Reaching Every Last Home to Prevent COVID-19’s Spread in Sierra Leone
Community health workers, social mobilizers key to education, referrals, and care in pandemic
Posted on Dec 18, 2020
Community health workers (CHWs) prove to be the backbone of any health system, providing a link between households and health facilities. As Partners In Health (PIH) learned during the Ebola epidemic in West Africa from 2014 to 2016, this link is especially critical during an infectious disease outbreak.
So as COVID-19 spread around the world, PIH wasted no time mobilizing the community-based teams in Kono District, Sierra Leone, where we support six health facilities and employ a cadre of CHWs dedicated to accompanying patients living with HIV and tuberculosis.
“We worked together to form a comprehensive community COVID-19 response centered around two pillars: screening and education,” said Kumba Tekuyama, head of community-based programs. That work was paired with local radio spots educating Kono residents about the virus and its prevention.
But to cover the entire district, and ensure every family had access to information and care amid a highly infectious, largely unknown virus, more help was needed. CHWs had their regular patient visits to maintain, and, as Tekuyama pointed out, some communities are so remote, they’re unreachable even by FM radio signal. A more innovative solution was needed.
“We decided to hire social mobilizers, who can actually go out there and do door-to-door sensitization,” Tekuyama said. “Social mobilization is a term that sometimes means different things to different people. But in our context, it’s a process of bringing people together to raise awareness and community involvement for health care.”
PIH trained 126 CHWs and its new 135 social mobilizers—a fully doubled community health staff—on identifying the most common signs and symptoms of the novel coronavirus, and on strict infection prevention and control measures to keep themselves and others safe. Wearing face masks and carrying with hand sanitizer, they visited homes across Kono’s 14 chiefdoms to screen patients for COVID-19 and promote handwashing, social distancing, and seeking care early.
Importantly, CHWs successfully continued their routine home visits during the response, not letting any of their regular patients slip through the cracks. One of the most vital messages that CHWs and social mobilizers shared in communities was to continue visiting health facilities for routine care—explaining that, despite any experiences or trauma from Ebola, hospitals and clinics remained safe and necessary to visit.
In fact, the community-based response helped identify not only potential COVID-19 cases, but also more than 1,500 patients with other health conditions in need of medical attention, varying from hernias, to tuberculosis, to mental health conditions. CHWs connected these patients with care at local primary health clinics, Koidu Government Hospital, and Wellbody Clinic—where new COVID-19 triage systems and safety protocols ensured all facility staff and patients would remain safe.
In all, the team screened 65,960 people for COVID-19 symptoms, educated 270,130 people about the virus, and referred 1,538 people to health facilities for non-COVID-19 conditions and 127 people to social support, such as food and financial assistance.
Below, CHWs and social mobilizers reflect on their work to keep Kono safe during a historic moment.
Comments have been edited for brevity and clarity.
Kumba Tekuyama
Community-Based Programs Manager
Whenever there is a disease outbreak, it brings flashbacks of Ebola, and the first thing people do is distrust the health system. So even before COVID-19 was confirmed in Sierra Leone, we began actively organizing and involving the CHWs, because they are from the communities and have built that trust. Communities believe in their CHWs.
The other thing we did, as we started to get COVID-19 patients and people quarantining, was to think about the social aspect: If you are asking people to quarantine, you must be able to provide their basic needs. We experienced this during Ebola; people were not staying in quarantine because they needed to go out for food. So we developed a strategy for supporting affected patients and families; clinicians would refer quarantining families to us, and we would make sure there was food at home.
Ramatulai Jalloh
Community Health Worker Supervisor
CHWs are the frontliners, the bridge between communities and health facilities. We are accompanying many people living with HIV and tuberculosis, and they’re used to us coming close. Just because of COVID-19, we can’t keep away from our patients.
We go out there and deal with lots of different infections, and coming home to our families can be risky. But for us CHWs, we’re used to this work. This is not our first time. And I don’t think any of my CHWs mentioned fear to me through COVID-19; we conquered Ebola and we continue to conquer tuberculosis. We followed all of the safety measures and were well-equipped with PPE. We had the confidence to go closer, go to the last step, the last door, for everyone that needs assistance. When you protect CHWs, you protect the nation.
Tamba Kanu
COVID-19 Social Mobilizer
I didn’t have any nerves going out into communities, because I was trained and followed all precautions. If I’m nervous talking to a patient, how would I counsel them? How would they have any confidence in me? So I had to believe my words and believe in myself before I passed on my message.
These messages were very necessary, because there was so much misinformation. People were saying that coronavirus does not live in Africa, in any hot countries, or that it was a lie being spread by the government or health care workers to make money. And during the first two weeks that we had positive cases in Kono, there were lots of people who went to the hospital and removed their admitted relatives, saying they will get the virus.
In every village, even remote ones, we engaged the elders, the chiefs, and households to correct these misconceptions.
Patrick T. Bona
COVID-19 Social Mobilization Supervisor
I was assigned to an area on the border of Kono, full of rough roads. There are certain areas where there are no pathways for even motorbikes, so you must walk up to six miles. That was the most challenging part, but there’s no work without a challenge. We made sure we got to all of the households.
In the initial stage, a lot of families were afraid to give us the right information about any symptoms, because they did not want us to tell them they might be sick and that they needed to go for a test. But we motivated them and explained that we were there to sensitize, to teach how they could protect themselves from the virus. It was very difficult for them to accept that COVID-19 is here, but now they believe it is real and can adhere to preventative measures.
Sahr Jawara
COVID-19 Social Mobilization Supervisor
One of the biggest drivers of suffering during COVID-19 has been lack of knowledge. We encountered a lot of nerves; when we approached some communities, people were scared that those taken to a health facility would not survive. Even if, as is often the case, they did not have the virus, they had something common like malaria, they wouldn’t go to the facility, thinking, “If I go, they’ll say it’s COVID.” We changed that mentality. We told them, "Come on, we are sons and daughters of Kono. We are not here to harm you. We are here to provide you the necessary knowledge and care.”
I supervised 19 social mobilizers, and we did extremely well. We referred a lot of cases and they have been treated. We referred a lot of cases that are in the pipeline to be treated. And we referred a lot of patients to the Acute Needs Program, through which PIH provides some money for them to take care of themselves. Because some patients don't have food, so they don't adhere to their medicine.
We have patients who experienced COVID-19 symptoms whom we referred. They regained their health. They're now serving as ambassadors for our program. Whenever there are similar patients, they tell them, "Go to the facility. I was there last month. I was taken to the facility by those mobilizers and today I'm healthy."
We have so many patients that we helped. I'll continue to think of them. Saving the lives of patients, especially those that are at risk of contracting the virus, it's the biggest reward. It makes me happy. It makes the community happy. And it saves the community.
Mohamed A. Sesay
COVID-19 Social Mobilization Supervisor
In every community we visited, we talked with the town chief and shared our phone number so they can contact us in case of sickness. A few days after we did our sensitization in one of these villages, a woman gave birth and was having a bleeding issue—I know this because, being that we dropped a phone number to the chief, he called me immediately for help. I called the ambulance and they rescued her. She’s now healthy. That is so amazing to me.
Mohamed Lamin Jarrah
Community Health Worker Supervisor
I’ve been working with PIH for five years now. There are some communities in Kono I’ve still not visited, because we don’t have HIV or tuberculosis patients there. And they’re so far away: a three- or four-hour motorbike ride followed by a two-hour walk. In our social mobilization work, we reached these communities, where no health worker had ever visited before. I asked, “So nobody has ever visited?” They said, “Nobody at all, except PIH.”
In one of the communities I visited, there was a grandfather who was sick; the whole community was praying for him. But no one, including him, accepted that he needed to go to a health facility. I went and spoke to his family and community members for three hours. Eventually, they told me to call the ambulance. He was having a stroke; the ambulance staff said, “If he had stayed for three more hours, he would have died.” He got treatment at Koidu Government Hospital and is doing much better.
Kumba F. Amara
COVID-19 Social Mobilizer
Initially, when we stopped recording cases in Kono, people were complacent with preventative measures. So we ramped up our education, because this is a time when we need to hold on to the fight. Eventually we’ll be able to go back to our normal lives, and we’ll be walking around without face masks. We’ll greet our loved ones again. But until the pandemic is over, there’s every need for us to keep going through the preventative measures. We talk to patients as our parents, our brothers, and our sisters, saying, “Let's keep a social distance, let's ensure we go to the hospital, let's use a face mask. Because each and everyone's life is very precious.”
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