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Stone H, Bailey E, Wurie H, Leather AJM, Davies JI, Bolkan HA, Sevalie S, Youkee D, Parmar D. A qualitative study examining the health system's response to COVID-19 in Sierra Leone. PLoS One 2024; 19:e0294391. [PMID: 38306321 PMCID: PMC10836672 DOI: 10.1371/journal.pone.0294391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 10/31/2023] [Indexed: 02/04/2024] Open
Abstract
The paper examines the health system's response to COVID-19 in Sierra Leone. It aims to explore how the pandemic affected service delivery, health workers, patient access to services, leadership, and governance. It also examines to what extent the legacy of the 2013-16 Ebola outbreak influenced the COVID-19 response and public perception. Using the WHO Health System Building Blocks Framework, we conducted a qualitative study in Sierra Leone where semi-structured interviews were conducted with health workers, policymakers, and patients between Oct-Dec 2020. We applied thematic analysis using both deductive and inductive approaches. Twelve themes emerged from the analysis: nine on the WHO building blocks, two on patients' experiences, and one on Ebola. We found that routine services were impacted by enhanced infection prevention control measures. Health workers faced additional responsibilities and training needs. Communication and decision-making within facilities were reported to be coordinated and effective, although updates cascading from the national level to facilities were lacking. In contrast with previous health emergencies which were heavily influenced by international organisations, we found that the COVID-19 response was led by the national leadership. Experiences of Ebola resulted in less fear of COVID-19 and a greater understanding of public health measures. However, these measures also negatively affected patients' livelihoods and their willingness to visit facilities. We conclude, it is important to address existing challenges in the health system such as resources that affect the capacity of health systems to respond to emergencies. Prioritising the well-being of health workers and the continued provision of essential routine health services is important. The socio-economic impact of public health measures on the population needs to be considered before measures are implemented.
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Affiliation(s)
- Hana Stone
- King’s Centre for Global Health and Health Partnerships, Department of Population Health Sciences, School of Life Course and Population Sciences, King’s College London, London, United Kingdom
| | - Emma Bailey
- King’s Centre for Global Health and Health Partnerships, Department of Population Health Sciences, School of Life Course and Population Sciences, King’s College London, London, United Kingdom
- King’s Sierra Leone Partnership, Connaught Hospital, Freetown, Sierra Leone
| | - Haja Wurie
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | - Andrew J. M. Leather
- King’s Centre for Global Health and Health Partnerships, Department of Population Health Sciences, School of Life Course and Population Sciences, King’s College London, London, United Kingdom
| | - Justine I. Davies
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
- Centre for Global Surgery, Department of Global Health, Stellenbosch University, Cape Town, South Africa
- Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit, Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Håkon A. Bolkan
- CapaCare, Freetown, Sierra Leone
- Institute of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Surgery, St. Olavs Hospital HF, Trondheim University Hospital, Trondheim, Norway
| | - Stephen Sevalie
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
- Case Management Pillar, National COVID-19 Emergency Response Centre, Freetown, Sierra Leone
- 34 Military Hospital, Wilberforce, Freetown, Sierra Leone
| | - Daniel Youkee
- King’s Sierra Leone Partnership, Connaught Hospital, Freetown, Sierra Leone
- Case Management Pillar, National COVID-19 Emergency Response Centre, Freetown, Sierra Leone
| | - Divya Parmar
- King’s Centre for Global Health and Health Partnerships, Department of Population Health Sciences, School of Life Course and Population Sciences, King’s College London, London, United Kingdom
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Witter S, Zou G, Cheedella K, Walley J, Wurie H. Learning from implementation of a COVID case management desk guide and training: a pilot study in Sierra Leone. BMC Health Serv Res 2023; 23:1026. [PMID: 37743494 PMCID: PMC10518973 DOI: 10.1186/s12913-023-10024-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 09/12/2023] [Indexed: 09/26/2023] Open
Abstract
BACKGROUND When the COVID pandemic hit the world, there was need for applied guides and training materials to support frontline health care staff to manage patients effectively and safely and to educate themselves and communities. This article reports on the development and piloting of such a set of materials in Sierra Leone, which were based on international evidence but adapted to the local context. Reflecting on this experience, including community and health system barriers and enablers, is important to prepare for future regional shocks. METHODS This study, in Bombali district in 2020, piloted user-friendly COVID guides for frontline health workers (the intervention), which was evaluated using facility checklists (pre and post training), routine data analysis and 32 key informant interviews. RESULTS Key informants at district, hospital and community health centre levels identified gains from the training and desk guides, including improved diagnosis, triaging, infection prevention and management of patients. They also reported greater confidence to share messages on protection with colleagues and community members, which was needed to encourage continued use of essential services during the pandemic. However, important barriers were also revealed, including the lack of testing facilities, which reduced the sense of urgency, as few cases were identified. Actions based on the Ebola experience, such as setting up testing and isolation centres, which the community avoided, were not appropriate to COVID. Stigma and fear were important factors, although these were reduced with outreach activities. Supplies of essential medicines and personal protective equipment were also lacking. CONCLUSION This pilot study demonstrated the relevance and importance of guides adapted to the context, which were able to improve the confidence of health staff to manage their own and the community's fears in the face of a new pandemic and improve their skills. Previous epidemics, particularly Ebola, complicated this by both creating structures that could be revitalised but also assumptions and behaviours that were not adapted to the new disease. Our study documents positive adaptations and resilience by health staff but also chronic system weaknesses (particularly for medicines, supplies and equipment) which must be urgently addressed before the next shock arrives.
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Affiliation(s)
- Sophie Witter
- NIHR Research Unit on Health in Situations of Fragility, Institute for Global Health and Development, Queen Margaret University, Edinburgh, UK
| | - Guanyang Zou
- School of Public Health and Management, Guangzhou University of Chinese Medicine, Guangzhou, China.
| | - Kiran Cheedella
- NIHR Research Unit on Health in Situations of Fragility, Institute for Global Health and Development, Queen Margaret University, Edinburgh, UK
| | - John Walley
- Nuffield Centre for International Health and Development, Leeds Institute for Health Sciences, University of Leeds, Leeds, UK
| | - Haja Wurie
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
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Cheedella K, Conteh P, Zou G, Walley J, Kamara A, Wurie H, Witter S. Developing a social mobilisation intervention for salt reduction: participatory action research in Bombali district, Sierra Leone. BMC Public Health 2023; 23:1774. [PMID: 37700274 PMCID: PMC10496325 DOI: 10.1186/s12889-023-16693-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 09/01/2023] [Indexed: 09/14/2023] Open
Abstract
BACKGROUND High salt intake is a major risk factor for hypertension, which in turn contributes to cardiovascular diseases, the major cause of death from non communicable diseases (NCDs). Research is limited on social mobilisation interventions to tackle NCDs, including in fragile health settings such as Sierra Leone. METHODS Participatory action research methods were used to develop a social mobilisation intervention for salt reduction in Bombali District, Sierra Leone. A team of 20 local stakeholders were recruited to develop and deliver the intervention. Stakeholder workshop reports and interviews were used to record outcomes, enablers, and barriers to the intervention. Focus group discussions were used to observe knowledge, attitudes, and behaviours of community members pre- and post- the intervention. RESULTS Stakeholders showed enthusiasm and were well engaged in the social mobilisation process around salt reduction. They developed radio jingles, radio show talks, organised community awareness raising meetings, school sensitisation outreaches, and door to door engagements. Stakeholders reported benefiting personally through developing their own skills and confidence in communication and felt positive about their role in educating their community. The interventions led to reported increased awareness of risks of high salt intake and NCDs, resulting in a reduction of salt use in the community, leading to perceived health gains. However, salt reduction was also met with some resistance due to social factors. Local community structures were also reactivated to work on the interventions and connect the community to the local health facility, which saw an increase in patients having their blood pressure checked. The comparison villages also experienced an increase in awareness and perceived reductions in salt intake behaviours. This was as messages had cascaded via the radio and initial focus group discussions. The social mobilisation stakeholders also agreed on future activities that could continue at no or low cost. CONCLUSION Social mobilisation interventions can provide low-cost strategies to tackle NCDs in fragile settings such as Sierra Leone through the utilisation of community structures. However, more research is required to ascertain the key enablers for replicability and if such successes can be sustained over a longer follow up period.
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Affiliation(s)
- Kiran Cheedella
- NIHR Research Unit On Health in Situations of Fragility, Institute for Global Health and Development, Queen Margaret University, Edinburgh, UK
| | - Peter Conteh
- NIHR Research Unit On Health in Situations of Fragility and College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | - Guanyang Zou
- School of Public Health and Management, Guangzhou University of Chinese Medicine, Guangzhou, China.
| | - John Walley
- Nuffield Centre for International Health and Development, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Ajaratu Kamara
- NIHR Research Unit On Health in Situations of Fragility and College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | - Haja Wurie
- NIHR Research Unit On Health in Situations of Fragility and College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | - Sophie Witter
- NIHR Research Unit On Health in Situations of Fragility, Institute for Global Health and Development, Queen Margaret University, Edinburgh, UK
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Chaudhry I, Thurtle V, Foday E, Leather AJM, Samai M, Wurie H, Parmar D. Strengthening ethics committees for health-related research in sub-Saharan Africa: a scoping review. BMJ Open 2022; 12:e062847. [PMID: 36410802 PMCID: PMC9680187 DOI: 10.1136/bmjopen-2022-062847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE Health-related research in sub-Saharan Africa (SSA) has grown over the years. However, concerns have been raised about the state of research ethics committees (RECs). This scoping review examines the literature on RECs for health-related research in SSA and identifies strategies that have been applied to strengthen the RECs. It focuses on three aspects of RECs: regulatory governance and leadership, administrative and financial capacity and technical capacity of members. DESIGN A scoping review of published literature, including grey literature, was conducted using the Joanna Briggs Institute approach. DATA SOURCES BioOne, CINAHL, Embase (via Ovid), Education Abstracts, Global Health, Google Scholar, Jstor, OpenEdition (French), Philosopher's Index, PsycINFO, PubMed, Science Citation and Expanded Index (Web of Science), reference lists of included studies and specific grey literature sources. ELIGIBILITY CRITERIA We included empirical studies on RECs for health-related research in SSA, covering topics on REC leadership and governance, administrative and financial capacity and the technical capacity of REC members. We included studies published between 01 January 2000 and 18 February 2022 and written in English, French, Portuguese or Swahili. DATA EXTRACTION AND SYNTHESIS Two independent reviewers screened the records. Data were extracted by one reviewer and cross-checked by another. Owing to the heterogeneity of included studies, thematic analysis was used. RESULTS We included 54 studies. The findings show that most RECs in SSA work under significant administrative and financial constraints, with few opportunities for capacity building for committee members. This has an impact on the quality of reviews and the overall performance of RECs. Although most countries have national governance systems for RECs, they lack regulations on accountability, transparency and monitoring of RECs. CONCLUSIONS This review provides a comprehensive overview of the literature on RECs for health-related research in SSA and contributes to our understanding of how RECs can be strengthened.
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Affiliation(s)
- Iqra Chaudhry
- Department of Population Health, School of Life Course and Population Sciences, King's College London, London, UK
| | - Val Thurtle
- King's Centre for Global Health and Health Partnerships, School of Life Course and Population Sciences, King's College London, London, UK
| | - Edward Foday
- Sierra Leone Ethics and Scientific Review Committee, Directorate of Training and Research, Sierra Leone Ministry of Health and Sanitation, Freetown, Sierra Leone
| | - Andrew J M Leather
- King's Centre for Global Health and Health Partnerships, School of Life Course and Population Sciences, King's College London, London, UK
| | - Mohamed Samai
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | - Haja Wurie
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | - Divya Parmar
- Department of Population Health, School of Life Course and Population Sciences, King's College London, London, UK
- King's Centre for Global Health and Health Partnerships, School of Life Course and Population Sciences, King's College London, London, UK
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Odland ML, Gassama K, Bockarie T, Wurie H, Ansumana R, Witham MD, Oyebode O, Hirschhorn LR, Davies JI. Cardiovascular disease risk profile and management among people 40 years of age and above in Bo, Sierra Leone: A cross-sectional study. PLoS One 2022; 17:e0274242. [PMID: 36084117 PMCID: PMC9462708 DOI: 10.1371/journal.pone.0274242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 08/24/2022] [Indexed: 11/18/2022] Open
Abstract
Introduction
Access to care for cardiovascular disease risk factors (CVDRFs) in low- and middle-income countries is limited. We aimed to describe the need and access to care for people with CVDRF and the preparedness of the health system to treat these in Bo, Sierra Leone.
Methods
Data from a 2018 household survey conducted in Bo, Sierra Leone, was analysed. Demographic, anthropometric and clinical data on CVDRF (hypertension, diabetes mellitus or dyslipidaemia) from randomly sampled individuals 40 years of age and above were collected. Future risk of CVD was calculated using the World Health Organisation–International Society of Hypertension (WHO-ISH) calculator with high risk defined as >20% risk over 10 years. Requirement for treatment was based on WHO package of essential non-communicable (PEN) disease guidelines (which use a risk-based approach) or requiring treatment for individual CVDRF; whether participants were on treatment was used to determine whether care needs were met. Multivariable regression was used to test associations between individual characteristics and outcomes. Data from the most recent WHO Service Availability and Readiness Assessment (SARA) were used to create a score reflecting health system preparedness to treat CVDRF, and compared to that for HIV.
Results
2071 individual participants were included. Most participants (n = 1715 [94.0%]) had low CVD risk; 423 (20.6%) and 431 (52.3%) required treatment based upon WHO PEN guidelines or individual CVDRF, respectively. Sixty-eight (15.8%) had met-need for treatment determined by WHO guidelines, whilst 84 (19.3%) for individual CVDRF. Living in urban areas, having education, being older, single/widowed/divorced, or wealthy were independently associated with met need. Overall facility readiness scores for CVD/CVDRF care for all facilities in Bo district was 16.8%, compared to 41% for HIV.
Conclusion
The number of people who require treatment for CVDRF in Sierra Leone is substantially lower based on WHO guidelines compared to CVDRF. CVDRF care needs are not met equitably, and facility readiness to provide care is low.
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Affiliation(s)
- Maria Lisa Odland
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, United Kingdom
- Department of Obstetrics and Gynecology, St Olav’s Hospital, Trondheim University Hospital, Trondheim, Norway
- Malawi-Liverpool-Wellcome Trust Research Institute, Blantyre, Malawi
- Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, United Kingdom
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
- * E-mail:
| | - Khadija Gassama
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, United Kingdom
| | - Tahir Bockarie
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Haja Wurie
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | - Rashid Ansumana
- School of Community Health Sciences, Njala University, Bo Campus, Bo, Sierra Leone
| | - Miles D. Witham
- AGE Research Group, NIHR Newcastle Biomedical Research Centre, Newcastle University and Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, United Kingdom
| | - Oyinlola Oyebode
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Lisa R. Hirschhorn
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America
| | - Justine I. Davies
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, United Kingdom
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Hanson K, Brikci N, Erlangga D, Alebachew A, De Allegri M, Balabanova D, Blecher M, Cashin C, Esperato A, Hipgrave D, Kalisa I, Kurowski C, Meng Q, Morgan D, Mtei G, Nolte E, Onoka C, Powell-Jackson T, Roland M, Sadanandan R, Stenberg K, Vega Morales J, Wang H, Wurie H. The Lancet Global Health Commission on financing primary health care: putting people at the centre. Lancet Glob Health 2022; 10:e715-e772. [PMID: 35390342 PMCID: PMC9005653 DOI: 10.1016/s2214-109x(22)00005-5] [Citation(s) in RCA: 89] [Impact Index Per Article: 44.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 12/16/2021] [Accepted: 12/17/2021] [Indexed: 01/18/2023]
Affiliation(s)
- Kara Hanson
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK.
| | - Nouria Brikci
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Darius Erlangga
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Abebe Alebachew
- Breakthrough International Consultancy, Addis Ababa, Ethiopia
| | - Manuela De Allegri
- Heidelberg Institute of Global Health, University Hospital and Faculty of Medicine, University of Heidelberg, Heidelberg, Germany
| | - Dina Balabanova
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | | | | | | | | | - Ina Kalisa
- World Health Organization, Kigali, Rwanda
| | | | - Qingyue Meng
- China Center for Health Development Studies, Peking University, Beijing, China
| | - David Morgan
- Health Division, The Organisation for Economic Co-operation and Development, Paris, France
| | | | - Ellen Nolte
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Chima Onoka
- Department of Community Medicine, University of Nigeria, Enugu, Nigeria
| | - Timothy Powell-Jackson
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Martin Roland
- Department of Public Health and Primary Care, University of Cambridge, UK
| | | | | | | | - Hong Wang
- Bill & Melinda Gates Foundation, Seattle, WA, USA
| | - Haja Wurie
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
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Mansour W, Arjyal A, Hughes C, Gbaoh ET, Fouad FM, Wurie H, Kyaw HK, Tartaggia J, Hawkins K, Than KK, Kallon LH, Saad MA, Chand O, Win PM, Yamout R, Regmi S, Baral S, Theobald S, Raven J. Health systems resilience in fragile and shock-prone settings through the prism of gender equity and justice: implications for research, policy and practice. Confl Health 2022; 16:7. [PMID: 35189938 PMCID: PMC8860254 DOI: 10.1186/s13031-022-00439-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 02/08/2022] [Indexed: 02/04/2023] Open
Abstract
Fragile and shock-prone settings (FASP) present a critical development challenge, eroding efforts to build healthy, sustainable and equitable societies. Power relations and inequities experienced by people because of social markers, e.g., gender, age, education, ethnicity, and race, intersect leading to poverty and associated health challenges. Concurrent to the growing body of literature exploring the impact of these intersecting axes of inequity in FASP settings, there is a need to identify actions promoting gender, equity, and justice (GEJ). Gender norms that emphasise toxic masculinity, patriarchy, societal control over women and lack of justice are unfortunately common throughout the world and are exacerbated in FASP settings. It is critical that health policies in FASP settings consider GEJ and include strategies that promote progressive changes in power relationships. ReBUILD for Resilience (ReBUILD) focuses on health systems resilience in FASP settings and is underpinned by a conceptual framework that is grounded in a broader view of health systems as complex adaptive systems. The framework identifies links between different capacities and enables identification of feedback loops which can drive or inhibit the emergence and implementation of resilient approaches. We applied the framework to four different country case studies (Lebanon, Myanmar, Nepal and Sierra Leone) to illustrate how it can be inclusive of GEJ concerns, to inform future research and support context responsive recommendations to build equitable and inclusive health systems in FASP settings.
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Affiliation(s)
- Wesam Mansour
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK.
| | | | | | - Emma Tiange Gbaoh
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | - Fouad Mohamed Fouad
- Faculty of Health and Sciences, American University in Beirut, Beirut, Lebanon
| | - Haja Wurie
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | | | | | | | | | - Lansana Hassim Kallon
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | - Maya Abou Saad
- Faculty of Health and Sciences, American University in Beirut, Beirut, Lebanon
| | | | | | - Rouham Yamout
- Faculty of Health and Sciences, American University in Beirut, Beirut, Lebanon
| | | | | | - Sally Theobald
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK
| | - Joanna Raven
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK
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Raven J, Wurie H, Baba A, Bah AJ, Dean L, Hawkins K, Idriss A, Kollie K, Nallo GE, Steege R, Theobald S. Supporting community health workers in fragile settings from a gender perspective: a qualitative study. BMJ Open 2022; 12:e052577. [PMID: 35121601 PMCID: PMC8819829 DOI: 10.1136/bmjopen-2021-052577] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To explore how gender influences the way community health workers (CHWs) are managed and supported and the effects on their work experiences. SETTING Two districts in three fragile countries. Sierra Leone-Kenema and Bonthe districts; Liberia-two districts in Grand Bassa county one with international support for CHW activities and one without: Democratic Republic of Congo (DRC)-Aru and Bunia districts in Ituri Province. PARTICIPANTS AND METHODS Qualitative interviews with decision-makers and managers working in community health programmes and managing CHWs (n=36); life history interviews and photovoice with CHWs (n=15, in Sierra Leone only). RESULTS While policies were put in place in Sierra Leone and Liberia to attract women to the newly paid position of CHW after the Ebola outbreak, these good intentions evaporated in practice. Gender norms at the community level, literacy levels and patriarchal expectations surrounding paid work meant that fewer women than imagined took up the role. Only in DRC, there were more women than men working as CHWs. Gender roles, norms and expectations in all contexts also affected retention and progression as well as safety, security and travel (over long distance and at night). Women CHWs also juggle between household and childcare responsibilities. Despite this, they were more likely to retain their position while men were more likely to leave and seek better paid employment. CHWs demonstrated agency in negotiating and challenging gender norms within their work and interactions supporting families. CONCLUSIONS Gender roles and relations shape CHW experiences across multiple levels of the health system. Health systems need to develop gender transformative human resource management strategies to address gender inequities and restrictive gender norms for this critical interface cadre.
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Affiliation(s)
- Joanna Raven
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, Liverpool, UK
| | - Haja Wurie
- Department of Nursing, College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | - Amuda Baba
- Institut Panafricain de Santé Communautaire et Medecine Tropicale, Bunia, Democratic Republic of the Congo
| | - Abdulai Jawo Bah
- Department of Pharmacology, College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | - Laura Dean
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, Liverpool, UK
| | | | - Ayesha Idriss
- Department of Pharmacology, College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | - Karsor Kollie
- Neglected Tropical Disease Program, Ministry of Health, Monrovia, Liberia
| | - Gartee E Nallo
- University of Liberia Pacific Institute for Research and Evaluation, Monrovia, Liberia
| | - Rosie Steege
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, Liverpool, UK
| | - Sally Theobald
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, Liverpool, UK
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Hemingway CD, Bella Jalloh M, Silumbe R, Wurie H, Mtumbuka E, Nhiga S, Lusasi A, Pulford J. Pursuing health systems strengthening through disease-specific programme grants: experiences in Tanzania and Sierra Leone. BMJ Glob Health 2021; 6:bmjgh-2021-006615. [PMID: 34615662 PMCID: PMC8496380 DOI: 10.1136/bmjgh-2021-006615] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 09/10/2021] [Indexed: 11/22/2022] Open
Abstract
Introduction Disease-specific ‘vertical’ programmes and health system strengthening (HSS) ‘horizontal’ programmes are not mutually exclusive; programmes may be implemented with the dual objectives of achieving both disease-specific and broader HSS outcomes. However, there remains an ongoing need for research into how dual objective programmes are operationalised for optimum results. Methods A qualitative study encompassing four grantee programmes from two partner countries, Tanzania and Sierra Leone, in the Comic Relief and GlaxoSmithKline ‘Fighting Malaria, Improving Health’ partnership. Purposive sampling maximised variation in terms of geographical location, programme aims and activities, grantee type and operational sector. Data were collected via semi-structured interviews. Data analysis was informed by a general inductive approach. Results 51 interviews were conducted across the four grantees. Grantee organisations structured and operated their respective projects in a manner generally supportive of HSS objectives. This was revealed through commonalities identified across the four grantee organisations in terms of their respective approach to achieving their HSS objectives, and experienced tensions in pursuit of these objectives. Commonalities included: (1) using short-term funding for long-term initiatives; (2) benefits of being embedded in the local health system; (3) donor flexibility to enable grantee responsiveness; (4) the need for modest expectations; and (5) the importance of micro-innovation. Conclusion Health systems strengthening may be pursued through disease-specific programme grants; however, the respective practice of both the funder and grantee organisation appears to be a key influence on whether HSS will be realised as well as the overall extent of HSS possible.
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Affiliation(s)
| | - Mohamed Bella Jalloh
- University of Sierra Leone College of Medicine and Allied Health Sciences, Freetown, Sierra Leone.,Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Richard Silumbe
- Malaria Program, Clinton Health Access Initiative, Freetown, Sierra Leone
| | - Haja Wurie
- University of Sierra Leone College of Medicine and Allied Health Sciences, Freetown, Sierra Leone
| | | | - Samuel Nhiga
- National Malaria Control Program, Dodoma, Tanzania, United Republic of
| | - Abdallah Lusasi
- National Malaria Control Program, Dodoma, Tanzania, United Republic of
| | - Justin Pulford
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
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Bockarie T, Odland ML, Wurie H, Ansumana R, Lamin J, Witham M, Oyebode O, Davies J. Correction to: Prevalence and socio-demographic associations of diet and physical activity risk-factors for cardiovascular disease in Bo, Sierra Leone. BMC Public Health 2021; 21:1806. [PMID: 34620150 PMCID: PMC8499498 DOI: 10.1186/s12889-021-11759-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Affiliation(s)
- Tahir Bockarie
- Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Maria Lisa Odland
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, B15 2TT, Birmingham, UK
| | - Haja Wurie
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Western Area, Sierra Leone
| | - Rashid Ansumana
- School of Community Health Sciences, Njala University, Bo Campus, Bo, Sierra Leone
| | - Joseph Lamin
- School of Community Health Sciences, Njala University, Bo Campus, Bo, Sierra Leone.,Mercy Hospital Research Laboratory, Bo, Sierra Leone
| | - Miles Witham
- AGE Research Group, NIHR Newcastle Biomedical Research Centre, Newcastle University, Newcastle upon Tyne, UK.,Newcastle upon Tyne Hospitals Trust, Newcastle upon Tyne, UK.,MRC/Wits Rural Public Health & Health Transitions Research Unit (Agincourt), University of the Witwatersrand, Johannesburg, South Africa
| | - Oyinlola Oyebode
- Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Justine Davies
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, B15 2TT, Birmingham, UK. .,MRC/Wits Rural Public Health & Health Transitions Research Unit (Agincourt), University of the Witwatersrand, Johannesburg, South Africa. .,Department for Global Health, Centre for Global Surgery, Stellenbosch University, Stellenbosch, South Africa.
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11
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Sevalie S, Youkee D, van Duinen AJ, Bailey E, Bangura T, Mangipudi S, Mansaray E, Odland ML, Parmar D, Samura S, van Delft D, Wurie H, Davies JI, Bolkan HA, Leather AJM. The impact of the COVID-19 pandemic on hospital utilisation in Sierra Leone. BMJ Glob Health 2021; 6:e005988. [PMID: 34635552 PMCID: PMC8506048 DOI: 10.1136/bmjgh-2021-005988] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 06/29/2021] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION The COVID-19 pandemic has adversely affected health systems in many countries, but little is known about effects on health systems in sub-Saharan Africa. This study examines the effects of COVID-19 on hospital utilisation in a sub-Saharan country, Sierra Leone. METHODS Mixed-methods study using longitudinal nationwide hospital data (admissions, operations, deliveries and referrals) and qualitative interviews with healthcare workers and patients. Hospital data were compared across quarters (Q) in 2020, with day 1 of Q2 representing the start of the pandemic in Sierra Leone. Admissions are reported in total and disaggregated by sex, service (surgical, medical, maternity and paediatric) and hospital type (government or private non-profit). Referrals in 2020 were compared with 2019 to assess whether any changes were the result of seasonality. Comparisons were performed using Student's t-test. Qualitative data were analysed using thematic analysis. RESULTS From Q1 to Q2, weekly mean hospital admissions decreased by 14.7% (p=0.005). Larger decreases were seen in male 18.8% than female 12.5% admissions. The largest decreases were in surgical admissions, a 49.8% decrease (p<0.001) and medical admissions, a 28.7% decrease (p=0.002). Paediatric and maternity admissions did not significantly change. Total operations decreased by 13.9% (p<0.001), while caesarean sections and facility-based deliveries showed significant increases: 12.7% (p=0.014) and 7.5% (p=0.03), respectively. In Q3, total admissions remained 13.2% lower (p<0.001) than Q1. Mean weekly referrals were lower in Q2 and Q3 of 2020 compared with 2019, suggesting findings were unlikely to be seasonal. Qualitative analysis identified both supply-side factors, prioritisation of essential services, introduction of COVID-19 services and pausing elective care, and demand-side factors, fear of nosocomial infection and financial hardship. CONCLUSION The study demonstrated a decrease in hospital utilisation during COVID-19, the decrease is less than reported in other countries during COVID-19 and less than reported during the Ebola epidemic.
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Affiliation(s)
- Stephen Sevalie
- 34th Military Hospital, Wilberforce, Freetown, Sierra Leone
- Case Management Pillar, National COVID-19 Emergency Response Centre, Freetown, Sierra Leone
| | - Daniel Youkee
- Case Management Pillar, National COVID-19 Emergency Response Centre, Freetown, Sierra Leone
- School of Population Health and Environmental Sciences, King's College London, London, UK
| | - A J van Duinen
- Institute of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Surgery, St Olavs Hospital University Hospital in Trondheim, Trondheim, Norway
| | - Emma Bailey
- King's Centre for Global Health and Health Partnerships, King's College London School of Population Health and Environmental Sciences, London, UK
| | - Thaimu Bangura
- King's Centre for Global Health and Health Partnerships, King's College London School of Population Health and Environmental Sciences, London, UK
| | - Sowmya Mangipudi
- King's Centre for Global Health and Health Partnerships, King's College London School of Population Health and Environmental Sciences, London, UK
| | - Esther Mansaray
- King's Centre for Global Health and Health Partnerships, King's College London School of Population Health and Environmental Sciences, London, UK
| | - Maria Lisa Odland
- Institute of Applied Health Research, University of Birmingham, Birmingham, Birmingham, UK
| | - Divya Parmar
- King's Centre for Global Health and Health Partnerships, King's College London School of Population Health and Environmental Sciences, London, UK
| | - Sorie Samura
- King's Centre for Global Health and Health Partnerships, King's College London School of Population Health and Environmental Sciences, London, UK
| | | | - Haja Wurie
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Western Area, Sierra Leone
| | - Justine I Davies
- Institute of Applied Health Research, University of Birmingham, Birmingham, Birmingham, UK
- Centre for Global Surgery, Department of Global Health, Stellenbosch University, Stellenbosch, Western Cape, South Africa
| | - H A Bolkan
- Institute of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Surgery, St Olavs Hospital University Hospital in Trondheim, Trondheim, Norway
| | - Andrew J M Leather
- King's Centre for Global Health and Health Partnerships, King's College London School of Population Health and Environmental Sciences, London, UK
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12
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Thurtle V, Leather AJ, Wurie H, Foday E, Samai M, Parmar D. Strengthening ethics committees for health-related research in sub-Saharan Africa: a scoping review protocol. BMJ Open 2021; 11:e046546. [PMID: 34385239 PMCID: PMC8362705 DOI: 10.1136/bmjopen-2020-046546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Health research in low-income and middle-income countries, which face the greatest burden of disease, is a vital component of efforts to combat global health inequality. With increased research, there has also been concern about ethical and regulatory issues and the state of research ethics committees, with various attempts to strengthen them. This scoping review examines the literature on ethics committees for health-related research in sub-Saharan Africa, with a focus on regulatory governance and leadership, administrative and financial capacity, and conduct of ethical reviews. METHODS AND ANALYSIS We will use the methodological approach proposed by Arksey and O'Malley and adapted by Levac et al and the Joanna Briggs Institute. Inclusion and exclusion criteria are based on the 'Population-Concept-Context' framework. Literature (from January 2000 to December 2020) will be searched in multiple databases including Embase and PubMed and websites of relevant organisations. All records will be screened by applying the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Review flowchart: two reviewers will independently screen titles and abstracts, and full text of included records. Using an inductive approach, we will synthesise the literature, identify best practice and gaps in evidence on strengthening research ethics committees. ETHICS AND DISSEMINATION Ethical approval is not required as the review will include only published literature. The findings will be published in a peer-reviewed journal and presented at stakeholder meetings and conferences.
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Affiliation(s)
- Val Thurtle
- King's Centre for Global Health and Health Partnerships, School of Population Health and Environmental Sciences, King's College London, London, UK
| | - Andy Jm Leather
- King's Centre for Global Health and Health Partnerships, School of Population Health and Environmental Sciences, King's College London, London, UK
| | - Haja Wurie
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | - Edward Foday
- Sierra Leone Ethics and Scientific Review Committee, Directorate of Policy, Planning and Information, Sierra Leone Ministry of Health and Sanitation, Freetown, Sierra Leone
| | - Mohamed Samai
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Western Area, Sierra Leone
| | - Divya Parmar
- King's Centre for Global Health and Health Partnerships, School of Population Health and Environmental Sciences, King's College London, London, UK
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13
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Bockarie T, Odland ML, Wurie H, Ansumana R, Lamin J, Witham M, Oyebode O, Davies J. Prevalence and socio-demographic associations of diet and physical activity risk-factors for cardiovascular disease in Bo, Sierra Leone. BMC Public Health 2021; 21:1530. [PMID: 34376163 PMCID: PMC8353867 DOI: 10.1186/s12889-021-11422-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 06/07/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Little is known about modifiable dietary and physical activity risk factors for cardiovascular diseases (CVDs) in Sierra Leone. This information is critical to the development of health improvement interventions to reduce the prevalence of these diseases. This cross-sectional study investigated the prevalence and socio-demographic correlates of dietary and physical activity risk behaviours amongst adults in Bo District, Sierra Leone. METHODS Adults aged 40+ were recruited from 10 urban and 30 rural sub-districts in Bo. We examined risk factors including: ≤150 min of moderate or vigorous-intensity physical activity (MVPA) weekly, physical inactivity for ≥3 h daily, ≤5 daily portions of fruit and vegetables, and salt consumption (during cooking, at the table, and in salty snacks). We used logistic regression to investigate the relationship between these outcomes and participants' socio-demographic characteristics. RESULTS 1978 eligible participants (39.1% urban, 55.6% female) were included in the study. The prevalence of behavioural risk factors was 83.6% for ≤5 daily portions of fruit and vegetables; 41.4 and 91.6% for adding salt at the table or during cooking, respectively and 31.1% for eating salty snacks; 26.1% for MVPA ≤150 min weekly, and 45.6% for being physically inactive ≥3 h daily. Most MVPA was accrued at work (nearly 24 h weekly). Multivariable analysis showed that urban individuals were more likely than rural individuals to consume ≤5 daily portions of fruit and vegetables (Odds Ratio (OR) 1.09, 95% Confidence Interval (1.04-1.15)), add salt at the Table (OR 1.88 (1.82-1.94)), eat salty snacks (OR 2.00 (1.94-2.07)), and do MVPA ≤150 min weekly (OR 1.16 (1.12-1.21)). Male individuals were more likely to add salt at the Table (OR 1.23 (1.20-1.27)) or consume salty snacks (OR 1.35 (1.31-1.40)) than female individuals but were less likely to report the other behavioural risk-factors examined. Generally, people in lower wealth quintiles had lower odds of each risk factor than those in the higher wealth quintiles. CONCLUSION Dietary risk factors for CVD are highly prevalent, particularly among urban residents, of Bo District, Sierra Leone. Our findings highlight that forthcoming policies in Sierra Leone need to consider modifiable risk factors for CVD in the context of urbanisation.
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Affiliation(s)
- Tahir Bockarie
- Warwick Medical School, University of Warwick, Coventry, CV4 7AL UK
| | - Maria Lisa Odland
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT UK
| | - Haja Wurie
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Western Area Sierra Leone
| | - Rashid Ansumana
- School of Community Health Sciences, Njala University, Bo Campus, Bo, Sierra Leone
| | - Joseph Lamin
- School of Community Health Sciences, Njala University, Bo Campus, Bo, Sierra Leone
- Mercy Hospital Research Laboratory, Bo, Sierra Leone
| | - Miles Witham
- AGE Research Group, NIHR Newcastle Biomedical Research Centre, Newcastle University, Newcastle upon Tyne, UK
- Newcastle upon Tyne Hospitals Trust, Newcastle upon Tyne, UK
- MRC/Wits Rural Public Health & Health Transitions Research Unit (Agincourt), University of the Witwatersrand, Johannesburg, South Africa
| | - Oyinlola Oyebode
- Warwick Medical School, University of Warwick, Coventry, CV4 7AL UK
| | - Justine Davies
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT UK
- MRC/Wits Rural Public Health & Health Transitions Research Unit (Agincourt), University of the Witwatersrand, Johannesburg, South Africa
- Department for Global Health, Centre for Global Surgery, Stellenbosch University, Stellenbosch, South Africa
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14
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Aktar B, Alam W, Ali S, Awal A, Bayoh M, Chumo I, Contay Y, Conteh A, Dean L, Dobson S, Edstrom J, Elsey H, Farnaz N, Garimella S, Gray L, Gupte J, Hawkins K, Hollihead B, Josyula KL, Kabaria C, Karuga R, Kimani J, Leyland AH, Te Lintelo D, Mansaray B, MacCarthy J, MacGregor H, Mberu B, Muturi N, Okoth L, Otiso L, Ozano K, Parray A, Phillips-Howard P, Rao V, Rashid S, Raven J, Refell F, Saidu S, Sobhan S, Saligram PS, Sesay S, Theobald S, Tolhurst R, Tubb P, Waldman L, Wariutu J, Whittaker L, Wurie H. How to prevent and address safeguarding concerns in global health research programmes: practice, process and positionality in marginalised spaces. BMJ Glob Health 2021; 5:bmjgh-2019-002253. [PMID: 32409330 PMCID: PMC7228499 DOI: 10.1136/bmjgh-2019-002253] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 04/07/2020] [Accepted: 04/08/2020] [Indexed: 11/12/2022] Open
Abstract
Safeguarding is rapidly rising up the international development agenda, yet literature on safeguarding in related research is limited. This paper shares processes and practice relating to safeguarding within an international research consortium (the ARISE hub, known as ARISE). ARISE aims to enhance accountability and improve the health and well-being of marginalised people living and working in informal urban spaces in low-income and middle-income countries (Bangladesh, India, Kenya and Sierra Leone). Our manuscript is divided into three key sections. We start by discussing the importance of safeguarding in global health research and consider how thinking about vulnerability as a relational concept (shaped by unequal power relations and structural violence) can help locate fluid and context specific safeguarding risks within broader social systems. We then discuss the different steps undertaken in ARISE to develop a shared approach to safeguarding: sharing institutional guidelines and practice; facilitating a participatory process to agree a working definition of safeguarding and joint understandings of vulnerabilities, risks and mitigation strategies and share experiences; developing action plans for safeguarding. This is followed by reflection on our key learnings including how safeguarding, ethics and health and safety concerns overlap; the challenges of referral and support for safeguarding concerns within frequently underserved informal urban spaces; and the importance of reflective practice and critical thinking about power, judgement and positionality and the ownership of the global narrative surrounding safeguarding. We finish by situating our learning within debates on decolonising science and argue for the importance of an iterative, ongoing learning journey that is critical, reflective and inclusive of vulnerable people.
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Affiliation(s)
- Bachera Aktar
- BRAC University James P Grant School of Public Health, Dhaka, Dhaka District, Bangladesh
| | - Wafa Alam
- BRAC University James P Grant School of Public Health, Dhaka, Dhaka District, Bangladesh
| | - Samiha Ali
- BRAC University James P Grant School of Public Health, Dhaka, Dhaka District, Bangladesh
| | - Abdul Awal
- BRAC University James P Grant School of Public Health, Dhaka, Dhaka District, Bangladesh
| | - Margaret Bayoh
- Federation of Urban and Rural Poor, Freetown, Sierra Leone
| | - Ivy Chumo
- African Population and Health Research Center, Nairobi, Kenya
| | - Yirah Contay
- Federation of Urban and Rural Poor, Freetown, Sierra Leone
| | - Abu Conteh
- Sierra Leone Urban Research Centre, Njala University, Freetown, Sierra Leone
| | - Laura Dean
- Liverpool School of Tropical Medicine, Liverpool, Liverpool, UK
| | - Skye Dobson
- Slum Dwellers International, Cape Town, South Africa
| | - Jerker Edstrom
- Institute of Development Studies, Brighton, Brighton and Hove, UK
| | - Helen Elsey
- Health Sciences, University of York, York, UK
| | - Nadia Farnaz
- BRAC University James P Grant School of Public Health, Dhaka, Dhaka District, Bangladesh
| | | | | | - Jaideep Gupte
- Institute of Development Studies, Brighton, Brighton and Hove, UK
| | - Kate Hawkins
- Pamoja Communications, Brighton and Hove, United Kingdom
| | - Beth Hollihead
- Liverpool School of Tropical Medicine, Liverpool, Liverpool, UK
| | | | | | | | - Joseph Kimani
- Slum and Shack Dwellers International Kenya, Nairobi, Kenya
| | | | - Dolf Te Lintelo
- Institute of Development Studies, Brighton, Brighton and Hove, UK
| | - Bintu Mansaray
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Western Area, Sierra Leone
| | - Joseph MacCarthy
- Sierra Leone Urban Research Centre, Njala University, Freetown, Sierra Leone
| | - Hayley MacGregor
- Institute of Development Studies, Brighton, Brighton and Hove, UK
| | - Blessing Mberu
- African Population and Health Research Center, Nairobi, Kenya
| | | | | | | | - Kim Ozano
- Liverpool School of Tropical Medicine, Liverpool, Liverpool, UK
| | - Ateeb Parray
- BRAC University James P Grant School of Public Health, Dhaka, Dhaka District, Bangladesh
| | | | | | - Sabina Rashid
- BRAC University James P Grant School of Public Health, Dhaka, Dhaka District, Bangladesh
| | - Joanna Raven
- Liverpool School of Tropical Medicine, Liverpool, Liverpool, UK
| | | | - Samuel Saidu
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Western Area, Sierra Leone
| | - Shafinaz Sobhan
- BRAC University James P Grant School of Public Health, Dhaka, Dhaka District, Bangladesh
| | | | - Samira Sesay
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Western Area, Sierra Leone
| | - Sally Theobald
- Liverpool School of Tropical Medicine, Liverpool, Liverpool, UK
| | - Rachel Tolhurst
- Liverpool School of Tropical Medicine, Liverpool, Liverpool, UK
| | - Phil Tubb
- Liverpool School of Tropical Medicine, Liverpool, Liverpool, UK
| | - Linda Waldman
- Institute of Development Studies, Brighton, Brighton and Hove, UK
| | - Jane Wariutu
- Slum and Shack Dwellers International Kenya, Nairobi, Kenya
| | - Lana Whittaker
- Liverpool School of Tropical Medicine, Liverpool, Liverpool, UK
| | - Haja Wurie
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Western Area, Sierra Leone
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Dean L, Cooper J, Wurie H, Kollie K, Raven J, Tolhurst R, MacGregor H, Hawkins K, Theobald S, Mansaray B. Psychological resilience, fragility and the health workforce: lessons on pandemic preparedness from Liberia and Sierra Leone. BMJ Glob Health 2021; 5:bmjgh-2020-002873. [PMID: 32988928 PMCID: PMC7523196 DOI: 10.1136/bmjgh-2020-002873] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 08/10/2020] [Accepted: 08/14/2020] [Indexed: 01/04/2023] Open
Affiliation(s)
- Laura Dean
- Centre for Health Systems Strengthening, Liverpool School of Tropical Medicine, Liverpool, Liverpool, UK
| | | | - Haja Wurie
- University of Sierra Leone College of Medicine and Allied Health Sciences, Freetown, Western Area, Sierra Leone
| | - Karsor Kollie
- Neglected Tropical Disease Programme, Ministry of Health, Monrovia, Liberia
| | - Joanna Raven
- Centre for Health Systems Strengthening, Liverpool School of Tropical Medicine, Liverpool, Liverpool, UK
| | - Rachel Tolhurst
- Centre for Health Systems Strengthening, Liverpool School of Tropical Medicine, Liverpool, Liverpool, UK
| | - Hayley MacGregor
- Institute of Development Studies, Brighton, Brighton and Hove, UK
| | | | - Sally Theobald
- Centre for Health Systems Strengthening, Liverpool School of Tropical Medicine, Liverpool, Liverpool, UK
| | - Bintu Mansaray
- University of Sierra Leone College of Medicine and Allied Health Sciences, Freetown, Western Area, Sierra Leone
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16
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Horn R, Arakelyan S, Wurie H, Ager A. Factors contributing to emotional distress in Sierra Leone: a socio-ecological analysis. Int J Ment Health Syst 2021; 15:58. [PMID: 34116686 PMCID: PMC8193165 DOI: 10.1186/s13033-021-00474-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 05/19/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND There is increasing global evidence that mental health is strongly determined by social, economic and environmental factors, and that strategic action in these areas has considerable potential for improving mental health and preventing and alleviating mental disorders. Prevention and promotion activities in mental health must address the needs prioritised by local actors. The aim of this study was to identify stressors with the potential to influence emotional wellbeing and distress within the general population of Sierra Leone, in order to contribute to an inter-sectoral public mental health approach to improving mental health within the country. METHODOLOGY Respondents were a convenience sample of 153 respondents (60 women, 93 men) from five districts of Sierra Leone. Using freelisting methodology, respondents were asked to respond to the open question 'What kind of problems do women/men have in your community?'. Data analysis involved consolidation of elicited problems into a single list. These were then organised thematically using an adaptation of the socio-ecological model, facilitating exploration of the interactions between problems at individual, family, community and societal levels RESULTS: Overall, respondents located problems predominantly at community and societal levels. Although few respondents identified individual-level issues, they frequently described how problems at other levels contributed to physical health difficulties and emotional distress. Women identified significantly more problems at the family level than men, particularly related to relationships with an intimate partner. Men identified significantly more problems at the societal level than women, primarily related to lack of infrastructure. Men and women were equally focused on problems related to poverty and lack of income generating opportunities. CONCLUSION Poverty and inability to earn an income underpinned many of the problems described at individual, family and community level. Actions to address livelihoods, together with improving infrastructure and addressing gender norms which are harmful to both men and women, are likely key to improving the wellbeing of the Sierra Leone population.
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Affiliation(s)
- Rebecca Horn
- Institute for Global Health and Development, Queen Margaret University, Edinburgh, UK
- NIHR Global Health Research Unit on Health in Situations of Fragility, Queen Margaret University, Edinburgh, UK
| | - Stella Arakelyan
- Institute for Global Health and Development, Queen Margaret University, Edinburgh, UK
- NIHR Global Health Research Unit on Health in Situations of Fragility, Queen Margaret University, Edinburgh, UK
| | - Haja Wurie
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
- NIHR Global Health Research Unit on Health in Situations of Fragility, Queen Margaret University, Edinburgh, UK
| | - Alastair Ager
- Institute for Global Health and Development, Queen Margaret University, Edinburgh, UK
- NIHR Global Health Research Unit on Health in Situations of Fragility, Queen Margaret University, Edinburgh, UK
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17
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Phull M, Grimes CE, Kamara TB, Wurie H, Leather AJM, Davies J. What is the financial burden to patients of accessing surgical care in Sierra Leone? A cross-sectional survey of catastrophic and impoverishing expenditure. BMJ Open 2021; 11:e039049. [PMID: 34006018 PMCID: PMC7942261 DOI: 10.1136/bmjopen-2020-039049] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVES To measure the financial burden associated with accessing surgical care in Sierra Leone. DESIGN A cross-sectional survey conducted with patients at the time of discharge from tertiary-level care. This captured demographics, yearly household expenditure, direct medical, direct non-medical and indirect costs for surgical care, and summary household assets. Missing data were imputed. SETTING The main tertiary-level hospital in Freetown, Sierra Leone. PARTICIPANTS 335 surgical patients under the care of the hospital surgical team receiving operative or non-operative surgical care on the surgical wards. OUTCOME MEASURES Rates of catastrophic expenditure (a cost >10% of annual expenditure), impoverishment (being pushed into, or further into, poverty as a result of surgical care costs), amount of out-of-pocket (OOP) costs and means used to meet these costs were derived. RESULTS Of 335 patients interviewed, 39% were female and 80% were urban dwellers. Median yearly household expenditure was US$3569. Mean OOP costs were US$243, of which a mean of US$24 (10%) was spent prehospital. Of costs incurred during the hospital admission, direct medical costs were US$138 (63%) and US$34 (16%) were direct non-medical costs. US$46 (21%) were indirect costs. Catastrophic expenditure affected 18% of those interviewed. Concerning impoverishment, 45% of patients were already below the national poverty line prior to admission, and 9% of those who were not were pushed below the poverty line following payment for surgical care. 84% of patients used household savings to meet OOP costs. Only 2% (six patients) had health insurance. CONCLUSION Obtaining surgical care has substantial economic impacts on households that pushes them into poverty or further into poverty. The much-needed scaling up of surgical care needs to be accompanied by financial risk protection.
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Affiliation(s)
- Manraj Phull
- Department of Surgery, West Hertfordshire Hospitals NHS Trust, Watford, UK
| | - Caris E Grimes
- Faculty of Life Sciences and Medicine, King's College London, London, UK
- Department of Surgery, Medway NHS Foundation Trust, Gillingham, UK
| | - Thaim B Kamara
- Department of Surgery, University of Sierra Leone College of Medicine and Allied Health Sciences, Freetown, Sierra Leone
| | - Haja Wurie
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | - Andy J M Leather
- King's Centre for Global Health, King's College London Faculty of Life Sciences and Medicine, London, UK
| | - Justine Davies
- Centre of Global Surgery, Department of Global Health, Stellenbosch University, Cape Town, South Africa
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
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Willott C, Boyd N, Wurie H, Smalle I, Kamara TB, Davies JI, Leather AJM. Staff recognition and its importance for surgical service delivery: a qualitative study in Freetown, Sierra Leone. Health Policy Plan 2021; 36:93-100. [PMID: 33246332 PMCID: PMC7938499 DOI: 10.1093/heapol/czaa131] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/04/2020] [Indexed: 11/12/2022] Open
Abstract
We examined the views of providers and users of the surgical system in Freetown, Sierra Leone on processes of care, job and service satisfaction and barriers to achieving quality and accessible care, focusing particularly on the main public tertiary hospital in Freetown and two secondary and six primary sites from which patients are referred to it. We conducted interviews with health care providers (N = 66), service users (n = 24) and people with a surgical condition who had chosen not to use the public surgical system (N = 13), plus two focus groups with health providers in primary care (N = 10 and N = 10). The overall purpose of the study was to understand perceptions on processes of and barriers to care from a variety of perspectives, to recommend interventions to improve access and quality of care as part of a larger study. Our research suggests that providers perceive their relationships with patients to be positive, while the majority of patients see the opposite: that many health workers are unapproachable and uncaring, particularly towards poorer patients who are unable or unwilling to pay staff extra in the form of informal payments for their care. Many health care providers note the importance of lack of recognition shown to them by their superiors and the health system in general. We suggest that this lack of recognition underlies poor morale, leading to poor care. Any intervention to improve the system should therefore consider staff-patient relations as a key element in its design and implementation, and ideally be led and supported by frontline healthcare workers.
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Affiliation(s)
- Chris Willott
- King’s Centre for Global Health and Health Partnerships, School of Population Health & Environmental Sciences, King’s College London, Room 2.13, Weston Education Centre, Cutcombe Road, London, SE5 9RJ, UK
| | - Nick Boyd
- King’s Centre for Global Health and Health Partnerships, School of Population Health & Environmental Sciences, King’s College London, Room 2.13, Weston Education Centre, Cutcombe Road, London, SE5 9RJ, UK
- Bristol Royal Hospital for Children, Upper Maudlin Street, Bristol BS2 8BJ, UK
| | - Haja Wurie
- College of Medicine and Allied Health Sciences, University of Sierra Leone, PMB, New England Ville, Freetown, Sierra Leone
| | - Isaac Smalle
- King’s Centre for Global Health and Health Partnerships, School of Population Health & Environmental Sciences, King’s College London, Room 2.13, Weston Education Centre, Cutcombe Road, London, SE5 9RJ, UK
- Department of Surgery, College of Medicine and Allied Health Sciences, University of Sierra Leone, 1 Percival Street, Freetown, Sierra Leone
| | - T B Kamara
- Department of Surgery, College of Medicine and Allied Health Sciences, University of Sierra Leone, 1 Percival Street, Freetown, Sierra Leone
| | - Justine I Davies
- Centre for Applied Health Research, University of Birmingham, Birmingham, B15 2TT, UK
- Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit, Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Parktown 2193, Johannesburg, South Africa
- Centre for Global Surgery, Department of Global Health, Stellenbosch University, Tygerberg 7505, South Africa
| | - Andrew J M Leather
- King’s Centre for Global Health and Health Partnerships, School of Population Health & Environmental Sciences, King’s College London, Room 2.13, Weston Education Centre, Cutcombe Road, London, SE5 9RJ, UK
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Brima N, Sevdalis N, Daoh K, Deen B, Kamara TB, Wurie H, Davies J, Leather AJM. Improving nursing documentation for surgical patients in a referral hospital in Freetown, Sierra Leone: protocol for assessing feasibility of a pilot multifaceted quality improvement hybrid type project. Pilot Feasibility Stud 2021; 7:33. [PMID: 33504369 PMCID: PMC7839195 DOI: 10.1186/s40814-021-00768-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 01/07/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND There is an urgent need to improve quality of care to reduce avoidable mortality and morbidity from surgical diseases in low- and middle-income countries. Currently, there is a lack of knowledge about how evidence-based health system strengthening interventions can be implemented effectively to improve quality of care in these settings. To address this gap, we have developed a multifaceted quality improvement intervention to improve nursing documentation in a low-income country hospital setting. The aim of this pilot project is to test the intervention within the surgical department of a national referral hospital in Freetown, Sierra Leone. METHODS This project was co-developed and co-designed by in-country stakeholders and UK-based researchers, after a multiple-methodology assessment of needs (qualitative, quantitative), guided by a participatory 'Theory of Change' process. It has a mixed-method, quasi-experimental evaluation design underpinned by implementation and improvement science theoretical approaches. It consists of three distinct phases-(1) pre-implementation(project set up and review of hospital relevant policies and forms), (2) intervention implementation (awareness drive, training package, audit and feedback), and (3) evaluation of (a) the feasibility of delivering the intervention and capturing implementation and process outcomes, (b) the impact of implementation strategies on the adoption, integration, and uptake of the intervention using implementation outcomes, (c) the intervention's effectiveness For improving nursing in this pilot setting. DISCUSSION We seek to test whether it is possible to deliver and assess a set of theory-driven interventions to improve the quality of nursing documentation using quality improvement and implementation science methods and frameworks in a single facility in Sierra Leone. The results of this study will inform the design of a large-scale effectiveness-implementation study for improving nursing documentation practices for patients throughout hospitals in Sierra Leone. TRIAL REGISTRATION Protocol version number 6, date: 24.12.2020, recruitment is planned to begin: January 2021, recruitment will be completed: December 2021.
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Affiliation(s)
- Nataliya Brima
- King's Centre for Global Health & Health Partnerships, School of Population Health & Environmental Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.
| | - Nick Sevdalis
- Centre for Implementation Science, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - K Daoh
- Connaught Teaching Hospital Complex, Freetown, Sierra Leone
| | - B Deen
- Connaught Teaching Hospital Complex, Freetown, Sierra Leone
| | - T B Kamara
- Department of Surgery, College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | - Haja Wurie
- Faculty of Nursing, College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | - Justine Davies
- Institute of Applied Health Research, University of Birmingham, UK; Centre for Global Surgery, Department of Global Health, Stellenbosch University, Stellenbosch, South Africa
| | - Andrew J M Leather
- King's Centre for Global Health & Health Partnerships, School of Population Health & Environmental Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
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Ignatowicz A, Odland ML, Bockarie T, Wurie H, Ansumana R, Kelly AH, Willott C, Witham M, Davies J. Knowledge and understanding of cardiovascular disease risk factors in Sierra Leone: a qualitative study of patients' and community leaders' perceptions. BMJ Open 2020; 10:e038523. [PMID: 33323429 PMCID: PMC7745312 DOI: 10.1136/bmjopen-2020-038523] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 07/02/2020] [Accepted: 09/24/2020] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES Prevalence of cardiovascular disease risk factors (CVDRF) is increasing, especially in low-income countries. In Sierra Leone, there are no previous studies on the knowledge and the awareness of these conditions in the community. This study aimed to explore the knowledge and understanding of CVDRF, as well as the perceptions of the barriers and facilitators to accessing care for these conditions, among patients and community leaders in Sierra Leone. DESIGN Qualitative study employing semistructured interviews and focus group discussions. SETTING Urban and rural Bo District, Sierra Leone. PARTICIPANTS Interviews with a purposive sample of 37 patients and two focus groups with six to nine community leaders. RESULTS While participants possessed general knowledge of their conditions, the level and complexity of this knowledge varied widely. There were clear gaps in knowledge regarding the coexistence of CVDRF and their consequences, as well as the link between behavioural factors and CVDRF. An overarching theme from the data was the need to create an understanding and awareness of CVDRF in the community in order to prevent and improve management of these conditions. Cost was also seen as a major barrier to accessing care for CVDRFs. CONCLUSIONS The knowledge gaps identified in this study highlight the need to design strategies and interventions that improve knowledge and recognition of CVDRF in the community. Interventions should specifically consider how to develop and enhance awareness about CVDRF and their consequences. They should also consider how patients seek help and where they access it.
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Affiliation(s)
- Agnieszka Ignatowicz
- Institute of Applied Health Research, University of Birmingham, Birmingham, West Midlands, UK
| | - Maria Lisa Odland
- Institute of Applied Health Research, University of Birmingham, Birmingham, West Midlands, UK
| | - Tahir Bockarie
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Haja Wurie
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Western Area, Sierra Leone
| | - Rashid Ansumana
- Mercy Hospital Research Laboratory, Bo, Sierra Leone
- School of Community Health Sciences, Njala University, Bo, Sierra Leone
| | - Ann H Kelly
- Department of Global Health and Social Medicine, King's College London, London, UK
| | - Chris Willott
- King's Centre for Global Health and Health Partnerships, King's College London, London, UK
| | - Miles Witham
- Age Research Group, NIHR Newcastle Biomedical Research Centre, Newcastle University, Newcastle upon Tyne, UK
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Justine Davies
- Institute of Applied Health Research, University of Birmingham, Birmingham, West Midlands, UK
- King's Centre for Global Health and Health Partnerships, King's College London, London, UK
- Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit, Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
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Odland ML, Bockarie T, Wurie H, Ansumana R, Lamin J, Nugent R, Bakolis I, Witham M, Davies J. Prevalence and access to care for cardiovascular risk factors in older people in Sierra Leone: a cross-sectional survey. BMJ Open 2020; 10:e038520. [PMID: 32907906 PMCID: PMC7482482 DOI: 10.1136/bmjopen-2020-038520] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Prevalence of cardiovascular disease risk factors (CVDRFs) is increasing, especially in low-income countries. In Sierra Leone, there is limited empirical data on the prevalence of CVDRFs, and there are no previous studies on the access to care for these conditions. METHODS This study in rural and urban Sierra Leone collected demographic, anthropometric measurements and clinical data from randomly sampled individuals over 40 years old using a household survey. We describe the prevalence of the following risk factors: diabetes, hypertension, dyslipidaemia, overweight or obesity, smoking and having at least one of these risk factors. Cascades of care were constructed for diabetes and hypertension using % of the population with the disease who had previously been tested ('screened'), knew of their condition ('diagnosed'), were on treatment ('treated') or were controlled to target ('controlled'). Multivariable regression was used to test associations between prevalence of CVDRFs and progress through the cascade for hypertension with demographic and socioeconomic variables. In those with recognised disease who did not seek care, reasons for not accessing care were recorded. RESULTS Of 2071 people, 49.6% (95% CI 49.3% to 50.0%) of the population had hypertension, 3.5% (3.4% to 3.6%) had diabetes, 6.7% (6.5% to 7.0%) had dyslipidaemia, 25.6% (25.4% to 25.9%) smoked and 26.5% (26.3% to 26.8%) were overweight/obese; a total of 77.1% (76.6% to 77.5%) had at least one CVDRF. People in urban areas were more likely to have diabetes and be overweight than those living in rural areas. Moreover, being female, more educated or wealthier increased the risk of having all CVDRFs except for smoking. There is a substantial loss of patients at each step of the care cascade for both diabetes and hypertension, with less than 10% of the total population with the conditions being screened, diagnosed, treated and controlled. The most common reasons for not seeking care were lack of knowledge and cost. CONCLUSIONS In Sierra Leone, CVDRFs are prevalent and access to care is low. Health system strengthening with a focus on increased access to quality care for CVDRFs is urgently needed.
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Affiliation(s)
- Maria Lisa Odland
- Institute of Applied Health Research, University of Birmingham, Birmingham, West Midlands, UK
| | - Tahir Bockarie
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Haja Wurie
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Western Area, Sierra Leone
| | - Rashid Ansumana
- Mercy Hospital Research Laboratory, Bo, Sierra Leone
- School of Community Health Sciences, Njala University, Bo Campus, Bo, Sierra Leone
| | - Joseph Lamin
- Mercy Hospital Research Laboratory, Bo, Sierra Leone
| | | | - Ioannis Bakolis
- Centre for Implementation Science, Health Services and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Miles Witham
- AGE Research Group, NIHR Newcastle Biomedical Research Centre, Newcastle University, Newcastle upon Tyne, UK
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, Newcastle upon Tyne, UK
| | - Justine Davies
- Institute of Applied Health Research, University of Birmingham, Birmingham, West Midlands, UK
- Centre for Global Surgery, Department for Global Health, Stellenbosch University, Stellenbosch, South Africa
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Raven J, Wurie H, Idriss A, Bah AJ, Baba A, Nallo G, Kollie KK, Dean L, Steege R, Martineau T, Theobald S. How should community health workers in fragile contexts be supported: qualitative evidence from Sierra Leone, Liberia and Democratic Republic of Congo. Hum Resour Health 2020; 18:58. [PMID: 32770998 PMCID: PMC7414260 DOI: 10.1186/s12960-020-00494-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 07/18/2020] [Indexed: 05/06/2023]
Abstract
BACKGROUND Community health workers (CHWs) are critical players in fragile settings, where staff shortages are particularly acute, health indicators are poor and progress towards Universal Health Coverage is slow. Like other health workers, CHWs need support to contribute effectively to health programmes and promote health equity. Yet the evidence base of what kind of support works best is weak. We present evidence from three fragile settings-Sierra Leone, Liberia and Democratic Republic of Congo on managing CHWs, and synthesise recommendations for best approaches to support this critical cadre. METHODS We used a qualitative study design to explore how CHWs are managed, the challenges they face and potential solutions. We conducted interviews with decision makers and managers (n = 37), life history interviews with CHWs (n = 15) and reviewed policy documents. RESULTS Fragility disrupts education of community members so that they may not have the literacy levels required for the CHW role. This has implications for the selection, role, training and performance of CHWs. Policy preferences about selection need discussion at the community level, so that they reflect community realities. CHWs' scope of work is varied and may change over time, requiring ongoing training. The modular, local and mix of practical and classroom training approach worked well, helping to address gender and literacy challenges and developing a supportive cohort of CHWs. A package of supervision, community support, regular provision of supplies, performance rewards and regular remuneration is vital to retention and performance of CHWs. But there are challenges with supervision, scarcity of supplies, inadequate community recognition and unfulfilled promises about allowances. Clear communication about incentives with facility staff and communities is required as is their timely delivery. CONCLUSIONS This is the first study that has explored the management of CHWs in fragile settings. CHWs' interface role between communities and health systems is critical because of their embedded positionality and the trusting relationships they (often) have. Their challenges are aligned to those generally faced by CHWs but chronic fragility exacerbates them and requires innovative problem solving to ensure that countries and communities are not left behind in reforming the way that CHWs are supported.
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Affiliation(s)
- Joanna Raven
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA UK
| | - Haja Wurie
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | - Ayesha Idriss
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | - Abdulai Jawo Bah
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | - Amuda Baba
- Institut Panafricain de Santé Communautaire et Medecine Tropicale, Bunia, Ituri Province Democratic Republic of Congo
| | - Gartee Nallo
- University of Liberia Pacific Institute for Research and Evaluation, Monrovia, Liberia
| | - Karsor K. Kollie
- Neglected Tropical Disease Program, Liberia Ministry of Health, Monrovia, Liberia
| | - Laura Dean
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA UK
| | - Rosie Steege
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA UK
| | - Tim Martineau
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA UK
| | - Sally Theobald
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA UK
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Idriss A, Diaconu K, Zou G, Senesi RG, Wurie H, Witter S. Rural-urban health-seeking behaviours for non-communicable diseases in Sierra Leone. BMJ Glob Health 2020; 5:e002024. [PMID: 32181002 PMCID: PMC7053783 DOI: 10.1136/bmjgh-2019-002024] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 12/10/2019] [Accepted: 12/22/2019] [Indexed: 02/06/2023] Open
Abstract
Introduction Non-communicable diseases (NCDs) are the leading cause of mortality globally. In Africa, they are expected to increase by 25% by 2030. However, very little is known about community perceptions of risk factors and factors influencing health-seeking behaviour, especially in fragile settings. Understanding these is critical to effectively address this epidemic, especially in low-resource settings. Methods We use participatory group model building techniques to probe knowledge and perceptions of NCD conditions and their causes, health-seeking patterns for NCDs and factors affecting these health-seeking patterns. Our participants were 116 local leaders and community members in three sites in Western Area (urban) and Bombali District (rural), Sierra Leone. Data were analysed using a prior framework for NCD care seeking developed in Ghana. Results Our findings suggest adequate basic knowledge of causes and symptoms of the common NCDs, in rural and urban areas, although there is a tendency to highlight and react to severe symptoms. Urban and rural communities have access to a complex network of formal and informal, traditional and biomedical, spiritual and secular health providers. We highlight multiple narratives of causal factors which community members can hold, and how these and social networks influence their care seeking. Care seeking is influenced by a number of factors, including supply-side factors (proximity and cost), previous experiences of care, disease-specific factors, such as acute presentation, and personal and community beliefs about the appropriateness of different strategies. Conclusion This article adds to the limited literature on community understanding of NCDs and its associated health-seeking behaviour in fragile settings. It is important to further elucidate these factors, which power hybrid journeys including non-care seeking, failure to prevent and self-manage effectively, and considerable expenditure for households, in order to improve prevention and management of NCDs in fragile settings such as Sierra Leone.
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Affiliation(s)
- Ayesha Idriss
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone.,Institute for Global Health and Development, Queen Margaret University Edinburgh, Musselburgh, UK
| | - Karin Diaconu
- Institute for Global Health and Development, Queen Margaret University Edinburgh, Musselburgh, UK
| | - Guanyang Zou
- School of Economics and Management, Guangzhou University of Chinese Medicine, Guangzhou, China, Guangzhou, China
| | - Reynold Gb Senesi
- Non-communicable Diseases and Mental Health Directorate, Sierra Leone Ministry of Health and Sanitation, Freetown, Western Area, Sierra Leone
| | - Haja Wurie
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | - Sophie Witter
- Institute for Global Health and Development, Queen Margaret University Edinburgh, Musselburgh, UK
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Affiliation(s)
- Alastair Ager
- NIHR Research Unit on Health in Situations of Fragility, Queen Margaret University, Queen Margaret Drive, Edinburgh, EH21 6UU, Scotland
| | - Shadi Saleh
- NIHR Research Unit on Health in Situations of Fragility, Global Health Institute, American University of Beirut, Beirut, Lebanon
| | - Haja Wurie
- NIHR Research Unit on Health in Situations of Fragility, College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | - Sophie Witter
- NIHR Research Unit on Health in Situations of Fragility, Queen Margaret University, Queen Margaret Drive, Edinburgh, EH21 6UU, Scotland
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Hay K, McDougal L, Percival V, Henry S, Klugman J, Wurie H, Raven J, Shabalala F, Fielding-Miller R, Dey A, Dehingia N, Morgan R, Atmavilas Y, Saggurti N, Yore J, Blokhina E, Huque R, Barasa E, Bhan N, Kharel C, Silverman JG, Raj A. Disrupting gender norms in health systems: making the case for change. Lancet 2019; 393:2535-2549. [PMID: 31155270 PMCID: PMC7233290 DOI: 10.1016/s0140-6736(19)30648-8] [Citation(s) in RCA: 131] [Impact Index Per Article: 26.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Revised: 03/06/2019] [Accepted: 03/11/2019] [Indexed: 12/21/2022]
Abstract
Restrictive gender norms and gender inequalities are replicated and reinforced in health systems, contributing to gender inequalities in health. In this Series paper, we explore how to address all three through recognition and then with disruptive solutions. We used intersectional feminist theory to guide our systematic reviews, qualitative case studies based on lived experiences, and quantitative analyses based on cross-sectional and evaluation research. We found that health systems reinforce patients' traditional gender roles and neglect gender inequalities in health, health system models and clinic-based programmes are rarely gender responsive, and women have less authority as health workers than men and are often devalued and abused. With regard to potential for disruption, we found that gender equality policies are associated with greater representation of female physicians, which in turn is associated with better health outcomes, but that gender parity is insufficient to achieve gender equality. We found that institutional support and respect of nurses improves quality of care, and that women's empowerment collectives can increase health-care access and provider responsiveness. We see promise from social movements in supporting women's reproductive rights and policies. Our findings suggest we must view gender as a fundamental factor that predetermines and shapes health systems and outcomes. Without addressing the role of restrictive gender norms and gender inequalities within and outside health systems, we will not reach our collective ambitions of universal health coverage and the Sustainable Development Goals. We propose action to systematically identify and address restrictive gender norms and gender inequalities in health systems.
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Affiliation(s)
| | - Lotus McDougal
- Center on Gender Equity and Health, Department of Medicine, School of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Valerie Percival
- Norman Paterson School of International Affairs, Carleton University, Ottawa, ON Canada
| | - Sarah Henry
- Department of Pediatrics, Stanford University School of Medicine, Stanford University, Stanford, CA, USA
| | - Jeni Klugman
- Georgetown Institute for Women, Peace and Security, Georgetown University, Washington, DC, USA; Women and Public Policy Program, Harvard Kennedy School, Cambridge, MA, USA
| | - Haja Wurie
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | - Joanna Raven
- Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Rebecca Fielding-Miller
- Center on Gender Equity and Health, Department of Medicine, School of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Arnab Dey
- Sambodhi Research & Communications, Noida, Uttar Pradesh, India
| | | | - Rosemary Morgan
- Johns Hopkins Bloomberg School of Public Health, Department of International Health, Baltimore, MD, USA
| | | | | | - Jennifer Yore
- Center on Gender Equity and Health, Department of Medicine, School of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Elena Blokhina
- Vladman Institute of Pharmacology, Department of Psychiatry, First Pavlov State Medical University of St Petersburg, Saint Petersburg, Russia
| | | | - Edwine Barasa
- Kemri-Wellcome Trust, Kenya Research Programme, Nairobi, Kenya
| | - Nandita Bhan
- Center on Gender Equity and Health, Department of Medicine, School of Medicine, University of California San Diego, La Jolla, CA, USA
| | | | - Jay G Silverman
- Center on Gender Equity and Health, Department of Medicine, School of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Anita Raj
- Center on Gender Equity and Health, Department of Medicine, School of Medicine, University of California San Diego, La Jolla, CA, USA.
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Bertone MP, Wurie H, Samai M, Witter S. The bumpy trajectory of performance-based financing for healthcare in Sierra Leone: agency, structure and frames shaping the policy process. Global Health 2018; 14:99. [PMID: 30342544 PMCID: PMC6195985 DOI: 10.1186/s12992-018-0417-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 10/02/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND As performance-based financing (PBF) has been increasingly implemented in low-income countries, a growing literature has developed, assessing its effectiveness and, more recently, focussing on the political dynamics of PBF introduction and implementation. This study contributes to the latter body of literature by exploring decision-making processes on PBF in Sierra Leone during the 2010-2017 period. Sierra Leone presents an interesting case because of the 'start-stop-start' trajectory of PBF. METHODS The qualitative case study is based on a document review and 25 key informant interviews with national stakeholders and international actors. Documents and interviews were analysed based on a political economy framework focusing on actors and structure, but also making use of concepts drawn from interpretive policy analysis to look at frames. RESULTS Our analysis describes the process of negotiation and re-negotiation of PBF in Sierra Leone, highlighting the role of different players, both internal and external, their ideas, capacity and power relations, and the shifting narratives around PBF. It is shown that external actors driving the debate make use of 'frames', both actual (i.e., defining the timing and pace of the discussions, the funding available, etc.) and metaphorical (i.e., how PBF is interpreted, defined and understood) to fit in and influence the debate. This is facilitated by the lack of capacity and resources in the fragile setting. Other strategies, such as 'venue shopping' are employed, though they may add to fragmentation in the volatile context. CONCLUSIONS The retrospective view of the study has an analytical advantage, but findings are also relevant to guide practice. Although power relations and rent-seeking issues are difficult to overcome in resource and capacity-constrained settings, more attention could be paid to other elements. In particular, adopting shared frames to ensure a common and inclusive understanding of technical concepts such as PBF may be useful to ensure the political sustainability of reforms. Also, the 'actual frames' which define negotiation and implementation should remain flexible, allowing for disrupting events (e.g., the Ebola epidemic in Sierra Leone) as well as for time to develop national capacity and ownership in order to ensure longer-term political support and better health system integration.
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Affiliation(s)
- Maria Paola Bertone
- ReBUILD & Institute for Global Health and Development (IGHD), Queen Margaret University, Edinburgh, UK
| | - Haja Wurie
- ReBUILD & College of Medicine and Allied Health Sciences (COMAHS), Freetown, Sierra Leone
| | - Mohamed Samai
- ReBUILD & College of Medicine and Allied Health Sciences (COMAHS), Freetown, Sierra Leone
| | - Sophie Witter
- ReBUILD & Institute for Global Health and Development (IGHD), Queen Margaret University, Edinburgh, UK
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Percival V, Dusabe-Richards E, Wurie H, Namakula J, Ssali S, Theobald S. Are health systems interventions gender blind? examining health system reconstruction in conflict affected states. Global Health 2018; 14:90. [PMID: 30157887 PMCID: PMC6116483 DOI: 10.1186/s12992-018-0401-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 07/30/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Global health policy prioritizes improving the health of women and girls, as evident in the Sustainable Development Goals (SDGs), multiple women's health initiatives, and the billions of dollars spent by international donors and national governments to improve health service delivery in low-income countries. Countries recovering from fragility and conflict often engage in wide-ranging institutional reforms, including within the health system, to address inequities. Research and policy do not sufficiently explore how health system interventions contribute to the broader goal of gender equity. METHODS This paper utilizes a framework synthesis approach to examine if and how rebuilding health systems affected gender equity in the post-conflict contexts of Mozambique, Timor Leste, Sierra Leone, and Northern Uganda. To undertake this analysis, we utilized the WHO health systems building blocks to establish benchmarks of gender equity. We then identified and evaluated a broad range of available evidence on these building blocks within these four contexts. We reviewed the evidence to assess if and how health interventions during the post-conflict reconstruction period met these gender equity benchmarks. FINDINGS Our analysis shows that the four countries did not meet gender equitable benchmarks in their health systems. Across all four contexts, health interventions did not adequately reflect on how gender norms are replicated by the health system, and conversely, how the health system can transform these gender norms and promote gender equity. Gender inequity undermined the ability of health systems to effectively improve health outcomes for women and girls. From our findings, we suggest the key attributes of gender equitable health systems to guide further research and policy. CONCLUSION The use of gender equitable benchmarks provides important insights into how health system interventions in the post-conflict period neglected the role of the health system in addressing or perpetuating gender inequities. Given the frequent contact made by individuals with health services, and the important role of the health system within societies, this gender blind nature of health system engagement missed an important opportunity to contribute to more equitable and peaceful societies.
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Affiliation(s)
- Valerie Percival
- International Affairs, Norman Paterson School of International Affairs, Carleton University, 5319 Richcraft Building, 1125 Colonel By Drive, Ottawa, ON K1S 5B6 Canada
| | | | - Haja Wurie
- ReBUILD Research Consortium, College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | - Justine Namakula
- ReBUILD Consortium, School of Public Health, Makerere University, Kampala, Uganda
| | - Sarah Ssali
- School of Women and Gender Studies, ReBUILD consortium, Makerere University, Kampala, Uganda
| | - Sally Theobald
- Social Science and International Health, ReBUILD and RinGs Consortium, Liverpool School of Tropical Medicine, Liverpool, UK
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Witter S, Namakula J, Wurie H, Chirwa Y, So S, Vong S, Ros B, Buzuzi S, Theobald S. The gendered health workforce: mixed methods analysis from four fragile and post-conflict contexts. Health Policy Plan 2018; 32:v52-v62. [PMID: 29244105 PMCID: PMC5886261 DOI: 10.1093/heapol/czx102] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/03/2017] [Indexed: 11/30/2022] Open
Abstract
It is well known that the health workforce composition is influenced by gender relations. However, little research has been done which examines the experiences of health workers through a gender lens, especially in fragile and post-conflict states. In these contexts, there may not only be opportunities to (re)shape occupational norms and responsibilities in the light of challenges in the health workforce, but also threats that put pressure on resources and undermine gender balance, diversity and gender responsive human resources for health (HRH). We present mixed method research on HRH in four fragile and post-conflict contexts (Sierra Leone, Zimbabwe, northern Uganda and Cambodia) with different histories to understand how gender influences the health workforce. We apply a gender analysis framework to explore access to resources, occupations, values, decision-making and power. We draw largely on life histories with male and female health workers to explore their lived experiences, but complement the analysis with evidence from surveys, document reviews, key informant interviews, human resource data and stakeholder mapping. Our findings shed light on patterns of employment: in all contexts women predominate in nursing and midwifery cadres, are under-represented in management positions and are clustered in lower paying positions. Gendered power relations shaped by caring responsibilities at the household level, affect attitudes to rural deployment and women in all contexts face challenges in accessing both pre- and in-service training. Coping strategies within conflict emerged as a key theme, with experiences here shaped by gender, poverty and household structure. Most HRH regulatory frameworks did not sufficiently address gender concerns. Unless these are proactively addressed post-crisis, health workforces will remain too few, poorly distributed and unable to meet the health needs of vulnerable populations. Practical steps need to be taken to identify gender barriers proactively and engage staff and communities on best approaches for change.
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Affiliation(s)
- Sophie Witter
- ReBUILD Consortium and Institute for Global Health and Development, Queen Margaret University, Edinburgh EH21 6UU, UK
| | - Justine Namakula
- ReBUILD and Department of Health Policy, Planning and Management, Makerere School of Public Health, Kampala, Uganda
| | - Haja Wurie
- ReBUILD Consortium and College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | - Yotamu Chirwa
- ReBUILD and Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Sovanarith So
- ReBUILD and Cambodian Development Resource Institute, Phnom Penh, Cambodia
| | - Sreytouch Vong
- ReBUILD and RinGS Consortia, Cambodian Development Resource Institute, Phnom Penh, Cambodia
| | - Bandeth Ros
- ReBUILD and RinGS Consortia, Cambodian Development Resource Institute, Phnom Penh, Cambodia
| | - Stephen Buzuzi
- ReBUILD and RinGS Consortia, Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Sally Theobald
- ReBUILD and RinGS Consortia, Liverpool School of Tropical Medicine, Liverpool, UK
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Witter S, Wurie H, Chandiwana P, Namakula J, So S, Alonso-Garbayo A, Ssengooba F, Raven J. How do health workers experience and cope with shocks? Learning from four fragile and conflict-affected health systems in Uganda, Sierra Leone, Zimbabwe and Cambodia. Health Policy Plan 2018; 32:iii3-iii13. [PMID: 29149313 DOI: 10.1093/heapol/czx112] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/15/2017] [Indexed: 11/15/2022] Open
Abstract
This article is grounded in a research programme which set out to understand how to rebuild health systems post-conflict. Four countries were studied-Uganda, Sierra Leone, Zimbabwe and Cambodia-which were at different distances from conflict and crisis, as well as having unique conflict stories. During the research process, the Ebola epidemic broke out in West Africa. Zimbabwe has continued to face a profound economic crisis. Within our research on health worker incentives, we captured insights from 128 life histories and in-depth interviews with a variety of staff that had remained in service. This article aims to draw together lessons from these contexts which can provide lessons for enhancing staff and therefore health system resilience in future, especially in similarly fragile and conflict-affected contexts. We examine the reported effects, both personal and professional, of the three different types of shock (conflicts, epidemics and prolonged political-economic crises), and how staff coped. We find that the impact of shocks and coping strategies are similar between conflict/post-conflict and epidemic contexts-particularly in relation to physical threats and psychosocial threats-while all three contexts create challenges and staff responses for working conditions and remuneration. Health staff showed considerable inventiveness and resilience, and also benefited from external assistance of various kinds, but there are important gaps which point to ways in which they should be better protected and supported in the future. Health systems are increasingly fragile and conflict-prone, and shocks are often prolonged or repeated. Resilience should not be taken for granted or used as an excuse for abandoning frontline health staff. Strategies should be in place at local, national and international levels to prepare for predictable crises of various sorts, rather than waiting for them to occur and responding belatedly, or relying on personal sacrifices by staff to keep services functioning.
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Affiliation(s)
- Sophie Witter
- ReBUILD and Institute for Global Health and Development, Queen Margaret University, Edinburgh, UK
| | - Haja Wurie
- ReBUILD and College of Medicine and Allied Health Sciences, Freetown, Sierra Leone
| | - Pamela Chandiwana
- ReBUILD and Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Justine Namakula
- ReBUILD and Department of Health Policy, Planning and Management, Makerere School of Public Health, Kampala, Uganda
| | - Sovannarith So
- ReBUILD and Cambodian Development Research Institute, Phnom Penh, Cambodia
| | | | - Freddie Ssengooba
- ReBUILD and Department of Health Policy, Planning and Management, Makerere School of Public Health, Kampala, Uganda
| | - Joanna Raven
- ReBUILD and Liverpool School of Tropical Medicine, Liverpool, UK
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Raven J, Wurie H, Witter S. Health workers' experiences of coping with the Ebola epidemic in Sierra Leone's health system: a qualitative study. BMC Health Serv Res 2018; 18:251. [PMID: 29622025 PMCID: PMC5887191 DOI: 10.1186/s12913-018-3072-3] [Citation(s) in RCA: 115] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Accepted: 03/28/2018] [Indexed: 02/08/2023] Open
Abstract
Background The 2014 Ebola Virus Disease epidemic evolved in alarming ways in Sierra Leone spreading to all districts. The country struggled to control it against a backdrop of a health system that was already over-burdened. Health workers play an important role during epidemics but there is limited research on how they cope during health epidemics in fragile states. This paper explores the challenges faced by health workers and their coping strategies during the Ebola outbreak in four districts – Bonthe, Kenema, Koinadugu and Western Area - of Sierra Leone. Methods We used a qualitative study design: key informant interviews (n = 19) with members of the District Health Management Teams and local councils, health facility managers and international partners; and in depth interviews with health workers (n = 25) working in public health facilities and international health workers involved with the treatment of Ebola patients. Results There were several important coping strategies including those that drew upon existing mechanisms: being sustained by religion, a sense of serving their country and community, and peer and family support. Externally derived strategies included: training which built health worker confidence in providing care; provision of equipment to do their job safely; a social media platform which helped health workers deal with challenges; workshops that provided ways to deal with the stigma associated with being a health worker; and the risk allowance, which motivated staff to work in facilities and provided an additional income source. Conclusions Supportive supervision, peer support networks and better use of communication technology should be pursued, alongside a programme for rebuilding trusting relations with community structures. The challenge is building these mechanisms into routine systems, pre-empting shocks, rather than waiting to respond belatedly to crises.
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Affiliation(s)
- Joanna Raven
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK.
| | - Haja Wurie
- College of Medicine and Allied Health Sciences, University of Sierra Leone, New England, Freetown, Sierra Leone
| | - Sophie Witter
- Institute for Global Health and Development, Queen Margaret University, Edinburgh, UK
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Raven J, Baral S, Wurie H, Witter S, Samai M, Paudel P, Subedi HN, Martineau T, Elsey H, Theobald S. What adaptation to research is needed following crises: a comparative, qualitative study of the health workforce in Sierra Leone and Nepal. Health Res Policy Syst 2018; 16:6. [PMID: 29415738 PMCID: PMC5804047 DOI: 10.1186/s12961-018-0285-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 01/15/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Health workers are critical to the performance of health systems; yet, evidence about their coping strategies and support needs during and post crisis is lacking. There is very limited discussion about how research teams should respond when unexpected crises occur during on-going research. This paper critically presents the approaches and findings of two health systems research projects that explored and evaluated health worker performance and were adapted during crises, and provides lessons learnt on re-orientating research when the unexpected occurs. METHODS Health systems research was adapted post crisis to assess health workers' experiences and coping strategies. Qualitative in-depth interviews were conducted with 14 health workers in a heavily affected earthquake district in Nepal and 25 frontline health workers in four districts in Ebola-affected Sierra Leone. All data were transcribed and analysed using the framework approach, which included developing coding frameworks for each study, applying the frameworks, developing charts and describing the themes. A second layer of analysis included analysis across the two contexts, whereas a third layer involved the research teams reflecting on the approaches used to adapt the research during these crises and what was learned as individuals and research teams. RESULTS In Sierra Leone, health workers were heavily stigmatised by the epidemic, leading to a breakdown of trust. Coping strategies included finding renewed purpose in continuing to serve their community, peer and family support (in some cases), and religion. In Nepal, individual determination, a sense of responsibility to the community and professional duty compelled staff to stay or return to their workplace. The research teams had trusting relationships with policy-makers and practitioners, which brought credibility and legitimacy to the change of research direction as well as the relationships to maximise the opportunity for findings to inform practice. CONCLUSIONS In both contexts, health workers demonstrated considerable resilience in continuing to provide services despite limited support. Embedded researchers and institutions are arguably best placed to navigate emerging ethical and social justice challenges and are strategically positioned to support the co-production of knowledge and ensure research findings have impact.
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Affiliation(s)
- Joanna Raven
- Department of International Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom.
| | - Sushil Baral
- Health Research and Social Development Forum, Kathmandu, Nepal
| | - Haja Wurie
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | - Sophie Witter
- Institute of Global Health and Development, Queen Margaret University, Edinburgh, United Kingdom
| | - Mohamed Samai
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | - Pravin Paudel
- Health Research and Social Development Forum, Kathmandu, Nepal
| | - Hom Nath Subedi
- Health Research and Social Development Forum, Kathmandu, Nepal
| | - Tim Martineau
- Department of International Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Helen Elsey
- Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom
| | - Sally Theobald
- Department of International Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
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Witter S, Wurie H, Namakula J, Mashange W, Chirwa Y, Alonso-Garbayo A. Why do people become health workers? Analysis from life histories in 4 post-conflict and post-crisis countries. Int J Health Plann Manage 2018; 33:449-459. [PMID: 29327468 PMCID: PMC6032858 DOI: 10.1002/hpm.2485] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Revised: 12/14/2017] [Accepted: 12/15/2017] [Indexed: 11/09/2022] Open
Abstract
While there is a growing body of literature on how to attract and retain health workers once they are trained, there is much less published on what motivates people to train as health professions in the first place in low- and middle-income countries and what difference this makes to later retention. In this article, we examine patterns in expressed motivation to join the profession across different cadres, based on 103 life history interviews conducted in northern Uganda, Sierra Leone, Cambodia, and Zimbabwe. A rich mix of reported motivations for joining the profession was revealed, including strong influence of "personal calling," exhortations of family and friends, early experiences, and chance factors. Desire for social status and high respect for health professionals were also significant. Economic factors are also important-not just perceptions of future salaries and job security but also more immediate ones, such as low cost or free training. These allowed low-income participants to access the health professions, to which they had shown considerably loyalty. The lessons learned from these cohorts, which had remained in service through periods of conflict and crisis, can influence recruitment and training policies in similar contexts to ensure a resilient health workforce.
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Affiliation(s)
- Sophie Witter
- ReBUILD Consortium, Queen Margaret University, Musselburgh, Edinburgh, UK
| | - Haja Wurie
- ReBUILD Consortium and College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | - Justine Namakula
- ReBUILD and Department of Health Policy, Planning and Management, Makerere School of Public Health, New Mulago Hospital Complex, Kampala, Uganda
| | - Wilson Mashange
- ReBUILD and Centre for International Health Policy and Biomedical Research and Training Institute, Health Systems unit, Harare, Zimbabwe
| | - Yotamu Chirwa
- ReBUILD and Centre for International Health Policy and Biomedical Research and Training Institute, Health Systems unit, Harare, Zimbabwe
| | - Alvaro Alonso-Garbayo
- ReBUILD and Department of International Public Health and Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, UK
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Witter S, Namakula J, Alonso-Garbayo A, Wurie H, Theobald S, Mashange W, Ros B, Buzuzi S, Mangwi R, Martineau T. Experiences of using life histories with health workers in post-conflict and crisis settings: methodological reflections. Health Policy Plan 2017; 32:595-601. [PMID: 28052985 PMCID: PMC5400054 DOI: 10.1093/heapol/czw166] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/14/2016] [Indexed: 11/16/2022] Open
Abstract
Introduction: Life history is a research tool which has been used primarily in sociology and anthropology to document experiences of marginalized individuals and communities. It has been less explored in relation to health system research. In this paper, we examine our experience of using life histories to explore health system trajectories coming out of conflict through the eyes of health workers. Methods: Life histories were used in four inter-related projects looking at health worker incentives, the impact of Ebola on health workers, deployment policies, and gender and leadership in the health sector. In total 244 health workers of various cadres were interviewed in Uganda, Sierra Leone, Zimbabwe and Cambodia. The life histories were one element within mixed methods research. Results: We examine the challenges faced and how these were managed. They arose in relation to gaining access, data gathering, and analysing and presenting findings from life histories. Access challenges included lack of familiarity with the method, reluctance to expose very personal information and sentiments, lack of trust in confidentiality, particularly given the traumatized contexts, and, in some cases, cynicism about research and its potential to improve working lives. In relation to data gathering, there was variable willingness to draw lifelines, and some reluctance to broach sensitive topics, particularly in contexts where policy-related issues and legitimacy are commonly still contested. Presentation of lifeline data without compromising confidentiality is also an ethical challenge. Conclusion: We discuss how these challenges were (to a large extent) surmounted and conclude that life histories with health staff can be a very powerful tool, particularly in contexts where routine data sources are absent or weak, and where health workers constitute a marginalized community (as is often the case for mid-level cadres, those serving in remote areas, and staff who have lived through conflict and crisis).
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Affiliation(s)
- Sophie Witter
- Professor of International Health Financing and Health Systems, ReBUILD and Queen Margaret University, Edinburgh, UK
| | - Justine Namakula
- Research Fellow, ReBUILD and Department of Health Policy, Planning and Management, Makerere School of Public Health, Kampala, Uganda
| | | | - Haja Wurie
- Health Systems Researcher, ReBUILD Consortium and College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown
| | - Sally Theobald
- Social Science and International Health, ReBUILD and RinGS consortia, Liverpool School of Tropical Medicine, Liverpool, UK.,Institute of Development Studies, Sussex, UK
| | - Wilson Mashange
- ReBUILD and Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Bandeth Ros
- ReBUILD and RinGS consortia, Cambodian Development Resource Institute, Phnom Penh, Cambodia
| | - Stephen Buzuzi
- Public Health Researcher, ReBUILD and RinGS consortia, Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Richard Mangwi
- ReBUILD and Department of Health Policy, Planning and Management, Makerere School of Public Health, Kampala, Uganda
| | - Tim Martineau
- Rebuild and Liverpool School of Tropical Medicine, Liverpool, UK
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Martineau T, McPake B, Theobald S, Raven J, Ensor T, Fustukian S, Ssengooba F, Chirwa Y, Vong S, Wurie H, Hooton N, Witter S. Leaving no one behind: lessons on rebuilding health systems in conflict- and crisis-affected states. BMJ Glob Health 2017; 2:e000327. [PMID: 29082000 PMCID: PMC5656126 DOI: 10.1136/bmjgh-2017-000327] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 05/23/2017] [Accepted: 05/26/2017] [Indexed: 11/03/2022] Open
Abstract
Conflict and fragility are increasing in many areas of the world. This context has been referred to as the 'new normal' and affects a billion people. Fragile and conflict-affected states have the worst health indicators and the weakest health systems. This presents a major challenge to achieving universal health coverage. The evidence base for strengthening health systems in these contexts is very weak and hampered by limited research capacity, challenges relating to insecurity and apparent low prioritisation of this area of research by funders. This article reports on findings from a multicountry consortium examining health systems rebuilding post conflict/crisis in Sierra Leone, Zimbabwe, northern Uganda and Cambodia. Across the ReBUILD consortium's interdisciplinary research programme, three cross-cutting themes have emerged through our analytic process: communities, human resources for health and institutions. Understanding the impact of conflict/crisis on the intersecting inequalities faced by households and communities is essential for developing responsive health policies. Health workers demonstrate resilience in conflict/crisis, yet need to be supported post conflict/crisis with appropriate policies related to deployment and incentives that ensure a fair balance across sectors and geographical distribution. Postconflict/crisis contexts are characterised by an influx of multiple players and efforts to support coordination and build strong responsive national and local institutions are critical. The ReBUILD evidence base is starting to fill important knowledge gaps, but further research is needed to support policy makers and practitioners to develop sustainable health systems, without which disadvantaged communities in postconflict and postcrisis contexts will be left behind in efforts to promote universal health coverage.
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Affiliation(s)
- Tim Martineau
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Barbara McPake
- Nossal Institute for Global Health, University of Melbourne, Melbourne, Australia
| | - Sally Theobald
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Joanna Raven
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Tim Ensor
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, UK
| | - Suzanne Fustukian
- Institute for Global Health and Development, Queen Margaret University, Edinburgh, UK
| | - Freddie Ssengooba
- Department of Health Policy, Planning and Management at the School of Public Health, Makerere University, Kampala, Uganda
| | - Yotamu Chirwa
- Centre for International Health Policy, Biomedical Research and Training Institute, Harare, Zimbabwe
| | | | - Haja Wurie
- Department of Biochemistry, College of Medicine and Applied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | - Nick Hooton
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Sophie Witter
- Institute for Global Health and Development, Queen Margaret University, Edinburgh, UK
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Orya E, Adaji S, Pyone T, Wurie H, van den Broek N, Theobald S. Strengthening close to community provision of maternal health services in fragile settings: an exploration of the changing roles of TBAs in Sierra Leone and Somaliland. BMC Health Serv Res 2017; 17:460. [PMID: 28679383 PMCID: PMC5498892 DOI: 10.1186/s12913-017-2400-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Accepted: 06/20/2017] [Indexed: 11/10/2022] Open
Abstract
Background Efforts to take forward universal health coverage require innovative approaches in fragile settings, which experience particularly acute human resource shortages and poor health indicators. For maternal and newborn health, it is important to innovate with new partnerships and roles for Traditional Birth Attendants (TBAs) to promote maternal health. We explore perspectives on programmes in Somaliland and Sierra Leone which link TBAs to health centres as part of a pathway to maternal health care. Our study aims to understand the perceptions of communities, stakeholder and TBAs themselves who have been trained in new roles to generate insights on strategies to engage with TBAs and to promote skilled birth attendance in fragile affected settings. Methods A qualitative study was carried out in two chiefdoms in Bombali district in Sierra Leone and the Maroodi Jeex region of Somaliland. Purposively sampled participants consisted of key players from the Ministries of Health, programme implementers, trained TBAs and women who benefitted from the services of trained TBAs. Data was collected through key informants and in-depth interviews and focus group discussions. Data was transcribed, translated and analyzed using the framework approach. For the purposes of this paper, a comparative analysis was undertaken reviewing similarities and differences across the two different contexts. Results Analysis of multiple viewpoints reveal that with appropriate training and support it is possible to change TBAs practices so they support pregnant women in new ways (support and referral rather than delivery). Participants perceived that trained TBAs can utilize their embedded and trusted community relationships to interact effectively with their communities, help overcome barriers to acceptability, utilization and contribute to effective demand for maternal and newborn services and ultimately enhance utilization of skilled birth attendants. Trained TBAs appreciated cordial relationship at the health centres and feeling as part of the health system. Key challenges that emerged included the distance women needed to travel to reach health centers, appropriate remuneration of trained TBAs and strategies to sustain their work. Conclusion Our findings highlight the possible gains of the new roles and approaches for trained TBAs through further integrating them into the formal health system. Their potential is arguably critically important in promoting universal health coverage in fragile and conflict affected states (FCAS) where human resources are additionally constrained and maternal and newborn health care needs particularly acute. Electronic supplementary material The online version of this article (doi:10.1186/s12913-017-2400-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Evelyn Orya
- National Primary Health Care Development Agency, Abuja, Nigeria.
| | - Sunday Adaji
- Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Thidar Pyone
- Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Haja Wurie
- College of Medicine and Allied Health Sciences Freetown, Freetown, Sierra Leone
| | - Nynke van den Broek
- Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Sally Theobald
- ReBUILD Consortium International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
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McPake B, Witter S, Ssali S, Wurie H, Namakula J, Ssengooba F. Ebola in the context of conflict affected states and health systems: case studies of Northern Uganda and Sierra Leone. Confl Health 2015; 9:23. [PMID: 26257823 PMCID: PMC4529686 DOI: 10.1186/s13031-015-0052-7] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Accepted: 08/03/2015] [Indexed: 11/10/2022] Open
Abstract
Ebola seems to be a particular risk in conflict affected contexts. All three of the countries most affected by the 2014-15 outbreak have a complex conflict-affected recent history. Other major outbreaks in the recent past, in Northern Uganda and in the Democratic Republic of Congo are similarly afflicted although outbreaks have also occurred in stable settings. Although the 2014-15 outbreak in West Africa has received more attention than almost any other public health issue in recent months, very little of that attention has focused on the complex interaction between conflict and its aftermath and its implications for health systems, the emergence of the disease and the success or failure in controlling it. The health systems of conflict-affected states are characterized by a series of weaknesses, some common to other low and even middle income countries, others specifically conflict-related. Added to this is the burden placed on health systems by the aggravated health problems associated with conflict. Other features of post conflict health systems are a consequence of the global institutional response. Comparing the experience of Northern Uganda and Sierra Leone in the emergence and management of Ebola outbreaks in 2000-1 and in 2014-15 respectively highlights how the various elements of these conflict affected societies came together with international agencies responses to permit the outbreak of the disease and then to successfully contain it (in Northern Uganda) or to fail to do so before a catastrophic cost had been incurred (in Sierra Leone). These case studies have implications for the types of investments in health systems that are needed to enable effective response to Ebola and other zoonotic diseases where they arise in conflict- affected settings.
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Affiliation(s)
- Barbara McPake
- Institute for International Health and Development, Queen Margaret University, Edinburgh, UK ; Nossal Institute for Global Health, University of Carlton, Carlton, Australia
| | - Sophie Witter
- Institute for International Health and Development, Queen Margaret University, Edinburgh, UK
| | - Sarah Ssali
- School of Women and Gender Studies, Makerere University, Kampala, Uganda
| | - Haja Wurie
- College of Medical and Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
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Abstract
There is an acknowledged gap in the literature on the impact of fee exemption policies on health staff, and, conversely, the implications of staffing for fee exemption. This article draws from five research tools used to analyse changing health worker policies and incentives in post-war Sierra Leone to document the effects of the Free Health Care Initiative (FHCI) of 2010 on health workers. Data were collected through document review (57 documents fully reviewed, published and grey); key informant interviews (23 with government, donors, NGO staff and consultants); analysis of human resource data held by the MoHS; in-depth interviews with health workers (23 doctors, nurses, mid-wives and community health officers); and a health worker survey (312 participants, including all main cadres). The article traces the HR reforms which were triggered by the FHCI and evidence of their effects, which include substantial increases in number and pay (particularly for higher cadres), as well as a reported reduction in absenteeism and attrition, and an increase (at least for some areas, where data is available) in outputs per health worker. The findings highlight how a flagship policy, combined with high profile support and financial and technical resources, can galvanize systemic changes. In this regard, the story of Sierra Leone differs from many countries introducing fee exemptions, where fee exemption has been a stand-alone programme, unconnected to wider health system reforms. The challenge will be sustaining the momentum and the attention to delivering results as the FHCI ceases to be an initiative and becomes just ‘business as normal’. The health system in Sierra Leone was fragile and conflict-affected prior to the FHCI and still faces significant challenges, both in human resources for health and more widely, as vividly evidenced by the current Ebola crisis.
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Affiliation(s)
- Sophie Witter
- ReBUILD/IIHD, Queen Margaret University, Edinburgh, Scotland,
| | - Haja Wurie
- ReBUILD programme, College of Medicine and Allied Health Sciences, Freetown, Sierra Leone and
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