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

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

Implementing a Multisite Clinical Trial in the Midst of an Ebola Outbreak: Lessons Learned From the Sierra Leone Trial to Introduce a Vaccine Against Ebola.

The Sierra Leone Trial to Introduce a Vaccine against Ebola (STRIVE), a phase 2/3 trial of investigational rVSV∆G-ZEBOV-GP vaccine, was conducted during an unprecedented Ebola epidemic. More than 8600 eligible healthcare and frontline response workers were individually randomized to immediate (within 7 days) or deferred (within 18-24 weeks) vaccination and followed for 6 months after vaccination for serious adverse events and Ebola virus infection. Key challenges included limited infrastructure to support trial activities, unreliable electricity, and staff with limited clinical trial experience. Study staff made substantial infrastructure investments, including renovation of enrollment sites, laboratories, and government cold chain facilities, and imported equipment to store and transport vaccine at ≤-60oC. STRIVE built capacity by providing didactic and practical research training to >350 staff, which was reinforced with daily review and feedback meetings. The operational challenges of safety follow-up were addressed by issuing mobile telephones to participants, making home visits, and establishing a nurse triage hotline. Before the Ebola outbreak, Sierra Leone had limited infrastructure and staff to conduct clinical trials. Without interfering with the outbreak response, STRIVE responded to an urgent need and helped build this capacity. CLINICAL TRIALS REGISTRATION: ClinicalTrials.gov [NCT02378753] and Pan African Clinical Trials Registry [PACTR201502001037220].

The Sierra Leone Trial to Introduce a Vaccine Against Ebola: An Evaluation of rVSV∆G-ZEBOV-GP Vaccine Tolerability and Safety During the West Africa Ebola Outbreak.

Clinical Trials Registration: ClinicalTrials.gov [NCT02378753] and Pan African Clinical Trials Registry [PACTR201502001037220].

Current tobacco use and susceptibility to using tobacco among non-users of tobacco: A cross-sectional study among school-going adolescents in Sierra Leone.

INTRODUCTION: Tobacco use is a global health threat associated with a high disease burden and death. Current tobacco use and susceptibility to using tobacco products among adolescents who are potential adult tobacco users have not been explored in Sierra Leone. Thus, we aimed to estimate the prevalence and correlates of current tobacco use and tobacco non-users susceptibility to using tobacco amongst high school students in Sierra Leone. METHODS: We used data obtained from the 2017 Sierra Leone Global Youth Tobacco Survey (GYTS), which presented information collected from 6680 students aged 11-17 years nationwide. Gender-based correlates of current use and susceptibility to using tobacco among non-tobacco users were determined by complex sample logistic regression analyses. Adjusted odds ratios (AOR) and respective 95% confidence intervals (CIs) are reported. A p<0.05 was considered significant. RESULTS: The prevalence of current tobacco use among high school adolescents in Sierra Leone was 24.6%, higher in males (27.9%) than in females (18.6%). Male (AOR=1.50; 95% CI: 1.18-1.91), parental smoking (AOR=1.73; 95% CI: 1.32-2.26) exposure to household secondhand smoke (AOR=1.82; 95% CI: 1.27-2.62), having peers who smoke (AOR=2.24; 95% CI: 1.51-3.31) were more likely to be currently using tobacco. The overall tobacco non-users susceptibility to using tobacco among adolescents in Sierra Leone was 18.2% (males 18.0%, females 18.5%). Exposure to tobacco promotion (AOR=1.50; 95% CI: 1.06-2.10) and non-exposure to anti-smoking education (AOR=1.39; 95% CI: 1.05-1.86) were significantly associated with tobacco non-users' susceptibility to using tobacco. CONCLUSIONS: Our study suggests that one in four school-going adolescents currently uses tobacco, with nearly one in five non-users susceptible to using tobacco. Given the high prevalence of tobacco product use among adults in Sierra Leone, our findings highlight the need for policies and interventions to prevent tobacco use behavior among adolescents, aimed at averting tobacco use in adulthood.

Using photovoice to inform and support health systems to reach marginalised populations: experiences from six low- and middle-income countries.

Photovoice methodology centralises the voices of marginalised populations within health systems using photography and critical dialogue to record, reflect and communicate community health issues. This paper presents findings from applying photovoice to explore and document the lived experiences of groups of marginalised populations in six low- and middle-income countries: Cambodia, Ghana, Nepal, Sierra Leone, Uganda and Zambia. The strengths of using photovoice included: creating safe spaces for communication; community solidarity and stakeholder engagement; community ownership of actions and advocacy; developing new soft skills and confidence; capturing hidden community challenges; and taking collective action. Suggestions for use in future photovoice studies include: providing space for the exploration of contextual factors before implementation; developing a capacity strengthening plan to ensure participants have the competencies required to effectively take part in research and dissemination; considering the use of non-visual methods alongside photovoice when needed; and having in place partnership structures between researchers and participants that facilitate power sharing, agency, empowerment and joint decision making. Lastly, we present recommendations that have the potential to strengthen the value and use of photovoice as more than a participatory method but also a vehicle for individual, relational and health systems improvements.

Supporting community health workers in fragile settings from a gender perspective: a qualitative study.

OBJECTIVE: To explore how gender influences the way community health workers (CHWs) are managed and supported and the effects on their work experiences. SETTING: Two districts in three fragile countries. Sierra Leone-Kenema and Bonthe districts; Liberia-two districts in Grand Bassa county one with international support for CHW activities and one without: Democratic Republic of Congo (DRC)-Aru and Bunia districts in Ituri Province. PARTICIPANTS AND METHODS: Qualitative interviews with decision-makers and managers working in community health programmes and managing CHWs (n=36); life history interviews and photovoice with CHWs (n=15, in Sierra Leone only). RESULTS: While policies were put in place in Sierra Leone and Liberia to attract women to the newly paid position of CHW after the Ebola outbreak, these good intentions evaporated in practice. Gender norms at the community level, literacy levels and patriarchal expectations surrounding paid work meant that fewer women than imagined took up the role. Only in DRC, there were more women than men working as CHWs. Gender roles, norms and expectations in all contexts also affected retention and progression as well as safety, security and travel (over long distance and at night). Women CHWs also juggle between household and childcare responsibilities. Despite this, they were more likely to retain their position while men were more likely to leave and seek better paid employment. CHWs demonstrated agency in negotiating and challenging gender norms within their work and interactions supporting families. CONCLUSIONS: Gender roles and relations shape CHW experiences across multiple levels of the health system. Health systems need to develop gender transformative human resource management strategies to address gender inequities and restrictive gender norms for this critical interface cadre.

Rural-urban health-seeking behaviours for non-communicable diseases in Sierra Leone.

Introduction: Non-communicable diseases (NCDs) are the leading cause of mortality globally. In Africa, they are expected to increase by 25% by 2030. However, very little is known about community perceptions of risk factors and factors influencing health-seeking behaviour, especially in fragile settings. Understanding these is critical to effectively address this epidemic, especially in low-resource settings. Methods: We use participatory group model building techniques to probe knowledge and perceptions of NCD conditions and their causes, health-seeking patterns for NCDs and factors affecting these health-seeking patterns. Our participants were 116 local leaders and community members in three sites in Western Area (urban) and Bombali District (rural), Sierra Leone. Data were analysed using a prior framework for NCD care seeking developed in Ghana. Results: Our findings suggest adequate basic knowledge of causes and symptoms of the common NCDs, in rural and urban areas, although there is a tendency to highlight and react to severe symptoms. Urban and rural communities have access to a complex network of formal and informal, traditional and biomedical, spiritual and secular health providers. We highlight multiple narratives of causal factors which community members can hold, and how these and social networks influence their care seeking. Care seeking is influenced by a number of factors, including supply-side factors (proximity and cost), previous experiences of care, disease-specific factors, such as acute presentation, and personal and community beliefs about the appropriateness of different strategies. Conclusion: This article adds to the limited literature on community understanding of NCDs and its associated health-seeking behaviour in fragile settings. It is important to further elucidate these factors, which power hybrid journeys including non-care seeking, failure to prevent and self-manage effectively, and considerable expenditure for households, in order to improve prevention and management of NCDs in fragile settings such as Sierra Leone.

Opportunities and challenges for delivering non-communicable disease management and services in fragile and post-conflict settings: perceptions of policy-makers and health providers in Sierra Leone.

BACKGROUND: The growing burden of non-communicable diseases in low- and middle-income countries presents substantive challenges for health systems. This is also the case in fragile, post-conflict and post-Ebola Sierra Leone, where NCDs represent an increasingly significant disease burden (around 30% of adult men and women have raised blood pressure). To date, documentation of health system challenges and opportunities for NCD prevention and control is limited in such settings. This paper aims to identify opportunities and challenges in provision of NCD prevention and care and highlight lessons for Sierra Leone and other fragile states in the battle against the growing NCD epidemic. METHODS: This paper focuses on the case of Sierra Leone and uses a combination of participatory group model building at national and district level, in rural and urban districts, interviews with 28 key informants and review of secondary data and documents. Data is analysed using the WHO's health system assessment guide for NCDs. RESULTS: We highlight multiple challenges typical to those encountered in other fragile settings to the delivery of preventive and curative NCD services. There is limited government and donor commitment to financing and implementation of the national NCD policy and strategy, limited and poorly distributed health workforce and pharmaceuticals, high financial barriers for users, and lack of access to quality-assured medicines with consequent high recourse to private and informal care seeking. We identify how to strengthen the system within existing (low) resources, including through improved clinical guides and tools, more effective engagement with communities, and regulatory and fiscal measures. CONCLUSION: Our study suggests that NCD prevention and control is of low but increasing priority in Sierra Leone; challenges to addressing this burden relate to huge numbers with NCDs (especially hypertension) requiring care, overall resource constraints and wider systemic issues, including poorly supported primary care services and access barriers. In addition to securing and strengthening political will and commitment and directing more resources and attention towards this area, there is a need for in-depth exploratory and implementation research to shape and test NCD interventions in fragile and post-conflict settings.

Implementing an Ebola Vaccine Study - Sierra Leone.

In October 2014, the College of Medicine and Allied Health Sciences of the University of Sierra Leone, the Sierra Leone Ministry of Health and Sanitation, and CDC joined the global effort to accelerate assessment and availability of candidate Ebola vaccines and began planning for the Sierra Leone Trial to Introduce a Vaccine against Ebola (STRIVE). STRIVE was an individually randomized controlled phase II/III trial to evaluate efficacy, immunogenicity, and safety of the recombinant vesicular stomatitis virus Ebola vaccine (rVSV-ZEBOV). The study population was health care and frontline workers in select chiefdoms of the five most affected districts in Sierra Leone. Participants were randomized to receive a single intramuscular dose of rVSV-ZEBOV at enrollment or to receive a single intramuscular dose 18-24 weeks after enrollment. All participants were followed up monthly until 6 months after vaccination. Two substudies separately assessed detailed reactogenicity over 1 month and immunogenicity over 12 months. During the 5 months before the trial, STRIVE and partners built a research platform in Sierra Leone comprising participant follow-up sites, cold chain, reliable power supply, and vaccination clinics and hired and trained at least 350 national staff. Wide-ranging community outreach, informational sessions, and messaging were conducted before and during the trial to ensure full communication to the population of the study area regarding procedures and current knowledge about the trial vaccine. During April 9-August 15, 2015, STRIVE enrolled 8,673 participants, of whom 453 and 539 were also enrolled in the safety and immunogenicity substudies, respectively. As of April 28, 2016, no Ebola cases and no vaccine-related serious adverse events, which by regulatory definition include death, life-threatening illness, hospitalization or prolongation of hospitalization, or permanent disability, were reported in the study population. Although STRIVE will not produce an estimate of vaccine efficacy because of low case frequency as the epidemic was controlled, data on safety and immunogenicity will support decisions on licensure of rVSV-ZEBOV.The activities summarized in this report would not have been possible without collaboration with many U.S. and international partners (http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/partners.html).