Background Intermittent preventive treatment of malaria in infants (IPTi) with sulfadoxine-pyrimethamine (SP) is a proven strategy to protect infants against malaria. Sierra Leone is the first country to implement IPTi nationwide. IPTi implementation was evaluated in Kambia, one of two initial pilot districts, to assess quality and coverage of IPTi services. Methods This mixed-methods evaluation had two phases, conducted 3 (phase 1) and 15–17 months (phase 2) after IPTi implementation. Methods included: assessments of 18 health facilities (HF), including register data abstraction (phases 1 and 2); a knowledge, attitudes and practices survey with 20 health workers (HWs) in phase 1; second-generation sequencing of SP resistance markers (pre-IPTi and phase 2); and a cluster-sample household survey among caregivers of children aged 3–15 months (phase 2). IPTi and vaccination coverage from the household survey were calculated from child health cards and maternal recall and weighted for the complex sampling design. Interrupted time series analysis using a Poisson regression model was used to assess changes in malaria cases at HF before and after IPTi implementation. Results Most HWs (19/20) interviewed had been trained on IPTi; 16/19 reported feeling well prepared to administer it. Nearly all HFs (17/18 in phase 1; 18/18 in phase 2) had SP for IPTi in stock. The proportion of parasite alleles with dhps K540E mutations increased but remained below the 50% WHO-recommended threshold for IPTi (4.1% pre-IPTi [95%CI 2–7%]; 11% post-IPTi [95%CI 8–15%], p < 0.01). From the household survey, 299/459 (67.4%) children ≥ 10 weeks old received the first dose of IPTi (versus 80.4% for second pentavalent vaccine, given simultaneously); 274/444 (62.5%) children ≥ 14 weeks old received the second IPTi dose (versus 65.4% for third pentavalent vaccine); and 83/217 (36.4%) children ≥ 9 months old received the third IPTi dose (versus 52.2% for first measles vaccine dose). HF register data indicated no change in confirmed malaria cases among infants after IPTi implementation. Conclusions Kambia district was able to scale up IPTi swiftly and provide necessary health systems support. The gaps between IPTi and childhood vaccine coverage need to be further investigated and addressed to optimize the success of the national IPTi programme.
After a decade of civil war and the 2014–2016 West African Ebola outbreak, Sierra Leone now faces the COVID-19 pandemic with a fragile health system. As was demonstrated during Ebola, preparedness is key to limiting a health crisis’ spread and impact on health systems and ensuring continued care for vulnerable populations including people living with HIV (PLHIV). To assess COVID-19 preparedness and inform interventions to ensure continuity of HIV services at health facilities (HFs) and community service points (CSPs), we conducted site readiness assessments in Freetown, the epicenter of COVID-19 in Sierra Leone. Data were collected at nine high-volume HIV HFs and seven CSPs in April 2020, a month after COVID-19 was declared a pandemic. CSPs comprised three community drop-in centers providing HIV counseling and testing services as well as HIV prevention services (e.g., condoms and lubricants) for key and priority populations and four community-based support groups serving PLHIV. At the time of assessment, CSPs did not provide antiretroviral therapy (ART) but were considered potential sites for expansion of differentiated service delivery (DSD)—a client-centered approach to HIV care—in the context of COVID-19. Overall, 5/9 HFs had trained staff on use of personal protective equipment (PPE) and prevention of COVID-19 transmission. Most had access to masks (5/9) and gloves (7/9) for management of suspected/confirmed COVID-19 cases, and 4/9 HFs had triage procedures for isolation of suspected cases. Conversely, few CSPs had access to masks (2/7) or gloves (2/7) and no staff were trained on PPE use or COVID-19 transmission. 7/9 HFs had adequate ART stock for multi-month dispensing though few had procedures for (3/9) or had trained staff in providing DSD (2/9). Among CSPs where measures were applicable, 2/4 had procedures for DSD, 1/3 had staff trained on DSD and none had adequate ART stock. Identification of gaps in COVID-19 preparedness is a critical step in providing support for infection control and modified service delivery. Findings from this assessment highlight gaps in COVID-19 preparedness measures at sites supporting PLHIV in Sierra Leone and indicate CSPs may require intensive supervision and training to ensure HIV services are uninterrupted while minimizing COVID-19 risk, especially if used as sites to scale up DSD.
Introduction: Community health workers (CHWs) play an integral role in Sierra Leone's health systems strengthening efforts. Our goal was to understand CHWs' experiences of providing immunization and malaria prevention services in urban settings and explore opportunities to optimize their contributions to these services.Methods: In 2018, we conducted an exploratory qualitative assessment in the Western Area Urban district, which covers most of the capital city of Freetown. We purposively selected diverse health facilities (i.e., type, ownership, setting) and recruited CHWs through their supervisors. We conducted eight focus group discussions (FGD) with CHWs, which were audio-recorded. The topics explored included participants' background, responsibilities and priorities of urban CHWs, sources of motivation at work, barriers to CHWs' immunization and malaria prevention activities, and strategies used to address these barriers. The local research team transcribed and translated FGDs into English; then we used qualitative content analysis to identify themes.Results: Four themes emerged from the qualitative content analysis: (1) pride, compassion, recognition, and personal benefits are important motivating factors to keep working as CHWs; (2) diverse health responsibilities and competing priorities result in overburdening of CHWs; (3) health system- and community-level barriers negatively affect CHWs' activities and motivation; (4) CHWs use context-specific strategies to address challenges in their work but require further support.Conclusion: Focused support for CHWs is needed to optimize their contributions to immunization and malaria prevention activities. Such interventions should be coupled with systems-level efforts to address the structural barriers that negatively affect CHWs' overall work and motivation, such as the shortage of work supplies and the lack of promised financial support.
Quantitative and qualitative assessments have revealed diverse factors that influence the uptake of childhood immunisation services and shed light on reasons for vaccination delays and refusals. UNICEF and partner organisations developed the Immunisation Caregiver Journey Framework as a novel way to understand caregiver experiences in accessing and receiving immunisation services for children. This framework aims to help immunisation programmes identify vaccination barriers and opportunities to improve vaccination uptake by enhancing the overall caregiver journey in a systems-focused manner, using human-centred design principles. In this paper, we adapt the framework into a flexible qualitative inquiry approach with theoretical guidance from interpretative phenomenology. We draw from the implementation experiences in Sierra Leone to inform methodological guidance on how to design and implement the Immunisation Caregiver Journey Interviews (ICJI) to understand the lived experiences of caregivers as they navigate immunisation services for their children. Practical guidance is provided on sampling techniques, conducting interviews, data management, data analysis and the use of data to inform programmatic actions. When properly implemented, the ICJI approach generates a rich qualitative understanding of how caregivers navigate household and community dynamics, as well as primary healthcare delivery systems. We argue that understanding and improving the caregiver journey will enhance essential immunisation outcomes, such as the completion of the recommended vaccination schedule, timeliness of vaccination visits and reduction in dropouts between vaccine doses.
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