An Exploratory Study to Examine the Effectiveness of Community Based Ebola Virus Disease Prevention and Management Strategies in Bo District, Sierra Leone

"During the Ebola crisis, World Vision Sierra Leone contributed to helping change the beliefs about Sierra Leone's health system."

Conducted in the context of the 2014 Ebola outbreak in West Africa, this study assessed the effectiveness of World Vision (WV) Sierra Leone's community-based efforts to increase Ebola virus disease (EVD) knowledge and to influence preventive and treatment-seeking practices in Bo Area Development Program (ADP). The study also explored differences between households with children who were sponsored by WV and had a documented case of Ebola, and those without. Furthermore, it provides an analysis of the community's perspective of the health system during the Ebola crisis, with a specific focus on the factors (facilitating and impeding) that impacted health-seeking behaviours. The findings may have implications for other future health emergencies in countries with weak healthcare systems.

In addition to providing communities with the necessary health supplies and food assistance, WV implemented many communication-related intervention strategies for Ebola infection, prevention, and control in Sierra Leone. These activities included: offering workshops and training sessions for community leaders, healthcare workers, religious leaders, and mothers' clubs; organising forums to facilitate community dialogue around fears, misconceptions, and myths around Ebola; establishing bylaws through paramount chiefs to protect communities from EVD; mobilising citizens to advocate for health services; and establishing Citizen Voice and Action programmes in an effort to enhance government accountability and transparency by improving communication mechanisms and citizen participation.

Given the exploratory and descriptive nature of the research, the study used both qualitative (i.e., key informant interviews and in-depth interviews) and quantitative methods (i.e. a survey of heads of households). The case-control strategy, which was based on recommendations from researchers with knowledge of the Ebola outbreak and expertise in the field of epidemiology, was used to calculate sample size as well as to identify households for inclusion. Cases were defined as households reporting a confirmed or suspected Ebola case in the family during the outbreak as recorded in the district case registers. Controls were defined based on geographically clustered houses surrounding the case household.

Some of the findings include:

• Appropriately tailored messaging is required from the onset - The majority of respondents identified WV's strategies as effective in terms of countering rumours and, ultimately, transforming public opinion and behaviours related to Ebola. This is considered in large part to be due to their unique position of trust and influence in communities throughout Bo District.
• Prioritisation of a "bottom-up" approach, including the engagement of community leaders from the onset, is important - In accordance with a "bottom-up" approach, WV acted as an outside agent and empowered community leaders to be instruments of change. This strategy was shown to be effective, as key informants and focus group discussants commonly reflected on the critical role that religious leaders played in stopping the outbreak and reestablishing trust with the health system.
• Laws are vital to controlling the outbreak - More than half the participants, particularly community members, remarked on the critical role of bylaws that instructed community members to, for example, not leave the village, not eat bush meat, or not accommodate strangers.
• Survivors are key in rebuilding trust with the health system - Community members also commonly referred to survivors as leaders and commented on their ability to engage community members and help them to trust the health system.
• Interaction with patients impacted knowledge of transmission mechanisms - The quantitative findings revealed differences in terms of one's beliefs and understanding of modes of transmission depending on whether or not s/he resided in a household with an Ebola patient. For example, compared to controls (43.0%), a higher proportion of cases (65.4%) believed touching the blood of an infected person transmits Ebola. Case households were also statistically significantly more likely to send a family member to an Ebola treatment unit or health care facility.

Overall, the study shows the critical role that effective communication plays in gaining the population's trust in the healthcare system during a public health emergency. The study also found that of all the intervention strategies implemented by WV, those based in the community were critical to the decline of the outbreak and even more effective than the international efforts initiated after the epidemic began to lose speed.

The findings also reinforce the notion that trust in a health system is essential to its use, particularly in countries characterised by fragile and dysfunctional health systems. As stated in the report, "The community's level of trust in the health care system is directly related to widespread fear and misconceptions surrounding Ebola due to poor communication and ineffective messaging from the onset of the outbreak. Similar to needing to know 'what works' in terms of preventing and responding to a public health emergency, the field also needs to improve its understanding of the impact of the relationship between the community and public institutions (i.e. health care facilities, workers, etc.) on care-seeking/utilization."

Based on lessons learned, the document offers the following recommendations for community engagement and social mobilisation for Ebola prevention and management:

• Facilitate encounters with WV staff and community health workers (CHWs), which were found to be instrumental in facilitating access to critical information and service utilisation for suspected Ebola cases, and subsequent psychosocial and developmental support to households affected by Ebola;
• Invest in trusted local community members, CHWs, religious and village leaders to facilitate community engagement and establish trust;
• Design effective strategies for early authentic communication to provide key messages, mitigate false assumptions, and provide key actions to be undertaken at the household and community level;
• Explore and build capacity of existing community resources to establish context specific community systems to address emergencies and liaise with district health systems and other development entities ensuring quality and effective universal coverage of interventions;
• Create effective user-friendly community-based monitoring systems for surveillance, ensuring equity and quality;
• Ensure integration of services, health, education, food security and livelihoods to ensure effective community participation;
• Include capacity building, learning and organisational strengthening must be included as an ongoing process for health systems in order to ensure they are prepared to respond to future emergencies; and
• Implement an effective response from the onset of an outbreak, as this is critical to gaining citizens' trust and ensuring their continued engagement with and utilisation of health systems.