@article{Horncastle_M-2026_225937,
title = {Resilience in Fragility: Community and Health System Responses to COVID-19 in Sierra Leone, Liberia, Lebanon, and Gaza},
author = {Horncastle, M. and Dakessian, A. and Zaizay, Z. and Kollie, K. and Wurie, H. and Loffreda, G. and Noubani, A. and Saleh, S. and Jamal, Z. and AlBaik, S. and ElKhatib, Z. and Dean, L. and Theobald, S. and Witter, S. and Diaconu, K.},
month = {mar},
year = {2026},
abstract = {This paper examines the experiences and coping strategies of health systems and communities in response to the COVID-19 pandemic across four fragile and shock-prone settings: Liberia, Sierra Leone, Lebanon, and Gaza. While much existing literature focuses on high-income countries (HICs), there is limited comparative research on low- and middle-income countries (LMICs), particularly in the context of previous health crises like Ebola, or in settings affected by conflict and displacement. Using a cross-country approach, we aim to document stressors, coping mechanisms, and response strategies during the pandemic, highlighting the interplay between health systems and communities. We collected data in 2020, employing a mixed-methods design that initially intended to be longitudinal, with weekly data collection via a digital platform, CoVoices, which allowed photo and audio submissions. The study targeted health care workers and community members, with purposive and convenience sampling based on digital access. The data collection process faced challenges (e.g. low participation and incomplete submissions), leading to a shift in focus toward analysing key themes from the data rather than a longitudinal, week-by-week analysis. Our findings refer to 164 individual submissions: 48 from Sierra Leone; 32 from Liberia; 82 from Lebanon; and 4 from Gaza. Additionally, we monitored responses at the government level, and triangulated the data from participants with official documents and reports. This study highlights that while government responses often followed global norms, their effectiveness was shaped by structural constraints, inequities in access, and the realities of daily life in fragile settings. Communities frequently encountered a dissonance between official directives and what was feasible in practice — whether due to lack of water, crowded living conditions, or the absence of livelihood support. At the same time, community health workers, local organisations, and informal coping strategies provided critical bridges of trust and resilience. The findings suggest that future preparedness must go beyond technical interventions, embedding equity, transparency, and community engagement as central pillars of response in order to align measures with lived realities and strengthen resilience in contexts of overlapping crises.},
volume = {6},
journal = {SSM - Health Systems},
publisher = {Elsevier BV},
url = {https://doi.org/10.1016/j.ssmhs.2026.100198},
}
