Community Engagement in Liberia: Routine Immunization Post-Ebola.

A national integrated polio, measles, and deworming campaign was implemented across Liberia May 8-14, 2015. The community engagement and social mobilization component of the campaign was based on structures that had been invested in during the Ebola response. This article provides an overview of the community engagement and social mobilization activities that were conducted and reports the key findings of a rapid qualitative assessment conducted immediately after the campaign that focused on community perceptions of routine immunization in the post-Ebola context. Focus group discussions and interviews were conducted across four counties in Liberia (Montserrado, Nimba, Bong, and Margibi). Thematic analysis identified the barriers preventing and drivers leading to the utilization of routine immunization. Community members also made recommendations and forwarded community-based solutions to encourage engagement with future health interventions, including uptake in vaccination campaigns. These should be incorporated in the development and implementation of future interventions and programs.

Occurrence of major infectious diseases and healthcare seeking among young children with disabilities in Sierra Leone using cross-sectional population-based survey data.

BACKGROUND: Children with disabilities are at risk of worse health outcomes compared to children without functional difficulties. Sierra Leone has one of the world's highest prevalences of functional difficulties among children, but little is known about the co-occurrence of major infectious diseases and healthcare-seeking behaviours among children with disabilities. METHODS: We used household survey cross-sectional data on children 2-4 years old and logistic regression models estimating ORs between functional difficulties and symptoms of infectious diseases including diarrhoea, fever and acute respiratory infection (ARI), adjusted for sex, age and stunting. We also examined whether caregivers sought advice or treatment for the illness from any source and if the child was given any treatment for the illness. RESULTS: There was an increased risk of fever among children with functional difficulty (adjusted OR (AOR)=1.3, 95% CI 1.1 to 1.8) and children with severe functional difficulty (AOR=1.6, 95% CI 1.0 to 2.7). Children with severe functional difficulty were also at increased risk of diarrhoea (AOR=1.8, 95% CI=1.1 to 3.3). There were no significant differences in seeking advice or treatment for diarrhoea, fever or ARI symptoms between the groups. CONCLUSIONS: In Sierra Leone, children with functional difficulties, especially severe functional difficulties, more often have symptoms of major childhood diseases that are known to increase under-5 mortality.

Prevalence of children under five with disabilities in Sierra Leone in 2017: Insights from a population-based multiple indicator cluster survey.

BACKGROUND: Children with disabilities have been low on the agenda of child health, including in Sierra Leone, and there are still many gaps in our knowledge and understanding of the issue. OBJECTIVE: To estimate the prevalence of children with disabilities in Sierra Leone using functional difficulty as a proxy and to understand the factors associated with disabilities among children two to four years living in Sierra Leone. METHODS: We used cross-sectional data from the Sierra Leone 2017 Multiple Indicator Cluster Survey. Disability was defined using a functional difficulty definition with additional thresholds used to define children with severe functional difficulty and multiple disabilities. Logistic regression models estimated odds ratios (ORs) of childhood disability and how they were associated with socioeconomic factors and living conditions. RESULTS: Prevalence of children with disabilities was 6.6% (95% confidence interval (CI) 5.8-7.6%) and there was a high risk of comorbidity between different functional difficulties. Children with disabilities were less likely to be girls (adjusted odds ratio (AOR) 0.8 (CI 0.7-1.0) and older (AOR 0.3 (CI 0.2-0.4)), but more prone to be stunted (AOR 1.4 (CI 1.1-1.7)) and have younger caregivers (AOR 1.3 (CI 0.7-2.3)). CONCLUSION: The prevalence of disabilities in young Sierra Leonean children was comparable to other countries in West and Central Africa when using the same measure of disability. Preventive as well as early detection and intervention efforts are recommended to be integrated with other programs, e.g vaccinations, nutrition, and poverty reducing programs.

Association of community engagement with vaccination confidence and uptake: A cross-sectional survey in Sierra Leone, 2019.

Background: The 2014-2016 Ebola epidemic disrupted childhood immunization in Sierra Leone, Liberia, and Guinea. After the epidemic, the Government of Sierra Leone prioritized community engagement to increase vaccination confidence and uptake. To support these efforts, we examined potential drivers of vaccination confidence and uptake in Sierra Leone. Methods: We conducted a population-based household survey with primary caregivers of children in a birth cohort of 12 to 23 months in four districts with low vaccination coverage in Sierra Leone in 2019. Modified Poisson regression modeling with robust variance estimation was used to examine if perceived community engagement in planning the immunization program in the community was associated with vaccination confidence and having a fully vaccinated child. Results: The sample comprised 621 age-eligible children and their caregivers (91% response rate). Half of the caregivers (52%) reported that it usually takes too long to get to the vaccination site, and 36% perceived that health workers expect money for vaccination services that are supposed to be given at no charge. When mothers were the decision-makers of the children's vaccination, 80% of the children were fully vaccinated versus 69% when fathers were the decision-makers and 56% when other relatives were the decision-makers. Caregivers with high confidence in vaccination were more likely to have fully vaccinated children compared to caregivers with low confidence (78% versus 53%). For example, caregivers who thought vaccines are 'very much' safe were more likely to have fully vaccinated children than those who thought vaccines are 'somewhat' safe (76% versus 48%). Overall, 53% of caregivers perceived high level of community engagement, 41% perceived medium level of engagement, and 6% perceived low level of engagement. Perceiving high community engagement was associated with expressing high vaccination confidence (adjusted prevalence ratio (aPR) = 2.60; 95% confidence interval (CI) = 1.67-4.04) and having a fully vaccinated child (aPR = 1.67; 95% CI = 1.18-2.38). Conclusions: In these four low coverage districts in Sierra Leone, the perceived level of community engagement was strongly associated with vaccination confidence among caregivers and vaccination uptake among children. We have provided exploratory cross-sectional evidence to inform future longitudinal assessments to further investigate the potential causal effect of community engagement on vaccination confidence and uptake.

Debunking highly prevalent health misinformation using audio dramas delivered by WhatsApp: evidence from a randomised controlled trial in Sierra Leone.

INTRODUCTION: Infectious disease misinformation is widespread and poses challenges to disease control. There is limited evidence on how to effectively counter health misinformation in a community setting, particularly in low-income regions, and unsettled scientific debate about whether misinformation should be directly discussed and debunked, or implicitly countered by providing scientifically correct information. METHODS: The Contagious Misinformation Trial developed and tested interventions designed to counter highly prevalent infectious disease misinformation in Sierra Leone, namely the beliefs that (1) mosquitoes cause typhoid and (2) typhoid co-occurs with malaria. The information intervention for group A (n=246) explicitly discussed misinformation and explained why it was incorrect and then provided the scientifically correct information. The intervention for group B (n=245) only focused on providing correct information, without directly discussing related misinformation. Both interventions were delivered via audio dramas on WhatsApp that incorporated local cultural understandings of typhoid. Participants were randomised 1:1:1 to the intervention groups or the control group (n=245), who received two episodes about breast feeding. RESULTS: At baseline 51% believed that typhoid is caused by mosquitoes and 59% believed that typhoid and malaria always co-occur. The endline survey was completed by 91% of participants. Results from the intention-to-treat, per-protocol and as-treated analyses show that both interventions substantially reduced belief in misinformation compared with the control group. Estimates from these analyses, as well as an exploratory dose-response analysis, suggest that direct debunking may be more effective at countering misinformation. Both interventions improved people's knowledge and self-reported behaviour around typhoid risk reduction, and yielded self-reported increases in an important preventive method, drinking treated water. CONCLUSION: These results from a field experiment in a community setting show that highly prevalent health misinformation can be countered, and that direct, detailed debunking may be most effective. TRIAL REGISTRATION NUMBER: NCT04112680.

Community knowledge, perceptions and practices around COVID-19 in Sierra Leone: a nationwide, cross-sectional survey.

OBJECTIVES: To assess the public's knowledge, attitudes and practices about the novel coronavirus in Sierra Leone to inform an evidence-based communication strategy around COVID-19. DESIGN: Nationwide, cross-sectional Knowledge, Attitudes and Practices survey. SETTING: 56 randomly selected communities in all 14 districts in Sierra Leone. PARTICIPANTS: 1253 adults aged 18 years and older of which 52% were men. MAIN OUTCOME MEASURES: We calculated proportions of core indicators (awareness, knowledge, risk perception, practices). A composite variable for knowledge (based on seven variables) was created, and categorised into low (0-2 correct), medium (3-4) and high (5-7). Predictors of knowledge were analysed with multilevel ordinal regression models. Associations between information sources, knowledge and two practices (washing hands with soap and avoiding crowds) were analysed using multilevel logistic regression models. RESULTS: We found that 75% of the respondents felt at moderate or great risk of contracting coronavirus. A majority (70%) of women did not know you can survive COVID-19, compared with 61% of men. 60% of men and 54% of women had already taken action to avoid infection with the coronavirus, mostly washing hands with soap and water (87%). Radio (73%) was the most used source for COVID-19 information, followed by social media (39%). Having a medium or high level of knowledge was associated with higher odds of washing hands with soap (medium knowledge: adjusted OR (AOR) 2.1, 95% CI 1.0 to 4.4; high knowledge: AOR 4.6, 95% CI 2.1 to 10.2) and avoiding crowds (medium knowledge: AOR 2.0, 95% CI 1.1 to 3.6; high knowledge: AOR 2.3, 95% CI 1.2 to 4.3). CONCLUSIONS: This study shows that in the context of COVID-19 in Sierra Leone, there is a strong association between knowledge and practices. Because the knowledge gap differs between genders, regions, educational levels and age, it is important that messages are specifically targeted to these core audiences.