Community engagement in outbreak response: lessons from the 2014-2016 Ebola outbreak in Sierra Leone

Abstract

Documentation of structured community engagement initiatives and real-time monitoring of community engagement activities during large-scale epidemics is limited. To inform such initiatives, this paper analyses the Community Led Ebola Action (CLEA) approach implemented through the Social Mobilization Action Consortium (SMAC) during the 2014-2016 Ebola epidemic in Sierra Leone. The SMAC initiative consisted of a network of 2466 community mobilisers, >6000 religious leaders and 42 local radio stations across all 14 districts of Sierra Leone. Community mobilisers were active in nearly 70% of all communities across the country using the CLEA approach to facilitate community analysis, trigger collective action planning and maintain community action plans over time. CLEA was complemented by interactive radio programming and intensified religious leader engagement.Community mobilisers trained in the CLEA approach used participatory methods, comprised of an initial community 'triggering' event, action plan development and weekly follow-ups to monitor progress on identified action items. Mobilisers collected operational and behavioural data on a weekly basis as part of CLEA. We conducted a retrospective analysis of >50 000 weekly reports from approximately 12 000 communities from December 2014 to September 2015. The data showed that 100% of the communities that were engaged had one or more action plans in place. Out of the 63 110 cumulative action points monitored by community mobilisers, 92% were marked as 'in-progress' (85%) or 'achieved' (7%) within 9 months. A qualitative examination of action points revealed that the in-progress status was indicative of the long-term sustainability of most action points (eg, continuous monitoring of visitors into the community) versus one-off action items that were marked as achieved (eg, initial installation of handwashing station). Analysis of behavioural outcomes of the intervention indicate an increase over time in the fraction of reported safe burials and fraction of reported cases referred for medical care within 24 hours of symptom onset in the communities that were engaged.Through CLEA, we have demonstrated how large-scale, coordinated community engagement interventions can be achieved and monitored in real-time during future Ebola epidemics and other similar epidemics. The SMAC initiative provides a practical model for the design, implementation and monitoring of community engagement, integration and coordination of community engagement interventions with other health emergency response pillars, and adaptive strategies for large-scale community-based operational data collection.

Keywords: Community Engagement; Ebola; Sierra Leone.

Figure 1

Community visits over time. Figure shows the number of community visits per day for the triggering events (top panel) and for the triggering and follow-up visits (bottom panel).

Figure 2

Behavioural impacts of community engagement. Increase in fraction of safe burials following deaths (left) and fraction of cases referred to a health facility with 24 hours (right). We divide the data per district and plot our estimates for per cent of cases referred, and per cent of safe burials following deaths, at different visits. The dotted line shows the transition from period 1 (paper based) and period 2 (digital) which also reflects a point when most communities were already triggered and beginning to undergo follow-up.

Figure 3

Content of community bylaws. (Left) Frequency of common topics mentioned in community bylaws over time during follow-up visits with regressions weighted by the number of bylaws in the month. (Bottom right) Qualitative representation of the most common concerns and topics in all community bylaws. Numbers refer to the toll-free national alert system (117) and to fines associated with the bylaws (eg, 500 000 SLL ≃ US$60). SLL, Sierra Leonean leone; US$, United States dollar.