Lara S. Ho

Healthcare providers on the frontlines: a qualitative investigation of the social and emotional impact of delivering health services during Sierra Leone’s Ebola epidemic

Although research on the epidemiology and ecology of Ebola has expanded since the 2014–15 outbreak in West Africa, less attention has been paid to the mental health implications and the psychosocial context of the disease for providers working in primary health facilities (rather than Ebola-specific treatment units). This study draws on 54 qualitative interviews with 35 providers working in eight peripheral health units of Sierra Leones Bo and Kenema Districts. Data collection started near the height of the outbreak in December 2014 and lasted 1 month. Providers recounted changes in their professional, personal and social lives as they became de facto first responders in the outbreak. A theme articulated across interviews was Ebola’s destruction of social connectedness and sense of trust within and across health facilities, communities and families. Providers described feeling lonely, ostracized, unloved, afraid, saddened and no longer respected. They also discussed restrictions on behaviors that enhance coping including attending burials and engaging in physical touch (hugging, handshaking, sitting near, or eating with colleagues, patients and family members). Providers described infection prevention measures as necessary but divisive because screening booths and protective equipment inhibited bonding or ‘suffering with’ patients. To mitigate psychiatric morbidities and maladaptive coping mechanisms—and to prevent the spread of Ebola—researchers and program planners must consider the psychosocial context of this disease and mechanisms to enhance psychological first aid to all health providers, including those in peripheral health settings.

Effects of a community scorecard on improving the local health system in Eastern Democratic Republic of Congo: qualitative evidence using the most significant change technique

BackgroundMore than a decade of conflict has weakened the health system in the Democratic Republic of Congo and decreased its ability to respond to the needs of the population. Community scorecards have been conceived as a way to increase accountability and responsiveness of service providers, but there is limited evidence of their effects, particularly in fragile and conflict-affected contexts. This paper describes the implementation of community scorecards within a community-driven reconstruction project in two provinces of eastern Democratic Republic of Congo.MethodsBetween June 2012 and November 2013, 45 stories of change in the health system were collected from village development committee, health committee, community members (20 men and 18 women) and healthcare providers (n = 7) in 25 sites using the Most Significant Change technique. Stories were analyzed qualitatively for content related to the types and mechanisms of change observed.ResultsThe most salient changes were related to increased transparency and community participation in health facility management, and improved quality of care. Quality of care included increased access to services, improved patient-provider relationships, improved performance of service providers, and improved maintenance of physical infrastructure. Changes occurred through many different mechanisms including provider actions in response to information, pressure from community representatives, or supervisors; and joint action and improved collaboration by health facility committees and providers.ConclusionsAlthough it is often assumed that confrontation is a primary mechanism for citizens to change state-provided services, this study demonstrates that healthcare providers may also be motivated to change through other means. Positive experiences of community scorecards can provide a structured space for interface between community members and the health system, allowing users to voice their opinions and preferences and bridge information gaps for both users and frontline healthcare providers. When solutions to problems identified through the scorecard are locally accessible, users and healthcare providers are able to work together to implement mutually acceptable solutions that improve quality of health services, and make them more responsive to users’ needs.

Picking up the bill - improving health-care utilisation in the Democratic Republic of Congo through user fee subsidisation: a before and after study

BackgroundUser fees have been shown to constitute a major barrier to the utilisation of health-care, particularly in low-income countries such as the Democratic Republic of Congo (DRC). Importantly, such barriers can lead to the exclusion of vulnerable individuals from health-care. In 2008, a donor-funded primary health-care programme began implementing user fee subsidisation in 20 health zones of the DRC. In this study, we quantified the short and long-term effects of this policy on health-care utilisation.MethodsSixteen health zones were included for analysis. Using routinely collected health-care utilisation data before and after policy implementation, interrupted time series regression was applied to quantify the temporal impact of the user fee policy in the studied health zones. Payment of salary supplements to health-care workers and provision of free drugs - the other components of the programme - were controlled for where possible.ResultsFourteen (88%) health zones showed an immediate positive effect in health-care utilisation rates (overall median increase of 19%, interquartile range 11 to 43) one month after the policy was introduced, and the effect was significant in seven zones (P <0.05). This initial effect was sustained or increased at 24 months in five health zones but was only significant in one health zone at P <0.05. Utilisation reduced over time in the remaining health zones (overall median increase of 4%, interquartile range -10 to 33). The modelled mean health-care utilisation rate initially increased significantly from 43 consultations/1000 population to 51 consultations/1000 population during the first month following implementation (P <0.01). However, the on-going effect was not significant (P =0.69).ConclusionsOur research brings mixed findings on the effectiveness of user fee subsidisation as a strategy to increase the utilisation of services. Future work should focus on feasibility issues associated with the removal or reduction of user fees and how to sustain its effects on utilisation in the longer term.

Improving Ebola infection prevention and control in primary healthcare facilities in Sierra Leone: a single-group pretest post-test, mixed-methods study

Background Accomplishing infection prevention and control (IPC) in health facilities in Sub-Saharan Africa is challenging. Owing to poor IPC, healthcare workers (HCWs) were frequently infected during Sierra Leones Ebola epidemic. In late 2014, IPC was rapidly and nationally scaled up. We carried out workshops in sampled facilities to further improve adherence to IPC. We investigated HCW experiences and observed practice gaps, before and after the workshops. Methods We conducted an uncontrolled, before and after, mixed-methods study in eight health facilities in Bo and Kenema Districts during December 2014 and January 2015. Quantitative methods administered to HCWs at baseline and follow-up included a survey on attitudes and self-efficacy towards IPC, and structured observations of behaviours. The intervention involved a workshop for HCWs to develop improvement plans for their facility. We analysed the changes between rounds in survey responses and behaviours. We used interviews to explore attitudes and self-efficacy throughout the study period. Results HCWs described IPC as ‘life-saving’ and personal protective equipment (PPE) as uncomfortable for providers and frightening for patients. At baseline, self-efficacy was high (median=4/strongly agree). Responses reflecting unfavourable attitudes were low for glove use (median=1/strongly disagree, IQR, 1–2) and PPE use with ill family members (median=1, IQR, 1–2), and mixed for PPE use with ill HCWs (median=2/disagree, IQR, 1–4). Observations demonstrated consistent glove reuse and poor HCW handwashing. The maintenance of distance (RR 1.09, 95% CI 1.02 to 1.16) and patient handwashing (RR 1.19, 95% CI 1.3 to 1.25) improved to >90%. Conclusions We found favourable attitudes towards IPC and gaps in practice. Risk perceptions of HCWs and tendencies to ration PPE where chronic supply chain issues normally lead to PPE stock-outs may affect practice. As Sierra Leones Ebola Recovery Strategy aims to make all facilities IPC compliant, socio-behavioural improvements and a secure supply chain are essential.

Universal versus conditional day 3 follow-up for children with non-severe unclassified fever at the community level in the Democratic Republic of the Congo: A cluster-randomized, community-based non-inferiority trial

Background The World Health Organization’s integrated community case management (iCCM) guidelines recommend that all children presenting with uncomplicated fever and no danger signs return for follow-up on day 3 following the initial consultation on day 1. Such fevers often resolve rapidly, however, and previous studies suggest that expectant home care for uncomplicated fever can be safely recommended. We aimed to determine if a conditional follow-up visit was non-inferior to a universal follow-up visit for these children. Methods and findings We conducted a cluster-randomized, community-based non-inferiority trial among children 2–59 months old presenting to community health workers (CHWs) with non-severe unclassified fever in Tanganyika Province, Democratic Republic of the Congo. Clusters (n = 28) of CHWs were randomized to advise caregivers to either (1) return for a follow-up visit on day 3 following the initial consultation on day 1, regardless of illness resolution (as per current WHO guidelines; universal follow-up group) or (2) return for a follow-up visit on day 3 only if illness continued (conditional follow-up group). Children in both arms were assessed again at day 8, and classified as a clinical failure if fever (caregiver-reported), malaria, diarrhea, pneumonia, or decline of health status (development of danger signs, hospitalization, or death) was noted (failure definition 1). Alternative failure definitions were examined, whereby caregiver-reported fever was first restricted to caregiver-reported fever of at least 3 days (failure definition 2) and then replaced with fever measured via axillary temperature (failure definition 3). Study participants, providers, and investigators were not masked. Among 4,434 enrolled children, 4,141 (93.4%) met the per-protocol definition of receipt of the arm-specific advice from the CHW and a timely day 8 assessment (universal follow-up group: 2,210; conditional follow-up group: 1,931). Failure was similar (difference: –0.7%) in the conditional follow-up group (n = 188, 9.7%) compared to the universal follow-up group (n = 230, 10.4%); however, the upper bound of a 1-sided 95% confidence interval around this difference (−∞, 5.1%) exceeded the prespecified non-inferiority margin of 4.0% (non-inferiority p = 0.089). When caregiver-reported fever was restricted to fevers lasting ≥3 days, failure in the conditional follow-up group (n = 159, 8.2%) was similar to that in the universal follow-up group (n = 200, 9.1%) (difference: −0.8%; 95% CI: −∞, 4.1%; p = 0.053). If caregiver-reported fever was replaced by axillary temperature measurement in the definition of failure, failure in the conditional follow-up group (n = 113, 5.9%) was non-inferior to that in the universal follow-up group (n = 160, 7.2%) (difference: −1.4%; 95% CI: −∞, 2.5%; p = 0.012). In post hoc analysis, when the definition of failure was limited to malaria, diarrhea, pneumonia, development of danger signs, hospitalization, or death, failure in the conditional follow-up group (n = 108, 5.6%) was similar to that in the universal follow-up group (n = 147, 6.7%), and within the non-inferiority margin (95% CI: −∞, 2.9%; p = 0.017). Limitations include initial underestimation of the proportion of clinical failures as well as substantial variance in cluster-specific failure rates, reducing the precision of our estimates. In addition, heightened security concerns slowed recruitment in the final months of the study. Conclusions We found that advising caregivers to return only if children worsened or remained ill on day 3 resulted in similar rates of caregiver-reported fever and other clinical outcomes on day 8, compared to advising all caregivers to return on day 3. Policy-makers could consider revising guidelines for management of uncomplicated fever within the iCCM framework. Trial registration ClinicalTrials.gov NCT02595827

Rebuilding people-centred maternal health services in post-Ebola Liberia through participatory action research

ABSTRACT During the March 2014–January 2016 Ebola crisis in Liberia, Redemption Hospital lost 12 staff and became a holding facility for suspected cases, prompting violent hostility from the surrounding New Kru Town community, in the capital city Monrovia. Inpatient services were closed for 6 months, leaving the population without maternity care. In January 2015, Redemption reopened, but utilization was low, especially for deliveries. A key barrier was community trust in health workers which worsened during the epidemic. The New Kru Town council, Redemption Hospital, the International Rescue Committee, and Training and Research Support Centre initiated participatory action research (PAR) in July 2015 to build communication between stakeholder groups, and to identify impacts of the epidemic and shared actions to improve the system. The PAR involved pregnant women, community-based trained traditional midwives (TTMs) and traditional birth attendants (TBAs), and community leaders, as well as health workers. Qualitative data and a pre-post survey of PAR participants and community members assessed changes in relationships and maternal health services. The results indicated that Ebola worsened community-hospital relations and pre-existing weaknesses in services, but also provided an opportunity to address these when rebuilding the system through shared action. Findings suggest that PAR generated evidence and improved communication and community and health worker interaction.