Re-analysing Ebola spread in Sierra Leone: The importance of local social dynamics.

BACKGROUND: The 2013-15 Ebola epidemic in West Africa was the largest so far recorded, and mainly affected three adjacent countries, Guinea, Liberia and Sierra Leone. The worst affected country (in terms of confirmed cases) was Sierra Leone. The present paper looks at the epidemic in Sierra Leone. The epidemic in this country was a concatenation of local outbreaks. These local outbreaks are not well characterized through analysis using standard numerical techniques. In part, this reflects difficulties in record collection at the height of the epidemic. This paper offers a different approach, based on application of field-based techniques of social investigation that provide a richer understanding of the epidemic. METHODS: In a post-epidemic study (2016-18) of two districts (Bo and Moyamba) we use ethnographic data to reconstruct local infection pathways from evidence provided by affected communities, cross-referenced to records of the epidemic retained by the National Ebola Response Commission, now lodged in the Ebola Museum and Archive at Njala University. Our study documents and discusses local social and contextual factors largely missing from previously published studies. RESULTS: Our major finding is that the epidemic in Sierra Leone was a series of local outbreaks, some of which were better contained than others. In those that were not well contained, a number of contingent factors helps explain loss of control. Several numerical studies have drawn attention to the importance of local heterogeneities in the Sierra Leone Ebola epidemic. Our qualitative study throws specific light on a number of elements that explain these heterogeneities: the role of externalities, health system deficiencies, cultural considerations and local coping capacities. CONCLUSIONS: Social issues and local contingencies explain the spread of Ebola in Sierra Leone and are key to understanding heterogeneities in epidemiological data. Integrating ethnographic research into epidemic-response is critical to properly understand the patterns of spread and the opportunities to intervene. This conclusion has significant implications for future interdisciplinary research and interpretation of standard numerical data, and consequently for control of epidemic outbreaks.

Fertility decisions and contraceptive use at different stages of relationships: windows of risk among men and women in accra.

CONTEXT: Despite declining fertility in Ghana, modern contraceptive use-even in urban areas-is low for reasons that remain unclear. Few studies have explored what drives fertility decisions and contraceptive use among contemporary urban residents within a relationship context. METHODS: In-depth contraceptive life history interviews were conducted among a purposive sample of 80 sexually active women and men living in Accra. RESULTS: Contraception is viewed favorably, although the timing and choice of method strongly depends on the type and stage of relationship. At sexual debut and at first sex with a new partner, sex is usually unprotected. Many women show agency in subsequently negotiating condom use; men also show motivation to practice contraception. As relationships stabilize, couples abandon condoms and adopt traditional methods, out of fear that modern methods could affect fertility. After a first birth, couples prefer modern contraceptives to space children, but side effects often lead women to switch methods or discontinue use; women in supportive relationships are more likely than those in unsupportive relationships to continue use of modern contraceptives despite side effects. After reproductive goals have been realized, couples revert to using traditional methods to avoid further exposure to "chemicals." CONCLUSIONS: Contraceptive programs may be more successful if they target messages according to stage of relationship, involve men and work with people's desires to use traditional methods at certain times to ensure that they can do so safely.