Stigma and Sierra Leone
Sierra Leone was part of a wider West African outbreak of Ebola which also included Guinea and Liberia. This epidemic lasted from December 2013 to June 2016.When it was over there were over 28,600 cases and 11,325 confirmed deaths.
Now the country is facing another epidemic; Covid-19. The proximity between these two infectious disease outbreaks has unfortunately led to the development of a large amount of stigma in Sierra Leone.This has a serious negative impact on the population’s health-seeking behaviour, something that we are seeing with a reduction in the rate stroke patients being consented onto the Connaught Stroke Register.
The views that are informing the stigma and comparisons between Ebola and COVID-19 are diverse and complicated. We will try and break down some of them in the first part of the blog and explain how they are affecting the general population.
An example of this stigma is the direct comparison between Ebola and COVID-19, many residents have had experience of Ebola, and the lack of public education on COVID-19 has meant people assume this disease is as severe as Ebola.
As a result , it is a common belief that if your family is quarantined or asked to go to the medical centre for a test, everyone will die, as was experienced when the Ebola contact tracers came to communities during that epidemic. People have become unwilling to come to the hospital when they are acutely unwell.
The Stroke Register during COVID-19
The pandemic has impacted the Connaught Hospital Stroke Register (part of SISLE).We are seeing is a substantial reduction in the number of stroke patients coming to the hospital. In March, before COVID-19 reached Sierra Leone, (the index Covid 19 case being on 30/3/20) we consented 46 patients onto the register. In April we consented 20 patients onto the register. The patients who do come to the hospital are taking much longer to arrive following the onset of stroke symptoms. Before the pandemic, the median time for register participants to present at hospital was 20 hours, in April this time rose to 35 hours. Regretably, we have also seen an increase of in hospital mortality. Pre Covid, the register reported a 35% in hospital mortality, it has now risen to 53%.
This pandemic has put a large strain on health systems all round the world. It is important the patients still seek care for other conditions, such as stroke during this time and Sierra Leone is no different. Despite these challenges, we have been able to continue providing care to stroke patients through the medium of the stroke register.
COVID-19 and Running the Register
The pandemic has not just impacted the patients that we are consenting onto the register, it has also affected the team on the ground at Connaught Hospital.
When the pandemic first started, we immediately paused all of our community work; both the stroke survivors’ meetings and the follow-up visits as part of participants’ journey on the register. We carried on the follow-up work using phone calls as a way of continuing our research during the pandemic. We also encouraged the stroke survivors to continue to engage with each other (and the SISLE team) via the ‘Whatsapp’ forum that has been established.
We began to work from home some days to reduce social contact in the office and on public transport. However, this was quite hard to sustain, as the unstable internet and electricity supply made effective working difficult.
To mitigate this, we had to find a new workspace in the hospital which could accommodate the team and allow for social distancing. We also have had to change the way we travel to work, so instead of getting crowded public transport we now charter a combination of Kekes and taxis to get into the office. This has proven to be more expensive, but much safer.
Improving Patient outcomes
With the stigma among the population and the effect on stroke patients clear to see, it is important to try and encourage people who are unwell with suspected stroke to seek care and come to Connaught Hospital. We have begun work on a context-specific Krio public health campaign that we are modelling on the successful FAST campaigns that have been used by Public Health England and the NHS.
This research was funded by the National Institute for Health Research (NIHR) (17/63/66) using UK aid from the UK Government to support global health research. The views expressed in this publication are those of the author(s) and not necessarily those of the NIHR or the UK Department of Health and Social Care.