University of Southern Denmark
Key experiences of community engagement and social mobilization in the Ebola response
Laverack, G.; Manoncourt, Erma
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Global Health Promotion
DOI:
10.1177/1757975915606674
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2016
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Laverack, G., & Manoncourt, E. (2016). Key experiences of community engagement and social mobilization in
the Ebola response. Global Health Promotion, 23(1), 79-82. https://doi.org/10.1177/1757975915606674
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606674
PED0010.1177/1757975915606674CommentaryG. Laverack and E. Manoncourt
research-article2015
Commentary
Key experiences of community engagement and social mobilization
in the Ebola response
Glenn Laverack1 and Erma Manoncourt2
Abstract: The ongoing outbreak of the Ebola virus in West Africa is the largest on record; it has
undermined already fragile healthcare systems and presented new challenges to contain the spread of
the disease. Based on our observations in the field and insights from referenced sources, we aimed to
identify key experiences of community engagement and social mobilization efforts in the current
Ebola response. We concluded that there is no excuse not to actively involve local people and that the
United Nations (UN) agencies and other partners did learn from their earlier mistakes to make a
genuine attempt to better engage with communities. However, bottom-up approaches have not been
widely implemented during the response and the reasons for not doing so must be further assessed.
Health promotion can make an important contribution, because it shows how to enable people to
take more control over their lives and health. This commentary can provide a guide to agencies to
understand an appropriate way forward when the next Ebola outbreak inevitably occurs. (Global
Health Promotion, 2016; 23(1): 79–82)
Keywords: anthropologists, community action, community engagement, community resistance,
disease management, Ebola, health promotion, outbreak response, public health, social mobilization
Based on our observations in the field and insights
from referenced sources, we aimed to identify key
experiences of community engagement and social
mobilization efforts in the recent Ebola response in
West Africa. These experiences were based on the
approach of the Ebola response, the role played
by anthropologists, the style of communication,
community resistance, and cross-border and urban
challenges. The community engagement and social
mobilization activities were led by United Nations
Children’s Fund (UNICEF) and United Nations
Mission for Ebola Emergency Response (UNMEER)
and had an operational cadre of ‘social mobilizers’
that were employed by different agencies as field
workers at the district and community levels. Their
purpose was to assist with communication, training,
stakeholder engagement, and the mobilization and
coordination of targeted interventions such as ‘lockdowns’. To bring the different partners together in a
common platform at the national level, a community
engagement and social mobilization ‘pillar’ was
established in Liberia, Sierra Leone and Guinea.
The pillar met on a regular basis to better plan,
to coordinate, to mediate between agencies, and
to facilitate the delivery of activities and the
policy response to a rapidly changing situation. We
have interpreted that community engagement and
social mobilization efforts are closely linked to
a health promotion practice that recognizes the
value of including local people in planning and
implementation, and that seeks to listen to and
respond to the expressed needs of communities. This
is called a ‘bottom-up approach’.
The Ebola response
The ongoing outbreak of Ebola virus disease in
West Africa is the largest on record, with a mortality
1. Health Promotion Research, University of Southern Denmark, Esbjerg, Denmark.
2. International Union for Health Promotion and Education, Saint-Denis, France.
Correspondence to: Glenn Laverack, Health Promotion Research, University of Southern Denmark, Esbjerg, Denmark.
Email:
[email protected]
Global Health Promotion 1757-9759; Vol 23(1): 79–82; 606674 Copyright © The Author(s) 2015, Reprints and permissions:
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80
G. Laverack and E. Manoncourt
rate of approximately 70% and an unprecedented
number of reported cases (n = 27,479 at 24 June
2015) and deaths (n = 11,222 at 24 June 2015) (1).
The outbreak had had a rapid transmission of the
disease within and across the countries of Guinea,
Liberia and Sierra Leone. The epidemic undermined
already fragile healthcare relationships and systems,
and presented challenges to contain the spread of
the disease and to develop new prevention and
treatment options. The task of managing the
outbreak was initially left to national governments
and non-governmental organizations (NGOs), but
as the epidemic continued to accelerate, it became
apparent that the disease posed a bigger threat; and
this triggered a global United Nations (UN)-led
response. With many organizations being deployed
on the ground, the first priority of sufficient beds for
patients was soon met; and the focus shifted to
surveillance, case management, safe burials, contacttracing and to a lesser extent, community engagement
and social mobilization.
The initial ‘getting to zero’ strategy was top-down
and driven by epidemiological data and the perceived
need to treat Ebola patients. The reported number of
cases continued to increase and more severe measures
began to follow; for example, in Sierra Leone on 19
September 2014 a three-day stay-at-home or lockdown period was enforced, with the threat of fines or
jail if violated. During the stay-at-home period, social
mobilizers went door to door in search of people
showing symptoms of infection, providing information
and giving out resources such as soap. In this manner,
263 cases of Ebola were identified and families and
communities were quarantined, leading to food
shortages and disrupted trade. Unsurprisingly, people
continued to violate the quarantine requirements. The
government decided to implement a modified threeday stay-at-home intervention in March 2015 which
allowed people to attend prayers. This received more
cooperation from the general population, as they
sensed the end of the Ebola outbreak.
At an early stage in the epidemic, many community
leaders recognized the value of prevention as the best
strategy to curtail the disease, including improved
hygiene, local surveillance, self-imposed quarantine
and the community management of burials. Chiefdoms
in Kono, Sierra Leone, for example, wanted their own
burial teams to counter the culturally insensitive
handling of their dead. Communities also wanted
community Ebola cemeteries where they could bury
IUHPE – Global Health Promotion Vol. 23, No. 1 2016
their dead, so future generations would have a
referential ancestral burial site (2). Self-imposed
quarantine proved to be an important factor in Ebola
control, especially when it was led by local and
religious leaders. It is crucial to minimize quarantine
violations, as well as to trace contacts and new cases.
The reliable delivery of resources was also an essential
part of building community-led self-imposed
quarantine, which included food, water, money
and information (3). Coercion was found to be
counterproductive after the negative repercussions of
using large-scale forced quarantines controlled by the
military, for example, in Liberia. The coercion was
responsible for breaking down the trust that was
required for successful community engagement (4).
The role of anthropology
Anthropological insights can significantly contribute
to Ebola control, because they take into account local
perspectives and help us to understand the complexity
of the problem (for example, in regard to notions of
purity, pollution and the exchange of bodily fluids);
however, we observed that anthropological insights
were not widely used in the ongoing Ebola response.
Anthropological studies require in-depth and
sometimes long-term input, whereas in a crisis
response, new information is required quickly as the
situation changes, often on a daily basis. We found that
anthropological insight can provide useful information
at the beginning of the outbreak; as the response
progresses, however, it is the ‘quick and dirty’ studies,
often produced by epidemiologists and social scientists,
which can best meet the requirements of rapidly
changing circumstances. For example, a rapid
assessment of the siting and construction of Community
Care Centers in Sierra Leone found that the fears of
communities were quickly alleviated when they had
been actively engaged in decisions (5).
We also found that anthropologists are trained to
provide ‘thick and dense’ accounts, which are difficult
to translate into practical recommendations, compounded by a poor understanding of how programs
function. Anthropological recommendations, when
they were provided, were sometimes disregarded for
being too vague. The missing link has been a
discussion between the program manager and the
anthropologist, or an intermediary who could
provide an interpretation of the practical relevance of
the findings.
81
Commentary
The communication approach
The findings from the Knowledge, Attitude and
Practice surveys in Liberia and Sierra Leone
suggested that knowledge levels about the
transmission of the disease were consistently high,
often above 90%. This is an endorsement of the
communication approach used in the Ebola
response: a combination of mass media, print
materials and face-to-face communication. We
observed that each country used a different variation
on this approach. Liberia applied the principles of
the Communication for Development (C4D)
approach, social behavior change communication
and information, education and communication
techniques. Sierra Leone also used C4D, with a
mixed-methods approach, strong on messaging and
print materials. Guinea was the exception: it relied
on the use of the radio and the Community Watch
Committees or ‘comité de veille’, a communitybased approach that in practice did not seemingly
deliver what was expected.
The rapid establishment and scale-up of more
than 2000 Community Watch Committees
throughout the country strained the monitoring and
supervision by both the government and its
implementing partners. Our estimation in the field
suggested that only 25% of the Community Watch
Committees were functional, and that guidance on
community representation was not always respected
by local leaders. There were exceptions, notably the
Social Mobilization Action Consortium in Sierra
Leone, which did develop a ‘community-led Ebola
approach’ to trigger local action; however, the
predominant communication approach relied on
the mass media, refined messaging and interpersonal
contact through thousands of social mobilizers. The
quality and coverage of the interpersonal
communication was variable, and was sometimes
carried out without sufficient discussion of the key
concerns.
The mass media approach was successful in Sierra
Leone, Liberia and Guinea in reaching a large
number of households to raise awareness; however,
as the outbreak progressed, the response was too
slow to adapt to a more targeted approach, to
engage people in a dialogue to address deep-seated
practices – in particular, those that continued to
allow the transmission of the disease, including the
hiding of sick people and dead bodies, and unsafe
burial practices. We observed that one reason why
the outbreak has persisted may have been that
overall, the response did not deliver bottom-up
approaches that could build a dialogue and promote
self-management, to convince those families and
communities that were unwilling to change their
traditional practices.
Community resistance and rumors
Non-compliant behavior was observed to be part
of a cycle of unwillingness to change traditional
practices that can be compounded by experiences of
poor service delivery and weak information flow (for
example, a lack of support for quarantined families
and patients). This can then create an atmosphere
of mistrust, fear, resistance and non-compliance.
Building a narrative of trust through communication
is difficult; ideally, community confidence should be
maintained from the beginning through bottom-up
approaches that include a respect for local
perspectives. Community resistance was a key issue
in Guinea, Liberia and Sierra Leone; as the outbreak
continued, we observed that the nature of the
resistance changed. For example, although the total
number of incidents across Guinea decreased, the
level of violence increased and continued to be
confined to specific areas. The exact causes of
resistance were unclear, but appeared to be a
combination of rumor, misinformation and poor
professional practice. Later in the response, efforts to
collect and analyze rumors were initiated by
Internews in Liberia, and this showed that people
continued to be concerned about government
interventions such as decommissioning, vaccinations,
and back-to-school and other transition activities (6).
Urban and cross-border issues
Epidemiological data have correctly projected that
the disease will recede into urban areas during the
final phases of the outbreak; however, we observed
that an alternative strategy to the ongoing ruralbased communication approach was not developed
in any of the three countries. The urban and rural
contexts present unique challenges; and the response
could learn valuable lessons from, for example, the
UNMEER/UN-Habitat intervention in Montserrado,
Monrovia, and approaches that engage local officials
within administrative boundaries in urban areas.
IUHPE – Global Health Promotion Vol. 23, No. 1 2016
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G. Laverack and E. Manoncourt
In West Africa, international borders are
porous and artificially separate closely interwoven
communities linked by common languages, ethnicity,
cultural traditions and access to markets. The crossborder movement of people is inevitable; whilst the
closing of official border crossings had prevented
motor vehicle traffic, foot and bicycle traffic
has never stopped, and may even have increased
in the remote areas, acting as a potential source
of transmission. We observed that a systematic
community management approach to record travel
histories, contacts and symptoms of illness in the
cross-border areas would improve the situation (for
example, engaging with village chiefs in crossborder control is critical to organize patrols of the
boundaries of their villages, to keep outsiders away
and to record people’s movements).
Conclusion
We conclude that Ebola control efforts must
actively involve people and this is critical to success.
The lead agencies did learn from their earlier mistakes
in the present outbreak and have made a genuine
attempt to better engage with communities; however,
bottom-up approaches have not been widely
implemented and this may lie in an agency preference
to use pre-packaged and top-down approaches, which
have an emphasis on behavior change communication.
This raises concerns about whether or not the lessons
on the success of community engagement have really
been learned, or if top-down approaches will continue
to dominate responses of the future. Commentators
have suggested that top-down tactics have had a
questionable effect, potentially worsening the
epidemic, and contributing to a greater social and
economic burden in West Africa (7).
The emerging evidence from the current Ebola
response suggested that communities have
understood what is required and can learn rapidly
to change high-risk traditional practices to help to
reduce transmission. In particular, community
engagement can offer an added value through the
self-management of quarantines, control of crossborder movement, safe and dignified burials, and
the siting of Community Care Centers. Plainly put,
there is no excuse not to actively involve local people
IUHPE – Global Health Promotion Vol. 23, No. 1 2016
in an Ebola response and the reasons for not doing
so must be assessed, including any assumptions
about local ignorance, weak capacity, and the lack
of trust between agencies and communities. Health
promotion can make an important contribution,
because it shows how to enable people to take more
control over their lives and health. Community
capacity building, participation and empowerment
are already intrinsic to a health promotion practice
that recognizes the value of a bottom-up approach.
This can provide a guide to agencies to understand
an appropriate way forward when the next Ebola
outbreak inevitably occurs.
Conflict of interest
The authors declare that there is no conflict of interest.
Funding
This research received no specific grant from any
funding agency in the public, commercial or not-forprofit sectors.
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