The impact of COVID-19 on primary health care service provision and utilisation in Tanzania, Sierra Leone and the Democratic Republic of Congo

Lead Research Organisation: London School of Hygiene & Tropical Medicine
Department Name: Epidemiology and Population Health

Abstract

Initial reports suggest the COVID-19 pandemic response has had an impact on the number of people seen for routine healthcare needs worldwide. Potential reasons suggested include the fact that the general public are not attending healthcare centres because they fear that they will contract COVID-19 and that it is difficult for people to travel for healthcare during lockdown. This project will look at whether the attendance of routine services, like antenatal care, immunisations and HIV treatment services, have been affected by the COVID-19 pandemic in 3 countries in East, West and Central Africa. If attendance has been affected, this could have a substantial detrimental effect on health problems that are unrelated to COVID-19, such as pregnancy outcomes, children's risk of contracting other infectious diseases and HIV outcomes. It will be important for the Ministries of Health of the respective countries to have this information in order to plan appropriate responses to ensure services are delivered and to encourage the population to resume seeking care. Recommendations resulting from this project will be useful to inform the response to the present COVID-19 crisis and future large outbreaks.

Technical Summary

The impact and implications of the COVID-19 pandemic on routine primary health care provision and utilisation in resource-poor settings is unknown. Initial reports suggest that as health care workers with comorbidities or pre-existing conditions are taken off the 'frontline', others are transferred to COVID-19 response activities, fear of COVID exposure increases absenteeism, and social distancing measures are put in place in health facilities, the capacity to provide services has been reduced. Utilisation has also been affected, potentially by users' fear of catching SARS-CoV-2 infection at health care facilities, misconceptions that services are shut, barriers to accessing health care due to fewer transport options and less disposable income during lockdowns. A reduction in primary healthcare provision could be particularly devastating in low income settings. This multidisciplinary project aims to investigate the impact that the COVID-19 pandemic is having on primary healthcare providers and users in three distinct settings in Central (Democratic Republic of the Congo), East (Tanzania) and West (Sierra Leone) Africa, by building on existing collaborative partnerships. We will conduct the following activities:
1. Data will be collected from healthcare facilities to estimate the change in the number of people seen for essential services e.g. antenatal care, outpatients, routine immunisations, family planning and HIV comprehensive care visits.
2. Qualitative interviews will be conducted with primary healthcare workers to understand barriers and facilitators for effective care provision during the COVID-19 outbreak.
3. Healthcare workers' exposure to SARS-CoV-2 will be estimated in a repeated sero-survey, using a validated serological assay.
4. Qualitative interviews will be conducted with a selection of healthcare users to understand barriers and facilitators of utilisation.
5. A set of recommendations/ key findings will be formulated together with stakeholder
 
Description In the space of 16 months, we rapidly recruited a research team, obtained all necessary research permits and approvals, collected samples and data for four different work packages, and analysed and disseminated the results. The collaboration included co-investigators based at the University of Sierra Leone who led study activities in Kambia District, Sierra Leone, the Uganda Virus Research Institute who led study activities in Masaka District, Uganda, and the National Institute of Biomedical research, who led study activities in Goma in the Democratic Republic of the Congo; co-investigators at the London School of Hygiene & Tropical Medicine provided coordination, statistical and laboratory support.

The longitudinal survey among healthcare workers documented high prevalence (70-90%) of antibodies (IgG/M) to SARS-CoV-2 (RBD/N-protein) across the three settings in 2021 and evidence of a high force of infection in these settings; almost all participants had acquired antibodies to SARS-CoV-2 by the end of 4 months of follow up. The longitudinal nature of the study and use of a multiplex assay allowed us to investigate how endemic coronaviruses may have affected the course of the pandemic in these settings. In these contexts with a high force of infection, baseline IgG to endemic coronaviruses did not associate with reduced acquisition of SARS-CoV-2. The roll out of vaccination programmes during the study allowed us to assess whether prior infection with SARS-CoV-2 primed the immune system for vaccination and we found baseline IgG to SARS-CoV-2 predicted higher IgG responses to COVID-19 vaccination.

The audit of activity levels at 25-30 health facilities in each of the study areas revealed that the COVID-19 pandemic had a varied impact on primary healthcare services in the three distinct settings. The extent that the pandemic impacted services correlated with the stringency of the lockdowns, community perceptions of the level of danger posed by the pandemic and communities' prior exposure to Ebola epidemics and response measures. We highlighted that strategies such as communication campaigns and outreach services limited the impact of lockdowns on essential services and would be valuable strategies to implement in future epidemics. Findings were disseminated to local Ministry of Health representatives in each area in the form of 1-page policy briefs.

The quantitative survey of COVID-19 vaccine acceptability provided encouraging results on COVID-19 vaccine acceptability among healthcare workers in the months following vaccine introduction. Concerns and misinformation about the COVID-19 vaccines were prevalent, yet these factors did not appear to have a major impact on the participant's vaccination status or reported intention to get vaccinated and vaccines were recognised as important tools in the COVID-19 pandemic response. Nonetheless, low vaccine coverage in the DRC was of concern. The survey highlighted important gaps in understanding among healthcare staff around vaccine development processes, and the available evidence on vaccine effectiveness and safety. Focus on improving knowledge of these areas would help, both to promote vaccine uptake in this group and to ensure appropriate and accurate communication about vaccines between healthcare staff and their patients or the wider communities. Findings were disseminated to local Ministry of Health representatives in each area.

During extensive qualitative interviews and focus group discussions, healthcare workers in Uganda revealed the pandemic had caused substantial mental health issues among staff at primary healthcare facilities who felt inadequately supported to triage and care of COVID patients as well as provide care for patients who otherwise couldn't access referral hospitals for severe illnesses due to the pandemic. In Sierra Leone and DRC common themes emerged from qualitative interviews to suggest how both Ebola and COVID-19 had interacted with existing structural challenges in the healthcare system and exacerbated broader experiences of crisis.

All of the original objectives of the award were met and we were able to perform some additional analyses that were not forseen at the beginning of the grant when it became clear that COVID-19 vaccine would become available for healthcare workers during the data collection period:
- We added the quantitative survey of COVID-19 vaccine acceptability to the study
- We were able to analyse the impact of baseline IgG to SARS-CoV-2 on vaccine-induced responses using the serosurvey data
Exploitation Route Key findings have already been disseminated to Ministry of Health representatives to inform epidemic response mechanisms in future, key take home messages included: the utility of outreach to mitigate the impact of the pandemic response on coverage of other primary healthcare services; the high force of infection among healthcare workers who were often first responders; the importance of informing healthcare workers about the vaccine development process to encourage vaccine uptake among staff members and counter vaccine hesitancy in the community.

The findings of the serosurvey have been published in pre-print and are submitted for publication in a peer-reviewed journal to inform the scientific community's understanding of how IgG and IgM to previously endemic human coronaviruses cross-bind and may confer some protection against symptomatic SARS-CoV-2 even if they do not prevent infection.
Sectors Healthcare
 
Description Key findings have already been disseminated to Ministry of Health representatives to inform epidemic response mechanisms in future, key take home messages included: the utility of outreach to mitigate the impact of the pandemic response on coverage of other primary healthcare services; the high force of infection among healthcare workers who were often first responders; the importance of informing healthcare workers about the vaccine development process to encourage vaccine uptake among staff members and counter vaccine hesitancy in the community. The findings of the serosurvey have been published in pre-print and are submitted for publication in a peer-reviewed journal to inform the scientific community's understanding of how IgG and IgM to previously endemic human coronaviruses cross-bind and may confer some protection against symptomatic SARS-CoV-2 even if they do not prevent infection.
First Year Of Impact 2021
Sector Healthcare
Impact Types Policy & public services
 
Description Partnership with COMAHS 
Organisation University of Sierra Leone
Country Sierra Leone 
Sector Academic/University 
PI Contribution After co-development of the proposal with our partners, our team won the funding for the research. We supplied epidemiological, statistical and laboratory expertise during co-development of the protocol; our partners contributed key inputs to ensure the research protocol was feasible and relevant to their context, and currently lead community engagement and oversight of data collection.
Collaborator Contribution After co-development of the proposal with our partners, our team won the funding for the research. We supplied epidemiological, statistical and laboratory expertise during co-development of the protocol; our partners contributed key inputs to ensure the research protocol was feasible and relevant to their context, and currently lead community engagement and oversight of data collection.
Impact n/a
Start Year 2020
 
Description Partnership with INRB 
Organisation Congo National Institute of Biomedical Research
Country Congo, the Democratic Republic of the 
Sector Academic/University 
PI Contribution After co-development of the proposal with our partners, our team won the funding for the research. We supplied epidemiological, statistical and laboratory expertise during co-development of the protocol; our partners contributed key inputs to ensure the research protocol was feasible and relevant to their context, and currently lead community engagement and oversight of data collection.
Collaborator Contribution After co-development of the proposal with our partners, our team won the funding for the research. We supplied epidemiological, statistical and laboratory expertise during co-development of the protocol; our partners contributed key inputs to ensure the research protocol was feasible and relevant to their context, and currently lead community engagement and oversight of data collection.
Impact N/a
Start Year 2020
 
Description Partnership with MITU 
Organisation National Institute for Medical Research, Tanzania
Department Mwanza Intervention Trials Unit (MITU)
Country Tanzania, United Republic of 
Sector Public 
PI Contribution After co-development of the proposal with our partners, our team won the funding for the research. We supplied epidemiological, statistical and laboratory expertise during co-development of the protocol; our partners contributed key inputs to ensure the research protocol was feasible and relevant to their context. Unfortunately it became clear that ethical approval from Tanzanian regulatory authorities was not possible as the project is related to COVID; however our Tanzanian partners will stay involved to input into the analysis of data from other countries.
Collaborator Contribution After co-development of the proposal with our partners, our team won the funding for the research. We supplied epidemiological, statistical and laboratory expertise during co-development of the protocol; our partners contributed key inputs to ensure the research protocol was feasible and relevant to their context.
Impact N/A
Start Year 2020
 
Description Partnership with MRC/UVRI 
Organisation Medical Research Council (MRC)
Department MRC/UVRI and LSHTM Research Unit Uganda
Country Uganda 
Sector Academic/University 
PI Contribution Our team won the funding for the research with MITU as a partner in Tanzania, when it became clear the Tanzanian regulatory authority was not going to approve any research on COVID-19 we approached UVRI as an alternative. We supplied epidemiological, statistical and laboratory expertise during co-development of the protocol; our partners contributed key inputs to ensure the research protocol was feasible and relevant to their context, and currently lead community engagement and oversight of data collection.
Collaborator Contribution We supplied epidemiological, statistical and laboratory expertise during co-development of the protocol; our partners contributed key inputs to ensure the research protocol was feasible and relevant to their context, and currently lead community engagement and oversight of data collection.
Impact n/a
Start Year 2020
 
Description District Medical Officer engagement on the results of the HWI study 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Policymakers/politicians
Results and Impact 2 District Medical Officers (1 in Masaka, Uganda, 1 in Kambia, Sierra Leone) and three health Zone Heads in Goma, DRC attended a workshop to talk through the results of the HWI study and co-develop interpretations and conclusions.
Year(s) Of Engagement Activity 2022