"If I had known, I would have applied": poor communication, job dissatisfaction, and attrition of rural health workers in Sierra Leone.
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ABSTRACT: Sierra Leone's health outcomes rank among the worst in the world. A major challenge is the shortage of primary healthcare workers (HCWs) in rural areas due to especially high rates of attrition. This study was undertaken to determine the drivers of job dissatisfaction and poor retention among Sierra Leone's rural HCWs.Interviews were conducted with 58 rural and 32 urban primary HCWs in Sierra Leone's public health sector, complemented by key informant discussions and review of national policy documents. HCW interviews included (1) semi-structured discussion, (2) questionnaire, (3) card sort about HCW priorities, and (4) free-listing of most pressing challenges and needs. Sampling for HCW interviews was stratified purposive, emphasizing rural HCWs.Among 90 HCWs interviewed, 67% were dissatisfied with their jobs (71% rural vs 52% urban) and 61% intended to leave their post (75% rural vs 38% urban). While working and living conditions and remuneration were significant factors, a major reason for rural HCW disenchantment was their inability to access worker rights, benefits, and advancement opportunities. This was caused by HCWs' lack of knowledge about human resource (HR) policies and procedures, as well as ambiguity in many policies and inequitable implementation. HCWs reported feeling neglected and marginalized and perceived a lack of transparency. These issues can be attributed to the absence of systems for regular two-way communication between the Ministry of Health and HCWs; lack of official national documents with up-to-date, clear HR policies and procedures for HCWs; pay statements that do not provide a breakdown of financial allowances and withholdings; and lack of HCW induction.HCWs in Sierra Leone lacked accurate information about entitlements, policies, and procedures, and this was a driver of rural HCW job dissatisfaction and attrition. System-oriented, low-cost initiatives can address these underlying structural causes in Sierra Leone. These issues likely apply to other countries facing HCW retention challenges and should be considered in development of global HCW retention strategies.
<h4>Background</h4>Sierra Leone's health outcomes rank among the worst in the world. A major challenge is the shortage of primary healthcare workers (HCWs) in rural areas due to especially high rates of attrition. This study was undertaken to determine the drivers of job dissatisfaction and poor retention among Sierra Leone's rural HCWs.<h4>Methods</h4>Interviews were conducted with 58 rural and 32 urban primary HCWs in Sierra Leone's public health sector, complemented by key informant discussio ...[more]
Project description:ObjectivesSierra Leone has one of the highest maternal mortality ratios in the world. Timely and well-coordinated referrals are necessary to reduce delays in providing adequate care for women with obstetric complications. This study describes factors affecting timely and adequate referral of women with obstetric complications in rural areas of Sierra Leone as viewed by health workers in rural health facilities.DesignQualitative research with semi-structured interviews using open-ended questions. Data were analysed by systematic text condensation.SettingInterviews were held in nine peripheral health units in rural Sierra Leone.Participants19 health workers including nurses, midwives and clinical health officers participated in nine interviews.ResultsFrom the interviews, four major themes describing possible factors of delay in referral of women in need of emergency obstetric care emerged: (1) communication between healthcare workers; (2) underlying influences on decision-making; (3) women's compliance to referral and (4) logistic constraints.Several factors in rural Sierra Leone are perceived to complicate timely and adequate referral of women in need of emergency obstetric care. Notable among these factors are fear among women for being referred and fear among healthcare workers for having maternal deaths or severe obstetric complications occurring at their own facilities. Furthermore, decision-making of healthcare workers whether to refer a woman or not is negatively influenced by a hierarchical culture with high power distance between healthcare workers.ConclusionFactors identified that complicate timely and adequate referral of women in need of emergency obstetric care must be considered in efforts to reduce maternal mortality. Possible interventions that may reduce delay in referral include increased communication by mobile phones between health workers for advice and feedback regarding referrals, involvement of influential stakeholders to increase women's compliance to referral, and consistent use of standardised management protocols.
Project description: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.
Project description:We assessed the effect of information sources on Ebola-specific knowledge and behavior during the 2014-2015 Ebola virus disease outbreak in Sierra Leone. We pooled data from 4 population-based knowledge, attitude, and practice surveys (August, October, and December 2014 and July 2015), with a total of 10,604 respondents. We created composite variables for exposures (information sources: electronic, print, new media, government, community) and outcomes (knowledge and misconceptions, protective and risk behavior) and tested associations by using logistic regression within multilevel modeling. Exposure to information sources was associated with higher knowledge and protective behaviors. However, apart from print media, exposure to information sources was also linked to misconceptions and risk behavior, but with weaker associations observed. Knowledge and protective behavior were associated with the outbreak level, most strongly after the peak, whereas risk behavior was seen at all levels of the outbreak. In future outbreaks, close attention should be paid to dissemination of information.
Project description:BackgroundHepatitis B virus (HBV) is considered highly prevalent in West Africa. However, major gaps in surveillance exist in Sierra Leone. Although healthcare workers (HCWs) are at high risk for HBV infection, little is known about the prevalence and knowledge of hepatitis B among HCWs in Sierra Leone.MethodsA cross-sectional study of all HCWs at the No. 34 Military Hospital located in Freetown, Sierra Leone, was conducted from March 20 to April 10, 2017. Whole blood was collected and screened for HBV markers using a one-step rapid immunochromatographic test with positive samples tested for HBV DNA. Additionally, questionnaires assessing self-reported knowledge of HBV infections were administered to all participants. Data were processed and analyzed using SPSS (version 17.0) software.ResultsA total of 211 HCWs were included in this study with a median age of 39.0 years (range: 18-59). Of the participating HCWs, 172 (81.5%) participants were susceptible (all markers negative), 21(10.0%) were current HBV (HBsAg positive) and nine (4.3%) were considered immune because of past infection (HBsAg negative and anti-HBc positive; anti-HBs positive). Additionally, nine (4.3%) participants displayed immunity to the virus as a result of prior hepatitis B vaccination (only anti-HBs positive). Of the 21 HCWs with positive HBsAg, 13 (61.9%) had detectable HBV DNA. There was a significantly lower risk for current HBV infection among HCWs older than 39 years (OR 0.337, p?=?0.046). In addition, only 14 (6.6%), 73 (34.6%) and 82 (38.9%) participants in this survey had adequate knowledge about the clinical outcome, routes of transmission, and correct preventive measures of HBV infection, respectively.ConclusionsHCWs in Sierra Leone lacked adequate knowledge of the hepatitis B virus. Additionally, the low coverage rate of hepatitis B vaccination among HCWs fails to meet WHO recommendations, leaving many of the sampled HCWs susceptible to infection. This study reaffirms the need for more intensive training for HCWs in addition to strengthening vaccination programmes to protect HCWs against HBV in Sierra Leone.
Project description:The current outbreak of Ebola Virus Disease in Upper West Africa is the largest ever recorded. Molecular evidence suggests spread has been almost exclusively through human-to-human contact. Social factors are thus clearly important to understand the epidemic and ways in which it might be stopped, but these factors have so far been little analyzed. The present paper focuses on Sierra Leone, and provides cross sectional data on the least understood part of the epidemic-the largely undocumented spread of Ebola in rural areas. Various forms of social networking in rural communities and their relevance for understanding pathways of transmission are described. Particular attention is paid to the relationship between marriage, funerals and land tenure. Funerals are known to be a high-risk factor for infection. It is suggested that more than a shift in awareness of risks will be needed to change local patterns of behavior, especially in regard to funerals, since these are central to the consolidation of community ties. A concluding discussion relates the information presented to plans for halting the disease. Local consultation and access are seen as major challenges to be addressed.
Project description:IntroductionThe scale and geographical distribution of the current outbreak in West Africa raised doubts as to the effectiveness of established methods of control. Ebola Virus Disease (EVD) was first detected in Sierra Leone in May 2014 in Kailahun district. Despite high case numbers elsewhere in the country, transmission was eliminated in the district by December 2014. We describe interventions underpinning successful EVD control in Kailahun and implications for EVD control in other areas.MethodsInternal service data and published reports from response agencies were analysed to describe the structure and type of response activities, EVD case numbers and epidemic characteristics. This included daily national situation reports and District-level data and reports of the Sierra Leone Ministry of Health and Sanitation, and Médecins Sans Frontières (MSF) patient data and internal epidemiological reports. We used EVD case definitions provided by the World Health Organisation over the course of the outbreak. Characteristics assessed included level of response activities and epidemiological features such as reported exposure (funeral-related or not), time interval between onset of illness and admission to the EVD Management Centre (EMC), work-related exposures (health worker or not) and mortality. We compared these characteristics between two time periods--June to July (the early period of response), and August to December (when coverage and quality of response had improved). A stochastic model was used to predict case numbers per generation with different numbers of beds and a varying percentage of community cases detected.ResultsThere were 652 probable/confirmed EVD cases from June-December 2014 in Kailahun. An EMC providing patient care opened in June. By August 2014 an integrated detection, treatment, and prevention strategy was in place across the district catchment zone. From June-July to August-December 2014 surveillance and contact tracing staff increased from 1.0 to 8.8 per confirmed EVD case, EMC capacity increased from 32 to 100 beds, the number of burial teams doubled, and health promotion activities increased in coverage. These improvements in response were associated with the following changes between the same periods: the proportion of confirmed/probable cases admitted to the EMC increased from 35% to 83% (χ(2) p-value<0·001), the proportion of confirmed patients admitted to the EMC <3 days of symptom onset increased from 19% to 37% (χ(2) p-value <0·001), and reported funeral contact in those admitted decreased from 33% to 16% (χ(2) p-value <0·001). Mathematical modelling confirmed the importance of both patient management capacity and surveillance and contact tracing for EVD control.DiscussionOur findings demonstrate that control of EVD can be achieved using established interventions based on identification and appropriate management of those who are at risk of and develop EVD, including in the context of ongoing transmission in surrounding regions. Key attributes in achieving control were sufficient patient care capacity (including admission to specialist facilities of suspect and probable cases for assessment), integrated with adequate staffing and resourcing of community-based case detection and prevention activities. The response structure and coverage targets we present are of value in informing effective control in current and future EVD outbreaks.
Project description:BACKGROUND: Ebola virus disease has taken a toll on more than 8,000 lives in West Africa in 2014. The most affected countries are Guinea, Liberia, and Sierra Leone. The number of people infected by Ebola in Sierra Leone surpassed that of Liberia in the last month in this year and almost half of human cases are distributed in this country. DISCUSSION: The ignorance on Ebola among people, including health workers at the early stage, plaid an important role in spread of Ebola virus disease. Subsequently, Ebola ravages urban settings for the first time and takes a huge toll on the lives. The government and international partners do make efforts to control the epidemic, however, lack of synergy make them lip service. SUMMARY: The leading role of government in the response to the epidemic should be emphasized. Basic information of Ebola should be quickly spread among communities by health education programme and social mobilization should be a basic measure for Ebola control.
Project description:IntroductionHepatitis B is a serious public health problem across sub-Saharan Africa. Sierra Leone has no national hepatitis B strategy plan or high quality estimates of prevalence. Healthcare workers are perceived as an at-risk group for hepatitis B. We assessed the prevalence of hepatitis B among healthcare workers at two hospital sites in Freetown, Sierra Leone.MethodsIn October 2017, healthcare workers were offered voluntary testing for hepatitis B surface antigen (HBsAg), hepatitis B surface antibody (anti-HBs), hepatitis B core antibody (anti-HBc), hepatitis B e antigen (HBeAg) and hepatitis B e antibody (anti-HBe) using rapid lateral flow assay for all samples, followed by Enzyme Immunosorbent Assay to confirm positive results. Participants completed a questionnaire about knowledge, attitudes and practices concerning hepatitis B. HBsAg positive participants were invited to a clinic for further assessment.ResultsOverall, 447 participants were tested for hepatitis B. Most (90.6%, 405/447) participants were nurses, 72.3% (323/447) were female and 71.6% (320/447) were 30 years or older. The prevalence of chronic hepatitis B (HBsAg positivity) was 8.7% (39 / 447, 95% CI 6.3-11.7%). There was no significant difference in prevalence by sex, age group, site of work or type of job. None of the 66.7% (26 / 39) of participants with chronic hepatitis B who attended the clinic met the 2015 WHO criteria to start treatment for hepatitis B on the basis of cirrhosis. Most participants (96.9% 432 / 446) stated that they were worried about their risk of hepatitis B at work.ConclusionsHepatitis B is highly prevalent among healthcare workers in Sierra Leone. It is unclear whether this reflects high community prevalence or is due to occupational risk. No participants with chronic hepatitis B needed to start treatment. In order to achieve the WHO target of elimination of viral hepatitis by 2030, introduction of birth dose vaccine for infants and catch-up vaccines for healthcare workers and healthcare students, together with a national hepatitis B screen and treat programme is advisable for Sierra Leone.
Project description:BackgroundLassa fever (LF), an often-fatal hemorrhagic disease caused by Lassa virus (LASV), is a major public health threat in West Africa. When the violent civil conflict in Sierra Leone (1991 to 2002) ended, an international consortium assisted in restoration of the LF program at Kenema Government Hospital (KGH) in an area with the world's highest incidence of the disease.Methodology/principal findingsClinical and laboratory records of patients presenting to the KGH Lassa Ward in the post-conflict period were organized electronically. Recombinant antigen-based LF immunoassays were used to assess LASV antigenemia and LASV-specific antibodies in patients who met criteria for suspected LF. KGH has been reestablished as a center for LF treatment and research, with over 500 suspected cases now presenting yearly. Higher case fatality rates (CFRs) in LF patients were observed compared to studies conducted prior to the civil conflict. Different criteria for defining LF stages and differences in sensitivity of assays likely account for these differences. The highest incidence of LF in Sierra Leone was observed during the dry season. LF cases were observed in ten of Sierra Leone's thirteen districts, with numerous cases from outside the traditional endemic zone. Deaths in patients presenting with LASV antigenemia were skewed towards individuals less than 29 years of age. Women self-reporting as pregnant were significantly overrepresented among LASV antigenemic patients. The CFR of ribavirin-treated patients presenting early in acute infection was lower than in untreated subjects.Conclusions/significanceLassa fever remains a major public health threat in Sierra Leone. Outreach activities should expand because LF may be more widespread in Sierra Leone than previously recognized. Enhanced case finding to ensure rapid diagnosis and treatment is imperative to reduce mortality. Even with ribavirin treatment, there was a high rate of fatalities underscoring the need to develop more effective and/or supplemental treatments for LF.