Background
In Sierra Leone, the Ebola Virus Disease (EVD) outbreak, which started in 2014 and officially ended in 2016, evolved in alarming ways, spreading nationwide. The country struggled to control the escalating outbreak against a backdrop of a health system that was already over-burdened [
1,
2]. Being a post-conflict country, the health system in Sierra Leone can be described as fragile and sub-optimal in the face of a disease outbreak as shown by its poor health outcomes. The health workforce was inadequate and ill-equipped to deal with the outbreak including limited national infectious disease expertise. In 2010, the population density of doctors was 2/100,000 population compared to the World Health Organisation’s (WHO) recommended threshold of 23/100,000 [
3]. In addition, only one hospital in Sierra Leone had a functional infectious disease unit, the Kenema Government Hospital’s Lassa Fever Unit, headed by the late Dr. Sheik Umar Khan. From this disadvantaged stand-point, the national capacity to manage the outbreak was further deflated when Dr. Khan, Sierra Leone’s only specialist virologist for viral haemorrhagic fever, succumbed to the virus, very early into the outbreak.
The outbreak quickly led to considerable morbidity and mortality, exacerbated by the weak health system with inadequate numbers of health personnel, surveillance systems, diagnostic facilities, isolation wards and protective equipment. A reported total of 3956 people died in Sierra Leone during the outbreak [
4], but this does not include deaths which were not reported by family members due to fear and other socio-cultural factors, for example, burying their loved ones according to religious practices, which was prohibited at that time. Health workers were 21–32 times more likely to be infected with Ebola than the general adult population [
5]. An unprecedented number of health workers were infected, with an estimated 221 deaths [
4], which is an estimated 21% of the overall health work force in Sierra Leone [
6].
Health workers are at the centre of health systems. In Sierra Leone, efforts made in the post-conflict period to strengthen human resources for health (HRH) suffered a major knock by the EVD outbreak [
7]. Recent papers have highlighted that a weak health system cannot be resilient and cope with crises such as an EVD outbreak, and called for ‘national governments, assisted by external partners, to develop and implement strategies to make their health systems stronger and more resilient’ [
2,
8,
9].
Research from high income settings identifies factors that influence health worker behaviour during epidemics: fear of contagion, concern for family health, interpersonal isolation, quarantine, trust in and support from their organisation, information about risks and what is expected of them, and stigma [
10‐
13]. Risk mitigating strategies included organisational implementation of infection prevention control (IPC) measures, avoidance of patients, and complying with personal protective equipment (PPE) [
10]. They called for more research into factors that influence healthcare workers’ decisions to provide care at the frontline.
However, there is limited research on how health workers experience and cope during health epidemics in fragile states. Previous studies highlight how individuals who survive Ebola (whether patients or health workers) often face stigmatization by family, co-workers and communities, depression and difficulties in reintegration into society [
14‐
16]. Commitment to their profession was identified as the underlying motivation to continue to work despite lack of PPE and other resources necessary to provide care safely [
14]. A recent study in Sierra Leone examined how health workers in peripheral health care facilities in two districts in Sierra Leone experienced the changes in their professional and personal lives during the EVD outbreak [
17]. Key findings included a weakened sense of trust within and across health facilities, providers, communities and households, and feelings of stigmatization, isolation and sadness amongst health workers. Enhanced psychosocial support for not only providers working in designated Ebola treatment and care facilities but also those working in facilities that are not specifically for Ebola management is needed.
Our earlier research in Sierra Leone, under the REBUILD programme (this DfID funded programme is a research consortium working in four post conflict countries generating evidence to rebuilding health systems post conflict and post crisis, and contributing towards health systems strengthening), investigated the post-crisis dynamics for human resources for health and ultimately how to reach and maintain incentives to support access to affordable, appropriate and equitable health services [
18]. In particular, it explored health worker experiences of working during and post conflict, identified factors that motivated or demotivated them to provide services, and their coping strategies through a combination of qualitative and quantitative methods. The research highlighted that developing the capacity of health workers and developing a motivated health workforce is an ongoing issue. We build on this by exploring health workers experiences during another type of crisis – the EVD outbreak.
In this study we explore the challenges faced by healthcare staff working in government facilities, which took on the brunt of managing the EVD outbreak, and their coping strategies in four districts of Sierra Leone: Western Area, Kenema, Bonthe and Koinadugu. Understanding how the health system responded to the outbreak, from a health workers’ perspective, is important in rebuilding the health sector in the post-Ebola phase, and building resilience to such shocks in the future.
Methods
This study was conducted between March and May 2015. It used qualitative research methods - in depth interviews (IDI) with health workers and key informant interviews (KII) – to explore their experiences before and during the EVD outbreak, that is from 2013 to March 2015. Qualitative interviews facilitate generation of in-depth and contextual information about an individual’s experience, beliefs and perceptions as well as exploration of reasons behind their answers through probing questions [
19,
20].
The study was conducted in four districts in Sierra Leone. The selected study districts were the same as those selected for the ReBUILD health worker incentive project, as they represent different regions of Sierra Leone with different timing and extent of outbreak, relationships with district and facility managers made it easier to conduct the study, and it allowed us to build on existing findings. The districts were:
1.
Western Area (Urban/Rural) District – high numbers of EVD patients and epicenter during the outbreak (between 501 and 4000 confirmed cases), large urban and rural populations and referral hospitals
2.
Kenema District (Eastern Region) – high numbers of EVD patients and epicenter during the outbreak (between 501 and 4000 confirmed cases), large urban and rural populations and referral hospital
3.
Bonthe District (Southern Region) – low numbers of EVD patients (between 1 and 5 confirmed cases), hard to reach area as riverine
4.
Koinadugu District (Northern Region) – hit by Ebola in the later stages of the epidemic (between 101 and 501 confirmed cases), no treatment centre, hard to reach as mountainous and 300 km from Freetown
In depth interviews with health workers
We conducted IDIs with frontline government health workers who provided clinical services, to explore their perceptions and experiences of the EVD outbreak in Sierra Leone and the impact of the outbreak on them, and to identify any coping mechanisms that they used. Four groups of health workers were selected:
1.
Health workers who were interviewed for the ReBUILD health worker incentive study [
13] we followed up as many as possible of the 23 participants included in the health worker incentive study. Even when not available for interview, we tried to document their current status, where possible.
2.
National health workers working in Ebola treatment or isolation centres: we selected 2 health workers working in each centre in the most hit study districts, Western Area and Kenema.
3.
National health workers working in other health facilities: we selected 2 health workers working in a district hospital and community health centre in each study district. This group allowed us to understand the wider effects of EVD, beyond the specific treatment centres.
4.
International health workers working in Ebola treatment or isolation centres: we selected international health workers working in these centres in the most hit study districts, Western Area and Kenema. These interviews captured the perceptions of outsiders with operational insights on the current functioning of service delivery in the districts. As health workers who have not worked in the Sierra Leone health system, they provided a unique and important perspective on how health workers coped with responding to the outbreak, and ways to rebuild the health system post- Ebola.
The key informants (KI) were purposefully selected based on them being a member of the District Health Management Team (DHMT) or local councils, health facility managers and international partners working in the study districts. The members of the DHMT and local councils do not have clinical roles but are involved in organising and managing the health care services including health workers. The health facility managers and the international partners play both a clinical and managerial role. They had a detailed knowledge of the health system response to the outbreak and could provide perceptions and experiences of the response.
Data collection and analysis
The interviews, were conducted in English, in a private room in the health facility, office or in their home where the participant felt most comfortable. Separate topic guides were used for the in-depth interviews with health workers and key informant interviews. The topic guides for the in-depth interviews covered health workers’ perceptions and experiences of working during the ongoing Ebola outbreak, any constraints that they faced, challenges in the health systems, their coping mechanisms, and options to increase the resilience of workers and the health system in the future. The topic guides for the key informants included the following areas: perceptions and experiences of the Ebola outbreak; its impact on health workers; constraints, challenges and opportunities in relation to leadership and governance, health workforce and service delivery during the Ebola outbreak; and options to increase the resilience of workers and the health system in the post Ebola phase.
The interviews were digitally recorded after gaining permission from the participants. The recordings of the interviews were transcribed verbatim and analysed using the framework approach which facilitates rigorous and transparent analysis [
21]. The coding framework was developed using themes emerging from the data, the topic guides and study objectives. The authors applied the coding framework to the transcripts, charts were developed for each theme, and these charts were used to describe the themes. NVIVO 10 was used to support the analysis.
Ethics
Ethical approval was obtained from the Sierra Leone Scientific and Ethics Committee and the Liverpool School of Tropical Medicine Research Ethics Committee. Rigorous informed consent process was followed: all participants were given verbal and detailed written information about the nature and purpose of the research before taking part; participants were made aware of their right to decline to answer questions, and were assured that measures are in place to anonymise responses. All participants gave written consent. All data were anonymised.
Discussion
This study engaged with health managers and staff working in routine and Ebola treatment centres in Sierra Leone, and documented their views and experiences not just on the epidemic but also how they coped through it, and what they require in the health sector reconstruction phase. There were challenges related to the readiness of the system to manage the Ebola outbreak, as well as effects on the personal and professional lives of health workers. Despite these challenges, huge resilience was evident – resilience being understood here as the ability to absorb shocks and maintain services in the face of them [
2] - facilitated through training, workshops, social media platform, support from colleagues, families and communities, religion, and the risk allowance. These findings resonate with wider literature about how health staff cope with different types of shocks [
22].
In terms of readiness, the lack of triage facilities, of training in IPC, of PPEs and other enablers, is consistent with other reports on the Ebola epidemic [
8,
23,
24]. A survey carried out in all 1185 Primary Health Units in October 2014 found that health personnel in 37% of the Primary Health Units felt they were not provided with adequate training on Ebola, 15% identified lack of information about Ebola as a challenge, an overwhelming 90% felt fear/misconception as being the main challenge confronted by the health system to fight Ebola, 87% reported lack of protective gear as a large gap and 26% reported lack of medicines as a big constraint [
25]. These findings resonate with McMahon et al. [
17] but also with other studies exploring health workers’ experiences in severe respiratory epidemics [
10‐
13]. The response to the epidemic will also have been affected by the underlying conditions and incentives facing health workers in Sierra Leone (e.g. lack of training and career opportunities, difficult working conditions, long working hours and limited financial and other rewards), even before the epidemic [
18], which were more challenging in rural areas where the epidemic emerged.
This study provides new insights into how health workers adopted coping strategies in Ebola epidemic in Sierra Leone. Over time, the health workers were able to cope better with the outbreak. Health workers reported that at the start of the outbreak, there was a lot of fear amongst health workers about Ebola. Training and workshops, as well as increased clinical experience, improved their knowledge and skills, which relieved this fear and helped them better cope with the outbreak. In addition, peer support and psychosocial support workshops helped health workers cope with the stigma of being health workers during an epidemic. Externally derived coping strategies included training, workshops, financial support, and the social media platform; and those strategies that draw upon existing mechanisms such as being sustained by religion, a sense of serving their country, peer support and family support. These are similar to the coping strategies documented in an earlier study of coping with conflict in Uganda [
26] and in Sierra Leone [
18], with the addition of innovations made during the Ebola outbreak (e.g. the social media platform, the risk allowance). Peer and manager support came out strongly from the interviews. In the context of an emergency, it is possible that non-financial, professional support approaches are more powerful motivators than in stable contexts.
Several recommendations for rebuilding a resilient health system post-EVD outbreak emerge from this study, including maintaining and building on IPC practices in order to contain future outbreaks through in-service training and supportive supervision, maintaining isolation wards with essential equipment, and institutionalising the triage system in all facilities. Some of the infrastructure which was created in response to Ebola should now be effectively incorporated into the health system, and the outstanding gap areas (such as limited drug supplies) filled. This fits with recent reports, such as the evaluation of the Free Health Care Initiative and the Partners In Health experiences of responding to the outbreak and ensuring future emergency preparedness [
27,
28].
It is also important to re-establish not only services but strong links with the community, to regain their trust and involvement. The opportunity to ‘build back better’ health facility committees should be seized and the community health staff used more effectively to link communities and health facilities [
20]. This is indeed anticipated in the post-Ebola plans including the Health Sector Recovery Plan 2015–2020 [
6], the review of the HRH strategic plan 2015–2020 [
29] and in the newly finalised Community Health Worker policy [
30].
Building on health workers’ existing coping strategies is needed. Implementation research to better understand how peer networks and ICT can support health workers should be undertaken. In addition, the participants highlight the responsibility of the government to provide a safe health system, for both patients and staff. Three hundred seven health workers were infected with Ebola in Sierra Leone and 221 died (out of a reported total of 518 health worker deaths in the region during this epidemic) [
31], and there is now a recognition that psychosocial support for them will need to be long-term [
17,
32].
There are several limitations of this study. We were mindful that health workers were being asked to relive difficult experiences when the outbreak was still ongoing. For some health workers, this was the first opportunity to process these experiences, which proved to be distressing. The study was conducted as the outbreak was abating and we were conscious of not detracting from essential work by health workers and managers. Interviews were sometimes interrupted and cut short as respondents were needed elsewhere. This study draws on qualitative methods and explores the issues from the health workers’ and managers’ perspectives, which means that it cannot reveal other perspectives, such as those of the community and patients. The sample was limited as the aim was exploratory rather than to develop generalizable findings. The study did not include health workers from private facilities. They may have different experiences of the Ebola outbreak as well as other coping mechanisms, which need exploration.
Conclusions
This study documents a very painful period with moving experiences of health workers as they continued to try to work and protect their households and communities. At the same time, it is clear that considerable reserves of health worker resilience were found. These patterns of resilience must be reinforced as the sector is rebuilt, both in Sierra Leone and elsewhere. Supportive supervision, peer support networks and better use of communication technology should be pursued, alongside a clear programme for rebuilding trust with community structures. Health workers are at the heart of the health system, and therefore listening to their voices about what helps them stay and do their job during a crisis is vital for building a responsive health system. The challenge is building these coping mechanisms into routine systems, pre-empting shocks, rather than waiting to respond belatedly to crises.