Journal Articles

JSI staff regularly publish their research and results from work in peer-reviewed journals. This section provides a brief abstract with a link to the journal where you can read more and either download or order the article, depending on the journal.

2017   |   2016   |   2015   |   All Journal Articles

December 2016

Social Determinants and Teen Pregnancy Prevention: Exploring the Role of Nontraditional Partnerships in Health Promotion Practice Vol. 1-8, 2016

Addressing the social determinants of health (SDOH) that influence teen pregnancy is paramount to eliminating disparities and achieving health equity. Expanding prevention efforts from purely individual behavior change to improving the social, political, economic, and built environments in which people live, learn, work, and play may better equip vulnerable youth to adopt and sustain healthy decisions. In 2010, the Centers for Disease Control and Prevention in partnership with the Office of Adolescent Health funded state- and community-based organizations to develop and implement the Teen Pregnancy Prevention Community-Wide Initiative. This effort approached teen pregnancy from an SDOH perspective, by identifying contextual factors that influence teen pregnancy and other adverse sexual health outcomes among vulnerable youth. Strategies included, but were not limited to, conducting a root cause analysis and establishing nontraditional partnerships to address determinants identified by community members. This article describes the value of an SDOH approach for achieving health equity, explains the integration of such an approach into community-level teen pregnancy prevention activities, and highlights two project partners’ efforts to establish and nurture nontraditional partnerships to address specific SDOH.

Authors: Taleria Fuller, Carla White, Jocelyn Chu, Deborah Dean, Naomi Clemmons, Carmen Chaparro, Jessica Thames, Anitra Belle Henderson, Pebbles King in Health Promotion Practice, No. 1-8, 2016

Mobile-Based Nutrition and Child Health Monitoring to Inform Program Development: An Experience from Liberia in Global Health: Science and Practice, December 23, 2016 vol. 4 no. 4 p. 661-670

Implementing complex nutrition and other public health projects and tracking nutrition interventions, such as women's diet and supplementation and infant and young child feeding practices, requires reliable routine data to identify potential program gaps and to monitor trends in behaviors in real time. However, current monitoring and evaluation practices generally do not create an environment for this real-time tracking.

This article describes the development and application of a mobile-based nutrition and health monitoring system, which collected monitoring data on project activities, women's nutrition, and infant and young child feeding practices in real time.

The Liberia Agricultural Upgrading Nutrition and Child Health (LAUNCH) project implemented a nutrition and health monitoring system between April 2012 and June 2014. The LAUNCH project analyzed project monitoring and outcome data from the system and shared selected behavioral and programmatic indicators with program managers through a short report, which later evolved into a visual data dashboard, during program-update meetings.

Digital data collection platforms can play a vital role in improving routine programmatic functions. Fixed gathering locations such as food distribution points represent an opportunity to easily access program participants and enable managers to identify strengths and weaknesses in project implementation. For programs that track individuals over time, a mobile tool combined with a strong database can greatly improve efficiency and data visibility and reduce resource leakages.

Authors: Agnes Guyon, Ariella Bock, Laura Buback, Barbara Knittel in Global Health Science in Practice, Dec 2016.

Explaining trends and patterns in attitudes towards wife-beating among women in Nigeria: analysis of 2003, 2008, and 2013 Demographic and Health Survey data in Genus, (2016) 72:11

This paper examines the patterns and trends in attitudes towards wife-beating among women in Nigeria and their determinants. Using the Nigeria Demographic and Health Survey datasets, the authors examined the relationships between sociocultural factors and a woman’s attitude towards being beaten by her spouse.

The results indicate a significant change over time in the percentage of Nigerian women who support or accept the notion that a man is justified in beating or hitting his wife. The findings show that during interviews in 2003, 2008, and 2013, 62.4%, 45.7%, and 37.1% of women, respectively, believed that wife-beating was justified for at least one of the reasons given. Education, place of residence, wealth index, ethnic affiliation, religious affiliation, women’s autonomy in household decision-making, and frequency of listening to the radio were significantly related to acceptance of wife-beating over the years. The study underscores the importance of these factors to the development of policies addressing gender-based violence and urges special attention and intervention to mitigate the effect of the cultural practices that underlie domestic violence against women in Nigeria.

Author: Kolawole Azeez Oyediran

Barriers to Timely and Safe Blood Transfusion for Postpartum Hemorrhage Patients: Evidence from a Qualitative Study in Dhaka, Bangladesh in PLoS ONE, 11(12): e0167399.

In Bangladesh, postpartum hemorrhage (PPH) is the leading cause of maternal mortality and accounts for 31% of all blood transfusions in the country. Although safe blood transfusion is one of the 8 signal functions of Comprehensive Emergency Obstetric Care (CEmOC) strategy, most of the designated public sector CEmOC facilities do not have on-site blood storage system. Emergent blood is mainly available from external blood banks. As a result, emergent patients are to rely on an unregulated network of brokers for blood which may raise question about blood safety.

This study explores lived experiences of patients' attendants, managers, providers, and blood brokers before and after the implementation of an on-line Blood Information and Management Application (BIMA) regarding barriers and facilitators of blood transfusion for emergent patients.

Authors: Sadika Akhter, Iqbal Anwar, Rashida Akter, Feroza Akhter Kumkum, Monjura Khatun Nisha, Fatema Ahsraf, Ferdousi Islam, Nazneen Begum, Mahbub Elahi Chowdhury, Anne Austin, Syed Shariful Islam and Aminur Rahman

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November 2016

Scaling-up the use of sulfadoxine-pyrimethamine for the preventive treatment of malaria in pregnancy: results and lessons on scalability, costs and programme impact from three local government areas in Sokoto State, Nigeria in Malaria Journal, (2016) 15:533.

Intermittent preventive treatment of malaria in pregnancy with 3+ doses of sulfadoxine-pyrimethamine (IPTp-SP) reduces maternal mortality and stillbirths in malaria endemic areas. Between December 2014 and December 2015, a project to scale up IPTp-SP to all pregnant women was implemented in three local government areas (LGA) of Sokoto State, Nigeria. The intervention included community education, and mobilization, household distribution of SP, and community health information systems that reminded mothers of upcoming SP doses. Health facility IPTp-SP distribution continued in three intervention (population 661,606) and one counterfactual (population 167,971) LGAs. During the project lifespan, 31,493 pregnant women were eligible for at least one dose of IPTp-SP.

The author's concluded that it is feasible, safe, and affordable to scale up the delivery of high impact IPTp-SP interventions in low-resource malaria endemic settings, where few women access facility-based maternal health services.

Authors: Nosa Orobaton, Anne Austin, Dele Abegunde, Mohammed Ibrahim, Zainab Mohammed, Jumare Abdul-Azeez, Hakeem Ganiyu, Zwalle Nanbol, Bolaji Fabohunda and Katherine Beal.

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October 2016

Variation in Human Papillomavirus Vaccine Uptake and Acceptability Between Female and Male Adolescents and Their Caregivers in Journal of Community Health, doi: 10.1007/s10900-016-0284-5

HPV vaccination coverage is suboptimal. Previous research largely focused on vaccinating girls. This study aimed to identify factors associated with HPV vaccination among male and female adolescents. A secondary analyses was conducted using the National Immunization Survey-Teen. Parallel logistic models were specified to examine associations of adolescent, caregiver, and provider characteristics with vaccination status among boys and girls.

Vaccination rates were higher among teens receiving a provider recommendation. Moreover, provider recommendation was associated with caregivers’ intent to initiate vaccination. Provider recommendation for vaccination was the strongest predictor for both genders; however, it is insufficient to achieve high coverage rates, especially among boys. Factors associated with HPV vaccination were different for males and females. These findings suggest providers should consider gender bias with regard to HPV vaccination.

Authors: Kristin Johnson, Meng-Yun Lin, Howard Cabral, Lewis Kazis and Ingrid Katz

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September 2016

Healthy Futures Program and Adolescent Sexual Behaviors in 3 Massachusetts Cities: A Randomized Controlled Trial in American Journal of Public Health, Vol. 106, No. S1, pp. S103-S109

Evaluation of the impact of a 3-year Healthy Futures program on reducing sexual behaviors among middle school students in 15 public middle schools in Haverhill, Lowell, and Lynn, Massachusetts. Student survey data was collected at baseline and immediately after each Nu-CULTURE curriculum (classroom component of Healthy Futures) in the sixth, seventh, and eigth grades, and at a 1-year follow up in the ninth grade.

There was some evidence of delaying sexual initiation by the end of Nu-CULTURE, for girls and Hispanics, but not for boys. Future research should focus on improving implementation of the supplemental components intended to foster interpersonal and environmental protective factors associated with sustained delays in sexual activity.

Research methods and results are presented in the full article, available at American Journal of Public Health

Authors: Tamara Calise, Wendy Chow, Katelyn Dore, Michael O'Brien, Elizabeth Heitz, Rebecca Millock.

Ethiopia's health extension workers use of work time on duty: time and motion study in Health Policy and Planning, 32, 2017, 320-328.

Ethiopia has implemented an innovative community-based health program, called the health extension program, to enhance access to basic health promotion, disease prevention, and selected curative services by establishing health posts in every village, also called kebeles, with average of 5,000 people, staffed with two health extension workers (HEWs).

This time and motion study was conducted to estimate the amount of time that HEWs spend on various work duties and to explore differences in urban compared with rural settings and among regions. 44 HEWs were observed for 21 consecutive days, and time and motion data were collected using tablet computers. On average, HEWs were on duty for 15.5 days out of the 21 days and worked about 6 hours per work day. Out of the total observed work time, the percentage of time spent on various activities was: 12.8% providing health education or services, 9.3% meetings and giving trainings, 0.8% conducting community mapping and mobilization, 13.2% reporting, managing family folders, 1.3% managing commodities and supplies, 3.2% receiving supervision, 1.6% receiving training, 15.5% travel between work activities, 24.9% waiting for clients in the health post/health center, 13.3% building relationships in the community, and 4% not meaningfully categorized.

The proportion of time spent on different activities and the total time worked varied significantly between the rural and urban areas and among the regions. Findings of this study indicate that only a minority of HEW time is spent on providing health education and services, and substantial time is spent waiting for clients. The efficiency of the HEW model may be improved by creating more demand for services or by redesigning service delivery modalities. Authors: Hibret Tilahun, Binyam Fekadu, Habtamu Abdisa, Maureen Canavan, Erika Linnander, Elizabeth H Bradley. and Peter Berman.

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July 2016

The power of siblings and caregivers: under-explored types of social support among children affected by HIV and AIDS in AIDS Care, Vol 28:sup2, 110-117, DOI: 10.1080/09540121.2016.1178942

A study conducted by JSI staff looks at social support among children affected by HIV. Children affected by HIV and AIDS have significantly higher rates of mental health problems than unaffected children. There is a need for research to examine how social support functions as a source of resiliency for children in high HIV-prevalence settings such as South Africa.

This study explored how family social support relates to depression, anxiety, and post-traumatic stress (PTS). Using the ecological model as a frame, data were drawn from a 2011 cross-sectional study of 1380 children classified as either orphaned by AIDS and/or living with an AIDS-sick family member. The children were from high-poverty, high HIV-prevalent rural and urban communities in South Africa.

Social support was analyzed in depth by examining the source (e.g. caregiver, sibling) and the type (e.g. emotional, instrumental, quality). These variables were entered into multiple regression analyses to estimate the most parsimonious regression models to show the relationships between social support and depression, anxiety, and PTS symptoms among the children. Siblings emerged as the most consistent source of social support on mental health.

Authors: Melissa Sharer, Lucie Cluver, Joseph J. Shields, Joseph Ahearn

Quality improvement practices to institutionalize supply chain best practices for iCCM: Evidence from Rwanda and Malawi in Research in Social & Administrative Pharmacy, 2016 Jul 28 (Epub ahead of print)

Supply chain bottlenecks that prevent community health workers (CHWs) from accessing essential medicines significantly increase under-5 child mortality, particularly in poor and rural areas. Using implementation research, interventions aimed at improving supply chain practices and access to medicines were tested in Malawi and Rwanda. These interventions included simple demand-based resupply procedures, using mobile technology and traditional methods for communication, and multilevel, performance-driven quality improvement (QI) teams.

While simple, streamlined, demand-based resupply procedures provide the basis for regular, functional, and efficient resupply of CHWs, the procedures alone are not sufficient to create consistent change in product availability. Supporting these procedures with multilevel QI teams reinforces the correct and consistent use of resupply procedures.

Yasmin Chandani, Malia Duffy, Barbara Lamphere, Megan Noel, Alexis Heaton and Sarah Andersson.
John Snow, Inc and JSI Research and Training Institute, Inc. 2016

HIV Testing Among Black and Hispanic Immigrants in the United States in AIDS Patient Care and STDs. July 2016, 30(7): 307-314.

Late presentation is common among black and Hispanic US immigrants living with HIV. Little is known about HIV testing in this population because data are aggregated into racial and ethnic categories without regard to nativity.

This study was undertaken to determine HIV testing patterns in these populations. We used data from the National Health Interview Survey (2007–2010), a nationally representative source of HIV testing data disaggregated by nativity. The sample consisted of 10,397 immigrants (83.9% Hispanic white, 13.1% non-Hispanic black, and 3.0% Hispanic black). The majority of participants were from the Caribbean, Central America, and Mexico (81.5%). Hispanic white immigrants were least likely to have undergone testing compared with non-Hispanic and Hispanic black immigrants (46.7% vs. 70.5% and 65.8%). Among immigrants with known risk factors or prior STDs, 59.2% and 74.8% reported previous HIV testing. Immigrants who had not recently talked to a healthcare provider were less likely to report testing: Hispanic white (AOR 0.65, 95% CI 0.58–0.72), non-Hispanic black (AOR 0.64, 95% CI 0.48–0.85), and Hispanic black (AOR 0.26, 95% CI 0.14–0.48). Only 17.2% of all immigrants intended to undergo HIV testing in the 12 months following participation in the survey.

Among all three racial and ethnic groups, immigrants who reported a history of prior STDs were more likely to intend to test for HIV in the future. Many black and Hispanic immigrants to the United States have not undergone HIV testing. Interventions to increase access to HIV testing and awareness of transmission risk should be developed.

Authors: Bisola Ojikutu, Emanuele Mazzola, Andrew Fullem, Rodolfo Vega, Stewart Landers, Rebecca Gelman and Laura Bogart.

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June 2016

Uncivil and skewed language on civil society? in The Lancet, Volume 387, No. 10036, P2377

This Comment published in the Lancet responds to questions that editor Richard Horton made in his "Offline" commentary, (March 12, 2016, p 1041), which summarised comments from a forum on the role of nongovernmental organisations (NGOs) in global health. Horton's "Offline" echoed a prevalent systematic bias in the treatment of NGOs.

The authors, including JSI's Craig Burgess, point out that NGOs are diverse and dynamic entities that are responsive to social, cultural, and political trends, with varying missions, foci, technical acumen, religious affiliation, experience, and quality assurance standards. The one-size-fits-all label of NGO is outdated. To tackle serious problems, the authors write, we need to evolve our language, and be both more specific and more systemic. Horton questioned the appropriateness of “uncritical acceptance of NGO participation” in global health on the basis of broadly assigned dysfunctions and with a passing acknowledgment that these dysfunctions also apply to other actors.

Authors: Eric Gilles Sarriot, Karen LeBan, Emma Sacks, Christine Sow, Craig Burgess

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May 2016

The Ethiopian Health Extension Program and Variation in Health Systems Performance: What Matters? in Plos One, 11(5): e0156438

Primary health care services are fundamental to improving health and health equity, particularly in the context of low and middle-income settings where resources are scarce. During the past decade, Ethiopia undertook an ambitious investment in primary health care known as the Ethiopian Health Extension Program that recorded impressive gains in several health outcomes. Despite this progress, substantial disparities in health outcomes persist across the country. The objective of this study was to understand how variation in the implementation of the primary health care efforts may explain differences in key health outcomes.

Authors: Netsanet Fetene, Erika Linnander, Binyam Fekadu, Hibret Alemu, Halima Omer, Maureen Canavan, Janna Smith, Peter Berman, Elizabeth Bradley


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April 2016

Assessment of Enterococcus Levels in Recreational Beach Sand in Journal of Environmental Health, Volume 78, No. 8, 12–17

Recent studies have shown that coastal beach sand as well as coastal ocean water can be contaminated with fecal indicator Enterococcus bacteria (ENT). A study of sand ENT concentrations over a four-week period at 12 Rhode Island beaches was conducted during the summer of 2009. While average contamination was low relative to water quality standards, every beach had at least one day with very high sand ENT readings. On 10 of the 12 beaches, a statistically significant gradient occurred in geometric mean ENT concentrations among tidal zones, with dry (supratidal, or above high tide mark) sand having the highest level, followed by wet (intratidal, or below high tide mark) and underwater sand. Beaches with higher wave action had significantly lower ENT levels in wet and underwater sand compared to beaches with lower wave action.

Authors: Eugenie Coakley, JSI Research and Training Institute; Amie L. Parris, Rhode Island Department of Health; Al Wyman, Permanent Environmental Solutions, LLC; Gretchen Latowsky, JSI Research and Training Institute

Sociocultural determinants of home delivery in Ethiopia: a qualitative study in International Journal of Women's Health, April 2016

Maternal health remains a major public health problem in Ethiopia. Despite the government’s measures to ensure institutional delivery assisted by skilled attendants, home delivery remains high, estimated at over 80% of all pregnant women.
This study, conducted by the Addis Ababa School of Public Health with JSI's IFHP+ program, aims to identify determinants that sustain home delivery in Ethiopia.

Authors: Mirgissa Kaba, Tesfaye Bulto, Zergu Tafesse, Wassie Lingerh, Ismael Ali

A case study of community-based distribution and use of Misoprostol and Chlorhexidine in Sokoto State, Nigeria in Global Public Health, 2016

The United States Agency for International Development/Targeted States High Impact Project supported Sokoto State, Nigeria government in the development of a community-based intervention aimed at preventing post-partum hemorrhage (PPH) and cord infection among women and children, respectively. This paper describes the innovative intervention within the Nigeria health delivery system. It then explains the case study approach to assessing this intervention and summarizes findings. Ultimately, the intervention was received well in communities and both drugs were added to the procurement list of all health facilities providing maternity services in the State. Key factors leading to such success include early advocacy efforts at the state-level, broad stakeholder engagement in designing the distribution system, early community engagement about the value of the drugs and concerted efforts to monitor and ensure availability of the drugs. Implementation challenges occurred in some areas, including shortage of community-based health volunteers (CBHVs) and drug keepers, and socio-cultural barriers. To maximize and sustain the effectiveness of such interventions, state government needs to ensure constant drug supply and adequate human resources at the community level, enhance counselling and mobilization efforts, establish effective quality improvement strategies and implement a strong M&E system. JSI, 2016

Investing in health information management: The right people, in the right place, at the right time in Health Information Management Journal

The MEASURE Evaluation project helped lead a review of the training curriculum for health professionals in health information management in Nigeria. The study was conducted in response to an earlier assessment which found that many health professionals were inadequately skilled in information and communications technology. The study findings are published in the April 2016 issue of the Health Information Management Journal.

Authors: Olusesan Ayodeji Makinde; Mohammed Ibrahim Mami; Benson Macaulay Oweghoro; Kolawole Azeez Oyediran; Stephanie Mullen

Read the full article at SAGE Journals.

Feasibility and acceptability of oral cholera vaccine mass vaccination campaign in response to an outbreak and floods in Malawi in The Pan African Medical Journal. 2016;23:203

Despite some improvement in provision of safe drinking water, proper sanitation and hygiene promotion, cholera still remains a major public health problem in Malawi with outbreaks occurring almost every year since 1998.

In response to 2014/2015 cholera outbreaks, the ministry of health and partners assessed the feasibility and acceptability of conducting a mass oral cholera vaccine (OCV) as an additional public health measure. This paper highlights the burden of the 2014/15 cholera outbreak, successes and challenges of OCV campaign conducted in March and April 2015.

This was a documentation of the first OCV campaign conducted in Malawi. The campaign targeted over 160,000 people aged one year or more living in 19 camps of people internally displaced by floods and their surrounding communities in Nsanje district. It was a reactive campaign as additional measure to improved water, sanitation and hygiene in response to the laboratory confirmed cholera outbreak.

This documentation has demonstrated that it was feasible, acceptable by the community to conduct a large-scale mass OCV campaign in Malawi within five weeks. Of 320,000 OCV doses received, Malawi managed to administer at least 294,221 (91.9%) of the doses. OCV could therefore be considered to be introduced as additional measure in cholera hot spot areas in Malawi.

Authors: Kelias Phiri Msyamboza, Maurice M’bang’ombe, Hannah Hausi, Alexander Chijuwa, Veronica Nkukumila, Hudson Wenji Kubwalo, Sachin Desai, Lorenzo Pezzoli, Dominique Legros

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March 2016

Promoting Healthy Behaviors among Egyptian Mothers: A Quasi-Experimental Study of a Health Communication Package Delivered by Community Organizations in Plos One, 11(3): e0151783

Decisions made at the household level, for example, to seek antenatal care or breastfeed, can have a direct impact on the health of mothers and newborns. The SMART Community-based Initiatives program in Egypt worked with community development associations to encourage better household decision-making by training community health workers to disseminate information and encourage healthy practices during home visits, group sessions, and community activities with pregnant women, mothers of young children, and their families. A quasi-experimental design was used to evaluate the program, with household surveys conducted before and after the intervention in intervention and comparison areas. Survey questions asked about women’s knowledge and behaviors related to maternal and newborn care and child nutrition and, at the endline, exposure to SMART activities. Findings suggest that there may have been a significant dose-response relationship between exposure to SMART activities and certain knowledge and behavioral indicators, especially in Upper Egypt. The findings demonstrate the ability of civil society organizations with minimal health programming experience to increase knowledge and promote healthy behaviors among pregnant women and new mothers. The SMART approach offers a promising strategy to fill gaps in health education and counseling and strengthen community support for behavior change.

Mapping the Prevalence and Sociodemographic Characteristics of Women Who Deliver Alone: Evidence From Demographic and Health Surveys From 80 Countries in Global Health: Science and Practice D-15-00261

An estimated 2 million women surveyed in low- and middle-income countries between 2005 and 2015 gave birth alone. This practice was concentrated in West and Central Africa and parts of East Africa. Women who delivered with no one present were very poor, uneducated, older, and of higher parity. Experience from northern Nigeria suggests the practice can be reduced markedly by mobilizing religious and civil society leaders to improve community awareness about the critical importance of having an attendant present.

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February 2016

The Impact of Integrated Community Case Management of Childhood Diseases Interventions to Prevent Malaria Fever in Children Less than Five Years Old in Bauchi State of Nigeria in PLOS One

Malaria accounts for about 300,000 childhood deaths and 30% of under-five year old mortality in Nigeria annually. JSI's Targeted States High Impact Project assessed the impact of intervention strategies that integrated Patent Medicines Vendors into community case management of childhood-diseases, improved access to artemisinin combination therapy (ACT) and distributed bed nets to households. Researchers explored the influence of household socioeconomic characteristics on the impact of the interventions on fever in the under-five year olds in Bauchi State Nigeria.

The study sampled 3077 and 2737 under-5 year olds from 1,588 and 1601 households in pre- and post-intervention periods respectively, wbetween 2013 to 2015. Read the full article at PLOS One.

Authors: Dele Abegunde, Nosa Orobaton , Amos Bassi , Olugbenga Oguntunde , Moyosola Bamidele , Masduq Abdulkrim , Ezenwa Nwizugbe

Value of Experiential STD Clinical Training in the Digital Age in Sexually Transmitted Diseases, Vol. 43 (2).

This publication looks at the importance of translating evidence-based guidelines for sexually transmitted disease (STD) care into clinical practice for the prevention and control of STDs. Conclusions will show that STD experiential clinical training program is still relevant to participants in the digital age and is valued more highly than other continuing education experiences.

Download the article or view it at the Journal of the American Sexually Transmitted Diseases Association

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January 2016

Infection prevention and control of the Ebola outbreak in Liberia, 2014–2015: key challenges and successes in BMC Medicine

Prior to the 2014–2015 Ebola outbreak, infection prevention and control (IPC) activities in Liberian healthcare facilities were basic. There was no national IPC guidance, nor dedicated staff at any level of government or healthcare facility (HCF) to ensure the implementation of best practices. Efforts to improve IPC early in the outbreak were ad hoc and messaging was inconsistent. In September 2014, at the height of the outbreak, the national IPC Task Force was established with a Ministry of Health (MoH) mandate to coordinate IPC response activities. A steering group of the Task Force, including representatives of the World Health Organization (WHO) and the United States Centers for Disease Control and Prevention (CDC), supported MoH leadership in implementing standardized messaging and IPC training for the health workforce. This structure, and the activities implemented under this structure, played a crucial role in the implementation of IPC practices and successful containment of the outbreak. Moving forward, a nationwide culture of IPC needs to be maintained through this governance structure in Liberia’s health system to prevent and respond to future outbreaks.

Authors: Catherine Cooper, Dale Fisher, Neil Gupta, Rose MaCauley, and Carmem L. Pessoa-Silva

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