Abstract
SummaryBackgroundThe 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.MethodsWe 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.FindingsIn 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).InterpretationCommunity-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.FundingBill & Melinda Gates, Bill & Melinda Gates Foundation, and National Institutes of Health.
Highlights
In the 2014–15 west African outbreak of Ebola virus disease, local populations were confronted with decisions on how to handle the sick and deceased
While these behaviours were counterproductive to transmission reduction, they were regarded by local populations as reasonable reactions to the intensified control or unexplained intervention exerted in a top-down manner
Prioritising community-based action plans ensures adoption of locally feasible, locally owned behaviour change through processes that satisfy needs, with the support of and resources allocated through community mobilisers; our results indicate that fewer unmet needs will lead to improved retention of preventive behaviour change during the course of an outbreak
Summary
In the 2014–15 west African outbreak of Ebola virus disease, local populations were confronted with decisions on how to handle the sick and deceased. Initial public health recommendations from international authorities were based on experiences with previous outbreaks of limited scale in central Africa, and were not adapted to reflect local ecological, sociocultural, and public health contexts Conflicts between these recommendations and local customs, as well as a lack of understanding about Ebola and its transmission, generated widespread community-level concerns.[1,2] discontent with response measures was compounded by high degrees of unfulfilled basic needs, distrust in authority, and fragile health and economic systems, with the three most affected countries ranking among the lowest 8% globally on the Human Development Index.[3,4]. Observed behaviours during the initial phases of the Ebola outbreak throughout west Africa ranged from individuals looting treatment centres, to families hiding the sick, to community-level rejection of safe burial practices While these behaviours were counterproductive to transmission reduction, they were regarded by local populations as reasonable reactions to the intensified control or unexplained intervention exerted in a top-down manner. By the end of 2014, sufficient funding and personnel had been released in Sierra Leone to ensure that response activities were informed by a social-behav ioural sciences approach that prioritised community
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