Unmet needs and behaviour during the Ebola response in Sierra Leone: a retrospective, mixed-methods analysis of community feedback from the Social Mobilization Action Consortium

Abstract

Background: The west African Ebola epidemic (2014-15) necessitated behaviour change in settings with prevalent and pre-existing unmet needs as well as extensive mechanisms for local community action. We aimed to assess spatial and temporal trends in community-reported needs and associations with behaviour change, community engagement, and the overall outbreak situation in Sierra Leone.

Methods: We did a retrospective, mixed-methods study. Post-hoc analyses of data from 12 096 mobiliser visits as part of the Social Mobilization Action Consortium were used to describe the evolution of satisfied and unsatisfied needs (basic, security, autonomy, respect, and social support) between Nov 12, 2014, and Dec 18, 2015, and across 14 districts. Via Bayesian hierarchical regression modelling, we investigated associations between needs categories and behaviours (numbers of individuals referred to treatment within 24 h of symptom onset or deaths responded to with safe and dignified burials) and the role of community engagement programme status (initial vs follow-up visit) in the association between satisfied versus unsatisfied needs and behaviours.

Findings: In general, significant associations were observed between unsatisfied needs categories and both prompt referrals to treatment and safe burials. Most notably, communities expressing unsatisfied capacity needs reported fewer safe burials (relative risk [RR] 0·86, 95% credible interval [CrI] 0·82-0·91) and fewer prompt referrals to treatment (RR 0·76, 0·70-0·83) than did those without unsatisfied capacity needs. The exception was expression of unsatisfied basic needs, which was associated with significantly fewer prompt referrals only (RR 0·86, 95% CrI 0·79-0·93). Compared with triggering visits by community mobilisers, follow-up visits were associated with higher numbers of prompt referrals (RR 1·40, 95% CrI 1·30-1·50) and safe burials (RR 1·08, 1·02-1·14).

Interpretation: Community-based development of locally feasible, locally owned action plans, with the support of community mobilisers, has potential to address unmet needs for more sustained behaviour change in outbreak settings.

Funding: Bill & Melinda Gates, Bill & Melinda Gates Foundation, and National Institutes of Health.

Figure 1:. Ecological framework for behaviour change in an epidemic setting

The evolution of needs during an outbreak is influenced by national and international policies as well as resource availability. That is, multiscale components of outbreak response are expected to affect the exaggeration and satisfaction of needs at the community level. Unmet needs affect the adoption of prescribed behaviour change recommendations. Structured participatory approaches (such as the Community-led Ebola Action methodology) that underpin community engagement provide a mechanism for promoting autonomy and guiding resource allocation to address needs for improved adoption of public health behaviours in accordance with or in addition to recommendations. The effectiveness of community mobilisation is therefore related to the availability of resources and needs-supportive policies across scales.

Figure 2:. Weekly trends in expression of needs, relative to the start of the Ebola outbreak in Sierra Leone

Blue bars represent weekly prevalence of needs satisfaction; red bars represent prevalence of expression of unsatisfied needs.

Figure 3:. Province-level pairwise comparisons for the frequency of expression of each satisfied and unsatisfied needs category

Statistical significance was based on the p value from pairwise χ² test after Bonferroni adjustment. Colour and size reflect proportion of needs category for a given province out of all needs expressed in that province. Lighter colours (from purple to yellow) and larger diameter circles represent more reporting of a given needs category, relative to other categories, in a given province. Each pairwise comparison that was significant (p<0·05 after Bonferroni adjustment) is represented by a link between corresponding provinces.

Figure 4:. Spatiotemporal trends in district-level prevalence of needs category expression

Sample maps are presented for unsatisfied autonomy needs, unsatisfied basic needs, unsatisfied security needs, and satisfied capacity needs. The maps represent once-monthly cross sections of the prevalence of a needs category after spatiotemporal interpolation. Prevalence was defined as the proportion of communities expressing a particular needs category divided by the total number of communities per space-time unit. Kenema was removed because of the limited data available in that district.

Figure 4:. Spatiotemporal trends in district-level prevalence of needs category expression

Sample maps are presented for unsatisfied autonomy needs, unsatisfied basic needs, unsatisfied security needs, and satisfied capacity needs. The maps represent once-monthly cross sections of the prevalence of a needs category after spatiotemporal interpolation. Prevalence was defined as the proportion of communities expressing a particular needs category divided by the total number of communities per space-time unit. Kenema was removed because of the limited data available in that district.

Figure 5:. Posterior distributions for coefficients of Poisson regression of counts of safe burials and negative binomial regression of counts of prompt referrals to treatment within 24 h of symptom onset

Thin and thick lines represent 95% and 50% credible intervals (CrIs), respectively. Parameters where 95% CrIs do not overlap 0 are indicated in red. Parameters where 95% or 50% CrIs overlap 0 are indicated in blue with closed or open circles, respectively. The CrIs around the coefficients for satisfied basic needs extend beyond the presented range for both outcomes.