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‘Ensemble On Sonne!’ Travels of KAP Studies (Knowledge, Attitudes and Practices) for the Prevention and Control of Covid-19 Infections in Upper Guinea

‘Ensemble on sonne!’ Circulation des enquêtes CAP (Connaissance, Attitudes et Pratiques) pour la prévention et le contrôle des infections à la Covid-19 en Haute-Guinée
‘Ensemble on sonne!’ Circulação dos inquéritos CAP (Conhecimentos, atitudes e práticas) para a prevenção e o controlo das infeções por Covid-19 na Alta Guiné
Carlos Rocha

Abstracts

The Covid-19 pandemic drove a surge of preparedness and response interventions structured under international guidelines to be directly introduced in any local setting. This article analyses a Covid-19 readiness intervention, carried out by a partnership between the Robert Koch Institute–Berlin and a hospital in Guinea, West Africa. An ethnographic approach to the partnership’s sources and materials, in particular the Knowledge–Attitudes–Practices (KAP) Interventional study, draws attention to the ordinary and daily practices that allow for an outbreak response intervention to travel and be implemented locally. In order to unravel the partnership’s logics, I critically examine the documents used in the hospital during that programme: the guidelines and training leading the intervention as well as the data collection tools measuring its impact. I then turn to my ethnography at the hospital to provide an everyday emphasis to the KAP logics whose implementation I facilitated. Through this, I intend to reflect on the mechanisms that allow global health partnerships to travel and land in specific contexts, as well as to produce scientific evidence on hospital dynamics. I describe the routine of the partnership, the circulation of the materials it is based on, as well as the new materials it produces as it travels and lands, including the results from my own fieldwork. I argue that this traction to travel and to land is more based on expectations and scientific assumptions from the partnership’s stakeholders and beneficiaries at the hospital than on outbreak preparedness and daily dynamics of response.

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Author’s notes

Ethical approval (036/CNERS/21) was granted by the National Health Research Ethics Committee of Guinea (Comité national d’éthique pour la recherche en santé).

Full text

Data related to the article:
“Travels of Knowledge, Attitudes and Practices (KAP) on Infection Prevention and Control, Upper Guinea: documents and images.”
https://doi.org/​10.34847/​NKL.B6FE9GY2.
Includes the materials presented in this article.

Introduction

  • 1 The name of the hospital has been anonymised. It will from now onwards be referred to as “the Hospi (...)

1In December 2020, the Centre for the Treatment of Epidemics (CT-EPI) of a hospital,1 located in the Upper Region, in Guinea, West Africa, has no patients. This CT-EPI covers an area of around 1,600 square metres and houses patient wards, a visitor’s centre, a morgue, an incinerating oven, waiting and consultation areas, and several staffrooms. A fence separates these facilities from the rest of the Hospital. A sole admission door allows entry of both visitors and staff. The Hospital’s healthcare worker showing the facilities explains that CT-EPIs were constructed in the aftermath of the 2014–2016 Ebola virus disease outbreak that affected Guinea and two of its neighbouring countries (Sierra Leone and Liberia). Their purpose is to strengthen the health system’s response capacity to outbreaks, and the treatment of patients suffering from HIV-AIDS, hepatitis or a viral haemorrhagic fever. The three patient wards of this CT-EPI only have a few beds. Furniture and other equipment have been, gradually, even before Covid-19, used in other hospital services to ease infrastructure shortages (Figure 1 shows some pictures of the CT-EPI taken in those days).

Figure 1: The Centre for the Treatment of Epidemics (CT-EPI), Guinea [anonymised location]

Figure 1: The Centre for the Treatment of Epidemics (CT-EPI), Guinea [anonymised location]

Up-left: ambulance road inside the hospital to access the facilities. Up-right: Entrance and hand washing kit. Down-left: The only ward that had some equipment. Down-right: The three patient wards and the fenced access to the bathrooms.

Photos by the author, 2020.
Persistent identifier: https://doi.org/​10.34847/​NKL.B6FE9GY2.
Download the images: up-left, up-right, down-left, down-right.

2With the declaration of the emergency state in the country due to Covid-19, on 26 March 2020, the National Agency for Sanitary Security (ANSS) orders hospitals to empty CT-EPI wards and to be ready to receive potential Covid-19 patients. One room of this CT-EPI is a Covid-19 rapid test centre, following the strategy of the ANSS to carry out rapid tests in all the country’s hospitals. In the region, whose main urban centre and adjacent rural areas have around 300,000 inhabitants, the hospital tests 226 people from October to December 2020, mostly staff of the hospital itself and jobseekers in the mining industry who need the test to be allowed to work in Guinea. Although the ANSS envisions a more systematic testing strategy starting with vulnerable populations or with people with comorbidities, the Hospital director explains to me that the Prefectural Health Directorate, which is responsible for this policy, did not formulate any local plan. PCR tests for Covid-19 only become available at the hospital in February 2021.

3I am visiting the Hospital as part of a German research team. The Centre for International Health Protection (ZIG) of the Robert Koch Institute (RKI) has a partnership with the Hospital—hereafter it will be referred to as “the Partnership.” I participate in the Partnership as a student research assistant for over two years. The Partnership aims at enhancing the Hospital’s response and healthcare capacity following mostly the World Health Organization’s (WHO) guidelines, while carrying out research on implementation and its impact. It employs a Berlin-based team composed of doctors, epidemiologists, experts in global health and research assistants from diverse disciplines, and one doctor and one nurse from the Hospital. During those weeks in December 2020, the Partnership organises a Covid-19 readiness and response intervention at the Hospital based on a Knowledge, Perception/Attitudes and Practices (KAP) impact study. Two medical doctors from the Berlin team and myself are at the Hospital for the interventional part of the study, which consists of training all the Hospital’s healthcare workers after analysing the KAP baseline. A KAP follow-up is planned right after the training is completed.

4As a student research assistant, I contribute to the setup of the Covid-19 KAP study. Since I am nearing the end of my master’s studies, I am granted permission to accompany this KAP study with an ethnography at the Hospital. While touring the CT-EPI and making my preliminary observations, it strikes me how empty it is. Although we are at one of the highest peaks of Covid-19 infections worldwide and we are here precisely to improve the response to this pandemic, there are no patients, much less the equipment to care for them. I also wonder what role, if any, the infrastructure at the Hospital for outbreak response is going to play in the KAP study.

5The aim of this article is to describe the process of implementation of this KAP study and to put it in dialogue with my own ethnographic materials gathered at the Hospital. I base my analysis on the materials that encapsulate the Partnership’s logic: the guidelines and training leading the KAP study, as well as the data collection tools measuring its impact. I then turn to my ethnography to emphasise daily realities vis-à-vis the KAP logics whose implementation I help to facilitate. Through this, I intend to reflect on the mechanisms that allow global health partnerships to travel and land in particular contexts, as well as to produce scientific evidence on hospital dynamics.

6This paper proceeds in four parts. The first situates the KAP studies as a methodology travelling within the field of global health. The second provides a description foregrounding how the KAP model travels to the Hospital. I show that the travel in itself is part of the improvement strategies by the Partnership. In the third section I establish connections between different documents from the Covid-19 KAP study envisioned by the Partnership and my ethnographic materials. In the fourth section, I critically reflect on my double positionality as an ethnographer studying the Partnership and at the same time as a member within the implementation team.

KAP studies travelling before and during Covid-19

Travelling global health models and KAP studies

7Global health social studies pinpoint the travel capability of global health technologies and/or interventional models (de Laet and Mol 2000; Müler-Rockstroh 2012). They emphasise the ease with which these interventional models, created for a particular context and with particular users in mind, are transferred to other situations. The aim of a travelling model is to induce changes in behaviour to make it more predictable and knowledgeable (Behrends et al. 2014). The model is made portable through a set of standardised programmes, protocols or guidelines that represent aspects of reality with the intention of reshaping it to induce social change (Olivier de Sardan 2021). For anthropology of development, models are unable to fully bring about their desired lasting social change because they are ill-suited to incorporate the routines, the daily practices and informal regulations of a particular context and reduce them to statistical or demographic variables—hygiene scores, knowledge levels, Gini index (Olivier de Sardan et al. 2017; Olivier de Sardan and Piccoli 2018; Olivier de Sardan 2018, 2021).

8To my knowledge, KAP studies have not been conceptualised as a travelling model, although their mobility and portability clearly make them one. KAP studies were originally developed in the 1950s in the field of family planning to enquire about the willingness to use different contraceptive methods, and to design health campaigns based on the knowledge, attitudes and practices revealed by the surveys (Andrade et al. 2020). In the following decades, this type of survey spread throughout the world with more than sixty countries undertaking KAP studies between 1950 and 1970 (Cleland 1973). On the African continent, KAP studies on sexual behaviour, particularly in relation to HIV/AIDS, travelled within the Global HIV Programme from the WHO. Validity issues arose from these standardised KAP studies on HIV/AIDS since it was noted that several factors—for example the order of questions, the location of the interview—influenced the quality of the answers, and therefore hindered comparisons in and between countries (Caraël 1995). Recent critics have highlighted as problematic the link between the data from the KAP and the public health interventions since campaigns are based on the false assumption that there is a direct relationship between knowledge and behaviour change (Launiala 2009). KAP are often used during epidemic outbreaks to obtain timely snapshots of particular situations, or to measure the impact of improvement strategies on infection prevention and control (Roth and Raab 2020). In the latter case, as I will show below, KAP studies have been developed as ready-to-use tools by multilateral organisations like the WHO. They are expected to travel and produce the same outcomes in all implementation contexts, with only minor adaptations.

9Beyond understanding how the KAP study on Covid-19 travels in the framework of the Partnership I introduced above, I am interested here in reflecting on how it is concretely operationalised through questionnaires and training. The literature on itinerant technology in global health highlights the importance of the “interstitial spaces”—where negotiations and planning happen within a project or a strategy—to make the model portable and to account for its capacity to travel to a new context (Rottenburg 2009). Between and within these interstitial spaces, a translation chain should take place that will re-inscribe the model in a new situation to induce the expected social change. The failure to acknowledge this necessary re-inscription will hinder the expected social change (Behrends et al. 2014, 25). Anthropology of development sees in the interstitial spaces a reengineering process (mise en réseau et en ingénierie) from the model in the hands of “development brokers” (Mosse 2013). The materiality that makes a travel possible has not been the focus of much attention. Through my experience of an embedded researcher within the Covid-19 KAP study led by the Partnership, I take the materials as a starting point and propose a reflection on what it means to be inside the translation chain/the reengineering process: to plan a KAP study, to develop the tools upon which it is based and to observe their practical application. I use my ethnographic observations to describe the life of the documents that make up the KAP study and to critically reflect on the reach and the limitations of the study. I argue that the Hospital, rather than a passive landing place for a travelling model, can better be understood as a complex reality created by the Partnership, its beneficiaries and myself.

KAP on hand hygiene and the advent of the Covid-19 pandemic

10Since 2004, the WHO launched a series of challenges which seek to guarantee a high standard of healthcare in hospitals worldwide (Pittet et al. 2006). Each challenge includes a toolbox for a study comprising a step-by-step methodology with data collection instruments to measure impact. The Partnership started in 2018 and implemented the first WHO challenge at the Hospital. Titled “Clean Care is Safer Care”, This challenge seeks to increase access to Alcohol-Based-Hand-Rub-Solution (ABHR) and to promote infection prevention and control through the study of the healthcare workers’ KAP regarding hand hygiene.

11The first phase established a baseline by evaluating the staff’s hand hygiene KAP. In the second phase, the Partnership reintroduced a local product of ABHR in the Hospital’s pharmacy. This local product is of particular importance because the Hospital, like many health facilities in the country, lacks access to running water and stable electricity. During the second and interventional phase, the Partnership also organised a tailored training for the staff which was adapted to enhance specific points of hand hygiene knowledge and practice identified during the baseline assessment. The third phase evaluated the impact and improvement with the same KAP assessment tools. This KAP study did not only focus on providing a snapshot of the knowledge, the attitudes and the practices concerning hand hygiene, but also measured impact by comparing the baseline with the follow-up evaluation, and by associating positive increases to the intervention. This challenge was implemented in similar settings in low- and middle-income countries (Allegranzi et al. 2010; Pfäfflin et al. 2017; Schmitz et al. 2014; Uneke et al. 2014). Main results from the Hospital are already published (Müller et al. 2020; Müller et al. 2021).

12Shortly after the declaration of the Covid-19 pandemic in Guinea in March 2020, the main funder of the Partnership—the German Ministry of Health—allowed reallocation of that year’s funds to pandemic-related benchmarks. With this decision, it became a question of quickly developing a new intervention that could build the Hospital’s capacity for Covid-19. Considering that the pandemic progress in the African continent was delayed by a couple of months, the timing was right to improve the Hospital’s readiness. Looking at what was happening in Europe and North America, the prognosis at the time was not encouraging since the response capacity of African health systems was considered substantially limited (Walker et al. 2020).

13The success of the previous intervention persuaded the RKI to design a similar step-by-step KAP study, following international guidelines. Once the Berlin-based team approved the study, it informed the Hospital about the funder’s decision and the new working strategy for the rest of the year. The Hospital-based team approved the KAP study, including guidelines to set up a triage area at the entrance of the Hospital.

14Besides the rush in developing an intervention before the situation in the continent could worsen, there was an interest in gathering data as soon as possible to publish information about the pandemic in regions as remote as the one where the Hospital is located. The pandemic did not progress as expected in the African continent (Ghosh et al. 2020). Even though the testing strategies were not systematic, the low mortality rates and the almost nonexistent number of positive cases in all the CT-EPIs pointed to a different behaviour of the pandemic, at least in Guinea (E. Bonnet et al. 2021). Figure 2 shows a timeline of the fieldwork and the development of the Partnership.

Figure 2. Timeline

Figure 2. Timeline

Figure by Author.

Covid-19 KAP study at the Hospital

15Weekly videoconferences, emails and telephone exchanges among the team allowed discussion of what was necessary to include or exclude from the data collection tools which needed to be developed for the KAP study. By May 2020, other KAP exploratory studies on Covid-19 had already been published, along with the respective questionnaires in the supplementary material sections (Bhagavathula et al. 2020; Olum et al. 2020; Zhong et al. 2020). The questions from these studies were taken as a basis for the knowledge and attitudes part, but the Berlin-based team decided to add new ones more in line with the context. For example, concerning the knowledge section, they drafted questions related to the country’s outbreak history, in particular the risk of contracting Covid-19 from rodents or bushmeat consumption.

16The attitudes section consisted of seven-point Likert scale numerical questions. Some questions enquired about perceptions on how Covid-19 could affect the African continent as well as the risk of contracting the disease on account of warm temperatures—given that the disease was perceived as only affecting wealthy and temperate countries. These questions were included, based on what the media at the time highlighted as the main perceptions on the African continent.

17When the documents were finalised at the end of the summer in 2020, they were sent as PDF files to the Hospital-based team who printed and distributed them to all the Hospital’s healthcare workers for the baseline assessment. Once filled out, they were scanned and sent back to Berlin (Figure 3 shows a snippet of one of the scans with knowledge and attitude questions).

Figure 3. Snippet of the KA questionnaire the Partnership developed (scanned by the Hospital-based team)

Figure 3. Snippet of the KA questionnaire the Partnership developed (scanned by the Hospital-based team)

See Annex for transcript and translation.

Centre for International Health Protection (ZIG) of the Robert Koch Institute (RKI), Berlin, Germany, and The Hospital (Upper Guinea), 2020.
Persistent identifier: https://doi.org/​10.34847/​NKL.B6FE9GY2.
Download the document (PDF, 196Kb).
Download the transcript and translation (ODT, 7 Kb)

18The responses were entered into EpI Info and then uploaded as an Excel file to Stata (StataCorp LLC, College Station, Texas, USA) for statistical analysis. The staff showed unexpected proficiency by scoring high enough in the knowledge section, raising doubts about the quality of the data collection tools developed by the Partnership, and raising uncertainties about the statistical improvement to be achieved after the training that was to take place the following months.

19The chain of events I just chronologically described helps me to highlight how easy KAP studies travel. The Partnership takes up and revitalises a strategy deemed successful in the past (a pre- and post-intervention analysis based on a KAP study). Knowledge is made portable (Strathern 2006) through a specific methodology—a KAP study—which guarantees a straightforward implementation and a fast publication strategy. Such studies also permit an easy and cost-effective measurement of impact by showing improvement based on a particular type of evidence: they link the results to the intervention through statistics (Biehl and Petryna 2013; Launiala 2009). If the baseline proficiency is too high (as it is the case this time), then it will be more difficult to measure a significant positive impact of the intervention. This is the reason why the Berlin-based team is surprised by the high baseline score. Following Caduff (2015, 5), the evidence this KAP study yields is less data-driven than “scientifically inspired” and rests not in the accuracy of its models, but in the resonance of its prognosis.

20This chain of events also directs attention to how certain features of the pandemic are channelled to become part of the KAP questionnaires developed by the Partnership. In what follows, I describe how this production of intended evidence gets linked to training, one of the mechanisms par excellence through which global health interventions land (Fuest 2014; Jordan Smith 2003). Ethnographic descriptions on how training takes place, on the basis of what evidence they are sustained, what documents make them possible and what their purposes and relevance are, remain scarce (Gruénais 2005). I contend that analysing the knowledge and attitudes questionnaires can in fact bring precious insights on the assumptions under which they are made, thus departing from the more classical reading of the questionnaires as sources of evidence about what the respondents know and do.

The intervention: training on infection prevention and control

Expected knowledge transmission and “attitude” change

21A fundamental aspect of the KAP study developed by the Partnership is the intervention itself. In order to narrow the gap between the baseline and the follow-up, the training has to focus particularly on the weak points found during the baseline assessment. In December 2020, a medical doctor from Guinea carries out a series of knowledge improvement and attitudes change training with all the Hospital’s staff. The Berlin-based team, myself included, take part in the training. The KAP questionnaires and results of the baseline assessment are shared ahead of time with the trainer to enhance the learning points. Colleagues from the Berlin team open each training session by welcoming the participants and presenting the baseline results.

22The trainer presents in French—the official language of medical science in Guinea—an introduction to Covid-19, its history, epidemiology, diagnosis, clinical presentation (Module 1); hand hygiene (Module 2); donning and doffing of personal protective equipment (Module 3); and triage, notification and isolation (Module 4). The trainer uses four PowerPoint presentations, each corresponding to one of the learning modules. All of the material is endorsed by the WHO and distributed by the ANSS. After explaining the topic of the first module, the trainer asks for a volunteer among the healthcare workers to read aloud. A doctor sitting in one of the front rows raises his hand and begins to read what the trainer is pointing out with a red laser:

23At the end of this presentation, the agents are expected to be able to:

  • Describe the coronavirus.
  • Describe the global spread of Covid-19.
  • Describe the incubation period, people at risk and modes of transmission.
  • Describe and recognise the clinical signs and symptoms of Covid-19.

24Slides 7 to 9 explain the origin of coronaviruses with a cycle diagram that describes the zoonotic transmission risk between bats, monkeys, snakes, rodents and humans. The trainer mentions the market in Wuhan in China as a potential spillover event and highlights environmental conditions like humidity, pollution and high temperatures as facilitating the virus spread.

25Medical documents, such as records and certificates, have been anthropologically characterised as artefacts determining the therapeutic relationships and the medical dynamics in hospitals (Tantchou 2018a). I argue that global health documents, like the knowledge and attitudes questionnaire, determine the relationship the Partnership establishes with the healthcare workers and the hospital. This relationship crystallises the training, because what the trainer explains and how he explains it reaffirms the assumptions under which the questionnaires are based.

26The trainer almost guarantees the success of the intervention and the subsequent publication strategy. If the healthcare workers do not learn during the training what is contained in the KAP questionnaires, the study will not be able to measure impact. The Partnership is aware that people are the carriers par excellence of scientific knowledge (Strathern 2006) and does everything to fix the unidirectional relationship between questionnaires, training and impact of the Covid-19 KAP. However, some parts of the trainer’s presentations did not correspond with questions in the questionnaires. The trainer’s emphasis on high temperatures due to global warming increasing zoonotic spillover risks seems to have added some confusion as it is interpreted as confirmation of the widespread idea at the time that high temperatures can indeed protect from the virus. During the baseline study, 42% strongly agreed with the statement linking protection from Covid-19 and warm weather, and 52% strongly agreed with this statement during the follow-up.

27The questions in the KAP questionnaires denote a specific reading of the pandemic defined by variables that measure what people are said to believe and do. It is expected, in turn, that this will be the knowledge that governs the strategies associated with preparedness and response at the hospital. The questions that the Partnership adds to the KAP questionnaires to account for the context and risk perceptions establish a unidirectional dynamic with the country’s outbreak history. Alleged rumours concerning risk perception linked to climate or wealth become statistically measurable. Likewise, the outbreak’s history acquires visibility and can be statistically measured by its relation with bushmeat consumption and/or cohabitation with rodents—perceived as risky behaviours, which have been held accountable for zoonotic spillovers in the region. The evidence these questionnaires yield, hand-in-hand with the content from the training, perpetuate the narrative that foregrounds the image of animals as epidemic villains necessitating regulation and control (Lynteris 2019) and thus speaks more about the perceptions of their creators than of their target population.

Outbreak preparedness and response as scientific literacy

28Each session finishes with a clapping game:

—“Ensemble on sonne!” [“Together we ring!”] says the trainer.
—“Une fois” [“Once”] responds the audience.
—“Clap!” applauds the whole group.
—“Triplet,” says the trainer.
—“Clap – clap, clap – clap – clap, clap!” applauds the whole group.

29The trainer explains to me that his work as a trainer began at the time of Ebola, and he is rehired during the pandemic. As a result of the population’s mistrust of the Ebola response strategies, especially regarding the admittance of infected people into treatment centres, the Guinean government developed a community engagement strategy. The government trained local health workers—including himself—on basic information about the virus to build trust with the communities. Trainees had to identify leaders and people with social and cultural capital within the communities to be trained on the same topics and who will in turn transmit the knowledge to their communities. The campaigns were to bring people closer to the government’s activities, communicate risk and dismantle rumours.

30This training of trainers’ strategy economically remunerates each of the trainers who must provide attendance lists of the people trained. Under a hierarchical structure, the trainer informs his superior on how many people he briefs every week. The trainer, hired by the Partnership, is also trained in andragogy — pedagogical strategies to train adults. The strategies to keep the audience engaged—for example the clapping dynamics—come from the training received and given during the Ebola epidemic.

31It is the Partnership’s policy to recruit local trainers for the interventions from the KAP studies in order to foster local expertise and tailor perspectives on local issues. The theatricality I describe above—for example the teaching strategies involving repetition and clapping developed during previous outbreaks—is familiar to the healthcare workers as each training since Ebola includes them. The Covid-19 training I observe is thus embedded in the country’s outbreak response history and its risk communication and community engagement strategies. The Partnership not only revitalises a methodology used during previous intervention phases at the Hospital, but also contributes to invigorate an outbreak preparedness and response infrastructure that appears not to vary with each outbreak as it focuses on repeating simplified biomedical information.

32The knowledge transmission strategies like the ones I observe during the training have been categorised as a deterrent of collaborative knowledge exchanges needed to diagnose and stop an epidemic (Briggs and Mantini-Briggs 2016). Previous research about knowledge circulation vis-à-vis past outbreaks stress the importance of working within and through local social practices and disease models (Bolten and Shepler 2017). The background of the trainer—for example his experience as a risk communicator during Ebola—denotes an attempt to work through these structures. Nonetheless, under the assumption that the disease would only be stopped through campaigns of scientific literacy, the risk communication and community engagement strategies privileges simplified biomedical knowledge, putting aside other expertise (D. Bonnet and Jaffré 2003; Richards 2016; Wilkinson 2017). The healthcare workers, for their part, as they repeat the clapping, they also repeat what they understand from the training to be able to answer the questions in the questionnaires. This demonstrates how this over-simplification of biomedical knowledge can backfire into a complex rapport with healthcare workers. They simplify their answers to comply with the “you say, I repeat” dynamic expected from the trainer, the Partnership and the country authorities (Roth and Raab 2020).

Practices of hand hygiene

33In the second module, targeting hand hygiene, the trainer consistently asks the audience rhetorical questions:

“—We need to wash our …?
—… hands!”

34One healthcare worker at a time comes to the front to wash their hands with the new batch of ABHR produced with funds from the Partnership. Once the audience assesses that the procedure is done correctly, the person puts their hands inside a luminescence box. Many are surprised when the trainer points out that all the luminescent spots indicate that some areas are still dirty. The person whose hands are being examined laughs and jokes with the audience, repeats the hand washing procedure until there are no more glowing spots. This part of the training is considered a refresher since hand hygiene—including the use of gloves—was at the centre of the first intervention carried out by the Partnership.

35Contrary to the knowledge and the attitudes where healthcare workers directly fill out questionnaires before and right after their training, the practices are evaluated through direct observation of medical routines. A member of the Hospital team goes to each service and observes hand hygiene. Each hand hygiene action is ticked in the observation form, which is based on what is known as “Your Five Moments of Hand Hygiene” (Figure 4). The observer targets one healthcare worker at a time, focuses on each interaction with the patient, then classifies their interactions into one of the five moments that require a hand hygiene action—rubbing hands with ABHR, or washing hands with soap and water, plus the possible use of gloves. I present in Figure 5a the observation form used for the Covid-19 KAP study to account for the practices, developed by the Partnership. The WHO form (Figure 5b) used during the first intervention is taken as the baseline, but the use of PPE—for example surgical masks in addition to gloves—is added as an indication to statistically highlight the presence of PPE. The baseline observations take place during the months of June and July, and the follow-up is done immediately after the training. As with the other questionnaires, the filled-out observation forms are scanned and sent to Berlin for statistical analysis.

Figure 4. “It takes just 5 moments to change the world. Clean your hands, stop the spread of drug-resistant germs!” Poster created by the World Health Organization

Figure 4. “It takes just 5 moments to change the world. Clean your hands, stop the spread of drug-resistant germs!” Poster created by the World Health Organization

World Health Organization, 2020.
Available on the World Health Organization website: https://www.who.int/​publications/​m/​item/​five-moments-for-hand-hygiene [archive].

36I would like to bring this observation form and their underlying hand hygiene data collection logics into dialogue with my ethnographic excerpts that describe the interaction of the healthcare workers, their patients and families at the maternity ward. Street (2011) argues for a reading of medical documents as artefacts of knowing and of not-knowing. The information within medical records should stabilise uncertainty for a better course of treatment, but Street (2011) finds that in Papua New Guinea, records document and perform uncertainty as a valuable source. I build on this (not)knowing-dyad to approach the logics of the observation forms from the Covid-19 KAP study. My intention is not to explore whether they stabilise uncertainty or not, but to highlight that they open up a field of knowledge and at the same time one of not-knowing regarding hand hygiene. The results from this observation form allow knowledge about the five moments, but not about all the care practices requiring hand hygiene, which run parallel to the ones the KAP study hypothesises (D. Bonnet and Jaffré 2003; Olivier de Sardan and Jaffré 1999).

Figure 5a. Observation form from World Health Organization (WHO)

Figure 5a. Observation form from World Health Organization (WHO)

See Annex for transcript and translation.

World Health Organization, 2020.
Persistent identifier: https://doi.org/​10.34847/​NKL.B6FE9GY2.
Download the document (PDF; 186 Kb).
Download the transcript (ODT, 12.5 Kb).

Figure 5b. Observation form adapted by the Partnership (scanned by the Hospital-based team)

Figure 5b. Observation form adapted by the Partnership (scanned by the Hospital-based team)

See Annex for transcript and translation.

Centre for International Health Protection (ZIG) of the Robert Koch Institute (RKI), Berlin, Germany, and The Hospital (Upper Guinea), 2020.
Persistent identifier: https://doi.org/​10.34847/​NKL.B6FE9GY2.
Download the document (PDF; 186 Kb).
Download the transcript & translation (ODT, 11.4 Kb).

Care at the maternity ward

37All the midwives expect the head gynaecologist every day at around 10 a.m.for ward rounds. Pushing a two-level cart carrying a bottle of ABHR, a sphygmomanometer, a box of gloves, a stethoscope and a thermometer, they enter each of the wards. As they approach each patient, one midwife takes the patient’s blood pressure and the temperature if deemed necessary. Additionally, she assists the physician while he’s examining the body and the wounds—in most cases due to caesarean sections (CS). Another midwife writes down in a large grid notebook—the admission notebook—the patient’s progression, other relevant information and the prescribed treatment. When it is necessary for the patient to buy some medication, they also write it down in the admission notebook of the patient which is kept by the patients themselves or their relatives. During ward rounds, the patient’s caregivers are requested to wait outside the wards.

38In the first ward, the first bed is occupied by a patient who has a transverse CS with a scar beginning in her pubic area and ending right before her chest cavity. Before examining her, the doctor, without removing his watch, rubs his hands with the ABHR from the cart which is given to him by one of the midwives. The hand hygiene process takes no more than ten seconds and does not follow the steps demonstrated during the training. The doctor attended a training session the previous day where there was a reminder that hand hygiene must be performed without any object in the hands or on the wrists, and for between 20–30 seconds.

39The doctor explains to me that the patient has malaria and is anaemic. She had lost her baby at birth. The physician examines her stomach without gloves, while the patient moves around in distress and breathes in deeply because of the pain caused by the examination. The physician then complains of an odour. He requests a midwife to take the patient’s temperature. Since he only speaks French and the patient Malinké, he asks another midwife to enquire if the patient has gone to wash herself as she was told to the day before. The other midwives, who do not take part in the examination process, sit on empty beds or chairs in the ward. The ones who had attended the training have a refilled bottle of ABHR in the pockets of their uniform.

40Another midwife, wearing two golden rings, interrogates the patient while taking her temperature with a flash thermometer. Meanwhile she translates that the patient washed herself with the help of her mother and sister the night before. The midwife never uses the ABHR. Because of the foul smell and the fever, the doctor decides to do a pelvic exam. For the procedure, he puts on gloves and declares that the patient has an infection. Removing the gloves, making sure that his fingers do not touch the contaminated areas and leaving them on the lower level of the cart, he requests that the patient be brought to one of the examination rooms after the day’s ward rounds, for treatment with antibiotics. He also tells the midwives to speak with the family to make sure that the CS wound stays dry, her sheets clean and she is properly fed and washed. Adjacent to the maternity block, there is a small building housing washrooms and bathrooms. Since the hospital has no sewage system, patients and relatives have to bring water to the washing facilities. The hospital’s well is located about 150 metres from the maternity block. Buckets used to transport the water have to be brought in by the patients themselves or their relatives.

41The physician tells one of the older and more experienced midwives to write down in the chart and admission notebook the treatment and medications the patient needs for the vaginal infection. At the end of that day’s ward rounds, two midwives take the patient to one of the consultation rooms for the disinfection procedure. On a stretcher with the separators commonly found on maternity beds, divided from the rest of the room only by a privacy screen, the doctor performs the procedure with another pair of gloves on. Once finished, he removes his gloves and asks the midwife to check on her at night. One of the midwives, who has the night shift, agrees to keep an eye on the patient. The following days, her haemoglobin level rises, the odour disappears and the patient’s mood improves.

The complexity and multiplicity of care

42These ethnographic excerpts clearly highlight a behaviour difference between what happens during the training and what occurs during day-to-day practices. The training by the Partnership and its underlying logics do not contemplate day-to-day practices by implementing a methodology allowing only one knowledge-enhancing takeover, and by simplifying knowledge transmission in one training with a scientific literacy discourse. The problematic differentiation drawn by most public health training and interventions between theoretical, practical and day-to-day knowledge has already been highlighted (Downey 2010; Marchand 2010; Rice 2010).

43Previous research on Personal Protective Equipment (PPE) in hospital settings has shown different uses and meanings that are given to wearing gloves. Use can be influenced by prior relationships, fear of infection and, when in short supply, reused several times to care for many patients, thus protecting the person who uses them but increasing the risk of infection for others (Brown 2010; Brown and Kelly 2014). In similar settings, supply shortages are reported even during epidemics (Beisel 2014). Changes in everyday practices and incorporation of new forms of knowledge can cause ubiquitous uses (Brown and Marí Sáez 2020).

44Anthropological literature on healthcare and maternal health in West Africa, especially francophone anthropology of development (Jaffré and de Sardan 2003; Jaffré et al. 2009), focuses on the organisational and operational modes of the healthcare system. They centre their analyses on the discrepancies between local contexts and institutional norms. These incompatibilities, mediated by practical norms, often give rise to a “revenge of contexts” which destines global health travelling models to failure, because they cannot bring about the expected social change (Olivier de Sardan 2021).

45My intention is not to dwell on the range of reasons stemming from the practical norms at the hospital that might explain the gap between knowledge and behavioural change—for example the lapse from the gynaecologist who forgets to remove his watch or does not systematically use the ABRH after being reminded to do so during training. By ethnographically approaching the medical practice at the maternity ward, I seek instead to underscore a reality of hand hygiene that goes beyond the “five moments of hand hygiene.” The comprehensive descriptions I provide from the maternity ward routines are very difficult to tick in the boxes on the observation forms with which the Partnership attempts to analyse hand hygiene compliance. Not only because several hand hygiene moments from multiple actors happen at the same time, but also because the care embedded in hand hygiene is entangled with other social and political orders.

46Next to the one provided by the staff, there is a whole care universe led by families, friends and other caregivers. This phenomenon speaks about a medical authority that is produced through complex negotiations of divergent modes of providing care (d’Alessandro 2012, 2015). In order to properly carry out their duties, the gynaecologist and the midwives rely on the patient’s family to keep the wounds dry, change the sheets and properly feed and wash the patients. This complementarity, also characterised as multiplicity (Mol 2008), shows how domestic practices inscribe themselves in the hospital by making it a place “where the biomedical discourse meets the domestic one” (Brown 2011, 19).

  • 2 The WHO’s Guidelines on hand hygiene in health care include a section on “Patient Involvement in Ha (...)

47The social and affective embeddedness of care provision directly challenges the Partnership’s past and present interventions. The underlying reasoning behind hand hygiene improvement is the reduction of healthcare associated infections.2 By only targeting the staff and producing data on their compliance, the interventions fail to take into account who performs hand hygiene at the Hospital and how. They do not acknowledge the complexity (Brown 2019) behind the negotiation and distribution of care as it is shared between families, other caregivers and staff. Failing to grasp all the social complexities of care provision speaks about intersections between not-knowing, knowledge, scientific attention and health infrastructure, and the unintended making of neglect (Kelly and Mari Saez 2018, 40; Brown 2020).

Aftermath of a KAP study

48The last slide from each of the modules shows once again the initial objectives. For the fourth module, the trainer asks his audience:

“Have we achieved our objectives? Who can help me confirm that we’ve reached them?”

49He chooses a volunteer from the audience and points with his red laser. The volunteer reads:

“Participants are now able to:
—Explain and perform triage.
—Identify who, where and how to isolate if Covid-19 is suspected.
—When and where to notify.”

50Figure 6 provides a snippet of a slide from the PowerPoint presentation from the fourth module.

Figure 6. Slide “Where to do the triage? Processes and infrastructure”

Figure 6. Slide “Where to do the triage? Processes and infrastructure”

Original title: “Où effectuer le triage ? Processus et infrastructure.”
The caption reads: “La mise en place du processus de triage ne nécessite pas la construction d’une infrastructure. Deux chaises séparées par une table (minimum 1 mètre) peuvent être suffisant.” [“Setting up the triage process does not require the construction of an infrastructure. Two chairs separated by a table (minimum 1 metre) may be enough.”]

Credit: Agence nationale de sécurité sanitaire de Guinée , World Health Organization.
Persistent identifier: ttps://doi.org/10.34847/NKL.B6FE9GY2.
Download the document (PDF, 109 Kb).

51Once the trainer finishes his four presentations, the team from the Partnership distributes to all the healthcare workers the knowledge and attitudes questionnaires for the follow-up assessment. The KAP study ends with the statistical comparison of the pre- and post-training results. The study yields a significant 3-points increase for the knowledge and hand hygiene observance leading to 80% compliance between the base-line and the follow-up (Landsmann et al. 2024).

52Rarely is the aftermath of a KAP intervention studied beyond the follow-up (post-intervention) data collection. In this section, I propose an ethnographic description of the management by the CT-EPI of a Covid-19 positive case to draw attention to how the grammar of statistical risk and prevention from the KAP study interplays with infrastructure at the Hospital for preparedness and response. Beyond underpinning the gap between training and behaviour change, the data from my fieldwork serves to widen the understanding of the KAP study by describing how things unfold on the ground”. I place the CT-EPI at the centre of this analysis to show how outbreak preparedness and responses to different epidemics inscribe themselves on each other. Thanks to the maps I present, I describe a reality about Covid-19 that runs parallel to the KAP study, while showing how different epidemic realities clash and overlap on the hospital infrastructure. These maps are also the gateway to the analysis of my role as ethnographer and researcher within the epidemic plot I have been describing.

The promise of a failed infrastructure

53During my second stay at the hospital, two days after the declaration of a new Ebola outbreak in the Forest Guinea region (14 February 2021), the internal medicine consultation service performs a rapid Covid-19 test on a patient suffering from malaria. Although the test is positive for Covid-19, it is not possible to isolate and admit the patient. By the time the results are ready, the patient has left and has refused to return. The next day, after several attempts to bring the person back, the patient shows up at the Hospital. It has been planned that CT-EPI staff would receive him. Since the CT-EPI ward is difficult to access, the person arrives at the emergency and consultation ward and sits down to wait to be admitted. The CT-EPI is notified, but admission takes about 30 minutes. Before showing up, they have to find the pharmacist to get the required PPE which is kept in the pharmacist’s office to control usage.

54The next day, during the staff meeting, the CT-EPI reports the patient’s normal disease progression. Although the person suffers from malaria, his airways do not seem compromised. The hospital director states that one of the three CT-EPI wards should be set aside for Covid-19 cases and another for suspected Ebola cases. The ease with which this new positive Covid-19 case enters and leaves the hospital rekindles discussions about setting up a triage at the entrance of the hospital. During the months of April and May 2020, following recommendations from the ANSS and the guidelines provided by the Partnership, a stand controlled by two hospital agents is set up at the hospital entrance. After some days, the staff refuse to return to the triage area. The city police department is then approached and asked to station two officers to enforce at least hand hygiene and mask wearing. The Hospital-based team hypothesise that the electoral tension of the following months—Guinea is in the midst of a presidential campaign that exacerbates old and structural ethnic tensions—will make it impossible to maintain this strategy, and will perhaps also keep the assigned agents from performing this duty.

55With the advent of this new Covid-19 case, the hospital decides to move the triage area to the entrance of the first block where the consultation rooms of each service and the emergency ward are located. It is known that moving the triage area to that location would make it difficult to cover all persons entering the Hospital, since it is possible to access the rest of the wards without having to go through the gates of the emergency and consultation ward. According to the Hospital director, it is not feasible to install a tent or adapt the Hospital entrance which will guarantee a bottleneck for everyone entering since the Hospital has been under renovation for over two years.

56“All that could have been built and invested would turn out to be very soon obsolete,” explained the hospital director when I enquired about this.

57It is nonetheless concluded to ask for some of the Partnership’s funds to build wooden stands that could separate the patients from the triage officers at the emergency ward. Due to the previous staff resistance, a decision is made to outsource the triage to someone with the necessary expertise to take sole responsibility. As days go by without finding a suitable candidate, the stands become the reception area where admission medical notebooks are sold. This place is originally located in a small room right next to the hospital entrance. Although one of the three wards of the CT-EPI has been set aside for Ebola cases and another for Covid-19, respectively, the facilities are not sufficiently equipped to treat diseases with such different symptomatology. Not only are beds, ventilators and other resuscitation and treatment equipment lacking, but the facilities are not built properly.

58The CT-EPI head explains to me that only two of the 33 centres in the country—not including the Hospital—were built in accordance with the construction and biosecurity standards. The main shortcoming is that the entry and exit of both patients and medical personnel is at the same place. This is problematic because these centres require the entrance and exit to be separate and exclusive to avoid the contamination of clean spaces. Since the Covid-19 health emergency declaration in the country, patients from the CT-EPI are admitted for other hospital services. Overcrowded services are to be expected, but an already marked community reluctance vis-à-vis the healthcare system increased with the declaration of the pandemic. The six CT-EPI agents—2 medical and 4 nursing staff—are waiting for a suspected case or contact to arrive since April 2020 when there are some isolated cases.

59Beyond the material obstacles faced at the Hospital to conform to the theoretical geography of isolation, other difficulties come from the institutional arrangements regarding the specific situation of Covid-19 confirmed patients. While the CT-EPI staff is in charge of nursing, food provision is the responsibility of the Prefectural Health Directorate. In the case of the single Covid-19 hospitalisation I observe during my fieldwork, it leads to more questioning and suspicion from the caregivers who are not allowed to approach their kin. Beginning of March 2021, after a rapid Covid-19 test with negative results, the patient is eventually discharged. After the fieldwork ends, two more Covid-19 positive cases are confirmed with similar hospitalisation procedures. The hospital never has a triage area.

Infrastructure, rigidity and the logic of separation

60To make sense of the challenges that are coming up as this co-infection (Engelmann and Kehr 2015) preparedness and response is unfolding, I sketch a couple of maps of the hospital and the CT-EPI hand-in-hand with the Hospital staff and the Hospital-based Partnership team (see figures 7 and 8). I draw different versions that I submit to the healthcare workers for correction and approval. This allows me to get even closer to the Hospital staff. These drawings yield how the spatial organisation of both the Hospital and the CT-EPI are in tension with the outbreak response.

61I will narrow down this tension by focusing on the underlying logic of separation and “the spatialized nature of protection” that these two figures underpin (Brown and Kelly 2014). There is a logic of separation through space that requires, for example, ward separation between contacts, suspected and confirmed cases (points number 7a, 7b, 7c in Figure 7). The CT-EPI provides a visitors’ room (Point 4) and thus addresses one of the major criticisms from the treatment centres initially built for the 2014–16 Ebola epidemic. Patients are reluctant to get admitted as they will lose sight of their families and have the perception they will only be discharged when they are dead (Gomez-Temesio and Le Marcis 2017). The visitors’ room is meant to allow families to stay close to their loved ones with the hope of building trust between the treatment centres and the communities.

Figure 7. Map of the Centre for the Treatment of Epidemics (CT-EPI)

Figure 7. Map of the Centre for the Treatment of Epidemics (CT-EPI)

Made by author.
Persistent identifier: https://doi.org/​10.34847/​NKL.B6FE9GY2.
Download the document (PDF, 75.9 Kb).

Figure 8. Map of the Hospital

Figure 8. Map of the Hospital

The lines trace the paths taken by the healthcare workers (blue) and the patient (orange).

Made by author.
Persistent identifier: https://doi.org/​10.34847/​NKL.B6FE9GY2.
Download the image (with lines, JPEG, 348 Kb).
Download the complete map (without lines, PDF, 130 Kb).

62The process of hospitalisation of the Covid-19 positive patient described above contrasts with the rigidity of this spatial organisation and that of the Partnership training. Although the hospital director designates one CT-EPI ward for Covid-19 positive cases and another for Ebola, it is not clear how the logic of separation required between contact of suspected and confirmed cases for these two diseases will be addressed. This spatial representation masks the fact that there is no equipment available within the CT-EPI to care for patients. Likewise, even if they know how to use it, the PPE is not available or is difficult to access.

63There is another logic of separation that responds to the triage area, since during epidemics it is considered even more necessary than in normal times to isolate the biomedical space from the surrounding social spaces. Figure 8 shows that the Hospital is right in front of the city’s main mosque and market. As for the hand hygiene practices, the difficulty in implementing the triage area reveals the impossibility of isolating the hospital from the social universe. For this CT-EPI to be able to respond to an epidemic, it needs to act based on a triage area at the Hospital entrance that would send suspect cases directly to the CT-EPI facilities. The CT-EPI location within the Hospital grounds does not allow it to do so. To showcase these shortcomings, I draw a few lines on Figure 8 to mark in orange the paths of the patient who tested positive for Covid-19 and in blue the paths of the CT-EPI health workers responsible for his hospitalisation. The construction zones shown in Figure 8 hint at the failed promise of infrastructural renovation and at the same time the frustration of not being able to tackle an issue from the present because of a promise from the future—the hospital renovation. The resources of the Partnership, especially those required for setting up a triage area at the entrance of the first block, are only subsidiary to these challenges.

64I seek to bring to life these maps by interpreting them or highlighting through drawn lines some certain features. The CT-EPIs are the materialisation of the country’s preparedness and response plan after the Ebola epidemic from 2016–18. I foreground daily situations related to the CT-EPI as a way of opening up the question of what that materialisation becomes once its construction is over. It is important to highlight the genealogy of preparedness (Lakoff 2017), how it warns about tragedies to come (Caduff 2015) and what is the ontological choreography that drives a response plan (Le Marcis 2022), but it is also necessary to look at how the infrastructure comes to be in everyday situations. My attempt at bringing epidemic outbreak infrastructure to life adds on to the arguments of Tantchou (2017, 2018b, 2021), which place a pragmatics of space at the heart of the so-called “attitudes problem” from healthcare workers. Their negative behaviour could be explained by the working conditions: the inadequate space for care practices, the lack of equipment and essential supplies.

Enlightening crisis and the ethnographic rapport

65Being at the Hospital at the time a new Ebola outbreak is declared in Guinea while investigating the response to another epidemic allowed an invaluable new take on my ethnography. I was witnessing a moment of “enlightening crisis” when “things that ordinarily go unsaid are suddenly brought to the surface, articulated, debated, and put into action” (McGovern 2017, 21).

66I had worked my way in my field and earned trust by serving as a mediator. Until that moment, due to my French fluency, I had facilitated online meetings where the scope of the Covid-19 strategy and the content from the questionnaires of the KAP study were discussed. I had translated the different versions of the documents and collaborated during the training by distributing the questionnaires or answering questions from the trainees. While the preparedness for Ebola and the response to Covid-19 were unfolding, my perception in the eyes of the healthcare workers as a member of a German partnership bringing funds to the Hospital was slowly wearing out. I was initially granted permission and access to Hospital spaces and routines as a way of ingratiating with the Partnership. Although my association with the Partnership never completely disappeared, my image shifted to one of a curious person with an interest in getting to know the Hospital routines. This was possible thanks to the time spent there and my attempt to take part in any activity from the Hospital: starting with my presence at the staff meeting every morning doing rounds, night shifts, surgical procedures, and chatting and sharing food during downtime.

67The trust I had earned crystalises when the CT-EPI service head approaches me and asks me if she could have a printed copy of the CT-EPI map we had drawn together the previous weeks. She says she needs it to show the health authorities the infrastructural shortcomings—she is asking for higher fences and separate pathways for patients and staff. After some days, I pay her a visit at the CT-EPI to ask her if the map is of any use. She replies that she is not sure, but that at least she has managed to visually show the authorities the shortcomings. I feel content that some of my material is “useful” for the preparedness and response. While accounting for this encounter in my notes, I realise the map is at the same time hiding the lack of occupation of the CT-EPI staff for the last eight months. This graphical representation is also masking the fact that the CT-EPI head was affected to the Hospital without having any family and social ties to this city. This “Médecin d’État” is therefore spending most of her days in Conakry, visiting her family.

68Sophie Caratini explains that, “It can happen that the problem of the object strongly determines the course of the investigation, without the subject (the researcher) having the slightest idea of the issues that bind or unbind the words he has come to collect” (Caratini and Godelier 2013, 87). Like the KAP study, I had chosen the Hospital as my fieldwork ground to produce data—this time ethnographic—on Covid-19. However, as my research unfolded, my fieldwork inevitably brought me back to the strategies of the Partnership. My ethnography, I realise, can only become meaningful if I am able to question the conditions through which collaboration between different worlds in the field of global health are possible — as I try to do with this article. Within these relationships, it is also important to situate the mediations thanks to my obtaining the necessary access to carry out my research. As the presence of anthropologists in response teams and global health institutes is normalised, room is left to further enquire on the limits of the ethnographic method, as well as all that is left unsaid about access to the field, the supposed utility of this method, and the critical spirit from any ethnographic endeavour.

Conclusion

69In this article, I describe the travel of a KAP study on Covid-19. I focus on the different materials—guidelines, questionnaires and training—upon which it relies to achieve its goal of building capacity on Covid-19 preparedness and response at a hospital in Guinea. The description of the daily life of these materials serves to highlight how a methodology often used by global health interventions in the African continent generates evidence. I situate my own ethnographic fieldwork as another source from the KAP study with a twofold intention. I emphasise the multilevel descriptive potential of an ethnographic endeavour that underscores how the materials from the KAP study are made, what is expected out of them and how they engage with the Hospital. At the same time, I try to make clear how my fieldwork is a product of that same KAP study. I reveal my positionality and the use I make of my research methods to gain access, build trust and make sense of the situation. This illuminates how an ethnography takes shape and how the ethnographer constructs the research object as the fieldwork unfolds according to the constraints and opportunities presented to him/her.

70With this ethnographic account, I have sought as well to make the various materials and sources I analyse move and gain traction. My interest is to highlight that, beyond the re-inscription process (Behrends et al. 2014) that makes a global health model travel or the unacknowledged implementation context that makes it crash (Olivier de Sardan 2021), there is an expectation that binds together the practices and materials from global health cooperation. This expectation generates an atemporal pandemic reality forcing hospitals’ outbreak preparedness and response plans to always move in the same straightforward way and yield the same results.

I want to extend my deepest appreciation to the Hospital’s healthcare workers, managers, maintenance and security staff, and patients, families and caregivers for their openness in sharing their work routines and their lives. I am also grateful to many colleagues from the Robert Koch Institute for their support in developing this research. This piece benefited enormously from the feedback provided by Dr. Almudena Marí-Sáez and Dr. Ute Zocher to whom I am deeply indebted. My warmest appreciation for their patience and trust. This research was possible thanks to the Global Health Protection Program (GHPP) from the Bundesministerium für Gesundheit (BMG) in Germany. I wish to also thank the two anonymous reviewers for their comments and the editorial team at sources for all their support.

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Appendix

Transcripts and translations

Snippet of the KA questionnaire the Partnership developed (scanned by the Hospital-based team). Transcript and translation

See supra, Figure 3. Snippet of the KA questionnaire the Partnership developed (scanned by the Hospital-based team).
Download the document (PDF, 196Kb).
Download the transcript and translation (ODT, 7 Kb).

Transcript (1)
Credits : Centre for International Health Protection (ZIG) of the Robert Koch Institute (RKI), Berlin, Germany, and The Hospital (Upper Guinea), 2020

Transcript (2)
Credits : Centre for International Health Protection (ZIG) of the Robert Koch Institute (RKI), Berlin, Germany, and The Hospital (Upper Guinea), 2020

Translation (1)
Credits : Centre for International Health Protection (ZIG) of the Robert Koch Institute (RKI), Berlin, Germany, and The Hospital (Upper Guinea), 2020

Translation (2)
Credits : Centre for International Health Protection (ZIG) of the Robert Koch Institute (RKI), Berlin, Germany, and The Hospital (Upper Guinea), 2020

Observation form from World Health Organization (WHO)

World Health Organization, 2020.
See supra, Figure 5a.
Download the document (PDF; 186 Kb).

Download the transcript (ODT, 12.5 Kb)..

Transcript

Observation Form

Facility:

 

Period Number*:

 

Session Number*:

 

Service:

 

Date:
(dd/mm/yy)

 / / 

Observer:
(initials)

 

Ward:

 

Start/Endtime:
(hh:mm)

 : / :

Page N°:

 

Department:

 

Session duration:
(mm)y

 

Citv**' :

 

Country**:

 

Prof.cat

 

Prof.cat

 

Prof.cat

Prof.cat

 

Code

 

Code

 

Code

Code

 

 

 

 

Opp.

Indication

HH Action

Opp.

Indication

HH Action

Opp.

Indication

HH Action

Opp.

Indication

HH Action

1

□ bef-pat.
□ bef-asept.
□ aft-b.f.
□ aft-pat.
□ aft.p.surr.

□ HR
□ HW
O missed
O gtoves

1

□ bef-pat.
□ bef-asept.
□ aft-b.f.
□ aft-pat.
□ aft.p.surr.

□ HR
□ HW
O missed
O gtoves

1

□ bef-pat.
□ bef-asept.
□ aft-b.f.
□ aft-pat.
□ aft.p.surr.

□ HR
□ HW
O missed
O staves

1

□ bef-pat.
□ bef-asept.
□ aft-b.f.
□ aft-pat.
□ aft.p.surr.

□ HR
□ HW
O missed
O gloves

2

□ bef-pat.
□ bef-asept.
□ aft-b.f.
□ aft-pat.
□ aft.p.surr.

□ HR
□ HW
O missed
O gloves

2

□ bef-pat.
□ bef-asept.
□ aft-b.f.
□ aft-pat.
□ aft.p.surr.

□ HR
□ HW
O missed
O gloves

2

□ bef-pat.
□ bef-asept.
□ aft-b.f
□ aft-pat.
□ aft.p.surr.

□ HR
□ HW
O missed
O gloves

2

□ bef-pat.
□ bef-asept.
□ aft-b.f.
□ aft-pat.
□ aft.p.surr.

□ HR
□ HW
O missed
O gtoves

Observation form adapted by the Partnership (scanned by the Hospital-based team)

Centre for International Health Protection (ZIG) of the Robert Koch Institute (RKI), Berlin, Germany, and The Hospital (Upper Guinea), 2020.
See supra, Figure 5b.
Download the document (PDF; 186 Kb).
Download the transcript & translation (ODT, 11.4 Kb).

Transcript

Formulaire d’observation *Adapté de l’OMS « les 5 moments à l’hygiène de mains » pour l’utilisation d’équipements de protection individuelle
Etablissement:
Service:
Département:
Numéro de période*:
Date: (mm/aa)
Durée de la session: (mm)
Numéro de session*:
Observateur:
Ville*/Pays** ::
Cat.prof.
Code
Nombre
Cat.prof.
Code
Nombre
Cat.prof.
Code
Nombre
Cat.prof.
Code
Nombre
Opp. Indication Action HM Opp. Indication Action HM Opp. Indication Action HM Opp. Indication Action HM
1 □ av-pat.
□ av-asept
□ ap-l.biol.
□ ap-pat.
□ ap.envir.
□ av-EPI
□ ap-EPl

□ frict.

□ lav.
O 0 act
0 gants

1 □ av-pat.
□ av-asept
□ ap-l.biol.
□ ap-pat.
□ ap.envir.
□ av-EPI
□ ap-EPl

□ frict.

□ lav.
O 0 act
0 gants

1 □ av-pat.
□ av-asept
□ ap-l.biol.
□ ap-pat.
□ ap.envir.
□ av-EPI
□ ap-EPl

□ frict.

□ lav.
O 0 act
0 gants

1 □ av-pat.
□ av-asept
□ ap-l.biol.
□ ap-pat.
□ ap.envir.
□ av-EPI
□ ap-EPl

□ frict.

□ lav.
O 0 act
0 gants

Translation

Observation *Adapté de l’OMS « les 5 moments à l’hygiène de mains » pour l’utilisation d’équipements de protection individuelle
Etablishment:
Service:
Department:
Period number*:
Date: (mm/yy)
Session Duration: (mm)
Session number*:
Observer:
City*/Country** ::
Cat.prof.
Code
Number
Cat.prof.
Code
Number
Cat.prof.
Code
Number
Cat.prof.
Code
Number
Opp. Indication Action HM Opp. Indication Action HM Opp. Indication Action HM Opp. Indication Action HM
1 □ av-pat.
□ av-asept
□ ap-l.biol.
□ ap-pat.
□ ap.envir.
□ av-EPI
□ ap-EPl

□ frict.

□ lav.
O 0 act
0 gants

1 □ av-pat.
□ av-asept
□ ap-l.biol.
□ ap-pat.
□ ap.envir.
□ av-EPI
□ ap-EPl

□ frict.

□ lav.
O 0 act
0 gants

1 □ av-pat.
□ av-asept
□ ap-l.biol.
□ ap-pat.
□ ap.envir.
□ av-EPI
□ ap-EPl

□ frict.

□ lav.
O 0 act
0 gants

1 □ av-pat.
□ av-asept
□ ap-l.biol.
□ ap-pat.
□ ap.envir.
□ av-EPI
□ ap-EPl

□ frict.

□ lav.
O 0 act
0 gants

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Notes

1 The name of the hospital has been anonymised. It will from now onwards be referred to as “the Hospital.”

2 The WHO’s Guidelines on hand hygiene in health care include a section on “Patient Involvement in Hand Hygiene Promotion.” This section contemplates the empowerment of patients through their participation in healthcare, and increasing their knowledge and skills. For example, patient empowerment models often include visual reminders such as badges or stickers worn by patients with messages such as: “Did you wash/sanitise your hands?” Nonetheless, there is no strategy targetting the hand hygiene of the patients’ families and caregivers, thereby failing to acknowledge the role they play in healthcare and nursing. See “WHO Guidelines on Hand Hygiene in Health Care” (Geneva, World Health Organization, 2009). https://www.who.int/publications/i/item/9789241597906 [archive].

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List of illustrations

Title Figure 1: The Centre for the Treatment of Epidemics (CT-EPI), Guinea [anonymised location]
Caption Up-left: ambulance road inside the hospital to access the facilities. Up-right: Entrance and hand washing kit. Down-left: The only ward that had some equipment. Down-right: The three patient wards and the fenced access to the bathrooms.
Credits Photos by the author, 2020.Persistent identifier: https://doi.org/​10.34847/​NKL.B6FE9GY2.Download the images: up-left, up-right, down-left, down-right.
URL http://journals.openedition.org/sources/docannexe/image/2543/img-1.jpg
File image/jpeg, 2.0M
Title Figure 2. Timeline
Credits Figure by Author.
URL http://journals.openedition.org/sources/docannexe/image/2543/img-2.jpg
File image/jpeg, 185k
Title Figure 3. Snippet of the KA questionnaire the Partnership developed (scanned by the Hospital-based team)
Caption See Annex for transcript and translation.
Credits Centre for International Health Protection (ZIG) of the Robert Koch Institute (RKI), Berlin, Germany, and The Hospital (Upper Guinea), 2020.Persistent identifier: https://doi.org/​10.34847/​NKL.B6FE9GY2. Download the document (PDF, 196Kb).Download the transcript and translation (ODT, 7 Kb)
URL http://journals.openedition.org/sources/docannexe/image/2543/img-3.png
File image/png, 614k
Title Figure 4. “It takes just 5 moments to change the world. Clean your hands, stop the spread of drug-resistant germs!” Poster created by the World Health Organization
Credits World Health Organization, 2020.Available on the World Health Organization website: https://www.who.int/​publications/​m/​item/​five-moments-for-hand-hygiene [archive].
URL http://journals.openedition.org/sources/docannexe/image/2543/img-4.png
File image/png, 2.0M
Title Figure 5a. Observation form from World Health Organization (WHO)
Caption See Annex for transcript and translation.
Credits World Health Organization, 2020.Persistent identifier: https://doi.org/​10.34847/​NKL.B6FE9GY2. Download the document (PDF; 186 Kb).Download the transcript (ODT, 12.5 Kb).
URL http://journals.openedition.org/sources/docannexe/image/2543/img-5.jpg
File image/jpeg, 79k
Title Figure 5b. Observation form adapted by the Partnership (scanned by the Hospital-based team)
Caption See Annex for transcript and translation.
Credits Centre for International Health Protection (ZIG) of the Robert Koch Institute (RKI), Berlin, Germany, and The Hospital (Upper Guinea), 2020.Persistent identifier: https://doi.org/​10.34847/​NKL.B6FE9GY2. Download the document (PDF; 186 Kb).Download the transcript & translation (ODT, 11.4 Kb).
URL http://journals.openedition.org/sources/docannexe/image/2543/img-6.jpg
File image/jpeg, 98k
Title Figure 6. Slide “Where to do the triage? Processes and infrastructure”
Caption Original title: “Où effectuer le triage ? Processus et infrastructure.”The caption reads: “La mise en place du processus de triage ne nécessite pas la construction d’une infrastructure. Deux chaises séparées par une table (minimum 1 mètre) peuvent être suffisant.” [“Setting up the triage process does not require the construction of an infrastructure. Two chairs separated by a table (minimum 1 metre) may be enough.”]
Credits Credit: Agence nationale de sécurité sanitaire de Guinée , World Health Organization.Persistent identifier: ttps://doi.org/10.34847/NKL.B6FE9GY2. Download the document (PDF, 109 Kb).
URL http://journals.openedition.org/sources/docannexe/image/2543/img-7.jpg
File image/jpeg, 543k
Title Figure 7. Map of the Centre for the Treatment of Epidemics (CT-EPI)
Credits Made by author.Persistent identifier: https://doi.org/​10.34847/​NKL.B6FE9GY2. Download the document (PDF, 75.9 Kb).
URL http://journals.openedition.org/sources/docannexe/image/2543/img-8.png
File image/png, 258k
Title Figure 8. Map of the Hospital
Caption The lines trace the paths taken by the healthcare workers (blue) and the patient (orange).
Credits Made by author.Persistent identifier: https://doi.org/​10.34847/​NKL.B6FE9GY2. Download the image (with lines, JPEG, 348 Kb).Download the complete map (without lines, PDF, 130 Kb).
URL http://journals.openedition.org/sources/docannexe/image/2543/img-9.jpg
File image/jpeg, 347k
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References

Electronic reference

Carlos Rocha, ‘Ensemble On Sonne!’ Travels of KAP Studies (Knowledge, Attitudes and Practices) for the Prevention and Control of Covid-19 Infections in Upper Guinea”Sources: Materials & Fieldwork in African Studies [Online], 9 | 2025, Online since 26 March 2025, connection on 26 April 2025. URL: http://journals.openedition.org/sources/2543; DOI: https://doi.org/10.4000/13kyl

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About the author

Carlos Rocha

Robert Koch Institute, Germany; Freie Universität Berlin. https://orcid.org/0000-0002-3881-4494

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Copyright

CC-BY-SA-4.0

The text only may be used under licence CC BY-SA 4.0. All other elements (illustrations, imported files) are “All rights reserved”, unless otherwise stated.

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