Barriers and Enablers to Treatment-Seeking Behavior and Causes of High-Risk Practices in Ebola: A Case Study From Sierra Leone.

Nine months after the start of the Ebola outbreak in Sierra Leone in May 2014, communities in Port Loko continued to engage in high-risk practices; many remained unwilling to seek treatment. In the face of such behaviors, Oxfam Community Outreach teams conducted qualitative research using in-depth interviews, focus groups, and questionnaires to better understand the barriers and enablers affecting treatment-seeking behavior. Analysis of their results highlights 3 primary barriers to treatment seeking: fear and limited information, concern about unknown outsiders, and the often prohibitive distance and limited accessibility of treatment. Communities were asked to provide suggestions on how to address these barriers. Their recommendations fell into 4 main categories: providing information and better communication, including community members in decisions, providing closer treatment facilities with opportunities to learn how they operate, and using survivors to inspire hope for other sufferers. This research highlights the need for social mobilization programs to invest early in understanding the underlying causes of risky behaviors in order to develop programs that address them.

Treatment Seeking and Ebola Community Care Centers in Sierra Leone: A Qualitative Study.

Ebola Treatment Units were able to provide only 60% of necessary treatment beds in Sierra Leone. As a result, the Government of Sierra Leone decided to construct Community Care Centers. These were intended to increase treatment-seeking behavior and reduce the community-level spread of Ebola by facilitating access to care closer to communities. Through qualitative data collection in 3 districts, this study seeks to understand the perceived impact that proximity to such Centers had on treatment-seeking behavior. Feedback from community members and Community Health Volunteers indicates that proximity to treatment reduced fears, especially those arising from the use of ambulances, lack of familiarity with medical Centers, and loss of contact with family members taken for treatment. Participants report that having a Center close to their home enables them to walk to treatment and witness survivors being discharged. Living close to Centers also enables communities to be involved in their design and daily operation, helping to build trust in them as acceptable treatment facilities. Further research is required to understand the appropriate design, operation, and epidemiological impact of Centers. Further investigation should incorporate the effect of an outbreak's severity and the stage (duration) of the outbreak on potential acceptance of Centers.

Exploring different health care providers´ perceptions on the management of diarrhoea in cholera hotspots in the Democratic Republic of Congo: A qualitative content analysis.

Global cholera guidelines support wider healthcare system strengthening interventions, alongside vertical outbreak responses, to end cholera. Well-trained healthcare providers are essential for a resilient health system and can create synergies with childhood diarrhoea, which has higher mortality. We explored how the main provider groups for diarrhoea in cholera hotspots interact, decide on treatment, and reflect on possible limiting factors and opportunities to improve prevention and treatment. We conducted focus group discussions in September 2022 with different healthcare provider types in two urban and two rural cholera hotspots in the North Kivu and Tanganyika provinces in the Eastern Democratic Republic of Congo. Content analysis was used with the same coding applied to all providers. In total 15 focus group discussions with medical doctors (n = 3), nurses (n = 4), drug shop vendors (n = 4), and traditional health practitioners (n = 4) were performed. Four categories were derived from the analysis. (i) Provider dynamics: scepticism between all cadres was prominent, whilst also acknowledging the important role all provider groups have in current case management. (ii) Choice of treatment: affordability and strong caregiver demands shaped by cultural beliefs strongly affected choice. (iii) Financial consideration on access: empathy was strong, with providers finding innovative ways to create access to treatment. Concurrently, financial incentives were important, and providers asked for this to be considered when subsiding treatment. (iv) How to improve: the current cholera outbreak response approach was appreciated however there was a strong wish for broader long-term interventions targeting root causes, particularly community access to potable water. Drug shops and traditional health practitioners should be considered for inclusion in health policies for cholera and other diarrhoeal diseases. Financial incentives for the provider to improve access to low-cost treatment and investment in access to potable water should furthermore be considered.

Facility capacity and provider knowledge for cholera surveillance and diarrhoea case management in cholera hotspots in the Democratic Republic of Congo - a mixed-methods study.

BACKGROUND: Wider healthcare-strengthening interventions are recommended in cholera hotspots and could benefit other types of diarrhoeal diseases which contribute to greater mortality than cholera. OBJECTIVE: Describe facility capacity and provider knowledge for case management of diarrhoea and cholera surveillance in cholera hotspots in the Democratic Republic of Congo (DRC) among health facilities, drug shops, and traditional health practitioners. METHODS: We conducted a sequential exploratory mixed-method study, using focus group discussions, facility audits, and provider knowledge questionnaires during September and October 2022 in North Kivu and Tanganyika provinces, Eastern DRC. Content analysis was used for qualitative data. Quantitative data were summarised by facility level and healthcare provider type. Audit and knowledge scores (range 0-100) were generated. Multivariable linear regression estimated association between scores and explanatory factors. Qualitative and quantitative data were triangulated during interpretation. RESULTS: Overall, 244 facilities and 308 providers were included. The mean audit score for health facilities was 51/100 (SD: 17). Private facilities had an -11.6 (95% CI, -16.7 to -6.6) lower adjusted mean score compared to public. Mean knowledge score was 59/100 (95% CI, 57 to 60) for health facility personnel, 46/100 (95% CI, 43 to 48) for drug shop vendors and 37/100 (95% CI, 34 to 39) for traditional health practitioners. Providers had particularly low knowledge concerning when to check for low blood sugar, use of nasogastric tubes, and dosing schedules. Knowledge about case definitions for cholera was similar between groups (range 41-58%) except for traditional health practitioners for the definition during an outbreak 15/73 (21%). CONCLUSIONS: Increasing awareness of cholera case definitions in this context could help improve cholera surveillance and control. Increased support and supervision, especially for private providers, could help ensure facilities are equipped to provide safe care. More nuanced aspects of case management should be emphasised in provider training.

Time to care and factors influencing appropriate Sudan virus disease care among case patients in Uganda, September to November 2022.

OBJECTIVES: Early isolation and care for Ebola disease patients at Ebola Treatment Units (ETU) curb outbreak spread. We evaluated time to ETU entry and associated factors during the 2022 Sudan virus disease (SVD) outbreak in Uganda. METHODS: We included persons with RT-PCR-confirmed SVD with onset September 20-November 30, 2022. We categorized days from symptom onset to ETU entry ("delays") as short (≤2), moderate (3-5), and long (≥6); the latter two were "delayed isolation." We categorized symptom onset timing as "earlier" or "later," using October 15 as a cut-off. We assessed demographics, symptom onset timing, and awareness of contact status as predictors for delayed isolation. We explored reasons for early vs late isolation using key informant interviews. RESULTS: Among 118 case-patients, 25 (21%) had short, 43 (36%) moderate, and 50 (43%) long delays. Seventy-five (64%) had symptom onset later in the outbreak. Earlier symptom onset increased risk of delayed isolation (crude risk ratio = 1.8, 95% confidence interval (1.2-2.8]). Awareness of contact status and SVD symptoms, and belief that early treatment-seeking was lifesaving facilitated early care-seeking. Patients with long delays reported fear of ETUs and lack of transport as contributors. CONCLUSION: Delayed isolation was common early in the outbreak. Strong contact tracing and community engagement could expedite presentation to ETUs.

Risk perception of Ebola virus disease and COVID-19 among transport drivers living in Ugandan border districts.

Background: Cross-border movements between districts bordering Uganda and the Democratic Republic of Congo (DRC) are common due to the interdependence between populations on either side, though this increases the risk of the international spread of infectious diseases. Due to the nature of their work, boda boda drivers (motorcycle taxis), taxis and truck drivers continue to cross the border during epidemics. However, perceived risk of contracting and spreading communicable diseases may be influenced by several factors such as the level of education, packaging and perception of health care messages, limited interaction with local socio-cultural dynamics or personal experiences. This study aims to explore differences in movement patterns and risk perceptions as factors for transmission among transport drivers in Ugandan border districts during the 2018-2020 Ebola Virus Disease (EVD) epidemic and the current COVID-19 pandemic. Methods: Between May and June 2021, in-depth interviews and focus group discussions were conducted with transport drivers in three Ugandan districts bordering DRC (Kasese, Kisoro and Hoima). Participants were asked about their knowledge and beliefs about EVD and COVID-19, perceived risk during epidemics, reasons for, and travel patterns during the EVD epidemic and COVID- 19 pandemic. A thematic content analysis was applied. Results: Participants' awareness of EVD was higher than that of COVID-19 however, the risk of transmission of Ebola virus was perceived as a remote threat. Measures restricting mobility during the COVID-19 pandemic had a greater impact on transport drivers compared to those implemented during the EVD epidemic, and were perceived as prohibitive rather than protective, largely due to fear of reprisals by security officers. Despite this, drivers were unlikely to be able to comply with the restrictions as they relied on their work as a source of income. Conclusion: The vulnerabilities of transport drivers should be considered in the context of epidemics such EVD and COVID-19 in Uganda. Policy makers should address these particularities and assess the impact of public health measures on transport drivers' mobility and involve them in designing of mobility-relatedpolicies.

Ebola virus disease nosocomial infections in the Democratic Republic of the Congo: a descriptive study of cases during the 2018-2020 outbreak.

OBJECTIVES: To describe the characteristics of nosocomial cases of Ebola virus disease (EVD) in the Democratic Republic of the Congo between July 2018 and May 2020 in order to inform future interventions. METHODS: Nosocomial cases of EVD were identified during outbreak response surveillance, and a retrospective analysis of cases was conducted according to demographic characteristics and type of health facility (HF). RESULTS: Of 3481 cases of EVD, 579 (16.6%) were nosocomial. Of these, 332 cases occurred in women (57.3%). Patients and visitors accounted for 419 cases (72.4%), of which 79 (18.9%) were aged 6-≤18 years and 108 (25.8%) were aged ≤5 years. Health workers (HWs) accounted for the remaining 160 (27.6%) nosocomial cases. The case fatality rate (CFR) for HWs (66/160, 41.3%) was significantly lower than the CFR for patients and visitors (292/419, 69.7%) (P<0.001). The CFR was higher among cases aged 6-≤18 years (54/79, 68.4%) and ≤5 years (89/108, 82.4%). Referral HFs (>39 beds) had the highest prevalence of nosocomial EVD (148/579, 25.6%). Among HFs with at least one case of nosocomial infection, 50.0% (98/196) were privately owned. CONCLUSIONS: Nurses and traditional healers should be targeted for infection prevention and control training, and supportive supervision should be provided to HFs to mitigate EVD transmission.

COVID-19 response: mitigating negative impacts on other areas of health.

'Vertical' responses focused primarily on preventing and containing COVID-19 have been implemented in countries around the world with negative consequences for other health services, people's access to and use of them, and associated health outcomes, especially in low-income and middle-income countries (LMICs). 'Lockdowns' and restrictive measures, especially, have complicated service provision and access, and disrupted key supply chains. Such interventions, alongside more traditional public health measures, interact with baseline health, health system, and social and economic vulnerabilities in LMICs to compound negative impacts. This analysis, based on a rapid evidence assessment by the Social Science in Humanitarian Action Platform in mid-2020, highlights the drivers and evidence of these impacts, emphasises the additional vulnerabilities experienced by marginalised social groups, and provides insight for governments, agencies, organisations and communities to implement more proportionate, appropriate, comprehensive and socially just responses that address COVID-19 in the context of and alongside other disease burdens. In the short term, there is an urgent need to monitor and mitigate impacts of pandemic responses on health service provision, access and use, including through embedding COVID-19 response within integrated health systems approaches. These efforts should also feed into longer-term strategies to strengthen health systems, expand universal healthcare coverage and attend to the social determinants of health-commitments, both existing and new-which governments, donors and international agencies must make and be held accountable to. Crucially, affected communities must be empowered to play a central role in identifying health priorities, allocating resources, and designing and delivering services.

Gender-based violence and infectious disease in humanitarian settings: lessons learned from Ebola, Zika, and COVID-19 to inform syndemic policy making.

BACKGROUND: The impacts of infectious disease outbreaks, epidemics, and pandemics are not gender neutral. Instead, infectious diseases and gender-based violence (GBV) mutually reinforce each other. Women and girls in humanitarian settings are disproportionately impacted as crises exacerbate gender inequality, violence, and community transmission. A syndemic model of infectious disease and GBV draws attention to their critical linkage, enabling more effective approaches to address both infectious disease transmission and GBV prevalence. MAIN BODY: Implementation of infectious disease control measures have been consistently absent of critical gender considerations in humanitarian settings. We drew learnings from Ebola, Zika, and COVID-19 to highlight how women and girls living in humanitarian settings have faced bi-directional syndemic vulnerabilities between GBV and infectious disease. Our findings indicate that Ebola, Zika, and COVID-19 exacerbated GBV risk and experience of GBV increased community transmission of these infectious diseases. Moreover, we identified a failure of existing policies to address this mutually deleterious linkage. Thus, we advocate for policymakers to ask three foundational questions: (i) What are the gendered bi-directional risk pathways between infectious disease and GBV?; (ii) How can we act on the gendered risk pathways?; and, (iii) Who should be involved in designing, implementing, and evaluating gender-sensitive policies? CONCLUSION: Our syndemic policy framework challenges existing thinking on a neglected issue that disproportionally impacts women and girls. By offering foundational guidance to address and thwart the syndemic of infectious disease and GBV in humanitarian settings, we endeavor to proactively and holistically address the reinforcing linkage between GBV and current or emergent infectious diseases.

Impact of the COVID-19 pandemic and response on the utilisation of health services in public facilities during the first wave in Kinshasa, the Democratic Republic of the Congo.

INTRODUCTION: Health service use among the public can decline during outbreaks and had been predicted among low and middle-income countries during the COVID-19 pandemic. In March 2020, the government of the Democratic Republic of the Congo (DRC) started implementing public health measures across Kinshasa, including strict lockdown measures in the Gombe health zone. METHODS: Using monthly time series data from the DRC Health Management Information System (January 2018 to December 2020) and interrupted time series with mixed effects segmented Poisson regression models, we evaluated the impact of the pandemic on the use of essential health services (outpatient visits, maternal health, vaccinations, visits for common infectious diseases and non-communicable diseases) during the first wave of the pandemic in Kinshasa. Analyses were stratified by age, sex, health facility and lockdown policy (ie, Gombe vs other health zones). RESULTS: Health service use dropped rapidly following the start of the pandemic and ranged from 16% for visits for hypertension to 39% for visits for diabetes. However, reductions were highly concentrated in Gombe (81% decline in outpatient visits) relative to other health zones. When the lockdown was lifted, total visits and visits for infectious diseases and non-communicable diseases increased approximately twofold. Hospitals were more affected than health centres. Overall, the use of maternal health services and vaccinations was not significantly affected. CONCLUSION: The COVID-19 pandemic resulted in important reductions in health service utilisation in Kinshasa, particularly Gombe. Lifting of lockdown led to a rebound in the level of health service use but it remained lower than prepandemic levels.

A review and agenda for integrated disease models including social and behavioural factors.

Social and behavioural factors are critical to the emergence, spread and containment of human disease, and are key determinants of the course, duration and outcomes of disease outbreaks. Recent epidemics of Ebola in West Africa and coronavirus disease 2019 (COVID-19) globally have reinforced the importance of developing infectious disease models that better integrate social and behavioural dynamics and theories. Meanwhile, the growth in capacity, coordination and prioritization of social science research and of risk communication and community engagement (RCCE) practice within the current pandemic response provides an opportunity for collaboration among epidemiological modellers, social scientists and RCCE practitioners towards a mutually beneficial research and practice agenda. Here, we provide a review of the current modelling methodologies and describe the challenges and opportunities for integrating them with social science research and RCCE practice. Finally, we set out an agenda for advancing transdisciplinary collaboration for integrated disease modelling and for more robust policy and practice for reducing disease transmission.

How to improve outbreak response: a case study of integrated outbreak analytics from Ebola in Eastern Democratic Republic of the Congo.

The emerging field of outbreak analytics calls attention to the need for data from multiple sources to inform evidence-based decision making in managing infectious diseases outbreaks. To date, these approaches have not systematically integrated evidence from social and behavioural sciences. During the 2018-2020 Ebola outbreak in Eastern Democratic Republic of the Congo, an innovative solution to systematic and timely generation of integrated and actionable social science evidence emerged in the form of the Cellulle d'Analyse en Sciences Sociales (Social Sciences Analytics Cell) (CASS), a social science analytical cell. CASS worked closely with data scientists and epidemiologists operating under the Epidemiological Cell to produce integrated outbreak analytics (IOA), where quantitative epidemiological analyses were complemented by behavioural field studies and social science analyses to help better explain and understand drivers and barriers to outbreak dynamics. The primary activity of the CASS was to conduct operational social science analyses that were useful to decision makers. This included ensuring that research questions were relevant, driven by epidemiological data from the field, that research could be conducted rapidly (ie, often within days), that findings were regularly and systematically presented to partners and that recommendations were co-developed with response actors. The implementation of the recommendations based on CASS analytics was also monitored over time, to measure their impact on response operations. This practice paper presents the CASS logic model, developed through a field-based externally led consultation, and documents key factors contributing to the usefulness and adaption of CASS and IOA to guide replication for future outbreaks.

Recommendations for the COVID-19 Response at the National Level Based on Lessons Learned from the Ebola Virus Disease Outbreak in the Democratic Republic of the Congo.

The tenth outbreak of Ebola virus disease (EVD) in North Kivu, the Democratic Republic of the Congo (DRC), was declared 8 days after the end of the ninth EVD outbreak, in the Equateur Province on August 1, 2018. With a total of 3,461 confirmed and probable cases, the North Kivu outbreak was the second largest outbreak after that in West Africa in 2014-2016, and the largest observed in the DRC. This outbreak was difficult to control because of multiple challenges, including armed conflict, population displacement, movement of contacts, community mistrust, and high population density. It took more than 21 months to control the outbreak, with critical innovations and systems put into place. We describe systems that were put into place during the EVD response in the DRC that can be leveraged for the response to the current COVID-19 global pandemic.

Health promotion for young people with profound and multiple learning disabilities.

Research confirms that children and young people with severe learning disabilities do not have the same level of access to high-quality care, health education and health promotion activities as children and young people without disabilities. This article discusses a quality improvement, action research project to investigate alternative approaches to health promotion that enhance the health and well-being of children and young people with complex neurodisabilities. The project involved assessment of school records and completion by staff of an eight-question survey. It found that the proactive approach of school nurses in raising awareness and understanding through questioning was positively received, and reinforced how meaningful and relevant information could be delivered to these young people. The project also had unexpected benefits, including more integrated team working, increased knowledge, greater awareness and understanding of the importance of health promotion participation, and student satisfaction.