Implementing infection prevention and control capacity building strategies within the context of Ebola outbreak in a “Hard-to-Reach” area of Liberia

Introduction In August 2014, WHO declared that Ebola outbreak ravaging West Africa including Liberia had become a Public Health Emergency of International Concern (PHEIC). Infection prevention and control (IPC) among healthcare workers was pivotal in reducing healthcare worker infection and containing the recent EVD outbreak. Hard to reach areas (HTRA) presents peculiar challenges in public health emergencies. We present the result of IPC capacity building strategies deployed in Gbarpolu County: an HTRA of Liberia. Methods Between April to October 2015, we conducted IPC training and mentorship at the county, district and facility levels in a selected HTRA of Liberia using the keep Safe, Keep Serving manual and the WHO core components of infection control. Serial follow-up assessments and mentoring using the Liberian Minimum standard tool for safe care in Liberian health facilities (MST) were done. Results 180 (100%) facility based healthcare workers were trained: including 59 clinicians (32%) and 121 (67%) non-clinicians. 100% of the healthcare workers in four selected very HTRAs were trained and underwent facility based-mentorship. Compliance with IPC practice increased: the MST score increased from 75% to 90% and for the MST score for waste management and isolation increased 60% to 87%. Conclusion Strengthening the capacity of healthcare workers for IPC was instrumental for containing the EVD epidemic but also critical for routine safe and quality services. A culture of IPC among healthcare workers in HTRA can be implemented through capacity building and training.


Introduction
The Ebola Virus Disease (EVD) outbreak which started in the forests of Guinea in Dec 2013, was the worst acute public health crisis in the last 50 years and eventually became a public health emergency of international concern [1][2][3] Hard-to-reach areas are those places with geographical, physical, communication, security, social, and economic barriers that make them receive a level of public service that is relatively inequitable and below the national benchmark [7][8][9]. Gbarpolu County is a landlocked area located in western Liberia; it shares a border directly with Sierra Leone, with Lofa County (which shares a border with Guinea), and Grand Cape Mount County. These border connections have implications for epidemiology, disease prevention, and control.
Gbarpolu has health facility density index of 1.45 per 10,000 population (which is one of the lowest in Liberia) and a population of 96,446 [10]. The County has five health districts and six political districts and has dense forests, poor basic infrastructure, and a poor road network, with no paved roads and the majority of the roads, are tertiary roads or trails [11]. Only 36% of the population lives within 5 kilometres of a health facility, which is the lowest in Liberia   [12]. Lack of relevant training, knowledge and practice in IPC was a common gap among health workers in the countries affected by the outbreak [13]. Knowledge and practice of IPC increase the confidence of healthcare workers and reduces the fear and myths associated with the EVD epidemic.
It was important therefore during and after the EVD to build the IPC capacity of the healthcare workers in the country as well as increase community awareness of basic IPC practices and its role in selfprotection and disease control. We highlight the combination strategies that were used to build local capacity and improve IPC practice in the health facilities and among the communities in Gbarpolu County. It is hoped that this might serve as a useful model for implementing IPC capacity building in other hard to reach areas.

Methods
We identified four key strategies and four levels of interventions as necessary to build IPC capacity in Gbarpolu County. The four levels were the county, district, facility, and the community levels. The key strategies we identified and implemented were to build IPC capacity through training, mentorship, improvement in supply chain management and enhanced health facility-community engagement.
We focused on the County IPC focal person and selected members of the County Health Team (CHT) who were clinicians and had some oversight functions to the health facilities in the County. We implemented these interventions with the CHT and other partners working in the County. We ensured and improved coordination through the weekly, monthly, and quarterly County IPC review meetings. After that, we commenced monthly follow-up supportive supervision and assessment visits by a combined IPC team of WHO, CHT, and other partners. The visits were used to assess healthcare workers' and facility's compliance with the MST and as an opportunity for healthcare worker engagement, mentoring, clinical process tracking, and building the confidence of healthcare workers for IPC compliance. In very hard-to-reach areas for which cumbersome logistics impeded routine visits, we conducted on-site facility training and mentoring which lasted about 2 to 5 days depending on pre-MST assessment findings and identified gaps. The assessment involved a visit to the facility, which was often unannounced, by assessors who were pre-trained on the use of the MST tool.
Healthcare workers were interviewed and observations made based on the survey items on the MST. For each item, the assessor ticked either 'Yes' or 'No' in the space provided on the survey tool document. Feedback was given to the healthcare workers immediately on any issues that needed correcting and on-site spot mentorship given. Gaps that were not immediately correctable were noted and referred to the County IPC committee, the CHT or the National IPC task force as was appropriate. We encouraged and conducted community engagement as part of the mentoring process. This enhanced facility-community collaboration and also helped to deal with identified gaps that were correctable. We held meetings with relevant community leaders and other stakeholders at a pre-arranged venue, which was usually at the 'palaver' or town hall. We explained and where necessary used job aids to emphasise the importance of triage control and IPC for individual, family and community benefits and why healthcare workers have to wear PPE.
We ensured that community engagement sessions were an interactive session with opportunities for clarifications, questions, and answers. security workers were 20(11.1%), (Table 1). Among the very hardto-reach areas, Belle Fassama and Kungbor clinics had 10 healthcare workers each; Kpayequelleh and Weasua clinics had eight and seven respectively. All the clinic based staffs in the very hard to reach areas were trained (Table 2). Compliance with MST increased from 75% in April-May 2015 to more than 80% in June-July for Gbarma and Guokala clinics and 90% in October 2015.
There was a drop in compliance in Bambuta and Guokala clinics in October compliance from almost 100% to 80% in both places. The  [19] noted that training incorporating participants' engagement, education, mentoring and feedback improved health workers compliance with IPC and safety practices.

This is especially relevant in Liberia and West African sub-region
where EVD and IPC knowledge and capacity has been deficient [1,5,[20][21][22][23][24]. One of the evidence of strengthened health workers' capacity for IPC was improved compliance with IPC standards and protocols as assessed using the MST. There was a consistent Uganda [20]. This is similar to our experience in Gbarpolu; community engagement resulted in communities taking ownership and support initiative for the construction of triage structure and fencing. Even though the focus of this paper is on capacity building for health workers, we note and acknowledge other partners who were involved in "community IPC" (e.g, distribution of household hygiene kits and re-enforcement of IPC and hygiene messages at family and community levels). These may have also influenced the positive attitude of the community, though this may be difficult to measure. We recognize some limitations of this study. The use of MST as an assessment tool tended towards assessment of more structural than process issues and secondly the problem of interobserver error. To reduce the error from these: assessments were done by IPC focal persons as part of a joint assessment team (at least two persons), engagement with health workers while at work Page number not for citation purposes 5 and mentoring sessions aimed to augment the process deficiencies in the MST.

Conclusion
Appropriate training, mentoring, health worker engagements and facility assessments resulted in improved capacity for IPC compliance among health workers in Gbarpolu County. We recommend the capacity building of healthcare workers in hard-toreach areas in such critical areas as IPC both as part of epidemic response preparedness and routine healthcare because when there is an outbreak, external help may be delayed. Secondly, in planning for public health interventions, emergency or routine, special, location-specific considerations need to be given hard to reach areas to ensure an improved outcome. Thirdly a separate, efficient supply chain management that puts into consideration the peculiarities of the terrain is critical for the success of healthcare programmes in HTRAs. Fourthly, government intervention is necessary to address the issues that make certain areas hard to reach. For Gbarpolu County, this is mainly physical and geographical barriers which could be overcome by improved access roads and network coverage.