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Paterson A, Olliaro PL, Rojek A. Addressing stigma in infectious disease outbreaks: a crucial step in pandemic preparedness. Front Public Health 2023; 11:1303679. [PMID: 38186713 PMCID: PMC10768929 DOI: 10.3389/fpubh.2023.1303679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 12/07/2023] [Indexed: 01/09/2024] Open
Abstract
There is a complex interplay between infectious disease outbreaks and the stigmatization of affected persons and communities. Outbreaks are prone to precipitating stigma due to the fear, uncertainty, moralisation, and abatement of freedoms associated with many infectious diseases. In turn, this stigma hampers outbreak control efforts. Understanding this relationship is crucial to improving coordinated outbreak response. This requires valid and reliable methods for assessing stigma towards and within impacted communities. We propose adopting a cross-outbreak model for developing the necessary assessment tools. A stigma-informed approach must then be integrated into outbreak preparedness and response efforts to safeguard public health and promote inclusivity and compassion in future outbreaks.
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Affiliation(s)
- Amy Paterson
- Pandemic Sciences Institute, University of Oxford, Oxford, United Kingdom
- Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Piero L. Olliaro
- Pandemic Sciences Institute, University of Oxford, Oxford, United Kingdom
| | - Amanda Rojek
- Pandemic Sciences Institute, University of Oxford, Oxford, United Kingdom
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2
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Pieterse P, Saracini F. Unsalaried health workers in Sierra Leone: a scoping review of the literature to establish their impact on healthcare delivery. Int J Equity Health 2023; 22:255. [PMID: 38066622 PMCID: PMC10709924 DOI: 10.1186/s12939-023-02066-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 11/26/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND The World Health Organisation (WHO) estimates a 10 million health worker shortage by 2030. Despite this shortage, some low-income African countries paradoxically struggle with health worker surpluses. Technically, these health workers are needed to meet the minimum health worker-population ratio, but insufficient job opportunities in the public and private sector leaves available health workers unemployed. This results in emigration and un- or underemployment, as few countries have policies or plans in place to absorb this excess capacity. Sierra Leone, Liberia and Guinea have taken a different approach; health authorities and/or public hospitals 'recruit' medical and nursing graduates on an unsalaried basis, promising eventual paid public employment. 50% Sierra Leone's health workforce is currently unsalaried. This scoping review examines the existing evidence on Sierra Leone's unsalaried health workers (UHWs) to establish what impact they have on the equitable delivery of care. METHODS A scoping review was conducted using Joanna Briggs Institute guidance. Medline, PubMed, Scopus, Web of Science were searched to identify relevant literature. Grey literature (reports) and Ministry of Health and Sanitation policy documents were also included. RESULTS 36 texts, containing UHW related data, met the inclusion criteria. The findings divide into two categories and nine sub-categories: Charging for care and medicines that should be free; Trust and mistrust; Accountability; Informal provision of care, Private practice and lack of regulation. Over-production of health workers; UHW issues within policy and strategy; Lack of personnel data undermines MoHS planning; Health sector finance. CONCLUSION Sierra Leone's example demonstrates that UHWs undermine equitable access to healthcare, if they resort to employing a range of coping strategies to survive financially, which some do. Their impact is wide ranging and will undermine Sierra Leone's efforts to achieve Universal Health Coverage if unaddressed. These findings are relevant to other LICs with similar health worker surpluses.
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Affiliation(s)
- Pieternella Pieterse
- School of Nursing, Psychotherapy and Community Health, Dublin City University, Dublin, Ireland.
| | - Federico Saracini
- School of Nursing, Psychotherapy and Community Health, Dublin City University, Dublin, Ireland
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Van Nuil JI, Schmidt-Sane M, Bowmer A, Brindle H, Chambers M, Dien R, Fricke C, Hong YNT, Kaawa-Mafigiri D, Lewycka S, Rijal S, Lees S. Conducting Social Science Research During Epidemics and Pandemics: Lessons Learnt. QUALITATIVE HEALTH RESEARCH 2023; 33:815-827. [PMID: 37403253 PMCID: PMC10323519 DOI: 10.1177/10497323231185255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/06/2023]
Abstract
The COVID-19 pandemic has had a significant impact on how field-based research is being conducted globally. Given the challenges of undertaking fieldwork during epidemics and the need for mixed methods research to address the social, political, and economic issues related to epidemics, there is a small but growing body of evidence in this area. To contribute to the logistical and ethical considerations for conducting research during a pandemic, we draw on the challenges and lessons learnt from adapting methods for two research studies conducted in 2021 during the COVID-19 pandemic in low- and middle-income country (LMIC) settings: (1) in-person research in Uganda and (2) combined remote and in-person research in South and Southeast Asia. Our case studies focus on data collection and demonstrate the feasibility of conducting mixed methods research, even with many logistical and operational constraints. Social science research is often used to identify the context of specific issues, to provide a needs assessment, or inform longer-term planning; however, these case studies have shown the need to integrate social science research from the start of a health emergency and in a systematic way. Social science research during future health emergencies can also inform public health responses during the emergency. It is also crucial to collect social science data after health emergencies to inform future pandemic preparedness. Finally, researchers need to continue research on other public health issues that are ongoing even during a public health emergency.
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Affiliation(s)
- Jennifer I. Van Nuil
- Oxford University Clinical Research Unit (OUCRU), Ho Chi Minh City, Vietnam
- Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford, UK
| | | | - Alex Bowmer
- London School of Hygiene and Tropical Medicine, London, UK
| | - Hannah Brindle
- London School of Hygiene and Tropical Medicine, London, UK
| | - Mary Chambers
- Oxford University Clinical Research Unit (OUCRU), Ho Chi Minh City, Vietnam
- Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford, UK
| | - Ragil Dien
- Eijkman Oxford Clinical Research Unit (EOCRU), Jakarta, Indonesia
| | | | - Yen Nguyen T. Hong
- Oxford University Clinical Research Unit (OUCRU), Ho Chi Minh City, Vietnam
| | | | - Sonia Lewycka
- Oxford University Clinical Research Unit (OUCRU), Ho Chi Minh City, Vietnam
- Oxford University Clinical Research Unit (OUCRU), Kathmandu, Nepal
| | - Samita Rijal
- Oxford University Clinical Research Unit (OUCRU), Kathmandu, Nepal
| | - Shelley Lees
- London School of Hygiene and Tropical Medicine, London, UK
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Arthur RF, Horng LM, Tandanpolie AF, Gilstad JR, Tantum LK, Luby SP. The lasting influence of Ebola: a qualitative study of community-level behaviors, trust, and perceptions three years after the 2014-16 Ebola epidemic in Liberia. BMC Public Health 2023; 23:682. [PMID: 37046227 PMCID: PMC10090752 DOI: 10.1186/s12889-023-15559-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 03/29/2023] [Indexed: 04/14/2023] Open
Abstract
The majority of disease transmission during the 2014-16 West Africa Ebola epidemic was driven by community-based behaviors that proved difficult to change in a social paradigm of misinformation, denial, and deep-seated distrust of government representatives and institutions. In Liberia, perceptions and beliefs about Ebola during and since the epidemic can provide insights useful to public health strategies aimed at improving community preparedness. In this 2018 study, we conducted nine focus groups with Liberians from three communities who experienced Ebola differently, to evaluate behaviors, attitudes, and trust during and after the epidemic. Focus group participants reported that some behaviors adopted during Ebola have persisted (e.g. handwashing and caretaking practices), while others have reverted (e.g. physical proximity and funeral customs); and reported ongoing distrust of the government and denial of the Ebola epidemic. These findings suggest that a lack of trust in the biomedical paradigm and government health institutions persists in Liberia. Future public health information campaigns may benefit from community engagement addressed at understanding beliefs and sources of trust and mistrust in the community to effect behavior change and improve community-level epidemic preparedness.
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Affiliation(s)
- Ronan F Arthur
- School of Medicine, Stanford University, Stanford, California, USA.
| | - Lily M Horng
- School of Medicine, Stanford University, Stanford, California, USA
| | | | - John R Gilstad
- School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Lucy K Tantum
- School of Medicine, Stanford University, Stanford, California, USA
| | - Stephen P Luby
- School of Medicine, Stanford University, Stanford, California, USA
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Liu S, Zhu J, Liu Y, Wilbanks D, Jackson JC, Mu Y. Perception of strong social norms during the COVID-19 pandemic is linked to positive psychological outcomes. BMC Public Health 2022; 22:1403. [PMID: 35869459 PMCID: PMC9305059 DOI: 10.1186/s12889-022-13744-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 06/27/2022] [Indexed: 11/10/2022] Open
Abstract
Social norms can coordinate individuals and groups during collective threats. Pandemic-related social norms (e.g., wearing masks, social distancing) emerged to curb the spread of COVID-19. However, little is known about the psychological consequences of the emerging norms. We conducted three experiments cross-culturally, during the early period of the COVID-19 pandemic in China (Study 1), the recovery period in China (Study 2), and the severe period in the United States and Canada (Study 3). Across the three studies, we first distinguished the opposite effects of social norms and risk perception on individuals’ psychological characteristics during the COVID-19 pandemic and further revealed that individuals who perceived stronger pandemic norms reported a lower level of COVID-19 risk perception, which in turn would be associated with fewer negative emotions, lower pressure, more positive emotions, higher levels of trusts, and more confidence in fighting against COVID-19. Our findings show that perceived tighter social norms are linked to beneficial psychological outcomes. This research helps governments, institutions, and individuals understand the mechanism and benefits of social norms during the pandemic, thereby facilitating policy formulation and better responses to social crises.
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Davidson MC, Lu S, Barrie MB, Freeman A, Mbayoh M, Kamara M, Tsai AC, Crea T, Rutherford GW, Weiser SD, Kelly JD. A post-outbreak assessment of exposure proximity and Ebola virus disease-related stigma among community members in Kono District, Sierra Leone: A cross-sectional study. SSM - MENTAL HEALTH 2022; 2:100064. [PMID: 35449727 PMCID: PMC9017820 DOI: 10.1016/j.ssmmh.2022.100064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background Based on findings from other contexts, informed by intergroup contact theory, that more contact is associated with less stigma, we hypothesized that community members with greater exposure to cases of Ebola virus disease (EVD) were less likely to report EVD-related stigma towards EVD survivors. We assessed personal stigmatizing attitudes towards Ebola survivors, which reflects personal fear and judgement, as well as perceived stigma towards EVD survivors, which reflects an individual's perception of the attitudes of the community towards a stigmatized group. Methods From September 2016 to July 2017, we conducted a cross-sectional, community-based study of EVD-related stigma among individuals who did not contract Ebola in four EVD-affected rural communities of Kono District, Sierra Leone. We identified individuals from all quarantined households and obtained a random sample of those who were unexposed. Exposed individuals either lived in a quarantined household or were reported to have been in contact with an EVD case. Our explanatory variable was proximity to an EVD case during the outbreak. Our primary outcome was stigma towards EVD survivors, measured by a 6-item adapted HIV-related stigma index validated in Zambia and South Africa, with 1 item reflecting personal stigmatizing attitudes and 5 items reflecting perceived community stigma. The 6-item EVD stigma index had good internal consistency (Cronbach's alpha=0.82). We used modified Poisson and negative binomial regression models, adjusting for potential confounders, to estimate the association between exposure proximity and EVD stigma. Results We interviewed 538 participants aged 12 to 85 years. Most (57%) had been quarantined. Over one-third (39%) reported personal stigmatizing attitudes or perceived community stigma; the most frequently endorsed item was fear and judgment towards EVD survivors. Having contact with someone with EVD was significantly associated with a lower likelihood of perceived community stigma (prevalence ratio [PR], 0.26; 95% CI, 0.13-0.54) and personal stigmatizing attitudes (PR, 0.44; 95% CI, 0.29-0.65). In contrast, being quarantined was significantly associated with a higher likelihood of perceived community stigma (PR, 3.9; 95% CI, 1.5-10.1). Conclusions In this cross-sectional study, we found evidence of an inverse relationship between EVD-related stigma and contact with an EVD case. This finding substantiates intergroup contact theory and may form the basis for anti-stigma interventions.
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Affiliation(s)
| | - Scott Lu
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
- Institute for Global Health Sciences, University of California, San Francisco, CA, USA
| | - M. Bailor Barrie
- Institute for Global Health Sciences, University of California, San Francisco, CA, USA
- Partners In Health, Freetown, Sierra Leone
| | | | | | | | - Alexander C. Tsai
- Center for Global Health and Mongan Institute, Massachusetts General Hospital, Boston, MA, USA
| | - Thomas Crea
- School of Social Work, Boston College, Boston, MA, USA
| | - George W. Rutherford
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
- Institute for Global Health Sciences, University of California, San Francisco, CA, USA
| | - Sheri D. Weiser
- Division of HIV, Infectious Disease, and Global Medicine, Department of Medicine, University of California, San Francisco, CA, USA
| | - J. Daniel Kelly
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
- Institute for Global Health Sciences, University of California, San Francisco, CA, USA
- F.I. Proctor Foundation, University of California, San Francisco, CA, USA
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Umer H. Does pro-sociality or trust better predict staying home behavior during the Covid-19? JOURNAL OF BEHAVIORAL AND EXPERIMENTAL ECONOMICS 2022; 100:101926. [PMID: 35975104 PMCID: PMC9372020 DOI: 10.1016/j.socec.2022.101926] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 06/25/2022] [Accepted: 08/09/2022] [Indexed: 06/15/2023]
Abstract
Voluntary compliance of preventive and mitigation measures due to social concerns can play a crucial role in slowing down the spread of the Covid-19. The existing economic models for disease spread however do not direct a lot of focus on the possible role of pro-social behavior and general trust in predicting preventive behaviors amid the Covid-19. Therefore, this study analyzes whether pro-sociality and general trust measured in the short run (2020 and 2019) and in the long run (2015 and 2010) predict attitudes towards the stay home behavior and the intended stay home behavior in case the government mandates it due to the Covid-19 in the Netherlands. The results suggest that these preferences positively influence attitudes towards staying home behavior. However, trust in comparison to pro-sociality is a stable and robust predictor of stay home attitudes both in the short as well as long run. On the other hand, neither trust nor pro-sociality influences the intended stay home behavior in case the government mandates the lockdown, and it is most likely due to the timing of the survey coinciding with a significant drop in the Covid-19 infections and easing out of the lockdown restrictions by the Dutch government.
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Affiliation(s)
- Hamza Umer
- Institute of Economic Research (IER), Hitotsubashi University, Tokyo, Japan
- International Research Fellow, Japan Society for the Promotion of Science (JSPS), Tokyo, Japan
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Kokou-Kpolou CK, Derivois D, Rousseau C, Balayulu-Makila O, Hajizadeh S, Birangui JP, Guerrier M, Bukaka J, Cénat JM. Enacted Ebola Stigma and Health-related Quality of Life in Post Ebola Epidemic: A Psychosocial Mediation Framework Through Social Support, Self-Efficacy, and Coping. APPLIED RESEARCH IN QUALITY OF LIFE 2022; 17:2809-2832. [PMID: 35966804 PMCID: PMC9362404 DOI: 10.1007/s11482-022-10039-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 12/08/2021] [Accepted: 01/24/2022] [Indexed: 05/31/2023]
Abstract
On-site experiences and reports have shown that the multiple outbreaks of Ebola virus disease (EVD) in the Democratic Republic of the Congo (DRC) resulted in pervasive experience of stigma against many people who have recovered from EVD as well as their families and close relatives. Three evidence-based protective factors which are supposed to mitigate the impact of enacted Ebola stigma on health-related quality of life (HRQoL) of individuals in this epidemic context were identified. We expected that positive religious coping, perceived social support, and general self-efficacy would mediate the relationship between enacted Ebola stigma and HRQoL. These hypotheses were tested through multiple mediation model using the structural equation modeling among a large sample of adult populations (N = 1614; 50% women) in the province of Equateur in the DRC, in the aftermath of the 9th Ebola outbreak. The mediation model yielded adequate fit statistics and the results provided strong evidence that higher levels of enacted Ebola stigma were associated with lower HRQoL. They confirmed the synergetic mediating effects of positive religious coping, perceived social support from family (but not from others sources) and general self-efficacy. Futher exploratory findings revealed that the perceived social support from family buffered the impact of enacted Ebola stigma on HRQoL. If replicated by a longitudinal study, our findings lay a solid foundation for empirical-based community mental health interventions for reducing enacted Ebola stigma and promoting HRQoL during epidemics, especially in the DRC.
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Affiliation(s)
- Cyrille Kossigan Kokou-Kpolou
- School of Psychology, University of Ottawa, 136 Jean-Jacques-Lussier 5045, Vanier Hall, K1N 6N5 Ottawa, Ontario Canada
- School of Psychology, Laval University, Pavillon Félix-Antoine-Savard ; 2325, rue des Bibliothèques, G1V 0A6, Québec, Canada
| | - Daniel Derivois
- Laboratory of Psychology Psy-DREPI, Université Bourgogne Franche Comté, 7458 Dijon, EA France
| | - Cécile Rousseau
- Division of Social and Transcultural Psychiatry, McGill University, Montreal, Canada
| | - Oléa Balayulu-Makila
- Laboratory of Psychology Psy-DREPI, Université Bourgogne Franche Comté, 7458 Dijon, EA France
- Department of psychology, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Saba Hajizadeh
- School of Psychology, University of Ottawa, 136 Jean-Jacques-Lussier 5045, Vanier Hall, K1N 6N5 Ottawa, Ontario Canada
| | - Jean-Pierre Birangui
- Department of psychology, University of Lubumbashi, Lubumbashi, Democratic Republic of Congo
| | - Mireille Guerrier
- School of Psychology, University of Ottawa, 136 Jean-Jacques-Lussier 5045, Vanier Hall, K1N 6N5 Ottawa, Ontario Canada
| | - Jacqueline Bukaka
- Department of psychology, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Jude Mary Cénat
- School of Psychology, University of Ottawa, 136 Jean-Jacques-Lussier 5045, Vanier Hall, K1N 6N5 Ottawa, Ontario Canada
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Anantharam P, Hoffman A, Noonan M, Bugli D, Pechta L, Bornemann J, Victory KR, Greiner AL. Addressing Operational Challenges Faced by COVID-19 Public Health Rapid Response Teams in Non-United States Settings. Disaster Med Public Health Prep 2022; 16:1599-1603. [PMID: 33719992 PMCID: PMC7985625 DOI: 10.1017/dmp.2020.487] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 10/28/2020] [Accepted: 11/24/2020] [Indexed: 11/08/2022]
Abstract
The coronavirus disease 2019 (COVID-19) global response underscores the need for a multidisciplinary approach that integrates and coordinates various public health systems-surveillance, laboratory, and health-care systems/networks, among others-as part of a larger emergency response system. Multidisciplinary public health rapid response teams (RRTs) are one mechanism used within a larger COVID-19 outbreak response strategy. As COVID-19 RRTs are deployed, countries are facing operational challenges in optimizing their RRT's impact, while ensuring the safety of their RRT responders. From March to May 2020, United States Centers for Disease Control and Prevention received requests from 12 countries for technical assistance related to COVID-19 RRTs and emergency operations support. Challenges included: (1) an insufficient number of RRT responders available for COVID-19 deployments; (2) limited capacity to monitor RRT responders' health, safety, and resiliency; (3) difficulty converting critical in-person RRT operational processes to remote information technology platforms; and (4) stigmatization of RRT responders hindering COVID-19 interventions. Although geographically and socioeconomically diverse, these 12 countries experienced similar RRT operational challenges, indicating potential applicability to other countries. As the response has highlighted the critical need for immediate and effective implementation measures, addressing these challenges is essential to ensuring an impactful and sustainable COVID-19 response strategy globally.
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Affiliation(s)
- Puneet Anantharam
- Centers for Disease Control and Prevention, Division of Global Health Protection, Emergency Response and Recovery Branch, Atlanta, Georgia, USA
| | - Adela Hoffman
- Centers for Disease Control and Prevention, Division of Global Health Protection, Emergency Response and Recovery Branch, Atlanta, Georgia, USA
| | - Michelle Noonan
- Centers for Disease Control and Prevention, Office of the Chief Operating Officer, Office of Safety, Security & Asset Management, Atlanta, Georgia, USA
| | - Dante Bugli
- Centers for Disease Control and Prevention, Division of Global Health Protection, Emergency Response and Recovery Branch, Atlanta, Georgia, USA
| | - Laura Pechta
- Centers for Disease Control and Prevention, Division of Global Health Protection, Office of the Director, Atlanta, Georgia, USA
| | - Jennifer Bornemann
- Centers for Disease Control and Prevention, Office of the Chief Operating Officer, Office of Safety, Security & Asset Management, Atlanta, Georgia, USA
| | - Kerton R. Victory
- Centers for Disease Control and Prevention, Division of Global Health Protection, Emergency Response and Recovery Branch, Atlanta, Georgia, USA
| | - Ashley L. Greiner
- Centers for Disease Control and Prevention, Division of Global Health Protection, Emergency Response and Recovery Branch, Atlanta, Georgia, USA
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Musaazi J, Namageyo-Funa A, Carter VM, Carter RJ, Lamorde M, Apondi R, Bakyaita T, Boore AL, Brown VR, Homsy J, Kigozi J, Koyuncu A, Nabaggala MS, Nakate V, Nkurunziza E, Stowell DF, Walwema R, Olowo A, Jalloh MF. Evaluation of Community Perceptions and Prevention Practices Related to Ebola Virus as Part of Outbreak Preparedness in Uganda, 2020. GLOBAL HEALTH: SCIENCE AND PRACTICE 2022; 10:GHSP-D-21-00661. [PMCID: PMC9242603 DOI: 10.9745/ghsp-d-21-00661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Accepted: 03/29/2022] [Indexed: 11/15/2022]
Abstract
Targeted risk communication and community engagement strategies to raise Ebola virus disease awareness and knowledge, particularly in setting where risk of infection is perceived to be low, may not be sufficient to motivate people to adopt protective behaviors and prevention practices. Introduction: During the 2018–2020 Ebola virus disease (EVD) outbreak in the Democratic Republic of the Congo, risk communication and community engagement (RCCE) were prioritized in geographic areas in Uganda considered at high risk of introduction of EVD. To inform EVD preparedness in Uganda, we evaluated community perceptions and prevention practices related to EVD in 6 districts in Uganda. Methods: In March 2020, we conducted a population-based survey in 6 purposively selected districts in Uganda using multistage cluster sampling. We examined differences between districts classified as high- versus low risk for EVD in terms of their message exposure from RCCE; risk perception; and EVD knowledge, attitudes, and prevention practices. Results: A total of 3,485 respondents were interviewed (91% response rate). EVD message exposure was more common in the high- versus low-risk districts. EVD risk perceptions were low overall but greater in the high- versus low-risk districts. Comprehensive knowledge was significantly greater in the high- versus low-risk districts (adjusted prevalence ratio [aPR] 1.61, 95% confidence interval [CI]=1.35, 1.93). Respondents' engagement in all 3 EVD prevention practices (frequent handwashing with soap, avoiding physical contact with suspected Ebola patients, and avoiding burials involving contact with a corpse) was very low (4%). However, respondents with comprehensive knowledge were more likely to engage in all 3 EVD prevention practices compared to respondents without comprehensive knowledge (aPR 1.87, 95% CI=1.08, 3.25). Conclusion: Our findings suggest that while RCCE efforts as part of EVD outbreak preparedness may have contributed to higher EVD knowledge in the targeted high-risk districts, uptake of prevention behaviors was similarly low across districts. In a non-outbreak setting, implementing targeted RCCE strategies may not be sufficient to motivate people to adopt protective behaviors in the absence of a high threshold of perceived threat such as in an active outbreak.
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Affiliation(s)
- Joseph Musaazi
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- Correspondence to Joseph Musaazi ()
| | - Apophia Namageyo-Funa
- Center for Global Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Victoria M. Carter
- National Center for Emerging and Zoonotic Infectious Diseases, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Rosalind J. Carter
- Center for Global Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Mohammed Lamorde
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Rose Apondi
- Center for Global Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Amy L. Boore
- Center for Global Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Vance R. Brown
- Center for Global Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Jaco Homsy
- Center for Global Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
- Institute for Global Health Sciences, University of California San Francisco, California, USA
| | - Joanita Kigozi
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Aybüke Koyuncu
- Center for Global Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Maria Sarah Nabaggala
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Vivian Nakate
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Emmanuel Nkurunziza
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Daniel F. Stowell
- Center for Global Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Richard Walwema
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Apollo Olowo
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Mohamed F. Jalloh
- Center for Global Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
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11
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Corona was scary, lockdown was worse: A mixed-methods study of community perceptions on COVID-19 from urban informal settlements of Mumbai. PLoS One 2022; 17:e0268133. [PMID: 35522676 PMCID: PMC9075633 DOI: 10.1371/journal.pone.0268133] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 04/23/2022] [Indexed: 11/19/2022] Open
Abstract
The COVID-19 pandemic has magnified the multiple vulnerabilities of people living in urban informal settlements globally. To bring community voices from such settlements to the center of COVID-19 response strategies, we undertook a study in the urban informal settlements of Dharavi, Mumbai, from September 2020-April 2021. In this study, we have examined the awareness, attitudes, reported practices, and some broader experiences of the community in Dharavi with respect to COVID-19. We have used a mixed-methods approach, that included a cross-sectional survey of 468 people, and in-depth interviews and focus group discussions with 49 people living in this area. Data was collected via a mix of phone and face-to-face interviews. We have presented here the descriptive statistics from the survey and the key themes that emerged from our qualitative data. People reported high levels of knowledge about COVID-19, with television (90%), family and friends (56%), and social media (47%) being the main sources of information. The knowledge people had, however, was not free of misconceptions and fear; people were scared of being forcefully quarantined and dying alone during the early days of COVID-19. These fears had negative repercussions in the form of patient-related stigma and hesitancy in seeking healthcare. A year into the pandemic, however, people reported a shift in attitudes from ‘extreme fear to low fear’ (67% reported perceiving low/no COVID risk in October 2020), contributing to a general laxity in following COVID-appropriate behaviors. Currently, the community is immensely concerned about the revival of livelihoods, that have been adversely impacted due to the lockdown in 2020 as well as the continued ‘othering’ of Dharavi for being a COVID hotspot. These findings suggest that urban informal settlements like Dharavi need community-level messaging that counters misinformation and denial of the outbreak; local reinforcement of COVID-appropriate behaviours; and long-term social protection measures.
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Misconceptions and Rumors about Ebola Virus Disease in Sub-Saharan Africa: A Systematic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19084714. [PMID: 35457585 PMCID: PMC9027331 DOI: 10.3390/ijerph19084714] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 04/10/2022] [Accepted: 04/11/2022] [Indexed: 02/01/2023]
Abstract
We sought to summarize knowledge, misconceptions, beliefs, and practices about Ebola that might impede the control of Ebola outbreaks in Africa. We searched Medline, EMBASE, CINAHL, and Google Scholar (through May 2019) for publications reporting on knowledge, attitudes, and practices (KAP) related to Ebola in Africa. In total, 14 of 433 articles were included. Knowledge was evaluated in all 14 articles, and they all highlighted that there are misconceptions and risk behaviors during an Ebola outbreak. Some communities believed that Ebola spreads through the air, mosquito bites, malice from foreign doctors, witchcraft, and houseflies. Because patients believe that Ebola was caused by witchcraft, they sought help from traditional healers. Some people believed that Ebola could be prevented by bathing with salt or hot water. Burial practices where people touch Ebola-infected corpses were common, especially among Muslims. Discriminatory attitudes towards Ebola survivors or their families were also prevalent. Some Ebola survivors were not accepted back in their communities; the possibility of being ostracized from their neighborhoods was high and Ebola survivors had to lead a difficult social life. Most communities affected by Ebola need more comprehensive knowledge on Ebola. Efforts are needed to address misconceptions and risk behaviors surrounding Ebola for future outbreak preparedness in Africa.
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"On the last day of the last month, I will go": A qualitative exploration of COVID-19 vaccine confidence among Ivoirian adults. Vaccine 2022; 40:2028-2035. [PMID: 35181151 PMCID: PMC8831134 DOI: 10.1016/j.vaccine.2022.02.032] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 12/01/2021] [Accepted: 02/06/2022] [Indexed: 12/02/2022]
Abstract
The authorization of several high-efficacy vaccines for use against the novel SARS-CoV2 virus signals a transition in the global COVID-19 response. Vaccine acceptance is critical for pandemic control and has a variety of context- specific drivers that operate at the individual, group, and sociopolitical levels. Social and behavior change interventions can influence individual knowledge, attitudes, and intentions as well as community norms to facilitate widespread vaccine uptake. While considerable research has been done to explore vaccine confidence in high-income populations as well as with respect to childhood vaccinations, much work remains to be done in understanding attitudes and intentions in low and middle income countries for adult or novel vaccines. We conducted in-depth interviews with individuals who had recovered from COVID-19 (n = 8), people who had lost a family member to COVID-19 (n = 4), and health providers (n = 17). We also conducted focus group discussions with members of the general population (n = 24 groups) to explore social norms and community perceptions related to COVID-19, including prevention behaviors, stigma, and vaccines. Researchers collected data in Abidjan, Côte d’Ivoire, in November 2020. In considering whether to accept a future COVID-19 vaccine or not, individuals in the study weighed perceived risk of the vaccine against the severity of the disease. Perceived severity of rumored side effects or safety issues of vaccines were also a factor. Convenience was a secondary, albeit also important, consideration. While concerns about vaccine safety tended to produce an expressed intention to delay vaccination, conspiracy theories about those developing and promoting vaccines and their motives led people to say they would opt out entirely. Behavior change interventions must raise awareness and address misunderstandings about the purpose of vaccines, transparently communicate about vaccine safety and development processes, and engage trusted influencers to build an enabling environment for COVID-19 vaccine roll out.
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Yuan H, Long Q, Huang G, Huang L, Luo S. Different roles of interpersonal trust and institutional trust in COVID-19 pandemic control. Soc Sci Med 2022; 293:114677. [PMID: 35101260 PMCID: PMC8692240 DOI: 10.1016/j.socscimed.2021.114677] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 12/14/2021] [Accepted: 12/20/2021] [Indexed: 12/18/2022]
Abstract
The absence of pharmaceutical interventions made it particularly difficult to mitigate the first outbreak of coronavirus disease 2019 (COVID-19). The current study investigated how interpersonal trust and institutional trust influenced the control process. Trusts and COVID-19 data in 44 countries and 50 US states were analyzed; institutional trust was associated with case fatality rate, and interpersonal trust was associated with control speed. Two independent behavioral experiments showed that institutional trust manipulation increased participants’ willingness to complete the COVID-19 test and that interpersonal trust manipulation increased conscious compliance with prevention norms and decreased unnecessary outdoor activities. Agent-based modeling further confirmed these behavioral mechanisms for two types of trust in the COVID-19 control process. New interventions are needed to help countries heighten interpersonal and institutional trust as they continue to battle COVID-19 and other collective threats.
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Affiliation(s)
- Hang Yuan
- Department of Psychology, Guangdong Provincial Key Laboratory of Social Cognitive Neuroscience and Mental Health, Guangdong Provincial Key Laboratory of Brain Function and Disease, Sun Yat-Sen University, Guangzhou 510006, China
| | - Qinyi Long
- Department of Psychology, Guangdong Provincial Key Laboratory of Social Cognitive Neuroscience and Mental Health, Guangdong Provincial Key Laboratory of Brain Function and Disease, Sun Yat-Sen University, Guangzhou 510006, China
| | - Guanglv Huang
- Department of Psychology, Guangdong Provincial Key Laboratory of Social Cognitive Neuroscience and Mental Health, Guangdong Provincial Key Laboratory of Brain Function and Disease, Sun Yat-Sen University, Guangzhou 510006, China
| | - Liqin Huang
- Department of Psychology, Guangdong Provincial Key Laboratory of Social Cognitive Neuroscience and Mental Health, Guangdong Provincial Key Laboratory of Brain Function and Disease, Sun Yat-Sen University, Guangzhou 510006, China
| | - Siyang Luo
- Department of Psychology, Guangdong Provincial Key Laboratory of Social Cognitive Neuroscience and Mental Health, Guangdong Provincial Key Laboratory of Brain Function and Disease, Sun Yat-Sen University, Guangzhou 510006, China.
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Lieberman Lawry L, Stroupe Kannappan N, Canteli C, Clemmer W. Cross-sectional study of mental health and sexual behaviours for Ebola Survivors in Beni, Butembo and Katwa health zones of the Democratic Republic of Congo. BMJ Open 2022; 12:e052306. [PMID: 35110316 PMCID: PMC8811576 DOI: 10.1136/bmjopen-2021-052306] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES To understand the prevalence of mental health disorders in Ebola-affected communities and their association with condom use. DESIGN Cross-sectional study. SETTING Beni, Butembo and Katwa health zones, Democratic Republic of Congo (DRC). PARTICIPANTS 223 adult Ebola survivors, 102 sexual partners and 74 comparison respondents. PRIMARY AND SECONDARY OUTCOME MEASURES Post-traumatic stress disorder (PTSD), depression, anxiety, substance use, suicidal ideation and attempts, stigma, condom use and sexual behaviour. RESULTS Most respondents reported to be married, Christian, from the Nande ethnic group, and farmers/herders. Survivors met symptom criteria for depression at higher rates than partners (23.5% (95% CI 18.0 to 29.1) vs 5.7 (1.2 to 10.1); p<0.001). PTSD symptom criteria for survivors (24.1%, 95% CI 18.5% to 29.7%) and partners (16.7%, 95% CI 9.4% to 23.9%) were four times greater than the comparison participants (6.0%, 95% CI 0.6% to 11.4%). Two times as many survivors as partners reported that sexual activity precautions were discussed at discharge (71.5% (95% CI 65.6 to 77.5) vs 36.2% (95% CI 26.9 to 45.5); p<0.001). The majority of survivors (95.0 (95% CI 85.1% to 98.5%) and partners 98.5% (95% CI 89.6% to 99.8%; p=0.26) participated in risky sexual behaviour after the survivor left the Ebola treatment centre. The ability to refuse sex or insist on condom use before Ebola had a threefold increase in the odds of condom use (adjusted OR 3.3, 95% CI 1.7 to 6.1, p<0.001). Up to 36% of the comparison group held discriminatory views of survivors. CONCLUSIONS The new outbreaks in both Guinea and DRC show Ebola remains in semen longer than previously known. Understanding and addressing condom non-use and updating condom use guidelines are necessary to protect against future Ebola outbreaks, especially among sexual partners who did not have similar access to health information regarding sexual transmission of Ebola. Mental health treatment and decreasing stigma in Ebola areas is a priority.
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Affiliation(s)
- Lynn Lieberman Lawry
- Preventive Medicine and Biostatistics, Uniformed Services University, Bethesda, Maryland, USA
| | | | | | - William Clemmer
- Health, IMA World Health, Goma, Democratic Republic of the Congo
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Arthur RF, Horng LM, Bolay FK, Tandanpolie A, Gilstad JR, Tantum LK, Luby SP. Community trust of government and non-governmental organizations during the 2014-16 Ebola epidemic in Liberia. PLoS Negl Trop Dis 2022; 16:e0010083. [PMID: 35085236 PMCID: PMC8824372 DOI: 10.1371/journal.pntd.0010083] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 02/08/2022] [Accepted: 12/11/2021] [Indexed: 01/08/2023] Open
Abstract
The West African Ebola Virus Disease epidemic of 2014-16 cost more than 11,000 lives. Interventions targeting key behaviors to curb transmission, such as safe funeral practices and reporting and isolating the ill, were initially unsuccessful in a climate of fear, mistrust, and denial. Building trust was eventually recognized as essential to epidemic response and prioritized, and trust was seen to improve toward the end of the epidemic as incidence fell. However, little is understood about how and why trust changed during Ebola, what factors were most influential to community trust, and how different institutions might have been perceived under different levels of exposure to the outbreak. In this large-N household survey conducted in Liberia in 2018, we measured self-reported trust over time retrospectively in three different communities with different exposures to Ebola. We found trust was consistently higher for non-governmental organizations than for the government of Liberia across all time periods. Trust reportedly decreased significantly from the start to the peak of the epidemic in the study site of highest Ebola incidence. This finding, in combination with a negative association found between knowing someone infected and trust of both iNGOs and the government, indicates the experience of Ebola may have itself caused a decline of trust in the community. These results suggest that national governments should aim to establish trust when engaging communities to change behavior during epidemics. Further research on the relationship between trust and epidemics may serve to improve epidemic response efficacy and behavior uptake.
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Affiliation(s)
- Ronan F. Arthur
- School of Medicine, Stanford University, Stanford, California, United States of America
- * E-mail:
| | - Lily M. Horng
- School of Medicine, Stanford University, Stanford, California, United States of America
| | | | | | - John R. Gilstad
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, United States of America
| | - Lucy K. Tantum
- School of Medicine, Stanford University, Stanford, California, United States of America
| | - Stephen P. Luby
- School of Medicine, Stanford University, Stanford, California, United States of America
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Cénat JM, Rousseau C, Bukaka J, Dalexis RD, Guerrier M. Severe Anxiety and PTSD Symptoms Among Ebola Virus Disease Survivors and Healthcare Workers in the Context of the COVID-19 Pandemic in Eastern DR Congo. Front Psychiatry 2022; 13:767656. [PMID: 35599776 PMCID: PMC9120641 DOI: 10.3389/fpsyt.2022.767656] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 04/01/2022] [Indexed: 11/13/2022] Open
Abstract
Ebola virus disease (EVD) survivors and healthcare workers (HCWs) face stress, fear, and stigma during the COVID-19 pandemic that can induce severe symptoms of anxiety and post-traumatic stress disorder (PTSD). We examined the prevalence and factors related to severe PTSD and anxiety symptoms, using a representative sample of survivors of the 2018-2020 EVD epidemic in DR Congo in comparison HCWs. Five hundred sixty-three participants (55.25% women, 309 survivors, 202 HCWs, and 52 HCWs and survivors) completed questionnaires assessing anxiety, PTSD, exposure to EVD and COVID-19, stigmatization related to EVD and COVID-19, interpersonal traumas, social support. During the COVID-19 pandemic, 45.6 and 75.0% of survivors and HCWs reported severe symptoms of PTSD and anxiety. Significant difference was observed among the three groups for both PTSD (53.7% survivors, 37.1% HCWs, and 30.8% HCWs-survivors, χ2= 18.67, p < 0.0001) and anxiety (88.3% survivors, 56.9% HCWs, and 65.4% HCWs- survivors, χ2= 67.03, p < 0.0001). Comorbidity of severe PTSD and anxiety symptoms was 42.3% between the three groups. Results revealed that exposure to EVD (b = 0.53; p = 0.001; b = 0.12; p = 0.042), EVD-related stigmatization (b = 0.14; p = 0.018; b = 0.07; p = 0.006), COVID-19-related stigmatization (b = 0.22; p < 0.0001; b = 0.08; p = 0.0001) and social support (b = -0.30; p < 0.0001; b = -0.14; p < 0.0001) predicted severe PTSD and anxiety symptoms. The last models explained 63.8 and 56.4% of the variance of PTSD and anxiety. Symptoms of PTSD and anxiety are common among EVD survivors and HCWs during the COVID-19 pandemic. Culturally-sensitive programs that address stigma are necessary to mitigate the cumulative effects of EVD and the COVID-19 pandemic on EVD survivors and HCWs.
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Affiliation(s)
- Jude Mary Cénat
- School of Psychology, University of Ottawa, Ottawa, ON, Canada
| | - Cécile Rousseau
- Division of Social and Transcultural Psychiatry, McGill University, Montreal, QC, Canada
| | - Jacqueline Bukaka
- Department of Psychology, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Rose Darly Dalexis
- Interdisciplinary School of Health Sciences, University of Ottawa, Ottawa, ON, Canada
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Kalam A, Shano S, Khan MA, Islam A, Warren N, Hassan MM, Davis M. Understanding the social drivers of antibiotic use during COVID-19 in Bangladesh: Implications for reduction of antimicrobial resistance. PLoS One 2021; 16:e0261368. [PMID: 34905563 PMCID: PMC8670684 DOI: 10.1371/journal.pone.0261368] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 11/29/2021] [Indexed: 12/13/2022] Open
Abstract
Antimicrobial resistance (AMR) is a global public health crisis that is now impacted by the COVID-19 pandemic. Little is known how COVID-19 risks influence people to consume antibiotics, particularly in contexts like Bangladesh where these pharmaceuticals can be purchased without a prescription. This paper identifies the social drivers of antibiotics use among home-based patients who have tested positive with SARS-CoV-2 or have COVID-19-like symptoms. Using qualitative telephone interviews, the research was conducted in two Bangladesh cities with 40 participants who reported that they had tested positive for coronavirus (n = 20) or had COVID-19-like symptoms (n = 20). Our analysis identified five themes in antibiotic use narratives: antibiotics as 'big' medicine; managing anxiety; dealing with social repercussions of COVID-19 infection; lack of access to COVID-19 testing and healthcare services; and informal sources of treatment advice. Antibiotics were seen to solve physical and social aspects of COVID-19 infection, with urgent ramifications for AMR in Bangladesh and more general implications for global efforts to mitigate AMR.
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Affiliation(s)
- Abul Kalam
- Bangladesh Country Office, Helen Keller International, Dhaka, Bangladesh
| | - Shahanaj Shano
- Institute of Epidemiology, Disease Control and Research (IEDCR), Dhaka, Bangladesh
- EcoHealth Alliance, New York, New York, United States of America
| | | | - Ariful Islam
- EcoHealth Alliance, New York, New York, United States of America
| | - Narelle Warren
- School of Social and Political Sciences, Monash University, Melbourne, Victoria, Australia
| | | | - Mark Davis
- School of Social and Political Sciences, Monash University, Melbourne, Victoria, Australia
- Centre to Impact Antimicrobial Resistance, Monash University, Melbourne, Victoria, Australia
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Bitanihirwe B, Ssewanyana D, Ddumba-Nyanzi I. Pacing Forward in the Face of Fragility: Lessons From African Institutions and Governments' Response to Public Health Emergencies. Front Public Health 2021; 9:714812. [PMID: 34900886 PMCID: PMC8655676 DOI: 10.3389/fpubh.2021.714812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 10/25/2021] [Indexed: 11/21/2022] Open
Abstract
Africa is home to 54 United Nation member states, each possessing a wealth of ethno-cultural, physiographic, and economic diversity. While Africa is credited as having the youngest population in the world, it also exhibits a unique set of “unfortunate realties” ranging from famine and poverty to volatile politics, conflicts, and diseases. These unfortunate realities all converge around social inequalities in health, that are compounded by fragile healthcare systems and a lack of political will by the continent's leaders to improve smart investment and infrastructure planning for the benefit of its people. Noteworthy are the disparities in responsive approaches to crises and emergencies that exist across African governments and institutions. In this context, the present article draws attention to 3 distinct public health emergencies (PHEs) that have occurred in Africa since 2010. We focus on the 2013–2016 Ebola outbreak in Western Africa, the ongoing COVID-19 pandemic which continues to spread throughout the continent, and the destructive locust swarms that ravaged crops across East Africa in 2020. Our aim is to provide an integrated perspective on how governments and institutions handled these PHEs and how scientific and technological innovation, along with educational response played a role in the decision-making process. We conclude by touching on public health policies and strategies to address the development of sustainable health care systems with the potential to improve the health and well-being of the African people.
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Affiliation(s)
- Byron Bitanihirwe
- Humanitarian and Conflict Response Institute, University of Manchester, Manchester, United Kingdom
| | - Derrick Ssewanyana
- Alliance for Health Development, Lunenfeld-Tanenbaum Research Institute, Toronto, ON, Canada
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20
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Wawrzuta D, Jaworski M, Gotlib J, Panczyk M. Social Media Sharing of Articles About Measles in a European Context: Text Analysis Study. J Med Internet Res 2021; 23:e30150. [PMID: 34570715 PMCID: PMC8663483 DOI: 10.2196/30150] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 07/17/2021] [Accepted: 08/12/2021] [Indexed: 11/13/2022] Open
Abstract
Background Despite the existence of an effective vaccine, measles still threatens the health and lives of many Europeans. Notably, during the COVID-19 pandemic, measles vaccine uptake declined; as a result, after the pandemic, European countries will have to increase vaccination rates to restore the extent of vaccination coverage among the population. Because information obtained from social media are one of the main causes of vaccine hesitancy, knowledge of the nature of information pertaining to measles that is shared on social media may help create educational campaigns. Objective In this study, we aim to define the characteristics of European news about measles shared on social media platforms (ie, Facebook, Twitter, and Pinterest) from 2017 to 2019. Methods We downloaded and translated (into English) 10,305 articles on measles published in European Union countries. Using latent Dirichlet allocation, we identified main topics and estimated the sentiments expressed in these articles. Furthermore, we used linear regression to determine factors related to the number of times a given article was shared on social media. Results We found that, in most European social media posts, measles is only discussed in the context of local European events. Articles containing educational information and describing world outbreaks appeared less frequently. The most common emotions identified from the study’s news data set were fear and trust. Yet, it was found that readers were more likely to share information on educational topics and the situation in Germany, Ukraine, Italy, and Samoa. A high amount of anger, joy, and sadness expressed within the text was also associated with a higher number of shares. Conclusions We identified which features of news articles were related to increased social media shares. We found that social media users prefer sharing educational news to sharing informational news. Appropriate emotional content can also increase the willingness of social media users to share an article. Effective media content that promotes measles vaccinations should contain educational or scientific information, as well as specific emotions (such as anger, joy, or sadness). Articles with this type of content may offer the best chance of disseminating vital messages to a broad social media audience.
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Affiliation(s)
- Dominik Wawrzuta
- Department of Education and Research in Health Sciences, Medical University of Warsaw, Warsaw, Poland
| | - Mariusz Jaworski
- Department of Education and Research in Health Sciences, Medical University of Warsaw, Warsaw, Poland
| | - Joanna Gotlib
- Department of Education and Research in Health Sciences, Medical University of Warsaw, Warsaw, Poland
| | - Mariusz Panczyk
- Department of Education and Research in Health Sciences, Medical University of Warsaw, Warsaw, Poland
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21
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Suwalowska H, Amara F, Roberts N, Kingori P. Ethical and sociocultural challenges in managing dead bodies during epidemics and natural disasters. BMJ Glob Health 2021; 6:bmjgh-2021-006345. [PMID: 34740913 PMCID: PMC8573672 DOI: 10.1136/bmjgh-2021-006345] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 10/03/2021] [Indexed: 12/23/2022] Open
Abstract
Background Catastrophic natural disasters and epidemics claim thousands of lives and have severe and lasting consequences, accompanied by human suffering. The Ebola epidemic of 2014–2016 and the current COVID-19 pandemic have revealed some of the practical and ethical complexities relating to the management of dead bodies. While frontline staff are tasked with saving lives, managing the bodies of those who die remains an under-resourced and overlooked issue, with numerous ethical and practical problems globally. Methods This scoping review of literature examines the management of dead bodies during epidemics and natural disasters. 82 articles were reviewed, of which only a small number were empirical studies focusing on ethical or sociocultural issues that emerge in the management of dead bodies. Results We have identified a wide range of ethical and sociocultural challenges, such as ensuring dignity for the deceased while protecting the living, honouring the cultural and religious rituals surrounding death, alleviating the suffering that accompanies grieving for the survivors and mitigating inequalities of resource allocation. It was revealed that several ethical and sociocultural issues arise at all stages of body management: notification, retrieving, identification, storage and burial of dead bodies. Conclusion While practical issues with managing dead bodies have been discussed in the global health literature and the ethical and sociocultural facets of handling the dead have been recognised, they are nonetheless not given adequate attention. Further research is needed to ensure care for the dead in epidemics and that natural disasters are informed by ethical best practice.
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Affiliation(s)
- Halina Suwalowska
- Nuffield Department of Population Health, Wellcome Centre for Ethics and Humanities, Ethox Centre, University of Oxford, Oxford, Oxfordshire, UK
| | - Fatu Amara
- Department of Chemistry, City University of New York, New York, New York, USA
| | - Nia Roberts
- Population Health and Primary Care Bodleian Health Care Libraries, University of Oxford, Oxford, Oxfordshire, UK
| | - Patricia Kingori
- Nuffield Department of Population Health, Wellcome Centre for Ethics and Humanities, Ethox Centre, University of Oxford, Oxford, Oxfordshire, UK
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22
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Nochaiwong S, Ruengorn C, Awiphan R, Kanjanarat P, Ruanta Y, Phosuya C, Boonchieng W, Nanta S, Chongruksut W, Thavorn K, Wongpakaran N, Wongpakaran T. COVID-19 Public Stigma Scale (COVID-PSS): development, validation, psychometric analysis and interpretation. BMJ Open 2021; 11:e048241. [PMID: 34728443 PMCID: PMC8568532 DOI: 10.1136/bmjopen-2020-048241] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE Amid the COVID-19 pandemic, social stigma towards COVID-19 infection has become a major component of public discourse and social phenomena. As such, we aimed to develop and validate the COVID-19 Public Stigma Scale (COVID-PSS). DESIGN AND SETTING National-based survey cross-sectional study during the lockdown in Thailand. PARTICIPANTS We invited the 4004 adult public to complete a set of measurement tools, including the COVID-PSS, global fear of COVID-19, perceived risk of COVID-19 infection, Bogardus Social Distance Scale, Pain Intensity Scale and Insomnia Severity Index. METHODS Factor structure dimensionality was constructed and reaffirmed with model fit by exploratory and confirmatory factor analyses and non-parametric item response theory (IRT) analysis. Psychometric properties for validity and reliability were tested. An anchor-based approach was performed for classifying the proper cut-off scores. RESULTS After factor analysis, IRT analysis and test for model fit, we created the final 10-item COVID-PSS with a three-factor structure: stereotype, prejudice and fear. Face and content validity were established through the public and experts' perspectives. The COVID-PSS was significantly correlated (Spearman rank, 95% CI) with the global fear of COVID-19 (0.68, 95% CI 0.66 to 0.70), perceived risk of COVID-19 infection (0.79, 95% CI 0.77 to 0.80) and the Bogardus Social Distance Scale (0.50, 95% CI 0.48 to 0.53), indicating good convergent validity. The correlation statistics between the COVID-PSS and the Pain Intensity Scale and Insomnia Severity Index were <0.2, supporting the discriminant validity. The reliability of the COVID-PSS was satisfactory, with good internal consistency (Cronbach's α of 0.85, 95% CI 0.84 to 0.86) and test-retest reproducibility (intraclass correlation of 0.94, 95% CI 0.86 to 0.96). The proposed cut-off scores were as follows: no/minimal (≤18), moderate (19-25) and high (≥26) public stigma towards COVID-19 infection. CONCLUSIONS The COVID-PSS is practical and suitable for measuring stigma towards COVID-19 in a public health survey. However, cross-cultural adaptation may be needed.
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Affiliation(s)
- Surapon Nochaiwong
- Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
- Pharmacoepidemiology and Statistics Research Center (PESRC), Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
| | - Chidchanok Ruengorn
- Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
- Pharmacoepidemiology and Statistics Research Center (PESRC), Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
| | - Ratanaporn Awiphan
- Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
- Pharmacoepidemiology and Statistics Research Center (PESRC), Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
| | - Penkarn Kanjanarat
- Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
- Pharmacoepidemiology and Statistics Research Center (PESRC), Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
| | - Yongyuth Ruanta
- Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
- Pharmacoepidemiology and Statistics Research Center (PESRC), Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
| | - Chabaphai Phosuya
- Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
- Pharmacoepidemiology and Statistics Research Center (PESRC), Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
| | | | - Sirisak Nanta
- Pharmacoepidemiology and Statistics Research Center (PESRC), Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
- Maesai Hospital, Maesai District, Chiang Rai, Thailand
| | - Wilaiwan Chongruksut
- Pharmacoepidemiology and Statistics Research Center (PESRC), Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
- Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Kednapa Thavorn
- Pharmacoepidemiology and Statistics Research Center (PESRC), Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
- Ottawa Hospital Research Institute, Ottawa Hospital, Ottawa, Ontario, Canada
- Institute of Clinical and Evaluative Sciences, ICES uOttawa, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Nahathai Wongpakaran
- Department of Psychiatry, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Tinakon Wongpakaran
- Department of Psychiatry, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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Koch L, Lopes AA, Maiguy A, Guillier S, Guillier L, Tournier JN, Biot F. Natural outbreaks and bioterrorism: How to deal with the two sides of the same coin? J Glob Health 2021; 10:020317. [PMID: 33110519 PMCID: PMC7535343 DOI: 10.7189/jogh.10.020317] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Lionel Koch
- Bacteriology Unit, French Armed Forces Biomedical Research Institute (IRBA), Bretigny sur Orge, France
| | - Anne-Aurelie Lopes
- Pediatric Emergency Department, AP-HP, Robert Debre Hospital, Paris, Sorbonne University, France
| | | | - Sophie Guillier
- Bacteriology Unit, French Armed Forces Biomedical Research Institute (IRBA), Bretigny sur Orge, France
| | - Laurent Guillier
- Risk Assessment Department, University of Paris-Est, French Agency for Food, Environmental and Occupational Health & Safety (ANSES), Maisons-Alfort, France
| | - Jean-Nicolas Tournier
- Department of Microbiology and Infectious Diseases, French Armed Forces Biomedical Research Institute (IRBA), Bretigny sur Orge, France
| | - Fabrice Biot
- Bacteriology Unit, French Armed Forces Biomedical Research Institute (IRBA), Bretigny sur Orge, France
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Koch MR, Kanneh L, Wise PH, Kurina LM, Alhasan F, Garry RF, Schieffelin JS, Shaffer JG, Grant DS. Health seeking behavior after the 2013-16 Ebola epidemic: Lassa fever as a metric of persistent changes in Kenema District, Sierra Leone. PLoS Negl Trop Dis 2021; 15:e0009576. [PMID: 34260615 PMCID: PMC8312964 DOI: 10.1371/journal.pntd.0009576] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 07/26/2021] [Accepted: 06/19/2021] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND The West African Ebola epidemic of 2013-2016 killed nearly 4,000 Sierra Leoneans and devastated health infrastructure across West Africa. Changes in health seeking behavior (HSB) during the outbreak resulted in dramatic underreporting and substantial declines in hospital presentations to public health facilities, resulting in an estimated tens of thousands of additional maternal, infant, and adult deaths per year. Sierra Leone's Kenema District, a major Ebola hotspot, is also endemic for Lassa fever (LF), another often-fatal hemorrhagic disease. Here we assess the impact of the West African Ebola epidemic on health seeking behaviors with respect to presentations to the Kenema Government Hospital (KGH) Lassa Ward, which serves as the primary health care referral center for suspected Lassa fever cases in the Eastern Province of Sierra Leone. METHODOLOGY/PRINCIPAL FINDINGS Presentation frequencies for suspected Lassa fever presenting to KGH or one of its referral centers from 2011-2019 were analyzed to consider the potential impact of the West African Ebola epidemic on presentation patterns. There was a significant decline in suspected LF cases presenting to KGH following the epidemic, and a lower percentage of subjects were admitted to the KGH Lassa Ward following the epidemic. To assess general HSB, a questionnaire was developed and administered to 200 residents from 8 villages in Kenema District. Among 194 completed interviews, 151 (78%) of respondents stated they felt hospitals were safer post-epidemic with no significant differences noted among subjects according to religious background, age, gender, or education. However, 37 (19%) subjects reported decreased attendance at hospitals since the epidemic, which suggests that trust in the healthcare system has not fully rebounded. Cost was identified as a major deterrent to seeking healthcare. CONCLUSIONS/SIGNIFICANCE Analysis of patient demographic data suggests that fewer individuals sought care for Lassa fever and other febrile illnesses in Kenema District after the West African Ebola epidemic. Re-establishing trust in health care services will require efforts beyond rebuilding infrastructure and require concerted efforts to rebuild the trust of local residents who may be wary of seeking healthcare post epidemic.
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Affiliation(s)
- Mikaela R. Koch
- Program in Human Biology, Stanford University, Stanford, California, United States of America
- * E-mail: (MRK); (JGS); (DSG)
| | - Lansana Kanneh
- Pediatrics–Neonatal and Developmental Medicine, Stanford University, Stanford, California, United States of America
| | - Paul H. Wise
- Pediatrics–Neonatal and Developmental Medicine, Stanford University, Stanford, California, United States of America
| | - Lianne M. Kurina
- Program in Human Biology, Stanford University, Stanford, California, United States of America
| | - Foday Alhasan
- Viral Hemorrhagic Fever Program, Kenema Government Hospital, Kenema, Sierra Leone
| | - Robert F. Garry
- Tulane University, School of Medicine, Department of Microbiology and Immunology, New Orleans, Louisiana, United States of America
- Zalgen Labs, LCC, Germantown, MD, United States of America
| | - John S. Schieffelin
- Sections of Infectious Disease, Department of Pediatrics, School of Medicine, Tulane University, New Orleans, Louisiana, United States of America
| | - Jeffrey G. Shaffer
- Department of Biostatistics and Bioinformatics, Tulane School of Public Health and Tropical Medicine, New Orleans, Louisiana, United States of America
- * E-mail: (MRK); (JGS); (DSG)
| | - Donald S. Grant
- Viral Hemorrhagic Fever Program, Kenema Government Hospital, Kenema, Sierra Leone
- Ministry of Health and Sanitation, Freetown, Sierra Leone
- * E-mail: (MRK); (JGS); (DSG)
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25
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Hendrickson ZM, Tibbels N, Sidikiba S, Mills H, Vondrasek C, Gurman T. 'I can't leave everything in the hands of my husband': Economic constraints and gender roles in care-seeking in post-Ebola Guinea. Glob Public Health 2021; 17:1578-1593. [PMID: 34242118 DOI: 10.1080/17441692.2021.1953107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The 2014-2016 Ebola epidemic in West Africa had enduring effects on health systems and healthcare utilisation. This study explores the intersection of economic constraints and gender roles in Guinea to understand delays in care-seeking post-Ebola. In-depth interviews (n = 45) and focus group discussions (n = 24) were conducted with mothers, male heads of household, grandmothers, and health workers in rural and urban areas in Basse-Guinée and Guinée Forestière. A thematic analysis identified salient themes related to gender and economic constraints on health care-seeking. Participants, particularly men, emphasised the high cost of seeking care, which led to delays as women secured funds. Men's engagement in care-seeking included providing funds and permission, picking up medication, and giving appointment reminders. As principal actors when 'navigating' the healthcare system, women were intimately involved in economic decisions and responsible for securing funds for services - even when lacking direct financial control. Essentialist descriptions of men as 'providers' and women as 'navigators', therefore, masked nuances in care-seeking and economic responsibilities. Programmes must acknowledge men's engagement in care-seeking and address both the economic barriers women face when seeking care and their economic roles. Greater attention to the complex intersection of economic constraints and gender roles could address care-seeking delays.
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Affiliation(s)
- Zoé Mistrale Hendrickson
- Johns Hopkins Center for Communication Programs, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Natalie Tibbels
- Johns Hopkins Center for Communication Programs, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Sidibé Sidikiba
- Public Health Department, Africa Center of Excellence for Prevention and Control of Communicable Diseases (CEA-PCMT), Université Gamal Abdel Nasser de Conakry , Conakry, Guinea
| | - Hannah Mills
- Johns Hopkins Center for Communication Programs, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Claudia Vondrasek
- Johns Hopkins Center for Communication Programs, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Tilly Gurman
- Johns Hopkins Center for Communication Programs, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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26
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Jalloh MF, Sengeh P, James N, Bah S, Jalloh MB, Owen K, Pratt SA, Oniba A, Sangarie M, Sesay S, Bedson J. Integrated digital system for community engagement and community-based surveillance during the 2014-2016 Ebola outbreak in Sierra Leone: lessons for future health emergencies. BMJ Glob Health 2021; 5:bmjgh-2020-003936. [PMID: 33355270 PMCID: PMC7757454 DOI: 10.1136/bmjgh-2020-003936] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 11/23/2020] [Accepted: 11/25/2020] [Indexed: 11/04/2022] Open
Abstract
Community engagement and community-based surveillance are essential components of responding to infectious disease outbreaks, but real-time data reporting remains a challenge. In the 2014-2016 Ebola outbreak in Sierra Leone, the Social Mobilisation Action Consortium was formed to scale-up structured, data-driven community engagement. The consortium became operational across all 14 districts and supported an expansive network of 2500 community mobilisers, 6000 faith leaders and 42 partner radio stations. The benefit of a more agile digital reporting system became apparent within few months of implementing paper-based reporting given the need to rapidly use the data to inform the fast-evolving epidemic. In this paper, we aim to document the design, deployment and implementation of a digital reporting system used in six high transmission districts. We highlight lessons learnt from our experience in scaling up the digital reporting system during an unprecedented public health crisis. The lessons learnt from our experience in Sierra Leone have important implications for designing and implementing similar digital reporting systems for community engagement and community-based surveillance during public health emergencies.
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Affiliation(s)
- Mohamed F Jalloh
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden .,Focus 1000, Freetown, Sierra Leone
| | | | | | - Saiku Bah
- Restless Development Sierra Leone, Freetown, Sierra Leone
| | | | | | | | | | | | - Samuel Sesay
- Health Education Division, Sierra Leone Ministry of Health and Sanitation, Freetown, Western Area, Sierra Leone
| | - Jamie Bedson
- Restless Development Sierra Leone, Freetown, Sierra Leone
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Schmidt-Hellerau K, Winters M, Lyons P, Leigh B, Jalloh MB, Sengeh P, Sawaneh AB, Zeebari Z, Salazar M, Jalloh MF, Nordenstedt H. Homecare for sick family members while waiting for medical help during the 2014-2015 Ebola outbreak in Sierra Leone: a mixed methods study. BMJ Glob Health 2021; 5:bmjgh-2020-002732. [PMID: 32694222 PMCID: PMC7375393 DOI: 10.1136/bmjgh-2020-002732] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 06/04/2020] [Accepted: 06/18/2020] [Indexed: 01/14/2023] Open
Abstract
INTRODUCTION Caring for an Ebola patient is a known risk factor for disease transmission. In Sierra Leone during the outbreak in 2014/2015, isolation of patients in specialised facilities was not always immediately available and caring for a relative at home was sometimes the only alternative. This study sought to assess population-level protective caregiving intentions, to understand how families cared for their sick and to explore perceived barriers and facilitators influencing caregiving behaviours. METHODS Data from a nationwide household survey conducted in December 2014 were used to assess intended protective behaviours if caring for a family member with suspected Ebola. Their association with socio-demographic variables, Ebola-specific knowledge and risk perception was analysed using multilevel logistic regression. To put the results into context, semi-structured interviews with caregivers were conducted in Freetown. RESULTS Ebola-specific knowledge was positively associated with the intention to avoid touching a sick person and their bodily fluids (adjusted OR (AOR) 1.29; 95% CI 1.01 to 1.54) and the intention to take multiple protective measures (AOR 1.38; 95% CI 1.16 to 1.63). Compared with residing in the mostly urban Western Area, respondents from the initial epicentre of the outbreak (Eastern Province) had increased odds to avoid touching a sick person or their body fluids (AOR 4.74; 95% CI 2.55 to 8.81) and to take more than one protective measure (AOR 2.94; 95% CI 1.37 to 6.34). However, interviews revealed that caregivers, who were mostly aware of the risk of transmission and general protective measures, felt constrained by different contextual factors. Withholding care was not seen as an option and there was a perceived lack of practical advice. CONCLUSIONS Ebola outbreak responses need to take the sociocultural reality of caregiving and the availability of resources into account, offering adapted and acceptable practical advice. The necessity to care for a loved one when no alternatives exist should not be underestimated.
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Affiliation(s)
| | - Maike Winters
- Department of Global Public Health, Karolinska Institute, Stockholm, Sweden
| | - Padraig Lyons
- Department of Global Public Health, Karolinska Institute, Stockholm, Sweden
| | - Bailah Leigh
- Department of Community Medicine, University of Sierra Leone College of Medicine and Allied Health Sciences, Freetown, Western Area, Sierra Leone
| | - Mohammad B Jalloh
- Office of the Chief Executive Officer, FOCUS 1000, Freetown, Sierra Leone
| | - Paul Sengeh
- Research and Evaluation, FOCUS 1000, Freetown, Sierra Leone
| | | | - Zangin Zeebari
- Jönköping International Business School, Jönköping University, Jonkoping, Sweden
| | - Mariano Salazar
- Department of Global Public Health, Karolinska Institute, Stockholm, Sweden
| | - Mohamed F Jalloh
- Department of Global Public Health, Karolinska Institute, Stockholm, Sweden.,Division of Global Health Protection, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Helena Nordenstedt
- Department of Global Public Health, Karolinska Institute, Stockholm, Sweden
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Jalloh MF, Kinsman J, Conteh J, Kaiser R, Jambai A, Ekström AM, Bunnell RE, Nordenstedt H. Barriers and facilitators to reporting deaths following Ebola surveillance in Sierra Leone: implications for sustainable mortality surveillance based on an exploratory qualitative assessment. BMJ Open 2021; 11:e042976. [PMID: 33986045 PMCID: PMC8126305 DOI: 10.1136/bmjopen-2020-042976] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVES To understand the barriers contributing to the more than threefold decline in the number of deaths (of all causes) reported to a national toll free telephone line (1-1-7) after the 2014-2016 Ebola outbreak ended in Sierra Leone and explore opportunities for improving routine death reporting as part of a nationwide mortality surveillance system. DESIGN An exploratory qualitative assessment comprising 32 in-depth interviews (16 in Kenema district and 16 in Western Area). All interviews were audio-recorded, transcribed and analysed using qualitative content analysis to identify themes. SETTING Participants were selected from urban and rural communities in two districts that experienced varying levels of Ebola cases during the outbreak. All interviews were conducted in August 2017 in the post-Ebola-outbreak context in Sierra Leone when the Sierra Leone Ministry of Health and Sanitation was continuing to mandate reporting of all deaths. PARTICIPANTS Family members of deceased persons whose deaths were not reported to the 1-1-7 system. RESULTS Death reporting barriers were driven by the lack of awareness to report all deaths, lack of services linked to reporting, negative experiences from the Ebola outbreak including prohibition of traditional burial rituals, perception that inevitable deaths do not need to be reported and situations where prompt burials may be needed. Facilitators of future willingness to report deaths were largely influenced by the perceived communicability and severity of the disease, unexplained circumstances of the death that need investigation and the potential to leverage existing death notification practices through local leaders. CONCLUSIONS Social mobilisation and risk communication efforts are needed to help the public understand the importance and benefits of sustained and ongoing death reporting after an Ebola outbreak. Localised practices for informal death notification through community leaders could be integrated into the formal reporting system to capture community-based deaths that may otherwise be missed.
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Affiliation(s)
- Mohamed F Jalloh
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Division of Global Health Protection, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - John Kinsman
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden
| | | | - Reinhard Kaiser
- Sierra Leone Country Office, U.S. Centers for Disease Control and Prevention, Freetown, Sierra Leone
| | - Amara Jambai
- Sierra Leone Ministry of Health and Sanitation, Freetown, Sierra Leone
| | - Anna Mia Ekström
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Rebecca E Bunnell
- Division of Global Health Protection, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Helena Nordenstedt
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
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LaVergne SM, Sakabe S, Kanneh L, Momoh M, Al-Hassan F, Yilah M, Goba A, Sandi JD, Gbakie M, Cubitt B, Boisen M, Mayeux JM, Smira A, Shore K, Bica I, Pollard KM, Carlos de la Torre J, Branco LM, Garry RF, Grant DS, Schieffelin JS, Oldstone MBA, Sullivan BM. Ebola-Specific CD8+ and CD4+ T-Cell Responses in Sierra Leonean Ebola Virus Survivors With or Without Post-Ebola Sequelae. J Infect Dis 2021; 222:1488-1497. [PMID: 32436943 DOI: 10.1093/infdis/jiaa268] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 05/15/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Ebola virus (EBOV) disease has killed thousands of West and Central Africans over the past several decades. Many who survive the acute disease later experience post-Ebola syndrome, a constellation of symptoms whose causative pathogenesis is unclear. METHODS We investigated EBOV-specific CD8+ and CD4+ T-cell responses in 37 Sierra Leonean EBOV disease survivors with (n = 19) or without (n = 18) sequelae of arthralgia and ocular symptoms. Peripheral blood mononuclear cells were infected with recombinant vesicular stomatitis virus encoding EBOV antigens. We also studied the presence of EBOV-specific immunoglobulin G, antinuclear antibodies, anti-cyclic citrullinated peptide antibodies, rheumatoid factor, complement levels, and cytokine levels in these 2 groups. RESULTS Survivors with sequelae had a significantly higher EBOV-specific CD8+ and CD4+ T-cell response. No differences in EBOV-specific immunoglobulin G, antinuclear antibody, or anti-cyclic citrullinated peptide antibody levels were found. Survivors with sequelae showed significantly higher rheumatoid factor levels. CONCLUSION EBOV-specific CD8+ and CD4+ T-cell responses were significantly higher in Ebola survivors with post-Ebola syndrome. These findings suggest that pathogenesis may occur as an immune-mediated disease via virus-specific T-cell immune response or that persistent antigen exposure leads to increased and sustained T-cell responses.
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Affiliation(s)
- Stephanie M LaVergne
- Viral-Immunobiology Laboratory, Department of Immunology and Microbiology, Scripps Research, La Jolla, California, USA.,Division of Infectious Diseases, University of California, San Diego, La Jolla, California, USA
| | - Saori Sakabe
- Viral-Immunobiology Laboratory, Department of Immunology and Microbiology, Scripps Research, La Jolla, California, USA
| | - Lansana Kanneh
- Viral Hemorrhagic Fever Program, Kenema Government Hospital, Kenema, Sierra Leone.,Ministry of Health and Sanitation, Freetown, Sierra Leone
| | - Mambu Momoh
- Viral Hemorrhagic Fever Program, Kenema Government Hospital, Kenema, Sierra Leone.,Ministry of Health and Sanitation, Freetown, Sierra Leone.,Eastern Polytechnic Institute, Kenema, Sierra Leone
| | - Foday Al-Hassan
- Viral Hemorrhagic Fever Program, Kenema Government Hospital, Kenema, Sierra Leone.,Ministry of Health and Sanitation, Freetown, Sierra Leone
| | - Mohamed Yilah
- Viral Hemorrhagic Fever Program, Kenema Government Hospital, Kenema, Sierra Leone.,Ministry of Health and Sanitation, Freetown, Sierra Leone
| | - Augustine Goba
- Viral Hemorrhagic Fever Program, Kenema Government Hospital, Kenema, Sierra Leone.,Ministry of Health and Sanitation, Freetown, Sierra Leone
| | - John Demby Sandi
- Viral Hemorrhagic Fever Program, Kenema Government Hospital, Kenema, Sierra Leone.,Ministry of Health and Sanitation, Freetown, Sierra Leone
| | - Michael Gbakie
- Viral Hemorrhagic Fever Program, Kenema Government Hospital, Kenema, Sierra Leone.,Ministry of Health and Sanitation, Freetown, Sierra Leone
| | - Beatrice Cubitt
- Viral-Immunobiology Laboratory, Department of Immunology and Microbiology, Scripps Research, La Jolla, California, USA
| | | | - Jessica M Mayeux
- Department of Molecular Medicine, Scripps Research, La Jolla, California, USA
| | - Ashley Smira
- Department of Pediatrics, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Kayla Shore
- Department of Tropical Medicine, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana, USA
| | - Iris Bica
- Department of Pediatrics, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - K Michael Pollard
- Department of Molecular Medicine, Scripps Research, La Jolla, California, USA
| | - Juan Carlos de la Torre
- Viral-Immunobiology Laboratory, Department of Immunology and Microbiology, Scripps Research, La Jolla, California, USA
| | | | - Robert F Garry
- Department of Immunology and Microbiology, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Donald S Grant
- Viral Hemorrhagic Fever Program, Kenema Government Hospital, Kenema, Sierra Leone.,Ministry of Health and Sanitation, Freetown, Sierra Leone.,College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | - John S Schieffelin
- Department of Pediatrics, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Michael B A Oldstone
- Viral-Immunobiology Laboratory, Department of Immunology and Microbiology, Scripps Research, La Jolla, California, USA
| | - Brian M Sullivan
- Viral-Immunobiology Laboratory, Department of Immunology and Microbiology, Scripps Research, La Jolla, California, USA
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Munawar K, Choudhry FR. Exploring stress coping strategies of frontline emergency health workers dealing Covid-19 in Pakistan: A qualitative inquiry. Am J Infect Control 2021; 49:286-292. [PMID: 32649990 PMCID: PMC7340021 DOI: 10.1016/j.ajic.2020.06.214] [Citation(s) in RCA: 78] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 06/29/2020] [Accepted: 06/30/2020] [Indexed: 12/30/2022]
Abstract
Background The COVID-19 outbreak has gravely impacted the physical and psychological health of people. As the outbreak is ongoing, it is crucial to equip the emergency healthcare workers (HCWs) to be medically and psychologically prepared. Objective To examine the psychological impact of COVID-19 on emergency HCWs and to understand how they are dealing with COVID-19 pandemic, their stress coping strategies or protective factors, and challenges while dealing with COVID-19 patients. Methods Using a framework thematic analysis approach, 15 frontline emergency HCWs directly dealing with COVID-19 patients from April 2, 2020 to April 25, 2020. The semi-structured interviews were conducted face-to-face or by telephone. Data were analyzed using thematic analysis. Results Findings highlighted first major theme of stress coping, including, limiting media exposure, limited sharing of Covid-19 duty details, religious coping, just another emergency approach, altruism, and second major theme of Challenges includes, psychological response and noncompliance of public/denial by religious scholar. Conclusions Participants practiced and recommended various coping strategies to deal with stress and anxiety emerging from COVID-19 pandemic. Media was reported to be a principal source of raising stress and anxiety among the public. Religious coping as well as their passion to serve humanity and country were the commonly employed coping strategies.
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31
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Murray RT, Drew LB, Memmott C, Bangura YM, Maring EF. A community's experience during and after the Ebola epidemic of 2014-2016 in Sierra Leone: A qualitative study. PLoS Negl Trop Dis 2021; 15:e0009203. [PMID: 33630847 PMCID: PMC7954283 DOI: 10.1371/journal.pntd.0009203] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 03/12/2021] [Accepted: 02/04/2021] [Indexed: 11/18/2022] Open
Abstract
Background The 2014–2016 Ebola epidemic devastated families and communities throughout West Africa. Due to its high mortality rate and infectious nature, most Ebola research to date has focused on healthcare response and interventions; however, little is known about the experiences of Ebola survivors and communities. This qualitative study aimed to better understand the lived experiences of community members, including children, during and after the Ebola epidemic in Sierra Leone. Methods During June 2016 and June 2017, we conducted four focus groups comprised of primary school students, female caretakers, male caretakers, and teachers, and two individual in-depth interviews with local nurses in Calaba Town, a small village outside of Freetown. Interviews were recorded, transcribed verbatim, and coded using a modified grounded theory methodology. Findings All participants shared that they experienced significant challenges during and after the Ebola epidemic. During the epidemic, participants endured daily life challenges pertaining to fear, financial distress, and school closures. They also experienced suffering, loss, isolation, grief, and compromised culture. Confusion and distrust were also prevalent during the epidemic, with participants reporting confusion around Ebola transmission and distrust in the government and healthcare services. We also found that the struggle for food and grief stemming from the loss of loved ones continued more than a year after the epidemic ended. Despite Sierra Leone being declared Ebola-free, stigma and fear persisted and community members shared their continuing distrust of the government due to their actions during and after the epidemic. Conclusions The findings of this qualitative study reveal that the Ebola epidemic was a traumatizing period for the Calaba Town community, and that confusion and distrust toward the government health care system have continued. Future studies should explore the extended impact of the epidemic on communities, including long-term psychological, social, and economic consequences of this outbreak. The Ebola epidemic of 2014–2016 in West Africa was the largest in history, resulting in over 28,000 infections and more than 11,300 deaths across Sierra Leone, Liberia, and Guinea. Little is known about the lived experiences of communities, families, and children during and after the epidemic, and this qualitative study sought to better understand these experiences in a community in Sierra Leone. Through focus groups and individual interviews, we discovered that participants endured daily life challenges pertaining to fear, financial distress, and school closures. They also experienced suffering, loss, isolation, grief, and compromised culture, especially regarding funeral traditions. Children expressed being unhappy while schools were closed due to their inability to learn and interact with their classmates. Healthcare workers reported the stigmatization that they experienced, along with fear of an unfamiliar disease that led to the deaths of their colleagues. Distrust in the government, particularly due to their epidemic response, fueled feelings of confusion about Ebola transmission and treatment, and an overall lack of trust in healthcare services. Despite Sierra Leone being declared Ebola-free in March 2016, stigma and fear persisted and community members shared their continuing distrust of the government.
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Affiliation(s)
- Rianna T. Murray
- Maryland Institute for Applied Environmental Health, University of Maryland School of Public Health, College Park, Maryland, United States of America
- * E-mail:
| | - Laura Briggs Drew
- Department of Family Science, University of Maryland School of Public Health, College Park, Maryland, United States of America
| | - Christina Memmott
- Public Health Science Program, University of Maryland School of Public Health, College Park, Maryland, United States of America
| | - Ya-Maila Bangura
- Department of Government & Politics, University of Maryland College of Behavioral and Social Sciences, College Park, Maryland, United States of America
| | - Elisabeth F. Maring
- Department of Family Science, University of Maryland School of Public Health, College Park, Maryland, United States of America
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Dixit D, Masumbuko Claude K, Kjaldgaard L, Hawkes MT. Review of Ebola virus disease in children - how far have we come? Paediatr Int Child Health 2021; 41:12-27. [PMID: 32894024 DOI: 10.1080/20469047.2020.1805260] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Ebola virus (EBOV) causes an extremely contagious viral haemorrhagic fever associated with high mortality. While, historically, children have represented a small number of total cases of Ebolavirus disease (EVD), in recent outbreaks up to a quarter of cases have been in children. They pose unique challenges in clinical management and infection prevention and control. In this review of paediatric EVD, the epidemiology of past EVD outbreaks with specific focus on children is discussed, the clinical manifestations and laboratory findings are described and key developments in clinical management including specific topics such as viral persistence and breastfeeding while considering unique psychosocial and anthropological considerations for paediatric care including of survivors and orphans and the stigma they face are discussed. In addition to summarising the literature, perspectives based on the authors' experience of EVD outbreaks in the Democratic Republic of the Congo (DRC) are described.Abbreviations: ARDS: acute respiratory distress syndrome; aOR: adjusted odds ratio; ALT: alanine transferase; ALIMA: Alliance for International Medical Action; AST: aspartate transaminase; BUN: blood urea nitrogen; CNS: central nervous system; CUBE: chambre d'urgence biosécurisée pour épidémie; COVID-19: coronavirus disease 2019; Ct: cycle threshold; DRC: Democratic Republic of Congo; ETC: ebola treatment centre; ETU: ebola treatment unit; EBOV: ebola virus; EVD: ebolavirus disease; FEAST: fluid expansion as supportive therapy; GP: glycoprotein; IV: intravenous; MEURI: monitored emergency use of unregistered interventions; NETEC: National Ebola Training and Education Centre; NP: nucleoprotein; ORS: oral rehydration solution; PALM: Pamoja Tulinde Maisha; PREVAIL: Partnership for Research on Ebola Virus in Liberia; PPE: personal protective equipment; PCR: polymerase chain reaction; PEP: post-exposure prophylaxis; RDTs: rapid diagnostic tests; RT: reverse transcriptase; RNA: ribonucleic acid; UNICEF: United Nations International Children's Emergency Fund; USA: United States of America; WHO: World Health Organization.
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Affiliation(s)
- Devika Dixit
- Department of Medicine and Pediatrics. Division of Infectious Diseases, University of Saskatchewan, Saskatoon, SK, Canada
| | | | | | - Michael T Hawkes
- Department of Pediatrics. Division of Infectious Diseases, University of Alberta, Edmonton, Alberta, Canada.,School of Public Health, University of Alberta, Edmonton, Canada.,Department of Medical Microbiology and Immunology, University of Alberta, Edmonton, Canada.,Stollery Science Laboratory, Edmonton, Alberta, Canada.,Women and Children's Health Research Institute, Edmonton, Alberta, Canada
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Ngo TM, Rogers B, Patnaik R, Jambai A, Sharkey AB. The Effect of Ebola Virus Disease on Maternal and Child Health Services and Child Mortality in Sierra Leone, 2014-2015: Implications for COVID-19. Am J Trop Med Hyg 2021; 104:1085-1092. [PMID: 33399047 DOI: 10.4269/ajtmh.20-0446] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 10/23/2020] [Indexed: 01/13/2023] Open
Abstract
During Sierra Leone's 2014-2015 Ebola virus disease (EVD) epidemic, early reports warned of health system collapse and potential effects on other-cause mortality. These same warnings are reverberating during the COVID-19 pandemic. Consideration of the impacts of EVD on maternal and child health services from facility data can be instructive during COVID-19. We surveyed all peripheral healthcare units (PHUs) in Sierra Leone in October 2014 and March 2015 to assess closures, staffing, amenities, medicines, supplies, and service utilization during May 2014-January 2015 and October 2013-January 2014. We report PHU characteristics and service utilization changes for equivalent 4-month periods during the epidemic and the prior year. We present utilization changes by district and service type, and model excess child mortality. PHU closures (-8%) and staff attrition (-3%) were limited, but many facilities lacked amenities, medicines, and supplies. Utilization of preventive and scheduled services fell more than individualized, clinical care interventions, aside from malaria treatment which declined significantly. Ebola virus disease intensity in districts was weakly associated with utilization, aside from two districts that were severely affected. Modeling suggests utilization declines resulted in 6,782 excess under-five deaths (an increase of 21%) between 2014 and 2015. Ebola virus disease negatively affected service provision, but utilization declined relatively more, particularly for preventive and scheduled interventions. Although these findings are specific to Sierra Leone's EVD epidemic, they illustrate the magnitude of possible effects in other settings due to COVID-19-induced service disruptions, where collateral impacts on child mortality from other preventable causes may far outweigh COVID-19 mortality.
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Affiliation(s)
| | - Braeden Rogers
- UNICEF East and Southern African Regional Office, Nairobi, Kenya
| | - Rajesh Patnaik
- UNICEF East and Southern African Regional Office, Nairobi, Kenya
| | - Amara Jambai
- Ministry of Health and Sanitation, Freetown, Sierra Leone
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Sun N, Wei L, Wang H, Wang X, Gao M, Hu X, Shi S. Qualitative study of the psychological experience of COVID-19 patients during hospitalization. J Affect Disord 2021; 278:15-22. [PMID: 32949869 PMCID: PMC7444461 DOI: 10.1016/j.jad.2020.08.040] [Citation(s) in RCA: 98] [Impact Index Per Article: 32.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 08/13/2020] [Accepted: 08/18/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) continues to spread across the globe, but patient experiences are rarely documented. OBJECTIVE To explore the psychology of COVID-19 patients during hospitalization. METHODS A phenomenological and robust sampling approach was employed. Sixteen patients admitted to the First Affiliated Hospital of Henan University of Science and Technology with COVID-19 from 20th January to 1st March 2020 were selected. Data were collected through semi-structured interviews, phone calls, or face-to-face interviews using quarantine measures. Data were analyzed using the Colaizzi method. RESULTS The psychological experience of COVID-19 patients during hospitalization could be summarized into five themes. Firstly, attitudes toward the disease included fear, denial, and stigma during the early stages, which gradually developed into acceptance in the later stages. Secondly, the major source of stress included the viral nature of the disease, quarantine measures, and concerns regarding the health of family members. Thirdly, reactions of body and mind included disease stage-dependent emotional responses, excessive attention to symptoms, rumination, and changes in diet, sleep, and behavior. Fourthly, supportive factors included psychological adjustments, medical care, and family and social support. Finally, the disease resulted in psychological growth and patients viewed problems with gratitude through the cherishing of life, family, bravery, and tenacity. CONCLUSION COVID-19 patients gradually changed their attitude toward the disease and displayed emotional responses dependent on the stage of the disease. Negative emotions dominated during the early stages but gradually gave way to mixed positive and negative emotions. Active guidance of psychological growth may therefore promote physical and mental recovery in COVID-19 patients.
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Affiliation(s)
- Niuniu Sun
- Humanities Teaching and Research Office, School of Nursing, Henan University of Science and Technology, The First Affiliated Hospital of Henan University of Science and Technology, Luoyang, China
| | - Luoqun Wei
- Department of Infection, The First Affiliated Hospital, and College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China
| | - Hongyun Wang
- Department of Infection, The First Affiliated Hospital, and College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China.
| | - Xianru Wang
- Department of Infection, The First Affiliated Hospital, and College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China
| | - Mingxia Gao
- Department of Infection, The First Affiliated Hospital, and College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China
| | - Xinjun Hu
- Department of Infection, The First Affiliated Hospital, and College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China
| | - Suling Shi
- Department of Infection, The First Affiliated Hospital, and College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China.
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35
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Jalloh MF, Nur AA, Nur SA, Winters M, Bedson J, Pedi D, Prybylski D, Namageyo-Funa A, Hageman KM, Baker BJ, Jalloh MB, Eng E, Nordenstedt H, Hakim AJ. Behaviour adoption approaches during public health emergencies: implications for the COVID-19 pandemic and beyond. BMJ Glob Health 2021; 6:e004450. [PMID: 33514594 PMCID: PMC7849902 DOI: 10.1136/bmjgh-2020-004450] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 01/08/2021] [Accepted: 01/11/2021] [Indexed: 12/29/2022] Open
Abstract
Human behaviour will continue to play an important role as the world grapples with public health threats. In this paper, we draw from the emerging evidence on behaviour adoption during diverse public health emergencies to develop a framework that contextualises behaviour adoption vis-à-vis a combination of top-down, intermediary and bottom-up approaches. Using the COVID-19 pandemic as a case study, we operationalise the contextual framework to demonstrate how these three approaches differ in terms of their implementation, underlying drivers of action, enforcement, reach and uptake. We illustrate how blended strategies that include all three approaches can help accelerate and sustain protective behaviours that will remain important even when safe and effective vaccines become more widely available. As the world grapples with the COVID-19 pandemic and prepares to respond to (re)emerging public health threats, our contextual framework can inform the design, implementation, tracking and evaluation of comprehensive public health and social measures during health emergencies.
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Affiliation(s)
- Mohamed F Jalloh
- Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Aasli A Nur
- Department of Sociology, University of Washington, Seattle, Washington, USA
| | - Sophia A Nur
- Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Maike Winters
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Jamie Bedson
- Independent Consultant, Seattle, Washington, USA
| | - Danielle Pedi
- Bill and Melinda Gates Foundation, Seattle, Washington, USA
| | - Dimitri Prybylski
- Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Apophia Namageyo-Funa
- Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Kathy M Hageman
- Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Brian J Baker
- Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | | | - Eugenia Eng
- Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Helena Nordenstedt
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Avi J Hakim
- CDC COVID-19 Response Team, Atlanta, Georgia, USA
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Designing, Implementing, and Managing a National Emergency Medical Service in Sierra Leone. Prehosp Disaster Med 2020; 36:115-120. [PMID: 33256859 DOI: 10.1017/s1049023x20001442] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Sierra Leone is one of the least developed low-income countries (LICs), slowly recovering from the effects of a devastating civil war and an Ebola outbreak. The health care system is characterized by chronic shortage of skilled human resources, equipment, and essential medicines. The referral system is weak and vulnerable, with 75% of the country having insufficient access to essential health care. Consequently, Sierra Leone has the highest maternal and child mortality rates in the world. This manuscript describes the implementation of a National Emergency Medical Service (NEMS), a project aiming to create the first prehospital emergency medical system in the country. In 2017, a joint venture of Doctors with Africa (CUAMM), Veneto Region, and Research Center in Emergency and Disaster Medicine (CRIMEDIM) was developed to support the Ministry of Health and Sanitation (MOHS) in designing and managing the NEMS system, one of the very few structured, fully equipped, and free-of-charge prehospital service in the African continent. The NEMS design was the result of an in-depth research phase that included a preliminary assessment, literature review, and consultations with key stakeholders and managers of similar systems in other African countries. From May 27, 2019, after a timeframe of six months in which all the districts have been progressively trained and made operational, the NEMS became operative at national level. By the end of March 2020, the NEMS operation center (OC) and the 81 ambulances dispatched on the ground handled a total number of 36,814 emergency calls, 35,493 missions, and 31,036 referrals.
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37
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Samuels RJ, Moon TD, Starnes JR, Alhasan F, Gbakie M, Goba A, Koroma V, Momoh M, Sandi JD, Garry RF, Engel EJ, Shaffer JG, Schieffelin JS, Grant DS. Lassa Fever among Children in Eastern Province, Sierra Leone: A 7-year Retrospective Analysis (2012-2018). Am J Trop Med Hyg 2020; 104:585-592. [PMID: 33241780 PMCID: PMC7866338 DOI: 10.4269/ajtmh.20-0773] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 10/01/2020] [Indexed: 01/09/2023] Open
Abstract
Pediatric Lassa fever (LF) usually presents as a nonspecific febrile illness, similar to other endemic diseases in countries like Sierra Leone, where LF is considered to be hyperendemic. The nonspecificity of presentation and lack of research have made it difficult to fully understand best practices for pediatric management. We aim to describe clinical characteristics of hospitalized pediatric patients suspected or diagnosed with LF and assess factors associated with hospital outcomes among those with LF antigen-positive results. We conducted a 7-year retrospective cohort study using routine data for all children younger than 18 years admitted at the Kenema Government Hospital's LF ward. A total of 292 children with suspected or confirmed LF were analyzed. Overall, mortality was high (21%). Children with antigen-positive results had a high case fatality rate of 63% (P < 0.01). In univariate analyses, children who presented with unexplained bleeding (odds ratio [OR]: 3.58; 95% CI: 1.08-11.86; P = 0.040) and confusion (altered sensorium) (OR: 5.37; 95% CI: 1.34-21.48; P = 0.020) had increased odds of death. Abnormal serum levels of alanine aminotransferase (P = 0.001), creatinine (P = 0.004), and potassium (P = 0.003) were associated with increased likelihood of death in these children. Treatment with ribavirin was not significantly associated with survival (P = 0.916). Our findings provide insights into current pediatric LF clinical presentation and management. More evidence-based, high-quality research in creating predictive algorithms of antigen-positivity and hospital outcomes is needed in the management of pediatric LF.
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Affiliation(s)
- Robert J Samuels
- Lassa Fever Program, Kenema Government Hospital, Ministry of Health and Sanitation, Kenema, Sierra Leone.,Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Troy D Moon
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Joseph R Starnes
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Foday Alhasan
- Lassa Fever Program, Kenema Government Hospital, Ministry of Health and Sanitation, Kenema, Sierra Leone
| | - Michael Gbakie
- Lassa Fever Program, Kenema Government Hospital, Ministry of Health and Sanitation, Kenema, Sierra Leone
| | - Augustine Goba
- Lassa Fever Program, Kenema Government Hospital, Ministry of Health and Sanitation, Kenema, Sierra Leone
| | - Veronica Koroma
- Lassa Fever Program, Kenema Government Hospital, Ministry of Health and Sanitation, Kenema, Sierra Leone
| | - Mambu Momoh
- Lassa Fever Program, Kenema Government Hospital, Ministry of Health and Sanitation, Kenema, Sierra Leone
| | - John Demby Sandi
- Lassa Fever Program, Kenema Government Hospital, Ministry of Health and Sanitation, Kenema, Sierra Leone
| | - Robert F Garry
- Department of Immunology and Microbiology, School of Medicine, Tulane University, New Orleans, Louisiana.,Lassa Fever Program, Kenema Government Hospital, Ministry of Health and Sanitation, Kenema, Sierra Leone
| | - Emily J Engel
- Department of Pediatrics and Internal Medicine, Sections of Pediatric and Adult Infectious Diseases, School of Medicine, Tulane University, New Orleans, Louisiana
| | - Jeffrey G Shaffer
- Department of Global Biostatistics and Data Science, School of Public Health and Tropical Medicine, Tulane University, New Orleans, Louisiana
| | - John S Schieffelin
- Department of Pediatrics and Internal Medicine, Sections of Pediatric and Adult Infectious Diseases, School of Medicine, Tulane University, New Orleans, Louisiana.,Lassa Fever Program, Kenema Government Hospital, Ministry of Health and Sanitation, Kenema, Sierra Leone
| | - Donald S Grant
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone.,Lassa Fever Program, Kenema Government Hospital, Ministry of Health and Sanitation, Kenema, Sierra Leone
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Abstract
This report describes the main adaptive and transformative changes adopted by the brand-new National Emergency Medical Service (NEMS) to face the novel coronavirus disease 2019 (COVID-19) in Sierra Leone, including ambulance re-distribution, improvements in communication flow, implementation of ad-hoc procedures and trainings, and budget re-allocation. In a time-span of four months, 1,170 COVID-19 cases have been handled by the NEMS through a parallel referral system, while efforts have been made to manage the routine emergencies of the country, causing a substantial intensification of daily activities.
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39
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Byrne A, Nichol B. A community-centred approach to global health security: implementation experience of community-based surveillance (CBS) for epidemic preparedness. GLOBAL SECURITY: HEALTH, SCIENCE AND POLICY 2020. [DOI: 10.1080/23779497.2020.1819854] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Affiliation(s)
- Abbey Byrne
- Health and Care Unit, International Federation of Red Cross and Red Crescent Societies (IFRC, Africa Regional Office, Nairobi, Kenya
| | - Bronwyn Nichol
- Health and Care Unit, International Federation of Red Cross and Red Crescent Societies (IFRC, Africa Regional Office, Nairobi, Kenya
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40
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Alva S, Davis N, Stan L, Pivato I, Sanderson J. Conducting mixed-methods research with Ebola survivors in a complex setting in Sierra Leone. BMC Public Health 2020; 20:1346. [PMID: 32883281 PMCID: PMC7470604 DOI: 10.1186/s12889-020-09469-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 08/28/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In late 2015, the Sierra Leone government established the Comprehensive Program for Ebola Survivors (CPES) to improve the well-being of 3466 registered Ebola virus disease (EVD) survivors. This case analysis outlines the challenges of conducting research studies on the health situation of these EVD survivors in a complicated, post-Ebola context. It outlines strategies to address these challenges without compromising research quality. The mixed-methods study sought to determine EVD survivors' access to health services offered through CPES, their health and disability status, and psychosocial and mental health issues faced. Qualitative data from survivors and stakeholders at multiple levels complemented and contextualized the survey results to help understand the unique health and associated socioeconomic challenges that EVD survivors face, which could be applied to other crisis settings. Study findings indicated that CPES had lasting impacts on Sierra Leone's health system, enabling it to respond to EVD survivors, who increasingly accessed health services and showed lower levels of disability after receiving care. DISCUSSION Understanding the health service needs of this specialized population in a country with an overloaded health system after the Ebola epidemic makes this research study important and timely. The study faced several challenges, including working in a low-resource and low-capacity setting marked by constantly changing priorities and activities of CPES donors and implementers. Further, the study aimed to measure sensitive topics, such as mental health and disability, with standardized tools that required careful contextualization for accurate reporting of findings. Strategies to overcome these challenges included utilizing a mixed-methods approach to contextualize and validate survey results. The study also enabled capacity building of local research teams to ensure that they could follow lines of inquiry and navigate the complex post-Ebola context. CONCLUSIONS Flexibility is paramount when conducting high-quality research for representative and useful results. Timely research and ongoing sharing of the findings with stakeholders is critical to ensure that they benefit study subjects. Furthermore, in such settings, there is a need to balance engagement of stakeholders with maintaining independence and impartiality in the research design and subsequent data produced.
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41
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Jalloh MF, Kaiser R, Diop M, Jambai A, Redd JT, Bunnell RE, Castle E, Alpren C, Hersey S, Ekström AM, Nordenstedt H. National reporting of deaths after enhanced Ebola surveillance in Sierra Leone. PLoS Negl Trop Dis 2020; 14:e0008624. [PMID: 32810138 PMCID: PMC7480832 DOI: 10.1371/journal.pntd.0008624] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 09/09/2020] [Accepted: 07/22/2020] [Indexed: 11/18/2022] Open
Abstract
Background Sierra Leone experienced the largest documented epidemic of Ebola Virus Disease in 2014–2015. The government implemented a national tollfree telephone line (1-1-7) for public reporting of illness and deaths to improve the detection of Ebola cases. Reporting of deaths declined substantially after the epidemic ended. To inform routine mortality surveillance, we aimed to describe the trends in deaths reported to the 1-1-7 system and to quantify people’s motivations to continue reporting deaths after the epidemic. Methods First, we described the monthly trends in the number of deaths reported to the 1-1-7 system between September 2014 and September 2019. Second, we conducted a telephone survey in April 2017 with a national sample of individuals who reported a death to the 1-1-7 system between December 2016 and April 2017. We described the reported deaths and used ordered logistic regression modeling to examine the potential drivers of reporting motivations. Findings Analysis of the number of deaths reported to the 1-1-7 system showed that 12% of the expected deaths were captured in 2017 compared to approximately 34% in 2016 and over 100% in 2015. We interviewed 1,291 death reporters in the survey. Family members reported 56% of the deaths. Nearly every respondent (94%) expressed that they wanted the 1-1-7 system to continue. The most common motivation to report was to obey the government’s mandate (82%). Respondents felt more motivated to report if the decedent exhibited Ebola-like symptoms (adjusted odds ratio 2.3; 95% confidence interval 1.8–2.9). Conclusions Motivation to report deaths that resembled Ebola in the post-outbreak setting may have been influenced by knowledge and experiences from the prolonged epidemic. Transitioning the system to a routine mortality surveillance tool may require a robust social mobilization component to match the high reporting levels during the epidemic, which exceeded more than 100% of expected deaths in 2015. By November 2015 when the World Health Organization declared the Ebola epidemic in Sierra Leone to be over, approximately 95% of the population had become aware of the risk of Ebola transmission linked to physical contact with infected corpses, especially during traditional burials. Enhanced Ebola surveillance was implemented between November 2015 and June 2016, i.e. after the epidemic had officially ended to improve detection of possible new cases. Reporting to the 1-1-7 system declined nationally after enhanced Ebola surveillance ended even though the Government of Sierra Leone continued to mandate that all deaths must be reported. Based on a request from the Sierra Leone Ministry of Health and Sanitation, we conducted a telephone survey with a national sample of people who had reported a death in 2017 after the end of enhanced surveillance to understand their motivations for reporting and describe the deaths that they reported. In addition, we analyzed the five-year trends (2014–2019) in the number of deaths reported through the system. Analysis of monthly summary data of deaths reported showed that on the last month of enhanced surveillance, 3,851 deaths were reported compared to 2,456 deaths in the month immediately after (July 2016). The monthly numbers of reported deaths continued to plummet and reached as low as 1,550 in January 2017, 673 in January 2018, and 586 in January 2019. In the survey, we uncovered that people who reported deaths were mainly motivated to do so in order to comply with the Government’s mandate. After adjusting for potential confounders, motivations to report were strongly associated with the presence of Ebola-like symptoms in the decedent. Additional investigations are needed to unveil reporting barriers among people who failed to report household deaths to the 1-1-7 system to optimize reporting levels. It has been shown that during the Ebola epidemic that it is possible to reach high levels of death reporting in Sierra Leone as exemplified by the fact that in 2015 more than 100% of the expected deaths nationally were reported; albeit not counting potential duplicates. The post-Ebola-outbreak setting provides a unique opportunity to improve future overall mortality surveillance in Sierra Leone and contribute to the establishment of civil registration of vital statistics.
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Affiliation(s)
- Mohamed F. Jalloh
- Division of Global Health Protection, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- * E-mail:
| | - Reinhard Kaiser
- Division of Global Health Protection, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | | | - Amara Jambai
- Ministry of Health and Sanitation, Freetown, Sierra Leone
| | - John T. Redd
- Division of Global Health Protection, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Rebecca E. Bunnell
- Division of Global Health Protection, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | | | - Charles Alpren
- Division of Global Health Protection, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Sara Hersey
- Division of Global Health Protection, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Anna Mia Ekström
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Helena Nordenstedt
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
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42
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Vallès X, Stenseth NC, Demeure C, Horby P, Mead PS, Cabanillas O, Ratsitorahina M, Rajerison M, Andrianaivoarimanana V, Ramasindrazana B, Pizarro-Cerda J, Scholz HC, Girod R, Hinnebusch BJ, Vigan-Womas I, Fontanet A, Wagner DM, Telfer S, Yazdanpanah Y, Tortosa P, Carrara G, Deuve J, Belmain SR, D’Ortenzio E, Baril L. Human plague: An old scourge that needs new answers. PLoS Negl Trop Dis 2020; 14:e0008251. [PMID: 32853251 PMCID: PMC7451524 DOI: 10.1371/journal.pntd.0008251] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Yersinia pestis, the bacterial causative agent of plague, remains an important threat to human health. Plague is a rodent-borne disease that has historically shown an outstanding ability to colonize and persist across different species, habitats, and environments while provoking sporadic cases, outbreaks, and deadly global epidemics among humans. Between September and November 2017, an outbreak of urban pneumonic plague was declared in Madagascar, which refocused the attention of the scientific community on this ancient human scourge. Given recent trends and plague's resilience to control in the wild, its high fatality rate in humans without early treatment, and its capacity to disrupt social and healthcare systems, human plague should be considered as a neglected threat. A workshop was held in Paris in July 2018 to review current knowledge about plague and to identify the scientific research priorities to eradicate plague as a human threat. It was concluded that an urgent commitment is needed to develop and fund a strong research agenda aiming to fill the current knowledge gaps structured around 4 main axes: (i) an improved understanding of the ecological interactions among the reservoir, vector, pathogen, and environment; (ii) human and societal responses; (iii) improved diagnostic tools and case management; and (iv) vaccine development. These axes should be cross-cutting, translational, and focused on delivering context-specific strategies. Results of this research should feed a global control and prevention strategy within a "One Health" approach.
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Affiliation(s)
- Xavier Vallès
- Epidemiology and Clinical Research Unit, Institut Pasteur de Madagascar, Antananarivo, Madagascar
| | - Nils Chr. Stenseth
- Centre for Ecological and Evolutionary Synthesis (CEES), Department of Biosciences, University of Oslo, Oslo, Norway
- Key Laboratory for Earth System Modelling, Department of Earth System Science, Tsinghua University, Beijing, China
| | - Christian Demeure
- Yersinia Research Unit, National Reference Centre “Plague & Other Yersinioses,” WHO Collaborating Research and Reference Centre for Yersinia, Institut Pasteur, Paris, France
| | - Peter Horby
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Paul S. Mead
- Bacterial Diseases Branch, Division of Vector Borne Diseases, Centers for Disease Control and Prevention, Fort Collins, Colorado, United States of America
| | - Oswaldo Cabanillas
- Control de Epidemia Desastres y Otras Emergencias Sanitarias, Oficina General de Epidemiologia, Ministerio de Salud, Perúu
| | - Mahery Ratsitorahina
- Epidemiology and Clinical Research Unit, Institut Pasteur de Madagascar, Antananarivo, Madagascar
| | - Minoarisoa Rajerison
- Plague Unit, Central Laboratory for Plague, Institut Pasteur de Madagascar, Antananarivo, Madagascar
| | | | - Beza Ramasindrazana
- Plague Unit, Central Laboratory for Plague, Institut Pasteur de Madagascar, Antananarivo, Madagascar
| | - Javier Pizarro-Cerda
- Yersinia Research Unit, National Reference Centre “Plague & Other Yersinioses,” WHO Collaborating Research and Reference Centre for Yersinia, Institut Pasteur, Paris, France
| | - Holger C. Scholz
- Reference Laboratory for Plague, Bundeswehr Institute of Microbiology, Munich, Germany
| | - Romain Girod
- Medical Entomology Unit, Institut Pasteur de Madagascar, Antananarivo, Madagascar
| | - B. Joseph Hinnebusch
- Rocky Mountain Laboratories, National Institute of Health, National Institutes of Allergy and Infectious Diseases, Hamilton, Montana, United States of America
| | - Ines Vigan-Womas
- Immunology of Infectious Diseases Unit, Institut Pasteur de Madagascar, Antananarivo, Madagascar
| | - Arnaud Fontanet
- Emerging Diseases Epidemiology Unit, Institut Pasteur, Paris, France
- PACRI unit, Conservatoire National des Arts et Métiers, Paris, France
| | - David M. Wagner
- The Pathogen and Microbiome Institute, Northern Arizona University, Flagstaff, Arizona, United States of America
| | - Sandra Telfer
- School of Biological Sciences, University of Aberdeen, Aberdeen, United Kingdom
| | - Yazdan Yazdanpanah
- REACTing, Inserm, Université Paris-Diderot, Sorbonne Paris Cité, Paris, France
- Service de Maladies Infectieuses et Tropicales, Hôpital Bichat-Claude Bernard, AP-HP, Paris, France
| | - Pablo Tortosa
- Université de La Réunion, Unité Mixte de Recherche Processus Infectieux en Milieu Insulaire Tropical, La Réunion, France
| | - Guia Carrara
- REACTing, Inserm, Université Paris-Diderot, Sorbonne Paris Cité, Paris, France
| | - Jane Deuve
- Department of International Affairs, Institut Pasteur, Paris, France
| | - Steven R. Belmain
- Natural Resources Institute, University of Greenwich, Chatham Maritime, Kent, United Kingdom
| | - Eric D’Ortenzio
- REACTing, Inserm, Université Paris-Diderot, Sorbonne Paris Cité, Paris, France
- Service de Maladies Infectieuses et Tropicales, Hôpital Bichat-Claude Bernard, AP-HP, Paris, France
| | - Laurence Baril
- Epidemiology and Clinical Research Unit, Institut Pasteur de Madagascar, Antananarivo, Madagascar
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Prevalence of mental health problems in populations affected by the Ebola virus disease: A systematic review and meta-analysis. Psychiatry Res 2020; 289:113033. [PMID: 32388176 DOI: 10.1016/j.psychres.2020.113033] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 04/21/2020] [Accepted: 04/22/2020] [Indexed: 12/31/2022]
Abstract
Studies have shown that, in addition to being associated with a high mortality rate, Ebola Virus Disease (EVD) is also related with mental health problems. This study aimed to determine prevalence of mental health problems and associated factors among survivors and individuals affected by EVD. A systematic review of peer-reviewed empirical studies was conducted using EMBASE, PubMed, PsycINFO and PsyARTICLES. A random effects meta-analysis was performed on the proportions of people diagnosed with depression after an EVD outbreak. Of 205 studies initially identified, 21 were included in the systematic review and 10 in the meta-analysis. Results indicated that EVD is associated with depression, anxiety, post-traumatic stress disorder, obsessive-compulsive disorder, among others. Results revealed that one person out of five affected to EVD has been diagnosed with depression (standardized mean difference 19.92%, 95% CI 10.43%; 34.70). The I2 provided evidence of heterogeneity in the results. This study demonstrated the evidence of the impact of EVD on the mental health of survivors and individuals affected by EVD. Further studies should consider the mental health consequences of EVD to plan culturally sensitive prevention and intervention programs based on the experience of communities affected by EVD.
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Secor A, Macauley R, Stan L, Kagone M, Sidikiba S, Sow S, Aronovich D, Litvin K, Davis N, Alva S, Sanderson J. Mental health among Ebola survivors in Liberia, Sierra Leone and Guinea: results from a cross-sectional study. BMJ Open 2020; 10:e035217. [PMID: 32461296 PMCID: PMC7259862 DOI: 10.1136/bmjopen-2019-035217] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVES To describe the prevalence and correlates of depression and anxiety among adult Ebola virus disease (EVD) survivors in Liberia, Sierra Leone and Guinea. DESIGN Cross-sectional. SETTING One-on-one surveys were conducted in EVD-affected communities in Liberia, Sierra Leone and Guinea in early 2018. PARTICIPANTS 1495 adult EVD survivors (726 male, 769 female). PRIMARY AND SECONDARY OUTCOME MEASURES Patient Health Questionnaire-9 (PHQ-9) depression scores and Generalised Anxiety Disorder-7 (GAD-7) scores. RESULTS Prevalence and severity of depression and anxiety varied across the three countries. Sierra Leone had the highest prevalence of depression, with 22.0% of participants meeting the criteria for a tentative diagnosis of depression, compared with 20.2% in Liberia and 13.0% in Guinea. Sierra Leone also showed the highest prevalence of anxiety, with 10.7% of participants meeting criteria for generalized anxiety disorder (GAD-7 score ≥10), compared with 9.9% in Liberia and 4.2% in Guinea. Between one-third and one-half of respondents reported little interest or pleasure in doing things in the previous 2 weeks (range: 47.0% in Liberia to 37.6% in Sierra Leone), and more than 1 in 10 respondents reported ideation of self-harm or suicide (range: 19.4% in Sierra Leone to 10.4% in Guinea). Higher depression and anxiety scores were statistically significantly associated with each other and with experiences of health facility-based stigma in all three countries. Other associations between mental health scores and respondent characteristics varied across countries. CONCLUSIONS Our results indicate that both depression and anxiety are common among EVD survivors in Liberia, Sierra Leone and Guinea, but that there is country-level heterogeneity in prevalence, severity and correlates of these conditions. All three countries should work to make mental health services available for survivors, and governments and organisations should consider the intersection between EVD-related stigma and mental health when designing programmes and training healthcare providers.
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Affiliation(s)
- Andrew Secor
- JSI Research and Training Institute Inc, Monrovia, Liberia
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Rose Macauley
- JSI Research and Training Institute Inc, Monrovia, Liberia
| | - Laurentiu Stan
- JSI Research and Training Institute Inc, Freetown, Sierra Leone
| | - Meba Kagone
- JSI Research and Training Institute Inc, Conakry, Guinea
| | | | - Sadou Sow
- JSI Research and Training Institute Inc, Conakry, Guinea
| | - Dana Aronovich
- JSI Research and Training Institute Inc, Arlington, Virginia, USA
| | - Kate Litvin
- JSI Research and Training Institute Inc, Arlington, Virginia, USA
| | - Nikki Davis
- JSI Research and Training Institute Inc, Arlington, Virginia, USA
| | - Soumya Alva
- JSI Research and Training Institute Inc, Arlington, Virginia, USA
| | - Jeff Sanderson
- JSI Research and Training Institute Inc, Arlington, Virginia, USA
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Badrfam R, Zandifar A. Stigma Over COVID-19; New Conception Beyond Individual Sense. Arch Med Res 2020; 51:593-594. [PMID: 32467051 PMCID: PMC7237948 DOI: 10.1016/j.arcmed.2020.05.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 05/14/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Rahim Badrfam
- Psychiatry Department, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Atefeh Zandifar
- Social Determinants of Health Research Center, Alborz University of Medical Sciences, Karaj, Iran.
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Marí Sáez A, Ronse M, Delamou A, Haba N, Bigey F, van Griensven J, Peeters Grietens K. The Plasma Mobile, 'A gift from heaven': The impact of health technology transfer on trial perceptions and expectations during the Ebola-Tx Trial, Conakry. PLoS Negl Trop Dis 2020; 14:e0008206. [PMID: 32320398 PMCID: PMC7176081 DOI: 10.1371/journal.pntd.0008206] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 03/10/2020] [Indexed: 01/22/2023] Open
Abstract
During the West African Ebola Virus Disease (EVD) epidemic from 2014 to 2016, a variety of technologies travelled considering the context of the emergency: a highly contagious fast-killing disease outbreak with no known remedy and a rapidly increasing number of cases. The Ebola-Tx clinical trial tested the efficacy of Convalescent Plasma (CP) as a treatment for EVD in Guinea. This paper is based on ethnographic research in the Ebola-Tx trial and focuses on the introduction of a mobile plasma collection centre, referred to as the 'Plasma Mobile', equipped with plasmapheresis and pathogen inactivation technologies, as well as how the transfer itself of this technology entailed complex effects on CP donors as trial participants (i.e. providers of the therapeutic product), directly involved staff and more broadly on the trial implementation as a whole. The transfer led to the emergence of a dimension of hope as CP donors hoped that the plasma would cure and, as providers of the therapeutic, hoped it would decrease their stigmatization and the economic impact of the disease. We conclude that, in light of the intricate effects that the transfer of such health technology can entail-in the localization to the specific context, as well as in the consequences they can have on actors involved in the implementation of such technologies-global health technologies should be put at the services of next epidemic and pandemic (preparedness) on condition that they are accompanied by an understanding of the technologies' own cultural meanings and social understandings.
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Affiliation(s)
- Almudena Marí Sáez
- Robert Koch Institute, Center for International Health Protection, Berlin, Germany
- Institute of Tropical Medicine, Medical Anthropology Unit, Department of Public Health, Antwerp, Belgium
| | - Maya Ronse
- Institute of Tropical Medicine, Medical Anthropology Unit, Department of Public Health, Antwerp, Belgium
| | - Alexandre Delamou
- Centre National de Formation et de Recherche en Santé Rurale de Maferinyah, Forécariah, Guinée
- Centre d’Excellence Africain pour la prévention et le contrôle des maladies transmissibles (CEA-PCMT), Faculty of health Sciences and Techniques, University Gamal Abdel Nasser of Conakry, Conakry, Guinea
| | - Nyankoye Haba
- Centre d’Excellence Africain pour la prévention et le contrôle des maladies transmissibles (CEA-PCMT), Faculty of health Sciences and Techniques, University Gamal Abdel Nasser of Conakry, Conakry, Guinea
- Centre National de Transfusion sanguine, Conakry, Guinea
| | - Frédéric Bigey
- Établissement Français du Sang Grand-Est, Strasbourg, France
| | - Johan van Griensven
- Institute of Tropical Medicine, HIV and Neglected Tropical Diseases Unit, Department of Clinical Sciences, Antwerp, Belgium
| | - Koen Peeters Grietens
- Institute of Tropical Medicine, Medical Anthropology Unit, Department of Public Health, Antwerp, Belgium
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James PB, Wardle J, Steel A, Adams J. Ebola survivors' healthcare-seeking experiences and preferences of conventional, complementary and traditional medicine use: A qualitative exploratory study in Sierra Leone. Complement Ther Clin Pract 2020; 39:101127. [PMID: 32379665 DOI: 10.1016/j.ctcp.2020.101127] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Revised: 02/27/2020] [Accepted: 02/28/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND and Purpose: This study explores Ebola survivors' healthcare-seeking experiences within the context of Sierra Leone's free healthcare initiative (FHCI) and comprehensive package for Ebola survivors (CPES) program while also exploring the enablers and barriers to their use of informal healthcare. MATERIALS AND METHODS We employed an inductive, exploratory qualitative approach using focus group discussion with 41 adults Ebola survivors in the four administrative regions of Sierra Leone. RESULTS Biomedical care was the first choice of treatment option for most survivors immediately following post-ETC discharge. Survivors' healthcare-seeking experience varies before and after their inclusion into FHCI and the establishment of the CPES program. Personal and health system factors influenced survivors' decision to seek multiple healthcare approaches, especially T&CM. CONCLUSION Our findings suggest the determinants of Ebola survivors' healthcare-seeking experiences should be considered when developing and implementing programs aimed at improving the current health status of Ebola survivors in Sierra Leone.
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Affiliation(s)
- Peter Bai James
- Australian Research Centre in Complementary and Integrative Medicine, Faculty of Health, University of Technology Sydney, Ultimo, NSW, 2007, Sydney, Australia; Faculty of Pharmaceutical Sciences, College of Medicine and Allied Health Sciences, University of Sierra Leone, Sierra Leone.
| | - Jon Wardle
- Australian Research Centre in Complementary and Integrative Medicine, Faculty of Health, University of Technology Sydney, Ultimo, NSW, 2007, Sydney, Australia; National Centre for Naturopathic Medicine, Southern Cross University, Lismore, NSW, 2480, Australia
| | - Amie Steel
- Australian Research Centre in Complementary and Integrative Medicine, Faculty of Health, University of Technology Sydney, Ultimo, NSW, 2007, Sydney, Australia
| | - Jon Adams
- Australian Research Centre in Complementary and Integrative Medicine, Faculty of Health, University of Technology Sydney, Ultimo, NSW, 2007, Sydney, Australia
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Witter S, Zou G, Diaconu K, Senesi RGB, Idriss A, Walley J, Wurie HR. Opportunities and challenges for delivering non-communicable disease management and services in fragile and post-conflict settings: perceptions of policy-makers and health providers in Sierra Leone. Confl Health 2020; 14:3. [PMID: 31921333 PMCID: PMC6945746 DOI: 10.1186/s13031-019-0248-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 12/24/2019] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND The growing burden of non-communicable diseases in low- and middle-income countries presents substantive challenges for health systems. This is also the case in fragile, post-conflict and post-Ebola Sierra Leone, where NCDs represent an increasingly significant disease burden (around 30% of adult men and women have raised blood pressure). To date, documentation of health system challenges and opportunities for NCD prevention and control is limited in such settings. This paper aims to identify opportunities and challenges in provision of NCD prevention and care and highlight lessons for Sierra Leone and other fragile states in the battle against the growing NCD epidemic. METHODS This paper focuses on the case of Sierra Leone and uses a combination of participatory group model building at national and district level, in rural and urban districts, interviews with 28 key informants and review of secondary data and documents. Data is analysed using the WHO's health system assessment guide for NCDs. RESULTS We highlight multiple challenges typical to those encountered in other fragile settings to the delivery of preventive and curative NCD services. There is limited government and donor commitment to financing and implementation of the national NCD policy and strategy, limited and poorly distributed health workforce and pharmaceuticals, high financial barriers for users, and lack of access to quality-assured medicines with consequent high recourse to private and informal care seeking. We identify how to strengthen the system within existing (low) resources, including through improved clinical guides and tools, more effective engagement with communities, and regulatory and fiscal measures. CONCLUSION Our study suggests that NCD prevention and control is of low but increasing priority in Sierra Leone; challenges to addressing this burden relate to huge numbers with NCDs (especially hypertension) requiring care, overall resource constraints and wider systemic issues, including poorly supported primary care services and access barriers. In addition to securing and strengthening political will and commitment and directing more resources and attention towards this area, there is a need for in-depth exploratory and implementation research to shape and test NCD interventions in fragile and post-conflict settings.
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Affiliation(s)
- Sophie Witter
- Institute for Global Health and Development, Queen Margaret University, Edinburgh, UK
| | - Guanyang Zou
- School of Economics and Management, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Karin Diaconu
- Institute for Global Health and Development, Queen Margaret University, Edinburgh, UK
| | - Reynold G. B. Senesi
- Directorate of Non-Communicable Diseases and Mental Health, Ministry of Health and Sanitation of Sierra Leone, Freetown, Sierra Leone
| | - Ayesha Idriss
- Institute for Global Health and Development, Queen Margaret University, Edinburgh, UK
| | - John Walley
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, UK
| | - Haja Ramatulai Wurie
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
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Masumbuko Claude K, Underschultz J, Hawkes MT. Social resistance drives persistent transmission of Ebola virus disease in Eastern Democratic Republic of Congo: A mixed-methods study. PLoS One 2019; 14:e0223104. [PMID: 31557243 PMCID: PMC6762146 DOI: 10.1371/journal.pone.0223104] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 09/14/2019] [Indexed: 11/18/2022] Open
Abstract
Background The second largest Ebola virus disease (EVD) epidemic in history is currently raging in Eastern Democratic Republic of Congo (DRC). Stubbornly persistent EVD transmission has been associated with social resistance, ranging from passive non-compliance to overt acts of aggression toward EVD reponse teams. Methods We explored community resistance using focus group discussions and assessed the prevalence of resistant views using standardized questionnaires. Results Despite being generally cooperative and appreciative of the EVD response (led by the government of DRC with support from the international community), focus group participants provided eyewitness accounts of aggressive resistance to control efforts, consistent with recent media reports. Mistrust of EVD response teams was fueled by perceived inadequacies of the response effort (“herd medicine”), suspicion of mercenary motives, and violation of cultural burial mores (“makeshift plastic morgue”). Survey questionnaires found that the majority of respondents had compliant attitudes with respect to EVD control. Nonetheless, 78/630 (12%) respondents believed that EVD was fabricated and did not exist in the area, 482/630 (72%) were dissatisfied with or mistrustful of the EVD response, and 60/630 (9%) sympathized with perpetrators of overt hostility. Furthermore, 102/630 (15%) expressed non-compliant intentions in the case of EVD illness or death in a family member, including hiding from the health authorities, touching the body, or refusing to welcome an official burial team. Denial of the biomedical discourse and dissatisfaction/mistrust of the EVD response were statistically significantly associated with indicators of social resistance. Conclusions We concluded that social resistance to EVD control efforts was prevalent among focus group and survey participants. Mistrust, with deep political and historical roots in this area besieged by chronic violence and neglected by the outside world, may fuel social resistance. Resistant attitudes may be refractory to short-lived community engagement efforts targeting the epidemic but not the broader humanitarian crisis in Eastern DRC.
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Affiliation(s)
| | | | - Michael T. Hawkes
- Department of Pediatrics, University of Alberta, Edmonton, Canada
- Department of Medical Microbiology and Immunology, University of Alberta, Edmonton, Canada
- Department of Global Health, School of Public Health, University of Alberta, Edmonton, Canada
- * E-mail:
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50
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Stolka KB, Ngoyi BF, Grimes KEL, Hemingway-Foday JJ, Lubula L, Nzanzu Magazani A, Bikuku J, Mossoko M, Manya Kitoto L, Mpangi Bashilebo S, Lufwa Maya D, Kebela Ilunga B, Rhea S, MacDonald PDM. Assessing the Surveillance System for Priority Zoonotic Diseases in the Democratic Republic of the Congo, 2017. Health Secur 2019; 16:S44-S53. [PMID: 30480506 DOI: 10.1089/hs.2018.0060] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
High-functioning communicable disease surveillance systems are critical for public health preparedness. Countries that cannot quickly detect and contain diseases are a risk to the global community. The ability of all countries to comply with the International Health Regulations is paramount for global health security. Zoonotic diseases can be particularly dangerous for humans. We conducted a surveillance system assessment of institutional and individual capacity in Kinshasa and Haut Katanga provinces in the Democratic Republic of the Congo for nationally identified priority zoonotic diseases (eg, viral hemorrhagic fever [VHF], yellow fever, rabies, monkeypox, and influenza monitored through acute respiratory infections). Data were collected from 79 health workers responsible for disease surveillance at 2 provincial health offices, 9 health zone offices, 9 general reference hospitals, and 18 health centers and communities. A set of questionnaires was used to assess health worker training in disease surveillance methods; knowledge of case definitions; availability of materials and tools to support timely case detection, reporting, and data interpretation; timeliness and completeness of reporting; and supervision from health authorities. We found that health workers either had not been recently or ever trained in surveillance methods and that their knowledge of case definitions was low. Timeliness and completeness of weekly notification of epidemic-prone diseases was generally well performed, but the lack of available standardized reporting forms and archive of completed forms affected the quality of data collected. Lessons learned from our assessment can be used for targeted strengthening efforts to improve global health security.
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Affiliation(s)
- Kristen B Stolka
- Kristen B. Stolka, MPH, is a Research Public Health Analyst, Biostatistics and Epidemiology, RTI International, Durham, North Carolina
| | - Bonaventure Fuamba Ngoyi
- Bonaventure Fuamba Ngoyi, MD, MPH-FELTP, is a Surveillance Officer, Biostatistics and Epidemiology, RTI International, Durham, North Carolina
| | - Kathyrn E L Grimes
- Kathyrn E. L. Grimes, MPH, is a Research Public Health Analyst, Biostatistics and Epidemiology, RTI International, Durham, North Carolina
| | - Jennifer J Hemingway-Foday
- Jennifer J. Hemingway-Foday, MPH, is a Research Epidemiologist, Biostatistics and Epidemiology, RTI International, Durham, North Carolina
| | - Leopold Lubula
- Leopold Lubula, MD, MPH-FELTP, is a Surveillance Manager, the Directorate of Disease Control, Ministry of Public Health, Kinshasa, Democratic Republic of the Congo
| | - Alain Nzanzu Magazani
- Alain Nzanzu Magazani, MD, MPH-FELTP, is a Technical Expert, the Directorate of Disease Control, Ministry of Public Health, Kinshasa, Democratic Republic of the Congo
| | - Joseph Bikuku
- Joseph Bikuku, MD, MPH, is a Technical Expert, the Directorate of Disease Control, Ministry of Public Health, Kinshasa, Democratic Republic of the Congo
| | - Mathias Mossoko
- Mathias Mossoko, MSc, is an Epidemiologist and Data Manager, the Directorate of Disease Control, Ministry of Public Health, Kinshasa, Democratic Republic of the Congo
| | - Leonie Manya Kitoto
- Leonie Manya Kitoto, MD, MPH, is a Technical Expert, the Directorate of Disease Control, Ministry of Public Health, Kinshasa, Democratic Republic of the Congo
| | - Sylvie Mpangi Bashilebo
- Sylvie Mpangi Bashilebo, MSc, is an Epidemiologist and Surveillance Supervisor, the Directorate of Disease Control, Ministry of Public Health, Kinshasa, Democratic Republic of the Congo
| | - Dieudonné Lufwa Maya
- Dieudonné Lufwa Maya, MD, MPH, is a Database Analyst, the Directorate of Disease Control, Ministry of Public Health, Kinshasa, Democratic Republic of the Congo
| | - Benoit Kebela Ilunga
- Benoit Kebela Ilunga, MD, MPH, is Director, the Directorate of Disease Control, Ministry of Public Health, Kinshasa, Democratic Republic of the Congo
| | - Sarah Rhea
- Sarah Rhea, DVM, PhD, is a Research Epidemiologist, Biostatistics and Epidemiology, RTI International, Durham, North Carolina
| | - Pia D M MacDonald
- Pia D. M. MacDonald, PhD, CPH, is a Senior Epidemiologist, Biostatistics and Epidemiology, RTI International, Durham, North Carolina
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