Multimethod evaluation of health services integration for neglected tropical diseases requiring case management in Liberia.

INTRODUCTION: The WHO neglected tropical disease (NTD) roadmap stresses the importance of integrating NTDs requiring case management (CM) within the health system. The NTDs programme of Liberia is among the first to implement an integrated approach and evaluate its impact. METHODS: A retrospective study of three of five CM-NTD-endemic counties that implemented the integrated approach was compared with cluster-matched counties with non-integrated CM-NTD. We compared trends in CM-NTD integrated versus non-integrated county clusters. We conducted a pre-post comparison of WHO high-level outcomes using data collected during intervention years compared with baseline in control counties. Changes in health outcomes, effect sizes for different diseases and rate ratios with statistically significant differences were determined. Complementary qualitative research explored CM-NTD stakeholders' perceptions, analysed through the framework approach, which is a transparent, multistage approach for qualitative thematic interdisciplinary data analysis. RESULTS: The detection rates for all diseases combined improved significantly in the intervention compared with the control clusters. Besides leprosy, detection rates improved with large effects, over fourfold increase with statistically significant effects for individual diseases (p<0.000; 95% CI 3.5 to 5.4). Access to CM-NTD services increased in integrated counties by 71 facilities, compared with three facilities in non-integrated counties. Qualitative findings highlight training and supervision as inputs underpinning increases in case detection, but challenges with refresher training, medicine supply and incentives negatively impact quality, equity and access. CONCLUSIONS: Integrating CM-NTDs improves case detection, accessibility and availability of CM-NTD services, promoting universal health coverage. Early case detection and the quality of care need further strengthening.

A syndemic born of war: Combining intersectionality and structural violence to explore the biosocial interactions of neglected tropical diseases, disability and mental distress in Liberia.

The intersections between NTDs, disability, and mental ill-health are increasingly recognised globally. Chronic morbidity resultant from many NTDs, particularly those affecting the skin-including lymphatic filariasis (LF), leprosy, Buruli ulcer (BU) and onchocerciasis-is well known and largely documented from a medicalised perspective. However less is known about the complex biosocial interaction shaping interconnected morbidities. We apply syndemic theory to explain the biosocial relationship between NTDs and mental distress in the context of structural violence in Liberia. By advancing syndemic theory to include intersectional thought, it is apparent that structural violence becomes embodied in different ways through interacting multi-level (macro, meso and micro) processes. Through the use of in-depth qualitative methods, we explore the syndemic interaction of NTDs and mental distress from the vantage point of the most vulnerable and suggest that: 1) the post-conflict environment in Liberia predisposes people to the chronic effects of NTDs as well as other 'generalised stressors' as a consequence of ongoing structural violence; 2) people affected by NTDs are additionally exposed to stigma and discrimination that cause additional stressors and synergistically produce negative health outcomes in relation to NTDs and mental distress; and 3) the impact and experience of consequential syndemic suffering is shaped by intersecting axes of inequity such as gender and generation which are themselves created by unequal power distribution across multiple systems levels. Bringing together health systems discourse, which is focused on service integration and centred around disease control, with syndemic discourse that considers the biosocial context of disease interaction offers new approaches. We suggest that taking a syndemic-informed approach to care in the development of people-centred health systems is key to alleviating the burden of syndemic suffering associated with NTDs and mental distress currently experienced by vulnerable populations in resource-limited settings.

Neglected tropical disease as a 'biographical disruption': Listening to the narratives of affected persons to develop integrated people centred care in Liberia.

BACKGROUND: Integrated disease management, disability and inclusion (DMDI) for NTDs is increasingly prioritised. There is limited evidence on the effectiveness of integrated DMDI from the perspective of affected individuals and how this varies by differing axes of inequality such as age, gender, and disability. We used narrative methods to consider how individuals' unique positions of power and privilege shaped their illness experience, to elucidate what practical and feasible steps could support integrated DMDI in Liberia and beyond. METHODS: We purposively selected 27 participants affected by the clinical manifestations of lymphatic filariasis, leprosy, Buruli Ulcer, and onchocerciasis from three counties in Liberia to take part in illness narrative interviews. Participants were selected to ensure maximum variation in age, gender and clinical manifestation. Narrative analysis was grounded within feminist intersectional theory. FINDINGS: For all participants, chronic illness, morbidity and disability associated with NTDs represented a key moment of 'biographical disruption' triggering the commencement of a restitution narrative. Complex health seeking pathways, aetiologies and medical syncretism meant that adoption of the 'sick role' was initially acceptable, but when the reality of permanency of condition was identified, a transition to periods of chaos and significant psycho-social difficulty occurred. An intersectional lens emphasises how biographical disruption is mediated by intersecting social processes. Gender, generation, and disability were all dominant axes of social inequity shaping experience. SIGNIFICANCE: This is one of the first studies to use narrative approaches to interrogate experience of chronic disabling conditions within LMICs and is the only study to apply such an analysis to NTDs. The emotive power of narrative should be utilised to influence the value base of policy makers to ensure that DMDI strategies respond holistically to the needs of the most marginalised, thus contributing to more equitable people-centred care.