The impact on key indicators of reproductive and child health after changes in program modalities in Sierra Leone, 2019.

BACKGROUND AND AIMS: In 2018, the transition to routine vitamin A supplementation (VAS) was integrated with caregivers' preparation of nutritious complementary food from local produce and confidential counseling and provision of modern contraceptives. In 2019, funding for complementary food ceased and Community Health Workers (CHWs) were trained to track defaulters, while national efforts to improve Health Management Information Systems, supply chains and reduce teenage pregnancies were intensified. We report on key indicators after these changes and in comparison, to those previously published. METHODS: The same Lot Quality Assurance Sampling methodology was used in both assessments: 19 villages were randomly selected in each of five lots in each of three districts then caregivers of children 6-59 months age randomly selected and interviewed. RESULTS: Coverage of VAS, Albendazole, and Pentavalent 3 before and after these changes was over 80%, 75%, and 80% respectively, equitable by sex, age, caregiver's religion, and educational status. Comparison with 2018 found more lots failed to reach 80% VAS by verbal affirmation (10 vs 2), and coverage in one district (Bo) had dropped (77.5% vs 92.3%). Fewer caregivers were aware that VAS should be taken every 6 months (27% vs 50%), that complementary feeding should start at 6 months (63% vs 77%) or were providing minimal dietary diversity (27% vs 45%). There was an increase in caregivers using modern contraception (45% vs 35%), obtaining information about contraception from a friend (14% vs 9%), while fewer thought country rope/herbs (traditional contraceptives) were "effective" (11% vs 21%) and stockouts of contraceptives at health facilities had dropped (24% vs 55%). Stipends for CHWs cost approximately $750 K vs complementary food: $112 K. CONCLUSION: Overall coverage for VAS, Albendazole, and Pentavalent remained effective but VAS had dropped significantly in one district. Complementary feeding practices had declined. Awareness, uptake, and contraceptives supply chains had improved.

Gender intersections identified whilst transitioning mass vitamin A supplementation into an integrated reproductive and child health programme in Sierra Leone.

Since 2006, Sierra Leone has achieved high rates of vitamin A supplementation (VAS) coverage (>88%) during mass campaigns. In 2017, campaigns started transitioning to routine VAS within a six-monthly contact point for integrated reproductive and child health (RCH) services. This contact point included improved counselling and provision of modern contraceptives; throughout this transition high VAS coverage (>85%) has been maintained. VAS programmes have traditionally operated on the assumption that they are gender-neutral, but recent research suggests these programmes should re-examine how they interact with gender. This qualitative study examined intersections between gender and Sierra Leone's integrated VAS programming by conducting 32 individual interviews with parents, district health management and national staff, and six focus group discussions with health workers and community health workers (CHWs) in three pilot program districts. The study found that most senior health positions are held by males, and the lower cadres of majority female health workers often felt unsupported/disrespected by their male superiors and male CHW supervisees, or that their years of experience were overlooked in favour of the academic qualifications of less experienced male colleagues. Gender was not included in program training, and most staff did not have a good understanding of gender intersections; however, health workers actively engaged in awareness raising with male stakeholders to increase male involvement in RCH. Routine delivery requires mothers to invest time and money to access health facilities, where most mothers felt that better qualified staff were able to offer better advice and more services. Health workers felt that outreach services utilizing CHWs could decrease this time/money burden; however, CHWs are unqualified to provide counselling and provision of modern contraception, and there are fewer female CHWs. Records kept in health facilities record VAS by sex, but monthly reports submitted to the district and onwards to the national Health Management Information System are not disaggregated by sex. Programme and policymakers should consider improving the representation by females in senior, decision-making positions, integrating gender information into all trainings, supporting female health workers, training and recruiting more female CHWs, and reporting VAS coverage by sex.

Routine vitamin A supplementation and other high impact interventions in Sierra Leone.

In 2017, transition to routine vitamin A supplementation (VAS) commenced as an integrated reproductive and child health service including vaccinations, Albendazole for deworming, complementary feeding demonstrations, 'quality' family planning counselling and provision of modern contraceptives. After 10 months, a lot quality assurance sampling survey evaluated coverage of these interventions. Each of three districts was divided into five supervision areas (lots), and 19 villages were randomly selected in each lot proportional to population size. Households were randomly selected, and a questionnaire was administered to a caregiver of a child 6-11, 12-23 and 24-59 months in each village. Overall, caregivers of 855 children were interviewed, and 19 questionnaires were completed for each age group (6-11, 12-23 and 24-59 months) in each of the five lots in each district. All lots in one district passed the threshold of 80% for VAS and 75% coverage for Albendazole, and two lots failed for either VAS/Albendazole in the other two districts. Overall, weighted VAS coverage for children 6-59 months was 86.9%, and weighted Albendazole coverage for children 12-59 months was 80.9%. Most caregivers (77.2%) knew that complementary feeding should be introduced at 6 months, 44.9% were providing three or more (of six) food groups, 84.9% were aware of family planning and 37.5% were using a modern contraceptive. Integration of reproductive and child health services appears to be a suitable platform for routine VAS and Albendazole whilst improving complementary feeding practices and access to family planning.

Integrating reproductive and child health services enables access to modern contraception in Sierra Leone.

BACKGROUND: From mid-2015, reproductive and child health interventions were integrated into a routine 6-month contact point: vitamin A supplementation, nutrition counseling with the mother's participation in the preparation of a complementary food, and confidential family planning counseling with provision of modern forms of contraceptives. By mid-2017, these services had reached 28% of health facilities nationwide. OBJECTIVE: To evaluate awareness and uptake of modern contraception and complementary feeding practices. METHODS: All health facilities were visited, and the health worker "in-charge" were interviewed to ascertain their training status and supply chains. Within each catchment, community mothers of children 6 to 23 months of age were interviewed. RESULTS: Interviews were conducted with 321 "in-charges" and 670 mothers. Advantages and different types of contraception were understood by 99.0% of mothers, and 52.7% reported they were utilizing depot injections, hormonal implants, or oral contraceptive pills (45.1%, 34.6%, and 20.6% of users, respectively). Uptake was higher among Christians (62.1%) versus Muslims (48.6%) and among those with secondary/tertiary (61.5%) or primary education (60.5%) versus no education (43.3%) (P < 0.005 and P < 0.05, respectively). Complementary feeding practices included minimal meal diversity, 49.2% (fed three or more of six food groups), and recommended minimal meal frequency appropriate for age, 52.6%. Health workers reported frequent stockouts of vitamin A capsules (8%), male condoms (1%), oral contraceptives (10%), depot injections (20%), and hormonal implants (30%). CONCLUSION: In communities served by these integrated services, awareness and uptake of modern contraception exceeded national targets despite weak supply chains, and complementary feeding practices were favorable compared with the national survey.

Changing patterns of health in communities impacted by a bioenergy project in northern Sierra Leone.

Large private sector investments in low- and middle-income countries are often critically evaluated with regards to their environmental, social, human rights, and health impacts. A health impact assessment, including a baseline health survey, was commissioned by the Addax Bioenergy Sierra Leone project in 2010. As part of the monitoring, a follow-up survey was conducted three years later. A set of health indicators was assessed at six impacted and two control sites. Most of these indices improved, particularly at the impacted sites. The prevalences of stunting, wasting, and Plasmodium falciparum in children under five years of age decreased significantly at impacted sites (all p < 0.05) and non-significantly at control sites. Anemia in children and in women of reproductive age (15-49 years) decreased significantly at impacted and control sites (p < 0.05 and p < 0.001, respectively). Health facility-based deliveries increased significantly at the impacted sites (p < 0.05). The prevalences of helminth infections in children aged 10-15 years remained approximately at the same levels, although focal increases at the impacted sites were noted. Access to improved sanitation decreased significantly (p < 0.05) at control and non-significantly at impacted sites. Water quality remained poor without significant changes. The epidemiologic monitoring of a bioenergy project provides a useful contribution for evidence-based decision-making.