Determinants of retention in care of newborns diagnosed with sickle cell disease in Liberia: Results from a mixed-methods study of caregivers.

High-income nations have established that early diagnosis and preventive treatment reduces early deaths in sickle cell disease (SCD). However, in low-/middle-income countries where SCD is common, attrition from clinical care is common. Reasons for poor retention in care are multi-factorial and poorly understood. The objective of this study was to identify factors that influence caregiver decision-making around chronic health care needs of a child with SCD. We conducted an exploratory sequential mixed methods study of caregivers of children diagnosed with SCD during a newborn screening program in Liberia. Caregivers completed questionnaires and semi-structured interviews designed to identify drivers of health decision-making. Interviews were digitally recorded, transcribed, coded, and analyzed using semi-structured thematic analysis to identify themes. Data integration occurred by using quantitative results to expand and clarify the qualitative themes. Twenty-six caregivers participated in the study. The mean age of the child at the interview was 43.7 months. Five themes influencing health decisions were identified: grief, the importance of support networks, stigma, perceived benefits, and the burden of chronic disease. The five themes crossed multiple domains of a socioecological model and identified complex interactions between family, community, social and cultural norms, and organizational structures. This study highlights the importance of community awareness of SCD and appropriate health communication by healthcare workers. Healthcare decision-making is multifactorial and complex. These results provide a framework for improving retention in care. In a low-resource country such as Liberia, much can be done by leveraging existing resources and cultural practices.

Understanding the Predictors that Contribute to Liberian Health Care Workers Feeling Protected From Ebola While at Work.

OBJECTIVE: To assess Liberian health care workers' feelings around safety in returning to work in the setting of the Ebola virus disease outbreak of 2014-2015 after receiving infection prevention and control (IPC) training. METHODS: Academic Consortium Combating Ebola in Liberia (ACCEL) training surveys were done at 21 public, Liberian hospitals to understand health care workers' attitudes surrounding Ebola and whether they felt safe while at work based on multiple factors. Logistic regression was used for analysis. RESULTS: We found that health care workers feeling safe at work during the Ebola outbreak was primarily predicted by the number of IPC/Ebola trainings received pre-ACCEL interventions. Health care workers felt increasingly safer and motivated to return to work as trainings approached 3 (OR 8, p-value < 0.001); however, more than 3 trainings resulted in decreased safety and motivation. In addition, health care workers who reported washing their hands before and after patient contact were 3.4 times more likely to understand how to protect themselves from Ebola. CONCLUSIONS: These results help to better understand the utility of repeated trainings on health care worker practice attitudes and the importance of IPC policies within hospitals, such as hand hygiene promotion and education, when coordinating humanitarian efforts.

Presentation and Treatment Outcomes of Liberian Children Age 5 Years and Under Diagnosed With Severe Malaria.

Malaria is endemic in Liberia with a prevalence rate of up to 60% in some regions, and it has been a major cause of death in children under 5 years of age. Prior to the recent Ebola epidemic, we undertook a prospective, hospital-based pilot study at the National Referral Hospital in Monrovia, to characterize the presentation, accuracy of diagnosis, and treatment outcomes of children presenting for treatment of malaria. From June 2013 to May 2014, we recruited children 5 years and under who presented to the JFK Medical Center with suspected malaria. We collected both clinical and laboratory data on admission and on discharge. We enrolled 477 patients with an average age of 1.6 years. Demographic factors associated with testing negative for malaria included regular bed net use and prior treatment for malaria. The most common presenting symptoms of severe malaria in this population were headache and seizures. Of 246 patients admitted and treated for severe malaria, 33% tested negative by rapid diagnostic test and blood smear for malaria. The case fatality rate was higher for the patients who tested negative for malaria (4.9%) versus those who tested positive (0.6%). Three children who tested negative for malaria showed evidence of undiagnosed Salmonella typhi infection. These results suggest that malaria may be overdiagnosed and that the diagnoses of other infectious diseases, which present in a similar fashion, may be neglected. These findings underscore the need to develop rapid diagnostic tests to screen for alternative causes of febrile illness.

Strengthening healthcare workforce capacity during and post Ebola outbreaks in Liberia: an innovative and effective approach to epidemic preparedness and response.

INTRODUCTION: The 2014-2016 Ebola virus disease (EVD) outbreak in Liberia highlighted the importance of robust preparedness measures for a well-coordinated response; the initially delayed response contributed to the steep incidence of cases, infections among health care workers, and a collapse of the health care system. To strengthen local capacity and combat disease transmission, various healthcare worker (HCW) trainings, including the Ebola treatment unit (ETU) training, safe & quality services (SQS) training and rapid response team (RRT), were developed and implemented between 2014 and 2017. METHODS: Data from the ETU, SQS and RRT trainings were analyzed to determine knowledge and confidence gained. RESULTS: The ETU, SQS and RRT training were completed by a total of 21,248 participants. There were improvements in knowledge and confidence, an associated reduction in HCWs infection and reduced response time to subsequent public health events. CONCLUSION: No infections were reported by healthcare workers in Liberia since the completion of these training programs. HCW training programmes initiated during and post disease outbreak can boost public trust in the health system while providing an entry point for establishing an Epidemic Preparedness and Response (EPR) framework in resource-limited settings.

Strengthening healthcare workforce capacity during and post Ebola outbreaks in Liberia : an innovative and effective approach to epidemic preparedness and response

Introduction: the 2014-2016 Ebola virus disease (EVD) outbreak in Liberia highlighted the importance of robust preparedness measures for a well-coordinated response; the initially delayed response contributed to the steep incidence of cases, infections among health care workers, and a collapse of the health care system. To strengthen local capacity and combat disease transmission, various healthcare worker (HCW) trainings, including the Ebola treatment unit (ETU) training, safe & quality services (SQS) training and rapid response team (RRT), were developed and implemented between 2014 and 2017.Methods: data from the ETU, SQS and RRT trainings were analyzed to determine knowledge and confidence gained.Results: the ETU, SQS and RRT training were completed by a total of 21,248 participants. There were improvements in knowledge and confidence, an associated reduction in HCWs infection and reduced response time to subsequent public health events.Conclusion: no infections were reported by healthcare workers in Liberia since the completion of these training programs. HCW training programmes initiated during and post disease outbreak can boost public trust in the health system while providing an entry point for establishing an Epidemic Preparedness and Response (EPR) framework in resource-limited settings

Health-Care Access during the Ebola Virus Epidemic in Liberia.

The Ebola virus disease (EVD) epidemic, which began in West Africa in December 2013, claimed more than 11,000 lives, with more than 4,800 of these deaths occurring in Liberia. The epidemic had an additional effect of paralyzing the health-care systems in affected countries, which led to even greater mortality and morbidity. Little is known about the impact that the epidemic had on the provision of basic health care. During the period from March to May 2015, we undertook a nationwide, community-based survey to learn more about health-care access during the EVD epidemic in Liberia. A cluster sampling strategy was used to administer a structured in-person survey to heads of households located within the catchment areas surrounding all 21 government hospitals in Liberia. A total of 543 heads of household from all 15 counties in Liberia participated in the study; more than half (67%) of urban respondents and 46% of rural respondents stated that it was very difficult or impossible to access health care during the epidemic. In urban areas, only 20-30% of patients seeking care during the epidemic received care, and in rural areas, only 70-80% of those seeking care were able to access it. Patients requiring prenatal and obstetric care and emergency services had the most difficulty accessing care. The results of this survey support the observation that basic health care was extremely difficult to access during the EVD epidemic in Liberia. Our results underscore the critical need to support essential health-care services during humanitarian crises to minimize preventable morbidity and mortality.