Assessing socioeconomic vulnerability and COVID‑19 infection risk among NCD patients in rural Sierra Leone: a cross‑sectional study

Background In Sierra Leone, non-communicable diseases (NCDs) are an increasingly important source of mortality and morbidity. However, Sierra Leonean NCD patients’ experience of direct exposure to COVID-19-related risks and indirect effects of the COVID-19 pandemic on socioeconomic determinants of health has not been described. Methods We conducted a cross-sectional telephone survey among adult (≥ 18 years) hypertensive, diabetic, and heart failure patients receiving treatment at the NCD clinic at Koidu Government Hospital (KGH) in rural Sierra Leone. We described patient demographics, COVID-19 related knowledge, and practice of infection prevention measures. Patients were categorized into nationally representative wealth quintiles using an asset-based wealth index and measures of social vulnerability were reported by clinical program and wealth category. Result Of the 400 respondents, 80.5% were between 40 and 69 years old and 46.1% were male. The majority of patients (> 90%) knew utilizing masks, social distancing, isolation from positive cases, and avoiding hand shaking were effective COVID-19 prevention measures. However, only 27.3% of the population had access to adequate handwashing facilities, 25.5% had attended crowded events in the past two weeks, and only 5.8% always used face masks. Compared with the national distribution of wealth,

Over the last 4 years, over 5,000 patients with non-communicable diseases, such as hypertension, chronic heart disease, chronic liver disease, diabetes, and stroke have been enrolled and followed up in this program.

Study population
Participants were selected from adult (≥ 18 years of age) hypertension, diabetes, and heart failure patients receiving treatment at KGH.Those diseases are the most commonly treated conditions among patients attending the NCD clinic.Patients without a recorded telephone number were excluded from the study.Because NCD patients are listed in the paper-based registers, we constructed a sampling frame by developing three groups of randomly selected line numbers, one for each clinical program.Study staff were instructed to look at each randomly selected line number and extract contact information for the next listed patient belonging to that clinical program.Because we anticipated a high nonresponse rate, 300 line numbers were initially sampled per clinical program in order to ensure we could achieve our target population of at least 167 patients per clinical program.Patients involved in multiple programs were recruited based on a hierarchy of hypertension, heart failure, and then diabetes until the sampling size criteria was met for the individual program.Additionally during patient selection, if the patient was recorded as deceased in the register, data collectors would go down the line until they reached the next patient enrolled in the eligible clinical program.
After extracting contact information, we planned to call the 300 identified patients in a random order until we reached 167 respondents for each group.However, in practice, the implementation of the random sampling scheme was flawed in that (a) hypertension patients were randomly selected from the register, but were called in the order of their register line number such that patients who had enrolled earlier in the program had a higher likelihood of being selected for participation in the interviews; (b) Rather than taking a random selection of diabetes patients, the first 300 diabetes patients were sampled and called in order; (c) Because fewer than 300 heart failure patients had a phone number listed in the register, all eligible heart failure patients were sampled and called in order of the register.Furthermore, the sample is not representative of the population the hospital serves as the patients in the NCD clinic tend to be older than the general population.

Data collection
We conducted a telephone survey, due to COVID-19 limitations for face-to-face interviews, using a questionnaire developed in collaboration with the PIH Cross-Site COVID-19 Cohort Technical Working Group, which coordinates and facilitates COVID-related cohort studies across participating PIH sites in eight countries.The questionnaire was adapted for the Sierra Leone context and had 11 modules: (1) demographic characteristics; (2) self-reported COVID-related symptoms; (3) self-reported COVID-19 risk factors and testing history; (4) food security in the past 30 days, assessed using four questions from the Household Food Insecurity Access Scale (HFIAS), including a subset of three questions that have been separately validated as the Household Hunger Scale (HHS) [20]; (5) infection prevention, including household adoption of select practices, access to handwashing stations, and household crowding; (6) access to medical care and essential services; (7) depression assessed using the PHQ-2 [21]; (8) anxiety, assessed using the GAD-2 [22]; (9) medication adherence assessed using a validated three-item self-report assessment [23]; (10) COVID-related knowledge questions adapted from Banda et.al [24]; and (11) household asset ownership, which was used to derive wealth categories [25] and exposure to income shocks [26].
Data collection occurred between March 2021 and December 2021, with all hypertensive patients interviewed between March 2021 and August 2021, heart failure patients interviewed between March 2021 and November 2021, and diabetes patients interviewed between May 2021 to December 2021.Data collectors were trained for two days on study objectives, study procedures, research ethics, respect for participants, and role-played questionnaire administration.Data collectors contacted each selected patient up to five times on different days before classifying the patient as non-responsive.If the patient agreed to participate in the study they were then verbally consented over the phone.Patient telephone surveys lasted for 17-20 minutes.Questionnaires were administered verbally in Krio and data was collected via the CommCare application in English.Completed questionnaires were synced to the cloud after every survey for easy data accessibility.Each participant was given a unique identification code to ensure anonymity.1 3

Data analysis
Demographic variables were described using medians and interquartile ranges (IQRs) for continuous variables, and frequencies and percentages for categorical variables, and were analyzed by clinical program.We compared demographic variables among clinical programs using Pearson's chi-squared test or a linear regression model as appropriate.An abbreviated asset-based wealth index was developed based on the proposed methodology from Chakraborty et al. [25].To create the shortened wealth index, first we selected 9 items (Supplementary file 1) from the Sierra Leone DHS [27] by multiplying the first principal component score by the standard deviation of the variable and selecting the variables whose product had the largest absolute value.Then, we conducted a principal component analysis of these variables using data from the 2019 DHS survey and used the loading factors of the first principal component to calculate an abbreviated wealth index score as well as cut points for wealth quintiles.We compared our results to the original DHS-calculated wealth index quintiles using Cohen's kappa statistic and percent agreement.For the overall population the kappa statistic was 0.63 and the percent agreement was 70.5%, which was comparable to findings from Chakraborty et al. [25].Compared with the national average, a relatively small proportion of our study population was in the bottom three wealth quintiles, and the small sample sizes within these quintiles resulted in imprecise estimates that were difficult to interpret.To improve the interpretability of the data, we collapsed the bottom three levels into a single category (poor-middle), and categorized wealth into a three-level variable (poor-middle, richer, and richest).
When reporting on COVID-related symptoms, testing, and risk factors, we defined COVID-19 compatible symptoms as a patient's self-report of experiencing a fever and cough or loss of taste or smell at any time since March 2020.Access to adequate handwashing stations was defined as having a place to wash their hands and having had soap or detergent for washing hands every day for the past month.Household crowding was calculated by dividing the number of household members by the number of sleeping rooms in the household.We assessed COVID-19 knowledge by asking patients to respond to 16 true-false questions, and an overall COVID-19 knowledge score was calculated for each patient as the percentage of correct answers.We also reported the proportion of patients providing a correct response to each item.We assessed household adoption of COVID-19 infection prevention measures by reporting the proportion of patients whose households were engaged in a list of potential prevention measures.We reported data on COVID-19-related symptoms, testing, and risk factors for the overall population as well as by time period: March 18, 2021-April 20, 2021; May 1, 2021-October 25, 2021; and October 26, 2021-December 13, 2021 (no surveys were conducted between April 20 and May 1 of 2021).We stratified the analysis by date to allow for comparisons over time as the pandemic progressed.For COVID-19 knowledge and COVID-19 infection prevention measures, we only reported data from the October 26, 2021-December 13, 2021 period because a preliminary analysis of prior periods revealed implausibly low variation in patient responses, suggesting that data collectors were not presenting the question to patients in an appropriate manner and resulting in a refresher training for data collectors in late October.
We reported on social vulnerabilities including household hunger, essential services, emergency coping mechanisms, medication adherence, and mental health for the overall population as well by clinical program.Household hunger, essential services, emergency coping mechanisms, and medication adherence was reported in the past 30 days and mental health was reported in the past two weeks.Additionally, we assessed whether socioeconomic and COVID-related factors were associated with wealth using a logistic regression model for binary outcomes or a linear regression model for continuous outcomes.Wealth category was modeled as a continuous variable, corresponding to an ordinal effect of wealth categories.Outcomes that were significantly associated with wealth (p-value < 0.05) were summarized in an equiplot.
Data was analyzed using STATA version 15.1 [28].All analyses used a complete case analysis.

Ethical consideration
The study obtained ethical clearance from the Sierra Leone Ethics and Scientific Review Committee and PIH Sierra Leone Research Review Committee.Verbal informed consent was obtained from participants before the administration of the survey.Participants' data were collected via CommCare and stored on a protected cloud-based system, and anonymous data were used for analysis.

Result
Among the 5,089 patients enrolled in the hypertensive, diabetes and heart failure programs at the Koidu Government Hospital NCD clinic on March 18, 2021, we attempted to reach a total of 671 patients and successfully interviewed a total of 400 patients for an overall response rate of 59.6% (Fig. 1).Response rates by clinical program were 79.5% for the heart failure patients (93/117), 65.0% for hypertensive patients (165/254), and 47.3% (142/300) for diabetic patients.Hypertensive, heart failure, and diabetes patients had median interview dates of June 2021, October 2021, and November 2021, respectively (Table 1).Almost all patients were between 40 and 69 years old (80.5%) and 46.1% were male.Compared with the national distribution of wealth, 33.0% of our population belonged in the richest quintile, 34.8% in the second-richest quintile, and 32.2% in the bottom 3 poorest-middle quintiles.There were similarities in sex among the three clinical programs, however there were statistical differences (p-value < 0.05) among survey dates, age, and wealth index quintiles.
Overall, almost one-fifth (19.5%) of participants reported COVID-19 compatible symptoms with a similar proportion (20.6%) receiving testing for COVID-19 (Table 2).The percentage of patients reporting COVID-19 compatible symptoms increased from 1.3% among patients interviewed before May 1, 2021 to 38.1% among patients interviewed after October 25, 2021.The proportion of patients having received a test followed a similar pattern.Of those who received COVID-19 testing, only 3.7% reported a positive test result, and all of the patients reporting a previous positive test result were interviewed after October 25, 2021.When asked about possible risk factors for exposure to COVID-19 in the past two weeks, 25.5% of patients had participated in a festival or mass gathering, 23.8% visited a health facility, and 17.3% traveled outside Kono District.Patients' exposures to all risk factors except contact with a known or suspected COVID-19 case increased over time.Only 27.3% of the population had access to adequate handwashing facilities and 43.7% lived in crowded conditions.Finally, 52.1% of the population responded they wear a mask always or more than half the time while 23.7% never used a mask.Reports of mask wearing peaked among  When assessing COVID-19-related knowledge among the 147 patients who completed the survey after October 25, 2021, we found that more than 90% of respondents knew that masks, avoiding handshakes, social distancing, and isolation from positive cases were effective prevention measures.More than 75% of the patients knew that the virus was spread through respiratory droplets and that unfiltered water, wild animals, or blood could not spread the infection.However, less than half of the population knew the virus could be spread by infected surfaces, asymptomatic or afebrile people could spread the virus, not everyone with COVID-19 becomes severely ill, there is currently no effective cure, older patients were at elevated risk to become severely ill, or children were at lower risk.Only 9% of NCD patients knew that people with pre-existing comorbidities were at risk of severe illness from COVID-19 (Fig. 2).When assessing measures patients' households reported to reduce the spread of COVID-19 among surveys conducted after October 25, 2021, 91% percent of the interviewees avoided crowded areas and 27% avoided markets (Fig. 3).More than 50% maintained social distance, avoided shaking hands, and touching their face.Only 36% of patients reported that their households used masks, 34% washed hands, and less than 20% avoided going out, covering their nose and mouth, or using hand sanitizer.
By analyzing social vulnerability experienced 30 days before the interview, we found that 91.0% of patients worried about having enough food at least once, 78.0% reported moderate hunger in the household, 47.5% experienced at least one barrier to accessing health care, and 61.2% had used at least one emergency coping mechanism to pay for food, housing, or health care for their household.The most common reason for being unable to access health care was lack of transport followed by lack of money while lack of services and fear of COVID-19 were reported infrequently (1.8-2.7%).Overall, 71.8% of patients reported having at least one medication prescribed with diabetic and heart failure patients being more likely to report having medication (99.3%, 100%, respectively) than hypertension patients (32.1%).Among patients who reported being prescribed medication, the median of the medication adherence scale was 80 [IQR: 76.7-90.0].Overall, only 1.8% of patients were screened positive for anxiety and 6.5% of patients were screened positive for depression, and depression was high among heart failure patients (19.4%).Those patients were referred to the Mental Health Unit (Table 3).
When assessing the associations between socioeconomic and COVID-related factors, and wealth, we observed the expected significant association between wealth and food security, access to essential services, use of emergency coping mechanisms, and no face mask usage with the poor-middle category being the most vulnerable and the richest  category being the least vulnerable (Fig. 4).Similarly, both reporting a medication prescription and medication adherence was significantly associated with wealth, with the poor-middle category reporting less medication use than the richer and richest categories.Wealthier groups were more likely to have been tested and to have engaged in behaviors that could expose them to COVID-19, including attending a festival or mass gathering, visiting a health facility, and traveling outside the district or internationally.The largest gap between the poor-middle and richest categories were seen in  1 3 the use of at least one emergency coping mechanism (87.4% vs. 39.5%),experiencing at least one barrier to access to health care (59.1% vs 32.3%), worrying sometimes about having food (38.6% vs 15.4%), ever receiving a COVID-19 test (11.9%vs 38.5%), attending a festival or mass gathering (19.7% vs 42.3%), visiting a health facility (15.9% vs 36.2%), and traveling domestically (8.7% vs 36.9%).Depression, anxiety, COVID-related symptoms, infection prevention, and selling assets as an emergency coping mechanism were not found to be statistically significant to a patient's wealth category.Detailed information regarding demographic characteristics and social vulnerability by wealth quintiles can be found in Supplementary file 2.

Discussion
In our cross-sectional telephone survey conducted among NCD patients in Sierra Leone, we observed substantial exposure to COVID-19-related risks and extremely high exposure to social vulnerabilities.Although the total number of patients reporting a positive COVID-19 diagnosis was low (3.7%), the proportion of patients reporting COVID-19-like symptoms and reporting exposure to COVID-19 risk factors increased over the course of the pandemic.Encouragingly, we also observed an increase in COVID-19 testing over time, possibly reflecting an increase of testing in Sierra Leone over time, due to more awareness, development of national strategic plans, and increase in diagnostic resources.
In general, patients expressed good knowledge about COVID-19 transmission and prevention pathways, but a poor understanding about COVID-19 severity and outcomes, which can explain poor compliance with preventative measures.Compared with other studies [29], knowledge about COVID-19 prevention practices has improved, perhaps as a result of the time passed since the COVID-19 global pandemic was declared.Following Sierra Leone's Ebola outbreak (2014-2016), substantial investments were made in national infection-prevention-control education campaigns [30].These investments may partially explain why Sierra Leone was ranked as highly prepared to respond to COVID-19 at the start of the pandemic [31].The most important strategy for infection-prevention-control education in Sierra Leone is conducted by community health workers [32].Consequently, community health workers have a good education on disease prevention due to their previous experiences with Ebola and additional COVID-19-related training, and may have Fig. 4 Experience of social vulnerabilities, COVID-related testing, and risk factors by wealth index categories (N = 394).Only outcomes with significant differences between wealth categories are shown been able to apply this knowledge when educating their communities about COVID-19.However, CHWs have low health literacy in general and may be less able to disseminate high-quality information about the severity of and treatment for COVID-19.For NCD patients, improving patients' understanding of their own higher risk of a severe COVID-19 infection could motivate them to increase their use of protection measures or vaccinate.Although our survey did not ask about vaccination in Sierra Leone, only 17.3% of the total population is fully vaccinated [31] and no national or local policies targeted NCD patients, including our clinic.
We also observed some substantial discrepancies between knowledge of COVID-19 prevention strategies and patient behavior.For example, although patients consistently knew that masks and handwashing were effective strategies for preventing COVID-19, use of masks or handwashing was much less common.These findings are in line with other studies published in sub-Saharan Africa [33].Poverty could be a contributing factor for low adherence [34].Previous studies have mentioned there is a paucity of handwashing items, such as soap, running water, or a handwashing station, in lowincome settings, impeding the use of this infection prevention strategy [29].Although we did not analyze if inadequate use of preventive measures is related with economic or behavioral factors, we do support the idea of the interrelation between them.The education that money could provide would impact the understanding and accessibility to information leading to behavior change.Additionally, these findings could reflect other psychological or behavioral factors that lead to a "know-do" gap.These factors include a general perception that COVID-19 is not a severe risk, a progressive loss in motivation, a reduction of community engagement with COVID-19 prevention measures [35], or a rational response to reduced COVID-19 cases in Sierra Leone.We also observed some discrepancies regarding patients' self-reported adherence to COVID-19 risk reduction strategies.For example, although a high percentage of patients said their household was avoiding crowded areas, shaking hands, and maintaining safe distances to prevent COVID-19, over a quarter of NCD patients also reported attending a mass gathering in the past two weeks.These discrepancies could be explained by poor data quality caused by social desirability bias, or communication challenges between data collectors and patients, related to low levels of education among patients as well as inadequate training and experience among data collectors.However, these apparent discrepancies could also suggest that although the households of NCD patients are seeking to reduce their COVID-19 exposure, practical considerations, such as the importance of accessing health care or earning a living, prevent NCD patients from fully engaging in social isolation.Ultimately, although this data suggests a number of possible behavorial, economic, or psychological reasons for not adhering to COVID-prevention practices, we cannot isolate the independent contribution of each of these factors.Future qualitative research may be better able to understand how these factors contribute to decision making.
Although our patients tended to be wealthier than the national average, possibly due to our use of telephone-based data collection, our NCD population still exhibited extremely high levels of socioeconomic vulnerability overall.This includes limited access to food and health services, medication adherence, use of emergency coping mechanisms to cover basic needs, and frequently engaging in behaviors that confer COVID-related risk.This high level of vulnerability partly reflects the high prevalence of absolute poverty in Sierra Leone.Sixty percent of the population of Sierra Leone live under the global poverty threshold [36] and the COVID-19 outbreak decreased the gross domestic product (GDB) per capita by 4% [37], compromising jobs, provision of supplies for farming with a consequential increase in the prices, difficult access to food, anger followed by stressful daily situations, and further increasing social vulnerability [14,38].For patients with chronic diseases, this poverty feeds and multiplies the risk of hospitalizations, disabilities, and death [39].Poverty modifications could explain the worryingly low proportion of hypertension patients who reported being prescribed medication, as almost all patients in our NCD program should be on medication to control their chronic conditions.Although some hypertension patients receive instructions on non-medication lifestyle interventions, we hypothesize that many of these patients who reported not being prescribed medication may require medication, but are not regularly collecting their prescription due to poverty-associated barriers.
Our findings, as well as strategies used during the COVID-19 pandemic to maintain continuity of care for NCD patients, suggest several methods that could be continued or intensified as part of future pandemic preparation and building resilient health systems.First, during COVID-19, PIH developed and implemented a home care visit plan to deliver health care, medical supplies, and food packages to the most vulnerable and disabled NCD patients.The home delivery program reached 200 families supplying medication every 1-3 months depending on the severity of the diseases and the accessibility of the household.Our findings suggest that PIH's ongoing initiatives need to be strengthened and expanded to a larger proportion of NCD patients.These emergency measures, together with providing continuous education of patient care for chronic diseases to prevent loss of follow up, creating safe spaces in the facilities to prevent nosocomial spreading of infectious diseases, facilitating long term supplies and routine vulnerability assessments, and developing 1 3 home-based care models led by community health workers can help to guarantee the sustainability of daily care for NCD patients living in highly resource-constrained settings, especially under the scenario of future pandemics.
Our study has some limitations.First, although we initially sought to interview a random sample of patients from the NCD program, our random selection procedure was not implemented as planned and our study population was restricted to patients who had telephone access, meaning that our respondents were non-representative of the NCD patient population in Kono District and likely reflect a wealthier selected population.Furthermore, our findings may not be generalizable to other districts in Sierra Leone due to PIH's extensive support, including free provision of care for NCD conditions.Second, self-reported telephone data collection in our setting could be inaccurate due to social desirability bias or recall bias, which could be particularly prevalent in our population due to their low average level of education and perception of health care workers as authority figures.Third, our data collection team was relatively inexperienced, which likely led to poor quality data collection early in the study.While we sought to address this limitation by retraining the data collectors and excluding some poor quality data collected after October 25, 2021 from our analysis of COVIDrelated knowledge and household infection prevention measures, because all hypertension patients were interviewed in the early phase of our study it is impossible to know whether observed differences between clinical populations are due to real differences between the clinical programs, in data collection, or patients experiences at various phases of the pandemic.

Conclusion
Despite these limitations, this paper is the first to explore social vulnerability and COVID-19 related outcomes among NCD patients in Sierra Leone.Patients demonstrated a good understanding about preventative measures of COVID-19; however, a gap between knowledge and implementing behaviors means these patients still face regular exposure to COVID-19 risks.Socioeconomic vulnerability was high overall, and even higher among the poorer NCD patients.Sierra Leone and other low-income countries should work towards health strategies and policies that guarantee an acceptable and equal level of care for the population regardless of any threatening condition.In light of the substantial socioeconomic vulnerability identified in this population, additional targeted economic support for NCDs patients in Sierra Leone is warranted.
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made.The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material.If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder.To view a copy of this licence, visit http:// creat iveco mmons.org/ licen ses/ by/4.0/.

Table 1
Demographic characteristics of study population (N = 400) a Our abbreviated assest-based wealth index score was used as cut points for wealth quintiles

Table 2
COVID-related symptoms, testing, and risk factors (N = 400) a Only reported data from the October 26, 2021-December 13, 2021 period because a preliminary analysis of prior periods revealed poor data quality

Table 3
Social vulnerability of study population (N = 400)