ABSTRACT
Facility-based sentinel testing for COVID-19 was implemented in May 2020 to monitor the prevalence of COVID-19 amongst the Rohingya and host community in Cox's Bazar, Bangladesh. In response both to low uptake of testing across all camps, and rumours of an outbreak of an influenza-like illness in May/June 2020, the International Organization for Migration (in partnership with ACAPS) undertook a qualitative study to collect accounts from the Rohingya relating to testing and treatment, and to explore the possibility that what was thought to be an outbreak of influenza may have been COVID-19. The report provided rich descriptions of the apprehension around testing and offered some clear recommendations for addressing these. We developed a testing 'script' in response to these recommendations, deploying it alongside a survey to determine reasons for declining a test. We compared testing uptake before deploying the testing script, and after (controlling for the total number of consultations), to generate a crude measure of the impact of the script on testing uptake. We coded reasons for declining a test thematically, disaggregated by status (Rohingya and host community) and sex. Despite the small sample size our results suggest an increase in testing uptake following the implementation of the script. Reasons provided by patients for declining a test included: 1) fear, 2) the belief that COVID-19 does not exist, that Allah will prevent them from contracting it, or that their symptoms are not caused by COVID-19, 3) no permission from husband/family, and 4) a preference to return at a later time for a test. Our findings largely mirror the qualitative accounts in the International Organization for Migration/ACAPS report and suggest that further testing amongst both populations will be complicated by fear, and a lack of clarity around testing. Our data lend force to the recommendations in the International Organization for Migration/ACAPS report and emphasise that contextual factors play a key role and must be considered in designing and implementing a health response to a novel disease.
ABSTRACT
BACKGROUND: A patient charter is an explicit declaration of the rights of patients within a particular health care setting. In early 2020 the Save the Children Emergency Health Unit deployed to Cox's Bazar Bangladesh to support the establishment of a severe acute respiratory infection isolation and treatment centre as part of the COVID-19 response. We developed a charter of patient rights and had it translated into Bangla and Burmese; however, the charter remained inaccessible to Rohingya and members of the host community with low literacy. METHODS: To both visualise and contextualise the patient charter we undertook a graphic elicitation method involving both the Rohingya and host communities. We carried out two focus group discussions during which we discussed the charter and agreed how best to illustrate the individual rights contained therein. RESULTS: Logistical constraints and infection prevention and control procedures limited our ability to follow up with the original focus group participants and to engage in back-translation as we had planned; however, we were able to elicit rich descriptions of each right. Reflecting on our method we were able to identify several key learnings relating to: 1) our technique for eliciting feedback on the charter verbatim versus a broader discussion of concepts referenced within each right, 2) our decision to include both men and women in the same focus group, 3) our decision to ask focus group participants to describe specific features of each illustration and how this benefited the inclusivity of our illustrations, and 4) the potential of the focus groups to act as a means to introduce the charter to communities. CONCLUSIONS: Though executing our method was operationally challenging we were able to create culturally appropriate illustrations to accompany our patient charter. In contexts of limited literacy it is possible to enable access to critical clinical governance and accountability tools.
ABSTRACT
BACKGROUND: Large epidemics frequently emerge in conflict-affected states. We examined the cholera response during the humanitarian crisis in Yemen to inform control strategies. METHODS: We conducted interviews with practitioners and advisors on preparedness; surveillance; laboratory; case management; malnutrition; water, sanitation and hygiene (WASH); vaccination; coordination and insecurity. We undertook a literature review of global and Yemen-specific cholera guidance, examined surveillance data from the first and second waves (28 September 2016-12 March 2018) and reviewed reports on airstrikes on water systems and health facilities (April 2015-December 2017). We used the Global Task Force on Cholera Control's framework to examine intervention strategies and thematic analysis to understand decision making. RESULTS: Yemen is water scarce, and repeated airstrikes damaged water systems, risking widespread infection. Since a cholera preparedness and response plan was absent, on detection, the humanitarian cluster system rapidly developed response plans. The initial plans did not prioritise key actions including community-directed WASH to reduce transmission, epidemiological analysis and laboratory monitoring. Coordination was not harmonised across the crisis-focused clusters and epidemic-focused incident management system. The health strategy was crisis focused and was centralised on functional health facilities, underemphasising less accessible areas. As vaccination was not incorporated into preparedness, consensus on its use remained slow. At the second wave peak, key actions including data management, community-directed WASH and oral rehydration and vaccination were scaled-up. CONCLUSION: Despite endemicity and conflict, Yemen was not prepared for the epidemic. To contain outbreaks, conflict-affected states, humanitarian agencies, and donors must emphasise preparedness planning and community-directed responses.
