Participatory Behavioral Change to Reinforce Infection Prevention and Control for Ebola Virus Disease

Owing to poor infection prevention and control (IPC), healthcare workers (HCWs) were frequently infected during Sierra Leone’s Ebola epidemic. In late 2014, IPC was rapidly and nationally scaled up. We carried out workshops in sampled facilities to further improve adherence to IPC, and investigated HCW experiences and observed practice gaps, before and after the workshops. We conducted an uncontrolled, before and after, mixed-methods study in eight health facilities in Bo and Kenema Districts during December 2014 and January 2015, using a survey on attitudes and self-efficacy towards IPC, and structured observations of behaviors. The intervention involved a workshop for HCWs to develop improvement plans for their facility. We analyzed the changes between rounds in survey responses and behaviors, and used interviews to explore attitudes and self-efficacy throughout the study period. HCWs described IPC as ‘life-saving’ and personal protective equipment (PPE) as uncomfortable for providers and frightening for patients. At baseline, self-efficacy was high. Responses reflecting unfavorable attitudes were low for glove use and PPE use with ill family members, and mixed for PPE use with ill HCWs. Observations demonstrated consistent glove reuse and poor HCW handwashing. The maintenance of distance and patient handwashing improved to >90%. We found favorable attitudes towards IPC and gaps in practice. Risk perceptions of HCWs and tendencies to ration PPE where chronic supply chain issues normally lead to PPE stock-outs may affect practice. As Sierra Leone’s Ebola Recovery Strategy aims to make all facilities IPC compliant, socio-behavioral improvements and a secure supply chain are essential.