Exploring health-seeking behavior among adolescent mothers during the Ebola epidemic in Western rural district of Freetown, Sierra Leone

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Study Justification:
– The study aims to understand health-seeking behavior among adolescent mothers during the Ebola epidemic in Sierra Leone.
– The Ebola outbreak had a significant impact on pregnant adolescent girls’ access to prenatal care.
– By exploring the challenges and barriers faced by adolescent mothers during the epidemic, the study can provide insights into improving maternal care and preparedness for future outbreaks.
Highlights:
– The study used qualitative methods, including focus group discussions, to gather data from adolescent mothers in Waterloo, Sierra Leone.
– Multiple challenges were identified, including fear of contracting Ebola, community perceptions, quarantines, national lockdowns, loss of income, and extreme poverty.
– The encounters with health workers and challenges at health facilities also influenced the decision of adolescent mothers not to seek healthcare.
– The study highlights the need to address pre-existing maternal health challenges and the new challenges posed by the Ebola epidemic, such as fear and mistrust towards health professionals and the health system.
– Recommendations are made to improve maternal care in general and enhance preparedness for future outbreaks, particularly for vulnerable groups like adolescent mothers.
Recommendations:
– Emphasize improving maternal care and access to healthcare services for adolescent mothers.
– Enhance preparedness for future outbreaks, including developing strategies to address fear and mistrust towards health professionals and the health system.
– Strengthen community education and awareness programs to dispel misconceptions and promote the importance of seeking healthcare.
– Provide support for economic empowerment and poverty alleviation among adolescent mothers to improve their access to healthcare.
Key Role Players:
– District Health Management Team (DHMT)
– Medical and non-medical staff working in health facilities in the Western Rural Area
– Local NGO coordinators
– ‘Health Alert’ NGO
– Researchers and healthcare professionals specializing in maternal health
Cost Items for Planning Recommendations:
– Community education and awareness programs
– Training programs for healthcare professionals on addressing fear and mistrust
– Economic empowerment and poverty alleviation initiatives for adolescent mothers
– Infrastructure improvements in health facilities
– Research and data collection expenses
– Translation and transcription services
– Administrative and logistical support for implementing recommendations

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is based on a qualitative study using the ‘Three Delay’ model as a theoretical framework. The study employed four focus group discussions with a total of 20 participants. Thematic analysis was used to analyze the data. While the study provides valuable insights into the health-seeking behavior of adolescent mothers during the Ebola epidemic in Sierra Leone, the evidence could be strengthened by including a larger sample size and utilizing additional data collection methods such as interviews or surveys. Additionally, the abstract could provide more specific details about the findings and implications for improving maternal care and preparedness for future outbreaks.

Background: From 2014 to 2016, the largest Ebola outbreak in history threatened Sierra Leone and its neighbouring countries, Guinea and Liberia. The Ebola outbreak impacted pregnant adolescent girl’s access to prenatal care during the pandemic. The aim of this study is to understand health-seeking behaviour among adolescent mothers who were pregnant during the Ebola epidemic in Waterloo, Sierra Leone. Methods: The present qualitative study uses the “Three Delay” model, as a theoretical framework to understand and explore adolescent mother’s health-seeking behaviour through four focus group discussions with five participants in each discussion group. The data were analysed using thematic analysis. Results: A multitude of challenges were identified following the Ebola epidemic. The fear of contracting Ebola was a common reason for not seeking care or utilising services. This notion was perpetuated by perceptions in the community and participants personal experiences. Quarantines, national lockdowns, roadblocks, loss of income and extreme poverty were also identified as barriers to accessing health facilities during Ebola. The different encounters with health workers and the challenges that arose at the health facilities were subsequently additional discouraging factors influencing participant’s decision not to seek health care. Conclusion: Many of the pre-existing maternal health, societal and social-economic challenges were exacerbated during the Ebola. The epidemic also contributed new challenges such as public fear, mistrust towards health professionals and the health system. Greater emphasis needs to be placed on improving maternal care in general, but also improving preparedness for maternal care in case of future outbreaks, especially for the most vulnerable groups such as adolescent mothers.

Sierra Leone has 4 provinces and 14 districts. The Western Area province is divided into an urban and rural district. The study was conducted in Waterloo, which is the capital in the Western Rural Area. The Western Rural Area has a population of 444,270, with (48.1%) of the population living in the Waterloo. The ethnic composition is predominantly Temne (48.7%) followed by a large minority of Mende (12.8%) and Limba (11.3%); and the majority of the population are Muslim (72%). Waterloo is one of five chiefdoms in the rural district [17]. The District Health Management Team (DHMT) has a total of 317 registered staff medical and non-medical staff working in health facilities in the District. The facilities available in Western Rural Area: 12 Community Health Centres (CHC), 20 Community Health Posts (CHP), 21 Maternal Child Health Post s (MCHP) and 1 hospital. Traditional medicine is also considered a part of the primary health care system in Sierra Leone. Western Rural Area reported the last two EVD cases on 20 April 2015. During the EVD, this area was considered an epicentre of the outbreak. The cumulative number of confirmed cases is 1164 for the area [18]. This study was a descriptive study design employing qualitative methods of data collection to explore attitudes and perceptions from adolescent mothers. This data was obtained in June 2016 and was guided by the framework of the “Three Delays” model to understand maternal outcome and how the EDV has influenced health-seeking behaviour and the utilisation of health services according to each delay: (1) deciding to seek appropriate medical help for an obstetric emergency; (2) reaching an appropriate obstetric facility; and (3) receiving adequate care when a facility is reached [19]. This study targeted adolescent mothers aged 15 to 24 who have been pregnant during the EVD outbreak from September 2014 to April 2015 and had been in contact with maternal health care services during their pregnancy or after childbirth. All participants were recruited through homogeneous sampling. With assistance from the local NGO coordinators in Waterloo who helped identify eligible participants. Twenty adolescent mothers were approached and recruited as participants. In a study with a relatively homogeneous population, using a semi-structured guide three Focus Group Discussions (FGDs) will likely capture 80% of the most broadly shared themes and topics [20]. The point of saturation was reached after 4 FGDs. Four FGDs with five participants in each group were employed as a primary mode of data collection to understand social norms, expectations, and experience and how community members form perceptions and attitudes to influence behaviour. The FGDs also aimed to produce group interactions and stimulate discussions based on shared experiences, realities, attitudes and perceptions toward health-seeking behaviour [20]. The duration of the FGDs was approximately 40–60 min. The principal researcher moderated all of the FGDs in the local language Krio which is a mixture of English and indigenous- and afro-descent language. The discussions were conducted in a local school building in a private office. All participants were recruited through in collaboration with ‘Health Alert’, an NGO known for its routine involvement and work with vulnerable girls and young women in Urban and Rural Western District Area. A focus group discussion guide was developed for the study to guide the conversations and provide prompts as attached in Additional file 1. Participants were also asked to comment on a short summary of the VSO report “Exploring the impact of the Ebola outbreak on routine maternal health services in Sierra Leone” [8]. The questions from the guide was also inspired by each delay in the Three Delay Model to help determine where improvements could best be made to reduce the risk of maternal mortality [19]. The guide was tested during a pilot semi-structured interview in order to help modify the questions. Data from the pilot interview was not included in the data set. The questions in the FGD guide included both broad open-ended questions regarding general perceptions on health care and specific questions regarding challenges relating to health care access. All the FGDs were audio-recorded and notes were taken during the FGDs to supplement the audio recording. The FGDs were transcribed verbatim, and translated from Krio to English by the first author. The transcripts were analysed in depth after re-reading the transcripts. Thematic analysis, as described by Braun and Clarke was found to be an appropriate framework for analysis due to the explorative nature of the study, the emergent design of the data collection, and the aim and objectives of the study [21]. Codes and themes were found manually by highlighting the transcript in sections and identifying the codes generated through the FGDs. The data were then rearranged according to the identified patterns. Furthermore, codes were then combined with more abstract sub-themes and themes. An inductive approach was used to find the correlation between codes, sub-theme, theme and the framework. Lastly, the dataset was re-read to ensure that themes correlated to the full dataset and that important data had not been missed.

Based on the provided information, here are some potential innovations that could improve access to maternal health:

1. Mobile Health Clinics: Implementing mobile health clinics that can travel to remote areas, including Waterloo, to provide maternal health services. This would help overcome barriers such as limited transportation options and lack of nearby health facilities.

2. Telemedicine: Introducing telemedicine services that allow pregnant women to consult with healthcare professionals remotely. This would enable them to receive medical advice and guidance without having to physically visit a healthcare facility.

3. Community Health Workers: Training and deploying community health workers in Waterloo and other rural areas to provide basic maternal health services, education, and support. These workers can bridge the gap between the community and formal healthcare system, improving access and awareness.

4. Awareness Campaigns: Conducting targeted awareness campaigns to educate adolescent mothers and their communities about the importance of prenatal care, debunking myths and misconceptions, and addressing the fear and mistrust towards health professionals and the healthcare system.

5. Strengthening Health Facilities: Investing in improving the infrastructure, staffing, and resources of existing health facilities in the Western Rural Area. This would enhance the quality and availability of maternal health services, making them more accessible to adolescent mothers.

6. Financial Support: Providing financial support or incentives to adolescent mothers to encourage them to seek maternal health services. This could include covering transportation costs, offering cash transfers, or providing vouchers for healthcare services.

7. Partnerships with NGOs: Collaborating with local NGOs, such as “Health Alert,” to leverage their expertise and networks in working with vulnerable girls and young women. This partnership can help identify and reach out to adolescent mothers, ensuring they receive the necessary support and care.

These innovations aim to address the challenges identified in the study and improve access to maternal health services for adolescent mothers in Waterloo and other rural areas of Sierra Leone.
AI Innovations Description
Based on the information provided, here is a recommendation that can be developed into an innovation to improve access to maternal health:

1. Strengthening community engagement and education: Develop a comprehensive community engagement and education program that focuses on raising awareness about the importance of maternal health, dispelling myths and misconceptions, and addressing the barriers identified in the study. This program should involve community leaders, local NGOs, and healthcare providers to ensure a holistic approach.

2. Improving healthcare infrastructure: Invest in improving healthcare infrastructure in the Western Rural Area, including the construction and renovation of health facilities, ensuring the availability of essential medical equipment and supplies, and training healthcare workers to provide quality maternal care.

3. Enhancing emergency obstetric care: Establish and strengthen emergency obstetric care services in the area to ensure timely access to life-saving interventions during obstetric emergencies. This can include training healthcare providers in emergency obstetric care, equipping health facilities with necessary resources, and establishing referral systems for complicated cases.

4. Promoting maternal health-seeking behavior: Develop targeted campaigns and interventions to promote positive health-seeking behavior among adolescent mothers. This can include providing information on the importance of prenatal care, addressing fears and misconceptions related to healthcare services, and providing incentives for seeking care, such as transportation vouchers or financial support.

5. Strengthening collaboration and coordination: Foster collaboration and coordination among key stakeholders, including government agencies, NGOs, and community-based organizations, to ensure a coordinated and integrated approach to improving maternal health. This can involve regular meetings, joint planning, and sharing of resources and best practices.

By implementing these recommendations, it is expected that access to maternal health services will be improved in the Western Rural Area of Sierra Leone, particularly for adolescent mothers.
AI Innovations Methodology
Based on the provided description, here are some potential recommendations for improving access to maternal health in Sierra Leone:

1. Strengthening community education and awareness: Implement programs that educate and raise awareness among community members, including adolescent mothers, about the importance of maternal health, available services, and the risks associated with not seeking care. This can be done through community health workers, local NGOs, and community-based organizations.

2. Improving transportation infrastructure: Enhance transportation infrastructure, particularly in rural areas, to ensure that pregnant women have access to health facilities. This can include building or improving roads, providing transportation subsidies or vouchers, and establishing emergency transportation systems.

3. Addressing financial barriers: Develop strategies to reduce financial barriers to accessing maternal health services, such as providing free or subsidized services, implementing health insurance schemes, and offering cash transfer programs for pregnant women.

4. Strengthening health facilities and services: Invest in improving the quality and availability of maternal health services in health facilities, including training healthcare providers, ensuring the availability of essential equipment and supplies, and improving the overall infrastructure of health facilities.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Define indicators: Identify specific indicators that can measure the impact of the recommendations, such as the number of pregnant women seeking prenatal care, the number of deliveries attended by skilled birth attendants, and the reduction in maternal mortality rates.

2. Collect baseline data: Gather data on the current state of maternal health access in the target area, including the number of pregnant women accessing care, the availability of transportation options, the financial barriers faced by pregnant women, and the quality of health facilities and services.

3. Develop a simulation model: Create a simulation model that incorporates the identified recommendations and their potential impact on the defined indicators. This model should consider factors such as population demographics, geographic distribution, and existing healthcare infrastructure.

4. Input data and run simulations: Input the baseline data into the simulation model and run multiple simulations to assess the potential impact of the recommendations. This can involve adjusting variables such as the coverage of community education programs, the improvement in transportation infrastructure, the level of financial support provided, and the enhancement of health facilities and services.

5. Analyze results: Analyze the results of the simulations to determine the potential impact of the recommendations on improving access to maternal health. This can include comparing the simulated outcomes with the baseline data and identifying any significant improvements or changes.

6. Refine and validate the model: Refine the simulation model based on the analysis of the results and validate it using additional data or expert input. This can help ensure the accuracy and reliability of the model for future use.

7. Communicate findings and make recommendations: Present the findings of the simulation study, including the potential impact of the recommendations, to relevant stakeholders, such as policymakers, healthcare providers, and community leaders. Use the findings to inform decision-making and advocate for the implementation of the recommended interventions.

It is important to note that the methodology described above is a general framework and can be adapted and customized based on the specific context and resources available for the simulation study.

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