What adaptation to research is needed following crises: a comparative, qualitative study of the health workforce in Sierra Leone and Nepal

Responding to fluctuations in public and community trust and health seeking behaviour during the COVID-19 pandemic: a qualitative study of national decision-makers' perspectives in Guinea and Sierra Leone

BACKGROUND

The level of trust in health systems is often in flux during public health emergencies and presents challenges in providing adequate health services and preventing the spread of disease. Experiences during previous epidemics has shown that lack of trust can impact the continuity of essential health services and response efforts. Guinea and Sierra Leone were greatly challenged by a lack of trust in the system during the Ebola epidemic. We thus sought to investigate what was perceived to influence public and community trust in the health system during the COVID-19 pandemic, and what strategies were employed by national level stakeholders in order to maintain or restore trust in the health system in Guinea and Sierra Leone.

METHODS

This qualitative study was conducted through a document review and key informant interviews with actors involved in COVID-19 and/or in malaria control efforts in Guinea and Sierra Leone. Key informants were selected based on their role and level of engagement in the national level response. Thirty Six semi-structured interviews (16 in Guinea, 20 in Sierra Leone) were recorded, transcribed, and analyzed using an inductive and deductive framework approach to thematic analysis.

RESULTS

Key informants described three overarching themes related to changes in trust and health seeking behavior due to COVID-19: (1) reignited fear and uncertainty among the population, (2) adaptations to sensitization and community engagement efforts, and (3) building on the legacy of Ebola as a continuous process. Communication, community engagement, and on-going support to health workers were reiterated as crucial factors for maintaining trust in the health system.

CONCLUSION

Lessons from the Ebola epidemic enabled response actors to consider maintaining and rebuilding trust as a core aim of the pandemic response which helped to ensure continuity of care and mitigate secondary impacts of the pandemic. Monitoring and maintaining trust in health systems is a key consideration for health systems resilience during public health emergencies.

From policy to practice: a qualitive study exploring the role of community health workers during the COVID-19 response in Sierra Leone

BACKGROUND

During the COVID-19 pandemic, community health workers (CHWs) were required to help their communities respond to the outbreak in Sierra Leone. The Government of Sierra Leone released a policy that provided an interim guidance on the specific role of CHWs during the pandemic including support required to maintain continuity of routine and essential services during the COVID-19 response. This study explores how CHWs adapted their roles during the COVID-19 pandemic in Sierra Leone and the support they received from families, communities, and the health system.

METHODS

A qualitative exploratory study was conducted in two districts in Sierra Leone. We conducted eight key informant interviews with district and community level managers and leaders and four focus group discussions with CHWs. Thematic data analysis and synthesis were guided by the interim guidance released by the Government of Sierra Leone at the onset of the COVID-19 pandemic and supported by NVivo 11.

RESULTS

CHWs quickly took on COVID-19 frontline roles which included surveillance, contact tracing, social mobilization, and provision of psychosocial support. CHWs were trusted with these responsibilities as they were recognized as being knowledgeable about the community, were able to communicate effectively with community members and had experience of dealing with other outbreaks. Despite the release of the interim guidance aimed to optimize CHW contribution, motivate CHWs, ensure continuity of core and essential community-based services alongside COVID-19 services, CHWs faced many challenges in their work during the pandemic including heavy workload, low financial remuneration, lack of mental health support, and shortages of protective equipment, communication and transportation allowances. However, they were generally satisfied with the quality of the training and supervision they received. Support from families and communities was mixed, with some CHWs experiencing stigma and discrimination.

CONCLUSION

During the COVID-19 pandemic, CHWs played a critical role in Sierra Leone. Although, a policy was released by the government to guide their role during the crisis, it was not fully implemented. This resulted in CHWs being overworked and under supported. It is important that CHWs are provided with the necessary training, tools and support to take on their vital roles in managing health crises at the community level. Strengthening the capacity of CHWs will not only enhance pandemic response, but also lay the foundation for improved primary health care delivery and community resilience in the face of future health emergencies.

A management perspective on resilience in healthcare: a framework and avenues for future research

Recent major health shocks, such as the 2014-16 Ebola, the Zika outbreak, and, last but not least, the COVID-19 pandemic, have strongly contributed to drawing attention to the issue of resilience in the healthcare domain. Nevertheless, the scientific literature appears fragmented, creating difficulties in developing incremental research in this relevant managerial field.To fill this gap, this systematic literature review aims to provide a clear state of the art of the literature dealing with resilience in healthcare. Specifically, from the analysis of the theoretical articles and reviews, the key dimensions of resilience are identified, and a novel classification framework is proposed. The classification framework is then used to systematize extant empirical contributions. Two main dimensions of resilience are identified: the approach to resilience (reactive vs. proactive) and the type of crisis to deal with (acute shocks vs. chronic stressors). Four main streams of research are thus identified: (i) proactive approaches to acute shocks; (ii) proactive approaches to chronic stressors; (iii) reactive approaches to acute shocks; and (iv) reactive approaches to chronic stressors. These are scrutinised considering three additional dimensions: the level of analysis, the resources to nurture resilience, and the country context. The classification framework and the associated mapping contribute to systematising the fragmented literature on resilience in healthcare, providing a clear picture of the state of the art in this field and drawing a research agenda that opens interesting paths for future research.

Human preparedness: Relational infrastructures and medical countermeasures in Sierra Leone

This paper examines health worker experiences in two areas of post-epidemic preparedness in Sierra Leone - vaccine trials and laboratory strengthening - to reflect on the place of people in current models of epidemic response. Drawing on ethnographic research and interviews with health workers in the aftermath of Ebola, it explores the hopes and expectations that interventions foster for frontline workers in under-resourced health systems, and describes the unseen work involved in sustaining robust response infrastructures. Our analysis focuses on what it means for the people who sustain health systems in an emergency to be 'prepared' for an epidemic. Human preparedness entails more than the presence of a labour force; it involves building and maintaining 'relational infrastructures', often fragile social and moral relationships between health workers, publics, governments, and international organisations. The COVID-19 pandemic has underscored the value of rethinking human resources from an anthropological perspective, and investing in the safety and support of people at the forefront of response. In describing the labour, personal losses, and social risks undertaken by frontline workers for protocols and practicality to meet in an emergency context, we describe the social process of preparedness; that is, the contextual engineering and investment that make response systems work.

Community response towards health care providers delivering health care services during COVID-19 pandemic: A strategy framework based on findings of a qualitative study in Odisha, India

Context

While there are studies on peoples' behaviour toward health professionals (doctors and nurses) during the Coronavirus diesease (COVID-19) pandemic in hospital settings, there is limited literature on Community Health Workers (CHWs). Our study attempted to explore the behaviour of community people towards CHWs during the pandemic and its underlying reasons.

Material and Method

A qualitative study using In-depth interviews (IDI) and focus group discussions (FGD) was conducted among CHWs and community people from six districts of Odisha from February to April 2021. The researchers transcribed the audio recordings in the vernacular language of the Odisha province, i.e., Odia, and later translated them into English. A qualitative content analysis method was used to prepare the detailed report using Max Weber Qualitative Data Analysis (MAXQDA) software.

Result

The study found two major categories-Reflection on community behaviour towards CHWs during the COVID-19 pandemic and reflection on availing health care services by community people during a pandemic. Many CHWs revealed that the community people acknowledged their work and dedication and extended all sorts of co-operation and support. However, few community people were non-cooperative and non-supportive. Community reluctance owing to perceptions that the CHWs might be infected, was the significant cause that they faced a lack of support from the community. Further, to create awareness of COVID-19 infection among community people, CHWs adopted different strategies such as door-to-door visits, wall painting, poster display, and awareness through mikes.

Conclusion

The efforts made by the CHWs during health emergencies need to be recognized and appraised.

Factors influencing medical and nursing students' willingness to care for COVID-19 patients in South Korea: a cross-sectional study

BACKGROUND

The COVID-19 pandemic has threatened the stability and adequacy of the global healthcare system. In this situation, authorities have considered engaging medical and nursing students to address the shortage of frontline healthcare workers. This study investigated the effect of COVID-19-related knowledge, attitudes, and preventive behaviors on medical and nursing students' willingness to care for COVID-19 patients.

METHODS

Medical and nursing students from universities in two regions of South Korea participated in this cross-sectional study. A total of 330 questionnaires were distributed; of them, 99.3% were collected, and 315 questionnaires were analyzed. Data were collected on participants' general characteristics, COVID-19-related knowledge, attitudes, and preventive behaviors, and willingness to care for COVID-19 patients.

RESULTS

In total, 66.3% of the participants were willing to care for patients during the COVID-19 pandemic. Students in higher grades and those with more clinical practice experience showed higher levels of willingness to care. Specifically, willingness to care was correlated with the senior year (OR = 3.58, 95% CI = 1.24 - 10.37, p = .019), a high level of COVID-19-related knowledge (OR = 1.03, 95% CI = 1.00 - 1.05, p = .041), an optimistic attitude that COVID-19 can be overcome (OR = 1.63, 95% CI = 1.24 - 2.14, p < .001), and increased engagement in infection prevention behaviors (OR = 1.41, 95% CI = 1.16 - 1.71, p < .001).

CONCLUSIONS

The findings indicated that a high level of knowledge regarding the COVID-19 pandemic, having an optimistic attitude, and engaging in preventive behaviors affected students' willingness to care for COVID-19 patients. Integrating disaster preparedness courses in the early years of their curriculum could increase future healthcare providers' willingness to care for patients.

Experiences of frontline healthcare workers and their views about support during COVID-19 and previous pandemics: a systematic review and qualitative meta-synthesis

BACKGROUND

Healthcare workers across the world have risen to the demands of treating COVID-19 patients, potentially at significant cost to their own health and wellbeing. There has been increasing recognition of the potential mental health impact of COVID-19 on frontline workers and calls to provide psychosocial support for them. However, little attention has so far been paid to understanding the impact of working on a pandemic from healthcare workers' own perspectives or what their views are about support.

METHODS

We searched key healthcare databases (Medline, PsychINFO and PubMed) from inception to September 28, 2020. We also reviewed relevant grey literature, screened pre-print servers and hand searched reference lists of key texts for all published accounts of healthcare workers' experiences of working on the frontline and views about support during COVID-19 and previous pandemics/epidemics. We conducted a meta-synthesis of all qualitative results to synthesise findings and develop an overarching set of themes and sub-themes which captured the experiences and views of frontline healthcare workers across the studies.

RESULTS

This review identified 46 qualitative studies which explored healthcare workers' experiences and views from pandemics or epidemics including and prior to COVID-19. Meta-synthesis derived eight key themes which largely transcended temporal and geographical boundaries. Participants across all the studies were deeply concerned about their own and/or others' physical safety. This was greatest in the early phases of pandemics and exacerbated by inadequate Personal Protective Equipment (PPE), insufficient resources, and inconsistent information. Workers struggled with high workloads and long shifts and desired adequate rest and recovery. Many experienced stigma. Healthcare workers' relationships with families, colleagues, organisations, media and the wider public were complicated and could be experienced concomitantly as sources of support but also sources of stress.

CONCLUSIONS

The experiences of healthcare workers during the COVID-19 pandemic are not unprecedented; the themes that arose from previous pandemics and epidemics were remarkably resonant with what we are hearing about the impact of COVID-19 globally today. We have an opportunity to learn from the lessons of previous crises, mitigate the negative mental health impact of COVID-19 and support the longer-term wellbeing of the healthcare workforce worldwide.

Health System Preparedness for COVID-19 and Its Impacts on Frontline Health-Care Workers in Nepal: A Qualitative Study Among Frontline Health-Care Workers and Policy-Makers

BACKGROUND

Rapidly growing coronavirus disease 2019 (COVID-19) pandemic has brought unprecedented challenges to the health system in Nepal. The main objective of this study was to explore the health system preparedness for COVID-19 and its impacts on frontline health-care workers in Nepal.

METHODS

Semi-structured interviews were conducted among 32 health-care workers who were involved in clinical care of COVID-19 patients and four policy-makers who were responsible for COVID-19 control and management at central and provincial level. Interviews were conducted through telephone or Internet-based tools such as Zoom and Skype. All interviews were audio-recorded, transcribed into English, and coded using inductive and deductive approaches.

RESULTS

Both health-care workers and policy-makers reported failure to initiate pre-emptive control measures at the early stages of the outbreak as the pivot in pandemic control. Although several measures were rolled out when cases started to appear, the overall health system preparedness was low. The poor governance, and coordination between three tiers of government was compounded by the inadequate personal protective equipment for health-care workers, insufficient isolation beds for patients, and poor engagement of the private sector. Frontline health-care workers experienced various degrees of stigma because of their profession and yet were able to maintain their motivation to continue serving patients.

CONCLUSION

Preparedness for COVID-19 was affected by the poor coordination between three tiers of governance. Specifically, the lack of human resources, inadequate logistic chain management and laboratory facilities for testing COVID-19 appeared to have jeopardized the health system preparedness and escalated the pandemic in Nepal. Despite the poor preparedness, and health and safety concerns, health-care workers maintained their motivation. There is an urgent need for an effective coordination mechanism between various tiers of health structure (including private sector) in addition to incentivizing the health-care workers for the current and future pandemics.

Iranian's healthcare system challenges during natural disasters: the qualitative case study of Kermanshah earthquake

Background

In order to the significance of lessons learned from the natural disasters for health care systems particularly in developing and under-developed countries, the main purpose of this study was to identify challenges and limitations in light of the earthquake experience in Kermanshah Province.

Methods

The present study was conducted in 2019 as a qualitative research using content analysis method. In this regard, 19 key informants were selected using snowball sampling. To enhance the accuracy of the study, the four validation criteria for qualitative studies in data coding developed by Guba and Lincoln including credibility, transferability, dependability and confirmability were used. Data was analyzed applying Graneheim and Lundman (2004) approach for analyzing the qualitative content of an interview text.

Results

Analysis of the data led to the identification of 2 main themes, 5 sub- themes and 17 main categories. The first main theme was health system oriented challenges containing challenges of medication supply and preparation, structural challenges, challenges in crisis-scene management and challenges of service delivery and the second main theme was non-health system oriented challenges including social and psychosocial challenges.

Conclusion

According to the results, along with health system oriented challenges with the inter-sectoral or intra-sectoral nature, the non-health system oriented challenges the same as social, cultural and psychological factors can be considered as the major challenges of Iran’s healthcare system in the face of crises. This complicated context can shed the light to policy makers that not only attention to the medicine and medical equipment supply chain, manpower preparation and service delivery system can be considered as an emergency, but also careful attention to the structural challenges and crisis-scene management should be planned and considered as a priority. Besides, the policy makers and the local managers should try to plan and act in a contingent situation according to the social and cultural characteristics of the region and the psychological condition and the mental needs of the people.

Community health workers for pandemic response: a rapid evidence synthesis

Introduction

Coronavirus disease (COVID-19), affects 213 countries or territories globally. We received a request from National Health Systems Resource Centre, a public agency in India, to conduct rapid evidence synthesis (RES) on community health workers (CHWs) for COVID-19 prevention and control in 3 days.

Methods

We searched PubMed, websites of ministries (n=3), public agencies (n=6), multilateral institutions (n=3), COVID-19 resource aggregators (n=5) and preprints (n=1) (without language restrictions) for articles on CHWs in pandemics. Two reviewers screened the records independently with a third reviewer resolving disagreements. One reviewer extracted data with another reviewer cross-checking it. A framework on CHW performance in primary healthcare not specific to pandemic was used to guide data extraction and narrative analysis.

Results

We retrieved 211 records and finally included 36 articles. Most of the evidence was from low-and middle-income countries with well-established CHW programmes. Evidence from CHW programmes initiated during pandemics and for CHW involvement in pandemic response in high-income countries was scant. CHW roles and tasks change substantially during pandemics. Clear guidance, training for changed roles and definition of what constitutes essential activities (ie, those that must to be sustained) is required. Most common additional activities during pandemics were community awareness, engagement and sensitisation (including for countering stigma) and contact tracing. CHWs were reported to be involved in all aspects of contact tracing - this was reported to affect routine service delivery. CHWs have often been stigmatised or been socially ostracised during pandemics. Providing PPE, housing allowance, equal training opportunities, transportation allowance, improving salaries (paid on time and for a broad range of services) and awards in high-profile public events contributed to better recruitment and retention. We also created inventories of resources with guiding notes on guidelines for health workers (n=24), self-isolation in the community (n=10) and information, education and counselling materials on COVID-19 (n=16).

Conclusions

CHWs play a critical role in pandemics. It is important to ensure role clarity, training, supportive supervision, as well as their work satisfaction, health and well-being. More implementation research on CHWs in pandemics is required.

PRIMARY HEALTH CARE ACTIONS IN NATURAL DISASTERS

ABSTRACT Objective: to identify in the national and international literature Primary Health Care actions in natural disasters. Method: an integrative literature review, which included 24 original surveys between 2006 and 2018 on natural disasters. Results: a qualitative analysis of the studies included primary care actions in the prevention and mitigation, preparation, response, and disaster recovery phases. Conclusion: Primary Health Care actions involve multidisciplinary teams, the community and families in the territory in which the teams operate, articulation in a network of intersectoral services, in managerial and educational dimensions to implement effective plans for disaster situations.

What makes health systems resilient against infectious disease outbreaks and natural hazards? Results from a scoping review

Background

The 2014–2016 Ebola outbreak was a wake-up call regarding the critical importance of resilient health systems. Fragile health systems can become overwhelmed during public health crises, further exacerbating the human, economic, and political toll. Important work has been done to describe the general attributes of a health system resilient to these crises, and the next step will be to identify the specific capacities that health systems need to develop and maintain to achieve resiliency.

Methods

We conducted a scoping review of the literature to identify recurring themes and capacities needed for health system resiliency to infectious disease outbreaks and natural hazards and any existing implementation frameworks that highlight these capacities. We also sought to identify the overlap of the identified themes and capacities with those highlighted in the World Health Organization’s Joint External Evaluation. Sources of evidence included PubMed, Web of Science, OAIster, and the websites of relevant major public health organizations.

Results

We identified 16 themes of health system resilience, including: the need to develop plans for altered standards of care during emergencies, the need to develop plans for post-event recovery, and a commitment to quality improvement. Most of the literature described the general attributes of a resilient health system; no implementation frameworks were identified that could translate these elements into specific capacities that health system actors can employ to improve resilience to outbreaks and natural hazards in a variety of settings.

Conclusions

An implementation-oriented health system resilience framework could help translate the important components of a health system identified in this review into specific capacities that actors in the health system could work to develop to improve resilience to public health crises. However, there remains a need to further refine the concept of resilience so that health systems can simultaneously achieve sustainable transformations in healthcare practice and health service delivery as well as improve their preparedness for emergencies.

Implementation research: new imperatives and opportunities in global health

Implementation research is important in global health because it addresses the challenges of the know-do gap in real-world settings and the practicalities of achieving national and global health goals. Implementation research is an integrated concept that links research and practice to accelerate the development and delivery of public health approaches. Implementation research involves the creation and application of knowledge to improve the implementation of health policies, programmes, and practices. This type of research uses multiple disciplines and methods and emphasises partnerships between community members, implementers, researchers, and policy makers. Implementation research focuses on practical approaches to improve implementation and to enhance equity, efficiency, scale-up, and sustainability, and ultimately to improve people's health. There is growing interest in the principles of implementation research and a range of perspectives on its purposes and appropriate methods. However, limited efforts have been made to systematically document and review learning from the practice of implementation research across different countries and technical areas. Drawing on an expert review process, this Health Policy paper presents purposively selected case studies to illustrate the essential characteristics of implementation research and its application in low-income and middle-income countries. The case studies are organised into four categories related to the purposes of using implementation research, including improving people's health, informing policy design and implementation, strengthening health service delivery, and empowering communities and beneficiaries. Each of the case studies addresses implementation problems, involves partnerships to co-create solutions, uses tacit knowledge and research, and is based on a shared commitment towards improving health outcomes. The case studies reveal the complex adaptive nature of health systems, emphasise the importance of understanding context, and highlight the role of multidisciplinary, rigorous, and adaptive processes that allow for course correction to ensure interventions have an impact. This Health Policy paper is part of a call to action to increase the use of implementation research in global health, build the field of implementation research inclusive of research utilisation efforts, and accelerate efforts to bridge the gap between research, policy, and practice to improve health outcomes.