Beyond the ‘shadow’ epidemic: Health service responses and help-seeking for violence against women during outbreaks in Sierra Leone

Background: Violence against women (VAW) and outbreaks are interconnected public health challenges. However, little is known about women’s experiences seeking help after violence in outbreak affected settings like those impacted by Ebola and COVID-19, or how health services responded during these crises. Methods: In 2022, thirty-seven in-depth interviews and four focus group discussions were conducted in Freetown and Kambia, Sierra Leone, with health providers, outbreak actors, community members, and women who had experienced physical or sexual violence during the Ebola or COVID-19 outbreaks. Data were analysed thematically. Additionally, a scoping review was conducted on VAW health service access during recent outbreaks in low and middle income settings, identifying thirty two papers. Findings: Women’s decisions to seek help and their choice of a support source were influenced by how ‘unacceptable’ the violence was perceived to be, their specific needs (physical, psychological or social trauma), and the risks and benefits they anticipated in accessing support. Outbreaks exacerbated existing challenges to VAW health service delivery, sometimes leading to a reconfiguration in which informal actors, such as medicine sellers and community mediators, played a key role in care provision. Health providers showed resilience, adapting to difficult conditions to maintain services. The scoping review identified articles from the COVID-19 period only. Studies revealed mixed trends in VAW health service utilisation during lockdowns. Health services for survivors were often deprioritized or closed down, some adapted by moving online introducing new concerns particularly around safety. Conclusions: VAW health services continue to be deprioritised during outbreaks, this research highlights opportunities to leverage informal actors within the health system in Sierra Leone, and to re-orientate towards survivor-defined interventions that are flexible in providing a wider range of support choices during outbreak periods.