Work-based risk factors and quality of life in health care workers providing maternal and newborn care during the Sierra Leone Ebola epidemic: findings using the WHOQOL-BREF and HSE Management Standards Tool.

INTRODUCTION: Before the 2014, Ebola epidemic in Sierra Leone, healthcare workers (HCWs) faced many challenges. Workload and personal risk of HCWs increased but their experiences of these have not been well explored. HCWs evaluation of their quality of life (QoL) and risk factors for developing work-based stress is important in helping to develop a strong and committed workforce in a resilient health system. METHODS: Cross-sectional study using World Health Organisation Quality of Life (WHOQOL)-BREF and Health and Safety Executive (HSE) Standards Tools in 13 Emergency Obstetric Care facilities to (1) understand the perceptions of HCWs regarding workplace risk factors for developing stress, (2) evaluate HCWs perceptions of QoL and links to risk factors for workplace stress and (3) assess changes in QoL and risk factors for stress after a stress management programme. RESULTS: 222 completed the survey at baseline and 156 at follow-up. At baseline, QoL of HCWs was below international standards in all domains. There was a significant decrease in score for physical health and psychological well-being (mean decrease (95% CI); 2.3 (0.5-4.1) and 2.3 (0.4-4.1)). Lower cadres had significant decreases in scores for physical health and social relationships (13.0 (3.6-22.4) and 14.4 (2.6-26.2)). On HSE peer-support and role understanding scored highly (mean scores 4.0 and 3.7 on HSE), workplace demands were average or high-risk factors (mean score 3.0). There was a significant score reduction in the domains relationships and understanding of role (mean score reduction (95% CI) 0.16 (0.01-0.31) and 0.11 (0.01-0.21)), particularly among lower cadres (0.83 (0.3-1.4). CONCLUSION: HCWs in low-resourced settings may have increased risk factors for developing workplace stress with low QoL indicators; further exploration of this is needed to support staff and develop their contribution to the development of resilient health systems.

'Even when you are afraid, you stay': Provision of maternity care during the Ebola virus epidemic: A qualitative study.

OBJECTIVE: to explore nurse-midwives understanding of their role in and ability to continue to provide routine and emergency maternity services during the time of the Ebola virus disease epidemic in Sierra Leone. DESIGN: a hermenuetic phenomenological approach was used to discover the lived experiences of nurse-midwives through 66 face to face interviews. Following verbatim transcription, an iterative approach to data analysis was adopted using framework analysis to discover the essence of the lived experience. SETTING: health facilities designated to provide maternity care across all 14 districts of Sierra Leone. PARTICIPANTS: nurses, midwives, medical staff and managers providing maternal and newborn care during the Ebola epidemic in facilities designated to provide basic or emergency obstetric care. FINDINGS: the healthcare system in Sierra Leone was ill prepared to cope with the epidemic. Fear of Ebola and mistrust kept women from accessing care at a health facility. Healthcare providers continued to provide maternity care because of professional duty, responsibility to the community and religious beliefs. KEY CONCLUSIONS: nurse-midwives faced increased risks of catching Ebola compared to other health workers but continued to provide essential maternity care. IMPLICATIONS FOR PRACTICE: future preparedness plans must take into account the impact that epidemics have on the ability of the health system to continue to provide vital routine and emergency maternal and newborn health care. Healthcare providers need to have a stronger voice in health system rebuilding and planning and management to ensure that health service can continue to provide vital maternal and newborn care during epidemics.

Strengthening pre-service training for skilled birth attendance - An evaluation of the maternal and child health aide training programme in Sierra Leone.

BACKGROUND: The high maternal mortality rate in Sierra Leone combined with an ongoing shortage of midwives has led to the introduction of new cadres of healthcare workers. Maternal and Child Health Aides are one such cadre and now provide 56% of patient care. The quality of the education training programme for MCHA is therefore of paramount importance if high quality maternal care is to be provided. OBJECTIVE: To conduct an evaluation of the MCHAide training programme in Sierra Leone. DESIGN: Mapping of programme and focus group discussions (FGDs) with key informants. Analysis of data using a thematic approach and formulation of recommendations for national, district and individual levels. SETTING: All 14 MCHAide schools across Sierra Leone. PARTICIPANTS: The National Coordinator, Coordinators from 14 MCHAide schools and District Health Sisters from District Health Management Teams. METHODS: Focus group discussions were held with tutors facilitated by a group member to encourage a free flowing discussion. Participants were divided into 4 groups, one for each province, with 5-8 participants per group and 50min for the discussion. RESULTS: Strengths, weaknesses and opportunities of the MCHAide training programme were identified. Four major themes were identified; the need for autonomy and support within the programme from stakeholders; the effect of poor infrastructure on teaching and student learning; the need to ensure rigorous academic quality including teaching quality, curricula content and the academic ability of the students; and the benefits of community support. CONCLUSIONS: It is important that the key personnel be involved in the development and introduction of training programmes for new cadres of staff from the earliest stages of development. On-going programme review and development is essential and those implementing the programme are the best placed to lead and contribute to this. Gathering the experiences and perceptions of key informants helps provide an in-depth examination that can inform recommendations.

Building capacity for skilled birth attendance: An evaluation of the Maternal and Child Health Aides training programme in Sierra Leone.

OBJECTIVE: Maternal and Child Health Aides (MCH Aide) in Sierra Leone provide the majority of maternity services at primary care level. To formulate recommendations for improving the quality and scale-up of MCH Aides training an evaluation of all schools across Sierra Leone was undertaken. DESIGN: Structured, direct observation of two randomly selected teaching sessions per school using pre-tested standardised review forms. Event sampling with random selection of timetabled sessions across all 14 MCH Aide Training Schools. SETTING: All MCH Aide training schools across Sierra Leone. PARTICIPANTS: Tutors across 14 MCH Aide training schools observed in August 2013. MEASUREMENTS: Assessment of four key elements of teaching and learning: (1) teaching style, (2) use of visual aids, (3) teaching environment and (4) student involvement. FINDINGS: In the majority of teaching schools there was over-crowding (11/14), lack of furniture and inconsistent electricity supply. Ten of 26 tutors used lesson plans and teaching was mostly tutor- rather than student-focused. Majority of tutors use a didactic approach rather than active learning methods. Teaching aides were rarely available (15% of lessons). Tutors were knowledgeable in their subject area and there was evidence of an excellent tutor-student relationship. KEY CONCLUSIONS: Training for Maternal and Child health Aides relies on teacher focused didactic methods, which may hinder student learning. Teaching and learning within the schools needs to be enhanced by a combination of tutor development and improvements in the learning environment. IMPLICATIONS FOR PRACTICE: Interventions to improve the quality of teaching are urgently needed and should include training on teaching techniques and student assessment for tutors, provision of audio visual equipment and teaching aides such as posters and mannequins. Monitoring and Evaluation of interventions is critical to be able to amend the programmes approach and address further challenges at an early stage.