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Background The studies on knowledge, attitudes, and practices of Antimicrobial resistance (AMR) and use among adolescents and young people are largely from Europe and the Asia region. All such studies reported a low level of understanding of antibiotic resistance and the rational use of antibiotics among adolescents and young people who are at a formative stage when health behaviours are being shaped. There are limited such studies from West Africa, despite a high AMR burden in the region. We therefore conducted a study to assess the knowledge, attitude, and practice on antibiotic use and resistance among adolescents and young people in Sierra Leone. Methods This cross-sectional study was conducted among adolescents and young people (15–29 years) who participated in the National Girls Summit-2024 in Sierra Leone. A validated self-administered questionnaire with 29 questions was used to collect data: demography (4 questions); knowledge (14 questions); attitude (3 questions); and practice (8 questions). Data were analyzed using Stata version 15, with results presented using frequencies and percentages. Results Of the 235 participants, over half (133, 56.6%) had attained university education, and a smaller proportion (14, 6.0%) had completed vocational training. The majority (144, 61.3%) of the adolescents and young people had used an antibiotic within the last 30 days before the study. Over two-thirds (180, 76.6%) of adolescents and young people had heard about antibiotic resistance, and most of them got the information from their academic institutions (67, 37.2%) and the radio (15.0%). Almost half (110, 46.8%) had poor knowledge about antibiotic use and resistance. The majority (139, 59.1%) had a negative attitude towards antibiotic use and resistance, and most (205, 87.2%) of them demonstrated poor practices in antibiotic use. Conclusion Our study revealed that adolescents and young people in Sierra Leone have a limited understanding of antibiotic resistance. Limited knowledge may drive inappropriate antibiotic use, further increasing the AMR burden in the country. We recommend implementing school and university-based antimicrobial stewardship initiatives to enhance awareness and understanding of antibiotic resistance and promote rational use of antibiotics.

ObjectiveHealthcare utilisation (HU) is key to improving the health of residents in urban informal settlements. This study aimed to explore household-level factors influencing HU among informal settlement households in Freetown, Sierra Leone.DesignCross-sectional survey.SettingThree informal settlements (Cockle Bay, Dwarzark and Moyiba) in Freetown, Sierra Leone.ParticipantsPrimary data from 4871 households were collected during the Health and Wellbeing survey conducted between April and May 2023, targeting households with adults aged 18 years and older.Primary outcome measuresThe primary outcomes were households HU both within and outside informal settlements. Household-level predisposing and enabling explanatory variables were derived from Andersen’s Behavioural Model of HU.ResultsDisability in households increases HU within settlements (especially in Dwarzark, 13% and Moyiba, 10%) but is less likely outside. Households engaged in income-generating activities are more likely to seek healthcare within settlements, but 12% less likely outside in Cockle Bay and Dwarzark. Food insecurity decreases HU within Dwarzark (9%) and increases HU outside by 174% in Moyiba. Longer water fetching times and water shortages were associated with higher HU (between 6% and 16%) within settlements, especially in Cockle Bay and Dwarzark. Clean water sources (eg, piped dwelling, bowser, surface, bottled) were consistently associated with higher HU both within and outside settlements. Shared sanitation facilities (such as shared toilets) were positively associated with HU both within and outside settlements, particularly in Dwarzark and Moyiba. Households with income from fishing, informal salaried work and bike riding showed higher HU both within and outside settlements, especially in Dwarzark and Moyiba.ConclusionsWe identified strong settlement-specific patterns of household-level factors that influence HU both within and outside Freetown’s informal settlements. These findings provide a foundation for developing targeted policies such as strengthening local services, addressing affordability and accessibility barriers and supporting vulnerable occupation groups.

Introduction Residents of informal settlements face significant intersectional inequalities, due to the overlapping and compounding effects of multiple social factors. This study aims to explore how these intersecting social factors, identified by community members, combine to shape household-level inequalities healthcare utilisation (HU) among residents of informal settlements in Freetown, Sierra Leone. Methods This study employed participatory action research to collaboratively identify key social determinants affecting healthcare utilisation in Freetown’s informal settlements. A cross-sectional health and wellbeing survey was implemented in April-May 2023 and collected data from 4,871 households in Cockle Bay, Dwazark, and Moyiba informal settlements. The survey questions were codesigned by researchers and community fieldworkers, informed by prior qualitative research. Two outcomes were analysed: HU within the settlement ( n  = 4,821), and outside the settlement ( n  = 4,616). A multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA) was conducted, nesting households within 122 intersectional strata. These strata were defined by six social factors: head of household gender, marital composition, engagement in income-generating activity, food security, disability and the household’s settlement. Intersectional measures included variance partition coefficient (VPC), the proportional change in variance (PCV), and residual intersectional effects. Results VPCs of 0.9% (PCV, of 92.8%) for HU within the settlements and of 3.9% (PCV, 81.7%) for HU outside the informal settlements suggest moderate but meaningful intersectional effects in shaping HU inequalities. The lowest levels of HU within informal settlements were observed among single, male, disabled individuals in Moyiba who lacked income-generating activities and experienced food insecurity. For HU outside the settlement, the lowest levels were found among female-headed households in Moyiba who were married, cohabiting, or engaged with a disabled household member, experienced food insecurity, and were engaged in income-generating activities. Conclusion This study identifies and quantifies inequalities in HU at the household level across three informal settlements in Freetown, driven by intersecting social factors. Addressing these inequalities requires policies that are universally accessible but implemented with an intensity proportionate to the level of vulnerability, ensuring that support is targeted to those most in need. Highlights The findings identify and quantify intersectional inequalities in healthcare utilisation (HU), particularly among the most vulnerable groups. Single women without income and single men with disabilities and no income in Moyiba were less likely to utilise healthcare. Households with protective factors against illness showed higher HU than those exposed to illness-enabling conditions. Stakeholders are encouraged to address HU inequalities through social security and health insurance, proportionately targeted by level of need.

Health system planners need to design context-specific responses that are informed by close to real-time data and systematic research focused on improving understanding of healthcare workers stresses and mental health needs. Nonetheless, psychological support and attention to ways of alleviating distress throughout all phases of systems shocks is central to mitigating longer-term impacts on HCW mental health.3 Sierra Leone and Liberia both experienced decades of conflict and fragility that have rendered fragile health systems and have undoubtably influenced the psychological well-being of their health workforce. During workshops, many HCWs reflected on their own experiences of trauma during previous conflict; emphasising how acute shocks can trigger underlying and potentially unaddressed trauma. Since the Ebola period, through the implementation of WHO’s Mental Health Gap Action Programme (mhGAP), MHPSS have been strengthened across both Sierra Leone and Liberia. mhGAP supports the scale-up of evidence based mental health services by equipping non-specialised HCWs with training and decision making tools.6 HCWs can access integrated mental health services associated with mhGAP, although a specific focus on HCWs support needs is limited and the provision of wide-scale longer-term psychological interventions for HCWs is an ongoing challenge. Strategies to promote systemic change and support systems strengthening Support ongoing implementation of interventions such as Mental Health Gap Action Programme postcrisis to ensure prioritisation of mental health services within systems strengthening.

COVID-19 brings uncertainties and new precarities for communities and researchers, altering and amplifying relational vulnerabilities (vulnerabilities which emerge from relationships of unequal power and place those less powerful at risk of abuse and violence). Research approaches have changed too, with increasing use of remote data collection methods. These multiple changes necessitate new or adapted safeguarding responses. This practice piece shares practical learnings and resources on safeguarding from the Accountability for Informal Urban Equity hub, which uses participatory action research, aiming to catalyse change in approaches to enhancing accountability and improving the health and well-being of marginalised people living and working in informal urban spaces in Bangladesh, India, Kenya and Sierra Leone. We outline three new challenges that emerged in the context of the pandemic (1): exacerbated relational vulnerabilities and dilemmas for researchers in responding to increased reports of different forms of violence coupled with support services that were limited prior to the pandemic becoming barely functional or non-existent in some research sites, (2) the increased use of virtual and remote research methods, with implications for safeguarding and (3) new stress, anxiety and vulnerabilities experienced by researchers. We then outline our learning and recommended action points for addressing emerging challenges, linking practice to the mnemonic ‘the four Rs: recognise, respond, report, refer’. COVID-19 has intensified safeguarding risks. We stress the importance of communities, researchers and co-researchers engaging in dialogue and ongoing discussions of power and positionality, which are important to foster co-learning and co-production of safeguarding processes.

Safeguarding is rapidly rising up the international development agenda, yet literature on safeguarding in related research is limited. This paper shares processes and practice relating to safeguarding within an international research consortium (the ARISE hub, known as ARISE). ARISE aims to enhance accountability and improve the health and well-being of marginalised people living and working in informal urban spaces in low-income and middle-income countries (Bangladesh, India, Kenya and Sierra Leone). Our manuscript is divided into three key sections. We start by discussing the importance of safeguarding in global health research and consider how thinking about vulnerability as a relational concept (shaped by unequal power relations and structural violence) can help locate fluid and context specific safeguarding risks within broader social systems. We then discuss the different steps undertaken in ARISE to develop a shared approach to safeguarding: sharing institutional guidelines and practice; facilitating a participatory process to agree a working definition of safeguarding and joint understandings of vulnerabilities, risks and mitigation strategies and share experiences; developing action plans for safeguarding. This is followed by reflection on our key learnings including how safeguarding, ethics and health and safety concerns overlap; the challenges of referral and support for safeguarding concerns within frequently underserved informal urban spaces; and the importance of reflective practice and critical thinking about power, judgement and positionality and the ownership of the global narrative surrounding safeguarding. We finish by situating our learning within debates on decolonising science and argue for the importance of an iterative, ongoing learning journey that is critical, reflective and inclusive of vulnerable people.

The fragile health system in Sierra Leone undermines healthcare, leading to substantial patient costs. We aimed to estimate the economic burden and inequalities in healthcare in urban informal settlements in Freetown, Sierra Leone. A cross-sectional survey was conducted in three informal settlements in Freetown in April and May 2023 to collect data on healthcare usage within and outside the boundaries of the informal settlements. Catastrophic expenditures were estimated using the payer's household budget. Logistic regression explored socioeconomic characteristics associated with catastrophic expenditures. Inequalities in healthcare expenditures were assessed through concentration curves and indices. A total of 2575 participants reported healthcare utilization. Dwarzark (US$6.9) and Moyiba (US$7.1) had higher costs than Cockle Bay (US$5.5) when utilizing healthcare within the communities. Households incurred higher costs when seeking healthcare outside their informal settlements than within (US$14 vs US$ 7). Over half of the households across the settlements incurred catastrophic expenditures when seeking care outside the communities (57%), with the poorest wealth quintile (poorest, 89%; wealthier, 12%) incurring in higher incidence. Attending informal healthcare had a protective effect against catastrophic expenditure for healthcare within the communities. Age + 35, residence in Dwarzark and Moyiba, and length of residence + 4 years were associated with catastrophic expenditures. Healthcare expenditure was progressive in Dwarzark and equally distributed across wealth quintiles in the other communities. Our findings indicate the need to provide accessible, affordable, and good-quality healthcare within communities to alleviate the catastrophic costs of healthcare utilization. The regulation of informal health providers and their integration into the formal health system should be considered.

The fragile health system in Sierra Leone undermines healthcare, leading to substantial patient costs. We aimed to estimate the economic burden and inequalities in healthcare in urban informal settlements in Freetown, Sierra Leone. A cross-sectional survey was conducted in three informal settlements in Freetown in April and May 2023 to collect data on healthcare usage within and outside the boundaries of the informal settlements. Catastrophic expenditures were estimated using the payer’s household budget. Logistic regression explored socioeconomic characteristics associated with catastrophic expenditures. Inequalities in healthcare expenditures were assessed through concentration curves and indices. A total of 2575 participants reported healthcare utilization. Dwarzark (US$6.9) and Moyiba (US$7.1) had higher costs than Cockle Bay (US$5.5) when utilizing healthcare within the communities. Households incurred higher costs when seeking healthcare outside their informal settlements than within (US$14 vs US$ 7). Over half of the households across the settlements incurred catastrophic expenditures when seeking care outside the communities (57%), with the poorest wealth quintile (poorest, 89%; wealthier, 12%) incurring in higher incidence. Attending informal healthcare had a protective effect against catastrophic expenditure for healthcare within the communities. Age + 35, residence in Dwarzark and Moyiba, and length of residence + 4 years were associated with catastrophic expenditures. Healthcare expenditure was progressive in Dwarzark and equally distributed across wealth quintiles in the other communities. Our findings indicate the need to provide accessible, affordable, and good-quality healthcare within communities to alleviate the catastrophic costs of healthcare utilization. The regulation of informal health providers and their integration into the formal health system should be considered.

The complexity of issues addressed by research for development (R4D) requires collaborations between partners from a range of disciplines and cultural contexts. Power asymmetries within such partnerships may obstruct the fair distribution of resources, responsibilities and benefits across all partners. This paper presents a cross-case analysis of five R4D partnership evaluations, their methods and how they unearthed and addressed power asymmetries. It contributes to the field of R4D partnership evaluations by detailing approaches and methods employed to evaluate these partnerships. Theory-based evaluations deepened understandings of how equitable partnerships contribute to R4D generating impact and centring the relational side of R4D. Participatory approaches that involved all partners in developing and evaluating partnership principles ensured contextually appropriate definitions and a focus on what partners value.