A qualitative study to understand how Ebola Virus Disease affected nutrition in Sierra Leone—A food value-chain framework for improving future response strategies

Background: This study sought understand how the 2014–2016 EVD Virus Disease (EVD) outbreak impacted the nutrition sector in Sierra Leone and use findings for improving nutrition responses during future outbreaks of this magnitude. Methodology: This qualitative study was iterative and emergent. In-depth interviews (n = 42) were conducted over two phases by purposively sampling both key informants (n = 21; government stakeholders, management staff from United Nations (UN) agencies and non-governmental organizations (NGO)), as well as community informants (n = 21; EVD survivors, health workers, community leaders) until data saturation. Multiple analysts collaborated in a team-based coding approach to identify key themes using Dedoose software. Findings are presented as both quotations and tables/figures. Results: The EVD outbreak effects and the related response strategies, especially movement restriction policies including 21-day quarantines, contributed to disruptions across the food value-chain in Sierra Leone. System-wide impacts were similar to those typically seen in large-scale disasters such as earthquakes. Participants described an array of direct and indirect effects on agricultural production and food storage and processing, as well as on distribution, transport, trade, and retailing. Secondary data were triangulated by interviews which described the aggregate negative effect of this outbreak on key pillars of food security, infant and young child feeding practices, and nutrition. During the humanitarian response, nutrition-specific interventions, including food assistance, were highly accepted, although sharing was reported. Despite EVD impacts across the entire food value-chain, nutrition-sensitive interventions were not central to the initial response as EVD containment and survival took priority. Culturally-appropriate social and behavior change communications were a critical response component for improving health, nutrition, and hygiene-related behaviors through community engagement. Conclusions: Infectious diseases such as EVD have far-reaching effects that impact health and nutrition through interrelated pathways. In Sierra Leone, the entire food value-chain was broken to the extent that the system-wide damage was on par with that typically resulting from large natural disasters. A food value-chain approach, at minimum, offers a foundational framework from which to position nutrition preparedness and response efforts for outbreaks in similar resource constrained settings. Author summary: The 2014–2016 EVD outbreak has greatly impacted the population health and nutrition of affected countries in West Africa, including that of Sierra Leone. Since this recent outbreak, the humanitarian community acknowledges the need for improved solutions to better prepare for, and respond. Despite the importance of nutrition during outbreaks, there has been little systematic research conducted for understanding lessons learned and improving upon the typical nutrition response options currently available. This study used qualitative interviews to collect in-depth narratives from government officials, front-line health workers, non-government organization management, and community members including local leaders and EVD survivors. Findings reveal the unprecedented magnitude of this outbreak, which had systems-wide impacts not dissimilar to those felt by natural disasters. Interviews with people who lived through this event in Sierra Leone described EVD effects which revealed the importance and fragility of multiple, interconnected systems comprising the food value-chain for optimal nutrition in Sierra Leone. Findings across the food value-chain reveal how this interconnected system was impacted at every level with consequences for population-level nutrition. In preparation for future outbreaks of this magnitude, such a framework may prove useful for policy and planning, including improved guidelines development for employing coordinated nutrition-specific and nutrition–sensitive approaches that address immediate and underlying determinants of nutritional status.