suggest that a lack of trust in the biomedical paradigm and government health institutions persists in Liberia. Future public health information campaigns may benefit from community engagement addressed at understanding beliefs and sources of trust and mistrust in the community to effect behavior change and improve community-level epidemic preparedness.

Addressing the Intersections of Health, Organizing, and Peacebuilding: A Case Study of Peacebuilding in Liberia.

The notion of peace and the "doing of peace(building)" are integral components of individual and community/societal well-being. Yet although health (defined broadly to include well-being), organizing, and peace are interrelated, there is a lack of research that considers them together. In this manuscript, we argue that peace is constituted through the processes and acts of organizing for well-being. "Peacebuilding" constitutes organizing processes by multiple actors over time to prevent and mitigate violence. To highlight the intersections between health, organizing, and peace, in this article we draw upon our peacebuilding collaborations in Liberia, West Africa, as part of the Violence Prevention Initiative (VPI; pseudonym). We elaborate on three projects from the VPI's work as a means through which to then propose ways in which communication scholars can theorize intersections among health, organizing, and peace and contribute to empirical research at these intersections.

'The solution is we need to have a centre': a study on diabetes in Liberia.

In Liberia, one of the poorest nations in sub-Saharan Africa, the burden of diabetes is a growing concern. The high mortality and morbidity associated with diabetes have significant implications for individuals, families and society at large. The aim of this critical hermeneutic study was to explore what it is like to live with diabetes in Liberia. We recruited 10 participants from Monrovia, Liberia to partake in this study. Photovoice, a well-established participatory data collection approach was used to gather images and stories that represented participants' everyday experiences of living with diabetes. Three major themes were uncovered, highlighting the strengths, challenges and solutions related to living with diabetes in Liberia: strengths-engagement in diabetes self-management practices, focused on participants' commitment to engage in diabetes self-management practices despite the socioeconomic challenges they experienced; challenges-lack of social and economic support, focused on limited access to food, diabetes medications and supplies and diabetes education; and solutions-centre for diabetes education, care and support, focused on participants' recommendations for a community-based diabetes centre, a single point of access for meeting the needs of people with diabetes. A strong commitment to prioritize diabetes on Liberia's national health agenda and increased resources for diabetes care is needed to address the challenges experienced by people living with this chronic disease in Liberia.

Cash transfers and nutrition education to improve dietary diversity among children aged 6-23 months in Grand Gedeh County, Liberia: a cluster-randomized trial.

OBJECTIVES: To evaluate the efficacy of a cash transfer and nutrition education program on dietary diversity among children in Liberia. We hypothesized that a multi-pronged intervention would result in improved dietary diversity among children. METHODS: We conducted a three-armed, cluster-randomized study in 42 communities (12 children per community) in Grand Gedeh County, Liberia, over a 12-month period. We randomly assigned communities to control (n = 14 communities), those that received both bimonthly cash transfers and a structured nutrition education program (n = 14 communities) and those that received bimonthly cash transfers alone (n = 14 communities). Community health assistants conducted bimonthly assessments in participants' homes. The primary outcome was the proportion of children aged 6-23 months who met minimum dietary diversity score (i.e., ≥4 food groups consumed per day). Secondary outcomes included meal frequency and healthcare utilization for illnesses (NCT04101487). RESULTS: There were 599 children enrolled; 533 (88.9%) were retained through the trial period. The proportion of children who consumed ≥4 food groups per day did not differ among the three arms. However, children randomized to receive cash transfers had higher dietary diversity scores than the control group. Children in communities that received cash transfers alone and with nutrition education consumed significantly more meals per day and were less likely to have visits to clinics or hospitals for illnesses than children in control communities. CONCLUSION: Bimonthly, unconditional cash transfers and nutrition education were associated with higher dietary diversity scores, greater meal frequency, and fewer healthcare visits for illnesses among children aged 6-23 months.

Worldwide, more than one in five children suffers from chronic malnutrition. Children aged <2 years who do not eat a diverse diet are at risk of chronic malnutrition and stunting of their height. Thus, interventions are needed to combat the common problem of chronic malnutrition, particularly in settings like rural Liberia where as much as 30% of children are stunted. In this study, caregivers of children aged 6­23 months in rural communities in Eastern Liberia were randomly assigned to receive either bimonthly cash transfers, bimonthly cash transfers and specific nutrition education, or routine support from community health assistants to see if giving caregivers money and nutrition education would increase the dietary diversity of their young children. There were 599 children enrolled and 533 were retained over a 12-month study period. Children in communities randomized to receive cash transfers had higher dietary diversity scores than the control group. Children in communities that received cash transfers alone and with nutrition education consumed significantly more meals per day and were less likely to have visits to clinics or hospitals for illnesses than children in control communities. Unconditional cash transfers in rural Liberia may be one way to reduce inadequate dietary diversity among young children.

Overlooking the Obvious: Communication of Efficacy by the Mass Media During the Ebola Crisis in Liberia.

The role of mass media during a public health crisis is an ineluctable part of providing the public with critical information rapidly, particularly messages about self- and response efficacy. However, little is known about the role local news media play in disseminating efficacy information during infectious disease outbreaks. Here, we use the 2014 Ebola outbreak in Liberia as a case to explore this question. We content analyzed newspaper and radio messages disseminated between March 2014 and March 2015, during the midst of the outbreak. Results show that both radio programs and newspaper articles mentioned over 21 prevention steps at some point, with noticeable differences within which disease prevention messages were communicated most frequently to the public. At least 1 mention of self-efficacy was identified in 31.5% of radio content (n = 127), 23.6% of radio programming (n = 55), and 10.6% of newspaper content (n = 745). Response efficacy, signifying effectiveness of preventive methods, was detected in 25.2% of radio (n = 127), 16.4% of radio programming (n = 55), and 15% of newspaper content (n = 745). This is important as efficacy reporting can impact public readiness to adopt preventative measures and affect beliefs about self- and response efficacy, ultimately decreasing chances of spreading the infection and poorer health outcomes.

Bombali Virus in Mops condylurus Bats, Guinea.

In 2018, a previously unknown Ebola virus, Bombali virus, was discovered in Sierra Leone. We describe detection of Bombali virus in Guinea. We found viral RNA in internal organs of 3 Angolan free-tailed bats (Mops condylurus) trapped in the city of N'Zerekore and in a nearby village.

'Researchers have love for life': opportunities and barriers to engage pregnant women in malaria research in post-Ebola Liberia.

BACKGROUND: Adoption of prevention and therapeutic innovations to ensure that National Malaria Control Programmes meet their incidence reduction targets is highly dependent on the conduct of rigorous clinical trials. In Liberia, malaria control virtually halted during the recent Ebola epidemic, and could enormously benefit from innovations to protect its most vulnerable populations, including pregnant women, against malaria. Health policy-planners could feel more inclined to adopt novel interventions with demonstrated safety and efficacy when trialled among their women population. However, pregnant women are especially vulnerable when targeted as research participants. Whilst some studies in the region attempted to understand the ethical issues around the conduct of clinical research, there is need of such information from Liberia to inform future malaria research. METHODS: This is a grounded theory study that aims to understand the barriers and opportunities for pregnant women to consent to participate in malaria research in Liberia. The study was conducted between November 2016 and May 2017 at the St Joseph's Catholic Hospital, Monrovia. In-depth interviews and focus group discussions were held with hospital staff, traditional community representatives, and pregnant women. RESULTS: According to the participants, useful strategies to motivate pregnant women to consent to participate in malaria research could be providing evidence-based education on malaria and research to the general population and encouraging engagement of traditional leaders in research design and community mobilization. Fears and suspicions towards research and researchers, which were amplified during the conduct of Ebola vaccine and drug clinical trials, may influence women's acceptance and willingness to engage in malaria research. Population's mistrust in the public healthcare system might hinder their acceptance of research, undermining the probability of their benefiting from any improved malaria control intervention. CONCLUSION: Benchmarking for acceptable practices from previous public health interventions; building community discussion and dissemination platforms; and mapping communication and information errors from how previous research interventions were explained to the Liberian population, are strategies that might help ensure a safe and fully informed participation of pregnant women in malaria research. Inequity issues impeding access and use of biomedical care for women must be tackled urgently.

Community-informed research on malaria in pregnancy in Monrovia, Liberia: a grounded theory study.

BACKGROUND: Liberia is a West African country that needs substantial investment to strengthen its National Malaria Control Programme (NMCP), which was disrupted during the 2014-2016 Ebola epidemic. As elsewhere, Liberian pregnant women are especially vulnerable to malaria. Understanding prevention and treatment-seeking behaviours among the population is crucial to strategize context-specific and women-centred actions, including locally-led malaria research, to improve women's demand, access and use of NMCP strategies against malaria in pregnancy. METHODS: In 2016, after the Ebola crisis, a qualitative inquiry was conducted in Monrovia to explore populations' insights on the aetiology, prevention and therapeutics of malaria, as well as the community and health workers' perceptions on the utility of malaria research for pregnant women. In-depth interviews and focus group discussions were conducted among pregnant women, traditional community representatives and hospital staff (n = 38), using a feminist interpretation of grounded theory. RESULTS: The narratives indicate that some Liberians believed in elements other than mosquito bites as causes of malaria; many had a low malaria risk perception and disliked current effective prevention methods, such as insecticide-treated nets; and some would resort to traditional medicine and spiritual care to cure malaria. Access to clinic-based malaria care for pregnant women was reportedly hindered by lack of financial means, by unofficial user fees requested by healthcare workers, and by male partners' preference for traditional medicine. The participants suggested that malaria research in Liberia could help to design evidence-based education to change current malaria prevention, diagnostic and treatment-seeking attitudes, and to develop more acceptable prevention technologies. CONCLUSION: Poverty, insufficient education on malaria, corruption, and poor trust in healthcare establishment are structural factors that may play a greater role than local traditional beliefs in deterring Liberians from seeking, accessing and using government-endorsed malaria control strategies. To increase access to and uptake of preventive and biomedical care by pregnant women, future malaria research must be informed by people's expressed needs and constructed meanings and values on health, ill health and healthcare.

Evaluation of regional project to strengthen national health research systems in four countries in West Africa: lessons learned.

BACKGROUND: Since the Commission on Health Research for Development (COHRED) published its flagship report, more attention has been focused on strengthening national health research systems (NHRS). This paper evaluates the contribution of a regional project that used a participatory approach to strengthen NHRS in four post-conflict West African countries - Guinea-Bissau, Liberia, Sierra Leone and Mali. METHODS: The data from the situation analysis conducted at the start of the project was compared to data from the project's final evaluation, using a hybrid conceptual framework built around four key areas identified through the analysis of existing frameworks. The four areas are governance and management, capacities, funding, and dissemination/use of research findings. RESULTS: The project helped improve the countries' governance and management mechanisms without strengthening the entire NHRS. In the four countries, at least one policy, plan or research agenda was developed. One country put in place a national health research ethics committee, while all four countries could adopt a research information management system. The participatory approach and support from the West African Health Organisation and COHRED were all determining factors. CONCLUSION: The lessons learned from this project show that the fragile context of these countries requires long-term engagement and that support from a regional institution is needed to address existing challenges and successfully strengthen the entire NHRS.

Survivors' perceptions of public health messages during an Ebola crisis in Liberia and Sierra Leone: An exploratory study.

The outbreak of Ebola virus disease in Guinea, Liberia, and Sierra Leone was the largest epidemic of Ebola ever recorded. The healthcare workforce was diminished and exhausted as the region emerged from civil war. Few qualitative, descriptive studies have been conducted to date that concentrate on the voices of Ebola survivors and their perceptions of health messages. In this study, we employed an interpretive, qualitative design to explore participant experiences. Twenty five survivors who had recovered from Ebola were recruited from three villages in Liberia and Sierra Leone in August 2015. Data were collected using semistructured interviews. Data analysis revealed four themes: (i) degrees of mistrust; (ii) messages conflicting with life and culture; (iii) seeing is believing; and (iv) recovery inspires hope. The findings were explored in the context of the relevant literature. The themes highlight the need to develop culturally-appropriate messages, underpinned by a sound understanding of the community and a willingness to work with the culture and trusted leaders.

Charting health system reconstruction in post-war Liberia: a comparison of rural vs. remote healthcare utilization.

BACKGROUND: Despite a growing global emphasis on universal healthcare, access to basic primary care for remote populations in post-conflict countries remains a challenge. To better understand health sector recovery in post-conflict Liberia, this paper seeks to evaluate changes in utilization of health services among rural populations across a 5-year time span. METHODS: We assessed trends in healthcare utilization among the national rural population using the Liberian Demographic and Health Survey (DHS) from 2007 and 2013. We compared these results to results obtained from a two-staged cluster survey in 2012 in the district of Konobo, Liberia, to assess for differential health utilization in an isolated, remote region. Our primary outcomes of interest were maternal and child health service care seeking and utilization. RESULTS: Most child and maternal health indicators improved in the DHS rural sub-sample from 2007 to 2013. However, this progress was not reflected in the remote Konobo population. A lower proportion of women received 4+ antenatal care visits (AOR 0.28, P < 0.001) or any postnatal care (AOR 0.25, P <0.001) in Konobo as compared to the 2013 DHS. Similarly, a lower proportion of children received professional care for common childhood illnesses, including acute respiratory infection (9 % vs. 52 %, P < 0.001) or diarrhea (11 % vs. 46 %, P < 0.001). CONCLUSIONS: Our data suggest that, despite the demonstrable success of post-war rehabilitation in rural regions, particularly remote populations in Liberia remain at disproportionate risk for limited access to basic health services. As a renewed effort is placed on health systems reconstruction in the wake of the Ebola-epidemic, a specific focus on solutions to reach isolated populations will be necessary in order to ensure extension of coverage to remote regions such as Konobo.

The timeliness of the US military response to the 2014 Ebola disaster: a critical review.

In the face of an unprecedented epidemic of Ebola Virus Disease, in September 2014, the US military began sending thousands of personnel to Liberia and supporting areas in Senegal in its largest deployment to the African continent in over two decades. In this review, media reports, published photographs and official statements are evaluated and summarized to identify and describe key time points in the US military response. Specific events include the initial establishment of the Monrovia Medical Unit and the buildup of forces for the expanded mission, which involved enhancement of laboratory testing capacity, construction of Ebola Treatment Units, and training of health care workers. The review concludes with a discussion and critical evaluation of the timeliness of this US military response in the context of the original expectations of the humanitarian community and government officials.

Ebola in West Africa--CDC's Role in Epidemic Detection, Control, and Prevention.

Since Ebola virus disease was identified in West Africa on March 23, 2014, the Centers for Disease Control and Prevention (CDC) has undertaken the most intensive response in the agency's history; >3,000 staff have been involved, including >1,200 deployed to West Africa for >50,000 person workdays. Efforts have included supporting incident management systems in affected countries; mobilizing partners; and strengthening laboratory, epidemiology, contact investigation, health care infection control, communication, and border screening in West Africa, Nigeria, Mali, Senegal, and the United States. All efforts were undertaken as part of national and global response activities with many partner organizations. CDC was able to support community, national, and international health and public health staff to prevent an even worse event. The Ebola virus disease epidemic highlights the need to strengthen national and international systems to detect, respond to, and prevent the spread of future health threats.

Mobile diagnostics in outbreak response, not only for Ebola: a blueprint for a modular and robust field laboratory.

We established a modular, rapidly deployable laboratory system that provides diagnostic support in resource-limited, remote areas. Developed as a quick response asset to unusual outbreaks of infectious diseases worldwide, several of these laboratories have been used as part of the World Health Organization response to the Ebola virus outbreaks by teams of the 'European Mobile Lab' project in West Africa since March 2014. Within three days from deployment, the first European mobile laboratory became operational at the Ebola Treatment Unit (ETU) in Guéckédou, southern Guinea. Deployment in close proximity to the ETU decreased the turnaround time to an average of 4 h instead of several days in many cases. Between March 2014 and May 2015, more than 5,800 samples were tested in this field laboratory. Further EMLab units were deployed to Nigeria, Liberia and Sierra Leone in the following months of the Ebola outbreak. The technical concept of the EMLab units served as a blueprint for other mobile Ebola laboratories which have been set up in Mali, Côte d'Ivoire, Sierra Leone and other countries in West Africa. Here, we describe design, capabilities and utility of this deployable laboratory system for use in response to disease outbreaks, epidemiological surveillance and patient management.

Providing Logistics Support to CDC-Deployed Staff for the Ebola Response in Liberia, Guinea, and Sierra Leone.

The first Ebola cases in West Africa were reported by the Guinea Ministry of Health on March 23, 2014, and by June it became the largest recorded Ebola outbreak. Centers for Disease Control and Prevention field teams were deployed to West Africa, including in-country logistics staff who were critical for ensuring the movement of staff, equipment, and supplies to locations where public health knowledge and experience were applied to meet mission-related requirements. The logistics role was critical to creating the support for epidemiologists, medical doctors, laboratory staff, and health communicators involved in health promotion activities to successfully respond to the epidemic, both in the capital cities and in remote villages. Logistics personnel worked to procure equipment, such as portable video projectors, and have health promotion materials printed. Logistics staff also coordinated delivery of communication and health promotion materials to the embassy and provided assistance with distribution to various partners.

Is the neglected tropical disease mass drug administration campaign approach an effective strategy to deliver universal health coverage? A case study of the Liberia neglected tropical disease programme.

BACKGROUND: Access to affordable, quality healthcare is the key element of universal health coverage (UHC). This study examines the effectiveness of the neglected tropical disease (NTD) mass drug administration (MDA) campaign approach as a means to deliver UHC, using the example of the Liberia national programme. METHODS: We first mapped the location of 3195 communities from the 2019 national MDA treatment data reporting record of Liberia. The association between coverage for onchocerciasis and lymphatic filariasis treatment achieved in these communities was then explored using a binomial geo-additive model. This model employed three key determinants for community 'remoteness': population density and the modelled travel time of communities to their supporting health facility and to their nearest major settlement. RESULTS: Maps produced highlight a small number of clusters of low treatment coverage in Liberia. Statistical analysis suggests there is a complex relationship between treatment coverage and geographic location. CONCLUSIONS: We accept the MDA campaign approach is a valid mechanism to reach geographically marginal communities and, as such, has the potential to deliver UHC. We recognise there are specific limitations requiring further study.

Examining the gender imbalance in the National Community Health Assistant Programme in Liberia: a qualitative analysis of policy and Programme implementation.

The Revised National Community Health Services Policy (2016-2021) (RNCHSP) and its programme implementation, the Liberian National Community Health Assistant Programme (NCHAP), exhibit a critical gender imbalance among the Community Health Assistants (CHAs) as only 17% are women. This study was designed to assess the gender responsiveness of the RNCHSP and its programme implementation in five counties across Liberia to identify opportunities to improve gender equity in the programme. Using qualitative methods, 16 semi-structured interviews were conducted with policymakers and 32 with CHAs, other members of the community health workforce and community members. The study found that despite the Government of Liberia's intention to prioritize women in the recruitment and selection of CHAs, the planning and implementation of the RNCHSP were not gender responsive. While the role of community structures, such as Community Health Committees, in the nomination and selection of CHAs is central to community ownership of the programme, unfavourable gender norms influenced women's nomination to become CHAs. Cultural, social and religious perceptions and practices of gender created inequitable expectations that negatively influenced the recruitment of women CHAs. In particular, the education requirement for CHAs posed a significant barrier to women's nomination and selection as CHAs, due to disparities in access to education for girls in Liberia. The inequitable gender balance of CHAs has impacted the accessibility, acceptability and affordability of community healthcare services, particularly among women. Strengthening the gender responsiveness within the RNCHSP and its programme implementation is key to fostering gender equity among the health workforce and strengthening a key pillar of the health system. Employing gender responsive policies and programme will likely increase the effectiveness of community healthcare services.

Sexual violence in post-conflict Liberia: survivors and their care.

Using routine data from three clinics offering care to survivors of sexual violence (SV) in Monrovia, Liberia, we describe the characteristics of SV survivors and the pattern of SV and discuss how the current approach could be better adapted to meet survivors' needs. There were 1500 survivors seeking SV care between January 2008 and December 2009. Most survivors were women (98%) and median age was 13 years (Interquartile range: 9-17 years). Sexual aggression occurred during day-to-day activities in 822 (55%) cases and in the survivor's home in 552 (37%) cases. The perpetrator was a known civilian in 1037 (69%) SV events. Only 619 (41%) survivors sought care within 72 h. The current approach could be improved by: effectively addressing the psychosocial needs of child survivors, reaching male survivors, targeting the perpetrators in awareness and advocacy campaigns and reducing delays in seeking care.

Sexual risk behaviour among school-going adolescents in Sierra Leone and Liberia: a secondary analysis of the 2017 Global school-based student health surveys.

BACKGROUND: Sierra Leone and Liberia have experienced civil wars and, recently, Ebola outbreaks that led to profound economic hardship, psychopathologies and family disruptions. These factors are associated with sexual risk behaviours among youths. However, there is very little information on sexual risk behaviour among Sierra Leonean and Liberian school-going adolescents. The present study assessed the prevalence and determinants of sexual risk behaviours among school-going adolescents (10-19 years) in Sierra Leone and Liberia.  METHOD: We used publicly available nationally representative cross-sectional datasets of the 2017 Sierra Leone and Liberia Global school health survey. The sample consisted of 2798 and 2744 school-going adolescents from Sierra Leone and Liberia, respectively. Complex sample descriptive and regression analysis was used to analyse our data. RESULTS: The majority of adolescents in the two countries were involved in multiple sexual risk behaviour (80.2%), with a higher prevalence observed in Sierra Leone (85.2%) than in Liberia (75.3%). Liberian adolescents showed lesser odds of indulging in multiple sexual risk behaviours than their Sierra Leonean counterparts (AOR = 0.572; 95%CI: 0.345-0.946). Male, compared to females, were more likely to engage in multiple sexual risk behaviour (AOR = 2.310;95%CI:1.543-3.458), with a similar pattern observed in both countries. Alcohol use was associated with multiple sexual risk behaviour (AOR = 3.064; 95%CI: 2.137-4.392). Also, in Sierra Leone and Liberia, adolescents with one and two or more forms of psychological distress were more likely to have ever had sex than those who did not show any form of psychological distress. Missing class/school was associated with multiple sexual risk behaviour (AOR = 1.655; 95%CI:1.133-2.418). Peer support was only found to be a protective factor against no condom use among Liberian adolescents (AOR = 0.608; 95%CI: 0.435-0.850). Less parental support was only associated with ever had sex among adolescents in Sierra Leone (AOR = 2.027; 95%CI: 1.322-3.107) but not in Liberia (AOR = 1.034; 95%CI: 0.650-1.644). CONCLUSION: Our study found a high sexual risk behaviour among school-going adolescents in Sierra Leone and Liberia. Our finding highlights the need to strengthen sexual and reproductive health education in schools and communities that incorporate mental health promotion activities tailored to this group.