Impact of health systems reform on COVID-19 control in Sierra Leone: a case study.

BACKGROUND: There are various impacts of COVID-19 on health systems of the world. The health systems of low- and middle-income countries are less developed. Therefore, they have greater tendencies to experience challenges and vulnerabilities in COVID-19 control compared to high-income countries. It is important to contain the spread of the virus, and likewise strengthen the capacity of health systems in order for the response to be effective and swift. The experience from 2014 to 2016 Ebola outbreak in Sierra Leone served as preparation for COVID-19 outbreak. The aim of this study is to determine how control of COVID-19 outbreak in Sierra Leone was enhanced by the lessons learned from 2014 to 2016 Ebola outbreak, and health systems reform. METHODS: We used data from a qualitative case study conducted in four districts in Sierra Leone through key informant interviews, focus group discussions, document, and archive record reviews. A total of 32 key informant interviews and 14 focus group discussions were conducted. A thematic analysis was used to analyze the data, and all transcripts were coded and analyzed with the aid of ATLAS.ti 9 software program. RESULTS: The six themes obtained were composed of categories that connect with each other and with codes to form networks. The analysis of the responses demonstrated that "Multisectoral Leadership and Cooperation", "Government Collaboration among International Partners", and "Awareness in the Community" were among the key interventions used during the control of 2014-2016 Ebola virus disease outbreak, which were applied in the control of COVID-19. An infectious disease outbreak control model was proposed based on the results obtained from the analysis of the lessons learned during the Ebola virus disease outbreak, and health systems reform. CONCLUSIONS: "Multisectoral Leadership and Cooperation", "Government Collaboration among International Partners" and "Awareness in the Community" are key strategies that enhanced the control of the COVID-19 outbreak in Sierra Leone. It is recommended that they are implemented in controlling COVID-19 pandemic or any other infectious disease outbreak. The proposed model can be used in controlling infectious disease outbreaks, especially in low- and middle-income countries. Further research is needed to validate the usefulness of these interventions in overcoming an infectious disease outbreak.

The process of overcoming conflicts among teachers in the implementation of comprehensive sexuality education at ordinary public senior high schools in Mataram City, Indonesia: a qualitative study.

BACKGROUND: Comprehensive sexuality education (CSE), which aims to help young people make responsible choices and acquire scientific knowledge and skills, has been promoted by UNESCO. Teachers experience conflicts in implementing CSE when teaching sexual topics in the local context, especially as the delivery of sexual knowledge and contraceptive methods is often prohibited by religious and traditional cultural norms. It was reported that there were multiple challenges in the implementation of sex education due to the religious and cultural background of societies and communities in Islamic countries. This study aimed to clarify the process of overcoming the conflicts, explore teachers' recognition and perception related to the implementation of CSE, and to suggest recommendations for promoting CSE in Islamic areas. METHODS: This qualitative study combined the methods of focus group discussions (FGDs) and in-depth interviews (IDIs) to explore the conflict among teachers. Ten ordinary public senior high schools in Mataram City, Indonesia, agreed to participate, and in total, 59 participants were involved in this study. FGDs were conducted with teachers (n = 49), and IDIs were focused on school principals (n = 10) in each school. The collected interview data were analyzed using a deductive thematic analysis and the findings triangulated for both the FGDs and IDIs. RESULTS: Overall, the teachers experienced conflicts in relation to religion, cultural background, and gender inequality in implementing CSE. The present study revealed the mutual recognition among teachers and acceptance of diverse backgrounds in the implementation of CSE at ordinary public senior high schools in Mataram City. Despite teachers reporting multiple conflicts, they made efforts to overcome these conflicts through mutual recognition and provided comprehensive guidance. The present findings indicated that teachers adapted CSE to follow multiple religions and cultural backgrounds. CONCLUSIONS: The teachers accepted diverse backgrounds and provided CSE by collaborating with related educational subjects and external institutions to overcome conflicts. To provide more specialized education, it would be necessary to advocate a formal policy that might be accepted by diverse societies. Further research is necessary to apply the findings and recommendations for CSE implementation globally in the contexts of different countries.

Agent-Based Modeling and Simulation of Nosocomial Infection among Healthcare Workers during Ebola Virus Disease Outbreak in Sierra Leone.

Healthcare workers (HCWs) are often exposed to nosocomial infection when caring for patients with Ebola Virus Disease (EVD). During the 2014-2016 EVD outbreak in West Africa, more than 200 HCWs died of EVD in Sierra Leone. To determine the factors that are important for preventing infection among HCWs during EVD outbreak, we used agent-based modeling and simulation (ABMS) by focusing on education, training and performance of HCWs. Here, we assumed 1, 000 HCWs as "agents" to analyze their behavior within a given condition and selected four parameters (P1-P4) that are important in the prevention of infection: "initially educated HCWs (P1)", "initially educated trained (P2)", "probability of seeking training (P3)" and "probability of appropriate care procedure (P4)." After varying each parameter from 0% to 100%, P3 and P4 showed a greater effect on reducing the number of HCWs infected during EVD outbreak, compared with the other two parameters. The numbers of infected HCWs were decreased from 897 to 26 and from 1,000 to 59, respectively, when P3 or P4 was increased from 0% to 100%. When P2 was increased from 0% to 100%, the number of HCWs infected was decreased from 166 to 44. Paradoxically, the number of HCWs infected was increased from 56 to 109, when P1 was increased, indicating that initial education alone cannot prevent nosocomial infection. Our results indicate that effective training and appropriate care procedure play an important role in preventing infection. The present model is useful to manage nosocomial infection among HCWs during EVD outbreak.

Intensive Education of Health Care Workers Improves the Outcome of Ebola Virus Disease: Lessons Learned from the 2014 Outbreak in Sierra Leone.

The rare and deadly Ebola virus disease (EVD) is caused by Ebola virus (EBOV) infection. The 2014-2015 EVD outbreak in West Africa was unprecedented. Person-to-person transmission of EBOV by direct contact with the body or bodily fluids of an infected person through broken skin or unprotected mucous membrane caused rapid outbreak in communities. Nosocomial infection was the cause of death of many health care workers (HCWs). This paper aims to reveal the importance and effect of intensive education of HCWs when combating an outbreak such as EVD. We compared the curricula of two educational programs and analyzed their effects by the trend of weekly new patients. In September 2014, a three-day training program on infection, prevention and control (IPC) was organized for nurses, but it was not sufficient to achieve good outcome. In December 2014, a newly established National Ebola Training Academy was set up to offer a platform of clinical training modules for frontline Ebola response workers. This academy addressed the training needs of clinicians and hygienists who were working or will work at Ebola treatment centers that were established after the onset of the 2014 outbreak. Increased intensive contents and simulated training at the academy improved HCWs' understanding of EVD, IPC and patient care, which subsequently contributed to the survival of patients. The rapid settlement of the outbreak after introducing the Academy indicates that appropriate intensive education of HCWs is the key activity carried out to control the outbreak of EVD in Sierra Leone.

Nation-Wide Implementation of Disaster Medical Coordinators in Japan.

In the 2011 Great East Japan Earthquake (GEJE), successful medical and public health coordination by pre-assigned disaster medical coordinators saved many affected people, though the coordination itself had difficulties. This study aims to clarify the implementation and the challenges of disaster medical coordinators in Japan. We performed questionnaire surveillance in 2012 and 2014 to all prefectural government on assignment of disaster medical coordinators, their expected roles and supporting system. Out of all 47 prefectures, assignment or planning of disaster medical coordinators jumped up from four (8.5%) to 43 (91.5%) by the end of 2015. The most expected role is the coordination with Japan Disaster Medical Assistant Team (DMAT) and with other early responders. The evacuation center management, public health coordination and preparedness before disaster are less frequently expected. The supporting materials, human resource, and tools for communication vary according to the prefecture. Successful implementation requires the effort of health and governmental stakeholders. The coordination between prefectural and local coordinators and the coordination between medical and public health authorities still need to be improved. The roles of disaster medical coordinators depend on the local context and types of hazards. Education and training to build fundamental capacity is necessary. In conclusion, Japanese disaster medical system rapidly implemented disaster medical coordinator after GEJE. Their roles and standardization are challenging, but education, training and systematic support by the local government will enhance the effective preparedness and response of the health sector in disasters.