Ebola lessons: Did prior epidemic experience protect against the spread of COVID-19 in Sierra Leone?

The COVID-19 pandemic has prompted a re-examination of public health preparedness with an emphasis on lessons learned following the West African Ebola epidemic. However, much of this work focuses on technological solutions rather than social learning. Drawing upon anthropological work, this paper examines how Sierra Leoneans prepared for COVID-19 through a lens of "embodied epidemic memory." Findings reveal that while people felt more empowered to respond to COVID-19 due to their past experiences, traumatic memories from the Ebola outbreak also sparked logics of fear and avoidance, driven by mistrust toward the state and its healthcare system. As a result, people avoided healthcare facilities, and rumors concerning government corruption threatened mitigation efforts. While local populations should be better leveraged for their existing epidemic expertise, greater attention is needed to the "higher hanging fruit" of preparedness: restoring trust in the government's ability to respond to epidemics.

Contemplating abortion: a qualitative study of men and women's reactions to unplanned pregnancy in Sierra Leone.

Globally, millions of unintended pregnancies result in unsafe abortions each year. In Sierra Leone, abortion-related complications are a major driver of maternal mortality. Despite these costs, women continue to seek unsafe abortions, yet how individuals understand the risks and benefits of pregnancy termination remains under-researched. This study seeks to understand perceptions of abortion by women and men experiencing unplanned pregnancy and to highlight factors that inform their abortion trajectories. Findings indicate that abortion was contemplated in response to anxieties regarding caring for a child, interruptions to schooling, and stigma associated with extra-marital pregnancy. While many women and men preferred not to abort-due to cultural values tied to parenthood-others faced obstacles stemming from lack of knowledge of and access to services. Findings can be used to inform interventions to support women and men in realising their fertility preferences in the face of unplanned pregnancy.

"If the Woman Doesn't Prevent, You Will Become Pregnant": Exploring Male Involvement in Contraceptive Use Preceding Unplanned Pregnancy in Sierra Leone.

Globally, millions of unintended pregnancies occur each year resulting in a host of social, economic, and health-related problems. Improving knowledge of and access to family planning services is an effective way to prevent unintended pregnancy, and research suggests that men's involvement promotes greater contraceptive uptake. To explore this issue, we assess contraceptive knowledge, attitudes, and behaviors among Sierra Leonean men who experienced an unplanned pregnancy. Findings indicate that men's participation in family planning was limited due to barriers including inadequate knowledge about contraception, poor access to services, and gender norms that consider family planning a woman's responsibility. As a result, men often resorted to a pattern of control that put the onus of contraceptive use on women and blamed women when they became pregnant, without considering their own role in pregnancy prevention. We suggest that family planning policies and interventions both engage men and address the barriers to their participation in reproductive health.

Caregiving in Crisis: Fatherhood Refashioned by Sierra Leone's Ebola Epidemic.

In much of the literature on Sierra Leone, young men have been recognized for perpetrating violence or resisting authority. This characterization extended into the Ebola crisis, as young men were depicted as "resisting" public health measures. In contrast, little scholarship has focused on men's roles as caregivers during the epidemic. This article draws on ethnographic research conducted between 2014 and 2016 in eastern Sierra Leone to demonstrate how men contributed to caregiving. Findings reveal that when men were unable to care via established means, they improvised new ways to care for their families, which included: paid labor in Ebola treatment facilities; protecting their families from risk of infection; and hands-on nurturing. By focusing on these diverse types of male caregiving, this article challenges the ways in which "care" and "women" are often neatly linked and calls for a rethinking of stereotypes associating African men with violence.

Reflechi twòp--thinking too much: description of a cultural syndrome in Haiti's Central Plateau.

A rich Haitian ethnopsychology has been described, detailing concepts of personhood, explanatory models of illness, and links between mind and body. However, little research has engaged explicitly with mental illness, and that which does focuses on the Kreyòl term fou (madness), a term that psychiatrists associate with schizophrenia and other psychoses. More work is needed to characterize potential forms of mild-to-moderate mental illness. Idioms of distress provide a promising avenue for exploring common mental disorders. Working in Haiti's Central Plateau, we aimed to identify idioms of distress that represent cultural syndromes. We used ethnographic and epidemiologic methods to explore the idiom of distress reflechi twòp (thinking too much). This syndrome is characterized by troubled rumination at the intersection of sadness, severe mental disorder, suicide, and social and structural hardship. Persons with "thinking too much" have greater scores on the Beck Depression Inventory and Beck Anxiety Inventory. "Thinking too much" is associated with 8 times greater odds of suicidal ideation. Untreated "thinking too much" is sometimes perceived to lead to psychosis. Recognizing and understanding "thinking too much" may allow early clinical recognition and interventions to reduce long-term psychosocial suffering in Haiti's Central Plateau.

Navigating the Tension between Fatherhood Ideals and Realities of a Post-Conflict Setting: A Phenomenological Study of Former Child Soldiers in Sierra Leone.

The concept of "fatherhood" in many African countries has traditionally been understood in terms of instrumental support to one's family, most notably, financial provision. However, in Sierra Leone and elsewhere, this narrow understanding of fatherhood is changing as a result of shifting demographic trends and responses to recent crises such as the Ebola pandemic and the aftermath of a civil war. Very little is understood about how male former children associated with armed forces and armed groups (CAAFAG) are navigating fatherhood and understanding their roles as fathers, particularly as many have grown up without fathers or parents themselves and experienced violence. Our study builds upon previous ethnographic research in Sierra Leone, and uses a phenomenological approach to understand 1) the meaning and importance of fatherhood to former child soldiers in Sierra Leone, 2) what fatherhood looks like normatively and ideally, with attention to norms about nurturing care as well as violence, and 3) how ideals of fatherhood may or may not be in tension with socioeconomic circumstances. We find that CAAFAG fathers in Sierra Leone are committed to providing emotional support, encouragement, and a loving upbringing in addition to striving to provide financially. CAAFAG fathers experienced the greatest tension between their ideals of fatherhood and their socio-economic circumstances in terms of financial support, such as paying school fees. In other words, fathers felt inhibited in becoming the types of fathers they hoped to be due to their experiences in a post-conflict, resource-constrained environment.

Depression, suicidal ideation, and associated factors: a cross-sectional study in rural Haiti.

BACKGROUND: Since the 2010 earthquake in Haiti, there has been increased international attention to mental health needs throughout the country. The present study represents one of the first epidemiologic studies of depression symptomatology, suicidal ideation, and associated factors in Haiti's Central Plateau. METHODS: We conducted a cross-sectional, zone-stratified household survey of 408 adults in Haiti's Central Plateau. Depression symptomatology was assessed with a culturally-adapted Kreyòl version of the Beck Depression Inventory (BDI). Multivariable linear and logistic regression models were built using backward elimination, with the outcomes being continuous BDI scores and endorsing suicidal ideation, respectively. RESULTS: The mean BDI score was 20.4 (95% confidence interval [CI]: 19.3-21.5), and 6.13% (N = 25) of participants endorsed current suicidal ideation. Factors associated with BDI scores were: continuous age (adjusted beta [aß]: 0.14, CI: 0.06-0.22), female gender (aß: 2.1, CI: 0.18-4.0), suicidal ideation (aß: 11.1, CI: 7.3-14.9), death in family (aß: 2.7, CI: 0.57-4.9), and prior life-threatening illness (aß: 2.6, CI: 0.77-4.5). Education was a risk factor for depression among women but not among men, and employment was a risk factor for both genders. Factors associated with endorsing suicidal ideation were: BDI score (ten point change) (adjusted odds ratio [aOR]: 2.5, CI: 1.7-3.6), lack of care if sick (aOR: 5.5, CI: 1.1-28.6), alcohol use (aOR: 3.3, CI: 1.3-8.2), and ever having been to a Vodou priest (aOR: 3.2, CI: 1.1-9.5). CONCLUSIONS: A large proportion of Haiti's Central Plateau may be experiencing high levels of depression symptomatology and/or current suicidal ideation. Screening could be conducted in biomedical, religious, and Vodou healing contexts. For prevention, poverty reduction and improved healthcare access are key elements. For treatment, general psychiatric services, psychosocial services for the medically ill and their families, and substance abuse interventions should be explored. Paradoxical associations related to education and employment require further exploration.

Mental health problems among children in Sierra Leone: Assessing cultural concepts of distress.

Globally, over 13% of children and adolescents are affected by mental disorders, yet relatively little scholarship addresses how risk factors, symptoms, and nosology vary by culture and context, especially in young children living in post-conflict and low-resource settings. To address this gap, we conducted a qualitative study to identify and describe the most salient mental health problems facing children aged 6 to 10 years in Sierra Leone, as well as the thoughts, feelings, and behaviors related to these problems. Free list interviews (N = 200) and semi-structured interviews (N = 66) were conducted among caregivers, children, and other relevant key informants to explore risk factors and locally meaningful concepts of distress. Our findings indicate that children are faced with a variety of challenges in their social environments that contribute to distress, including hunger, unmet material needs, and excessive work. Our research identifies five contextually defined mental health problems faced by young children: gbos gbos (angry, destructive behavior), poil at (sad, disruptive behavior), diskoraj (sad, withdrawn), wondri (excessive worry), and fred fred (abnormal fear). The manifestations of these distress concepts are described in detail and contextualized according to Sierra Leone's history of war and current backdrop of poverty and insecurity. Implications are discussed for locally relevant diagnosis and treatment as well as for the wider literature on global child mental health.

Men's experiences of pregnancy and childbirth in Sierra Leone: Reexamining definitions of "male partner involvement".

In recent decades, global health researchers and policy makers have advocated for men's increased involvement in pregnancy and childbirth with the goal of improving maternal health outcomes. By "involvement," these actors generally refer to narrow-largely Western-definitions of participation: accompanying women to antenatal and postpartum care visits, engaging in childbirth education, or being present during delivery. However, such approaches often fail to account for the culturally valid and gendered ways in which men already are involved in supporting women's reproductive health. This study is based on participant observation, semi-structured interviews, and life histories conducted among 106 fathers in eastern Sierra Leone over the course of 2013-2016. Findings demonstrate that in Sierra Leone, where pregnancy and childbirth are considered to belong to the domain of women, men's primary role is to supply the material resources for a safe and healthy birth: a nutritious diet, transportation to healthcare facilities, medicines and supplies in the case of emergency, and the items to wash and dress the baby. While evidence suggests that gender norms are shifting to include other forms of intimate and emotional involvement, it is important to recognize existing forms of material support as valuable and essential forms of care. By restricting male involvement to biomedical notions of care, global health programs and policies risk discounting other types of socially meaningful support. Rather than disparaging young, African men for falling short of what Western organizations and researchers perceive to be "correct" behaviors, this paper attempts to highlight men's own understandings of involvement, so as to provide a more complete picture of the gendered nature of reproductive health in this context.

Community-based reports of morbidity, mortality, and health-seeking behaviours in four Monrovia communities during the West African Ebola epidemic.

The goal of this study was to assess morbidity, mortality, and health-seeking behaviours during the 2014 Ebola outbreak in Monrovia, Liberia. This study examined commonly reported symptoms of illness, pre-clinical diagnostic practices, typical healthcare-seeking strategies, and health resources available to populations, in order to identify salient needs and gaps in healthcare that would inform local emergency response efforts. Semi-structured interviews were conducted with household members in four Monrovia neighbourhoods. Researchers used a multi-stage cluster approach to recruit participants. Within 555 households sampled, 505 individuals were reported sick (69%) or recently sick (38%) or deceased (7%). Common self-diagnoses included malaria, hypertension, influenza, typhoid, and Ebola. The most cited health-seeking strategy was to purchase medications from the private sector. Respondents also obtained healthcare from community members known to have medical experience. Findings suggest that non-formal healthcare systems played an important role in managing morbidity during the West African Ebola virus disease (EVD) outbreak. Lay community members engaged in complex assessments of health symptoms and sought biomedical care at rates perhaps higher than anticipated during the response. This study highlights how informal networks of healthcare providers can play an important role in preventing and curbing future emerging disease outbreaks.

Task sharing in rural Haiti: Qualitative assessment of a brief, structured training with and without apprenticeship supervision for community health workers.

Despite growing support for supervision after task sharing trainings in humanitarian settings, there is limited research on the experience of trainees in apprenticeship and other supervision approaches. Studying apprenticeships from trainees' perspectives is crucial to refine supervision and enhance motivation for service implementation. The authors implemented a multi-stage, transcultural adaptation for a pilot task sharing training in Haiti entailing three phases: 1) literature review and qualitative research to adapt a mental health and psychosocial support training; 2) implementation and qualitative process evaluation of a brief, structured group training; and 3) implementation and qualitative evaluation of an apprenticeship training, including a two year follow-up of trainees. Structured group training revealed limited knowledge acquisition, low motivation, time and resource constraints on mastery, and limited incorporation of skills into practice. Adding an apprenticeship component was associated with subjective clinical competency, increased confidence regarding utilising skills, and career advancement. Qualitative findings support the added value of apprenticeship according to trainees.

Community-centered responses to Ebola in urban Liberia: the view from below.

BACKGROUND: The West African Ebola epidemic has demonstrated that the existing range of medical and epidemiological responses to emerging disease outbreaks is insufficient, especially in post-conflict contexts with exceedingly poor healthcare infrastructures. In this context, community-based responses have proven vital for containing Ebola virus disease (EVD) and shifting the epidemic curve. Despite a surge in interest in local innovations that effectively contained the epidemic, the mechanisms for community-based response remain unclear. This study provides baseline information on community-based epidemic control priorities and identifies innovative local strategies for containing EVD in Liberia. METHODOLOGY/PRINCIPAL FINDINGS: This study was conducted in September 2014 in 15 communities in Monrovia and Montserrado County, Liberia--one of the epicenters of the Ebola outbreak. Findings from 15 focus group discussions with 386 community leaders identified strategies being undertaken and recommendations for what a community-based response to Ebola should look like under then-existing conditions. Data were collected on the following topics: prevention, surveillance, care-giving, community-based treatment and support, networks and hotlines, response teams, Ebola treatment units (ETUs) and hospitals, the management of corpses, quarantine and isolation, orphans, memorialization, and the need for community-based training and education. Findings have been presented as community-based strategies and recommendations for (1) prevention, (2) treatment and response, and (3) community sequelae and recovery. Several models for community-based management of the current Ebola outbreak were proposed. Additional findings indicate positive attitudes towards early Ebola survivors, and the need for community-based psychosocial support. CONCLUSIONS/SIGNIFICANCE: Local communities' strategies and recommendations give insight into how urban Liberian communities contained the EVD outbreak while navigating the systemic failures of the initial state and international response. Communities in urban Liberia adapted to the epidemic using multiple coping strategies. In the absence of health, infrastructural and material supports, local people engaged in self-reliance in order to contain the epidemic at the micro-social level. These innovations were regarded as necessary, but as less desirable than a well-supported health-systems based response; and were seen as involving considerable individual, social, and public health costs, including heightened vulnerability to infection.

Determinants of care seeking for mental health problems in rural Haiti: culture, cost, or competency.

OBJECTIVE: This study examined patterns, determinants, and costs of seeking care for mild to moderate psychiatric distress in order to determine optimal approaches for expanding mental health care in rural Haiti. METHODS: A cross-sectional, zone-stratified household survey of 408 adults was conducted in Haiti's Central Plateau. Multivariable logistic regression models were built to assess determinants of first-choice and lifetime health service use by provider type. RESULTS: Thirty-two percent of respondents endorsed God as their first choice for care if suffering from mental distress, and 29% of respondents endorsed clinics and hospitals as their first choice. Forty-seven percent of respondents chose potential providers on the basis of anticipated efficacy. Suicidal individuals were 7.6 times (95% confidence interval [CI]=1.4-42.0) as likely to prefer community-based providers (herbal healer, church priest or pastor, or Vodou priest) over hospitals or clinics. Depression severity was associated with increased odds (adjusted odds ratio [AOR]=1.8, CI=1.5-2.3) of ever having been to an herbal healer. Having a household member with mental health problems was associated with increased odds of ever having been to church pastors or priests (AOR=5.8, CI=2.8-12.0) and decreased odds of ever having been to hospitals or clinics (AOR=.3, CI=.1-.8). Median actual service costs were US $1 for hospitals or clinics, $6 for herbal healers, and $120 for Vodou priests. CONCLUSIONS: Three out of four rural Haitians said they would seek community resources over clinical care if suffering from mental distress. Therefore, isolated clinical interventions may have limited impact because of less frequent use. Efforts to expand mental health care should consider differential provider costs when selecting community resources for task shifting.

Suicide in rural Haiti: clinical and community perceptions of prevalence, etiology, and prevention.

Suicide is a complex global public health problem, yet few studies have examined local socio-cultural explanatory models and other contextual factors surrounding suicide in low-and-middle-income countries. Such research is critical, as suicide frequency and etiology, as well as care-seeking in the case of distress, differ contextually and by sub-groups within a population. This is the first study of its kind to explore the dual perspectives of both healthcare workers and community members regarding suicide in Haiti. We conducted semi-structured, in-depth interviews between May and June 2011 with eight biomedical healthcare workers and 16 lay community members. Qualitative data analysis, drawing on interpretive phenomenological analysis, addressed themes including perceived suicide frequency, veracity of suicidal ideation claims, perceived causal factors, religious constructs related to suicide, and support resources for suicidality. Compared to community members, healthcare workers underestimated the frequency of suicide and were less likely to interpret suicide-related claims as representing true intent. Religious perspectives influenced attitudes toward suicide, albeit in different ways: Christian concern with the afterlife resulted in suicide being unacceptable and sinful, while Vodou explanatory frameworks displaced blame and stigma away from suicidal individuals. Healthcare workers' failure to recognize suicide as a serious problem suggests that the formal health system is currently ill-equipped to respond to suicide-related needs. Religious practice and community supports in rural Haiti may serve as essential resources for prevention programs.