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Ebola response, Sierra Leone

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Is sensitisation effective in changing behaviour to prevent Ebola transmission?

The current Ebola Virus Disease outbreak is the largest ever recorded.  The virus has now been confirmed in Guinea, Liberia, Sierra Leone, Nigeria and Senegal.  The latest number of probable and confirmed cases totals 4,269 resulting in 2,288 deaths[1]. The West African countries affected by the epidemic have neither the health infrastructure nor the resources to effectively combat the disease. In fact, Ebola is killing some of the very few medical practitioners needed to fight its spread.

There are two dimensions to fighting the spread of Ebola. On the one hand, the international community has provided trained medical staff, funds, protective equipment and training to mitigate the impact of Ebola On the other hand, it is critically important that local communities are informed about the epidemic. Public policy and awareness raising campaigns provide real-time information about how to avoid getting Ebola and how to deal with suspected cases. Given the severity of the disease, and the limited nature of the resources available to fight it, accurate and timely information is one of the leading tools for combating the further spread of the disease. There are many myths to dispel, and sharing knowledge saves lives.

ActionAid, Christian Aid, Concern and Save the Children responded to the outbreak in Sierra Leone from 28 June – 12 August with Start Fund grants, a month after the first Ebola case was reported.  They focused their efforts on social mobilisation and sensitisation campaigns to equip the population with the knowledge needed to identify and respond to the infection. With £280,042, they reached 13.7% of Sierra Leone’s 5,979,000 people directly and 26% of the population indirectly through radio messaging. But what lessons did they learn about community sensitization in the process?

A little about Ebola

Ebola is transmitted through direct contact with body fluids of an infected person, contaminated surfaces or equipment.  It is highly contagious but hard to spot. The signs and symptoms of the virus are initially non-descript and can easily be mistaken for malaria or a diarrheal disease.  Since the incubation period can be up to 21 days, preventing early transmission is extremely difficult.

If patients seek care early enough, there is a chance of survival if given intensive care.   Infected patients must be isolated and carefully treated by health workers through personal protective equipment. Sierra Leone so far has maintained the lowest case fatality rate at 37% compared to 65% in Guinea and 59% in Liberia. It is critical for people to go to health centres and not treat the disease at home. Unfortunately, this does not always happen.

A little about Ebola myths

This is the first Ebola outbreak in Sierra Leone so most people have no knowledge about the disease.  Instead, there is widespread fear, anxiety and panic.  This confusion in some cases has resulted in rumours and deep mistrust of the health workers and the response efforts. In the eyes of many people, loved ones who go to health centres with normally treatable symptoms never come back.

Agencies faced a critical task of gaining communities’ trust in order to raise awareness and ensure adoption of the control measures.  Save the Children conducted a knowledge, attitudes and practice (KAP) survey in Freetown to establish a baseline about the community’s knowledge of the disease before designing their interventions.  They found that 67% of 2,050 respondents did not know any method of preventing Ebola and 47% did not even believe Ebola existed.  Further, when asked how Ebola reached Sierra Leone, 88% said it was a way for the government and NGOs to make money.  This shows just one subset of the population but highlights the urgency agencies face in communicating the nature of the disease and how to control it.

A little about Ebola sensitization

Agencies had to rapidly sensitise communities to the facts about the disease.  They teamed up with the Ministry of Health and Sanitation, community leaders, civil society organisations, other international agencies and local NGOs and health workers to organize widespread awareness campaigns.  They had to be creative and cost-effective in maximizing their reach while giving each community enough attention to ensure a strong reception of the control measures.  One of the agencies observed that the more time their teams spent in one location, the more interested the residents became in the messaging and more confident to ask questions and clarifications.

The production of radio jingles, posters, factsheets, banners, newspaper ads, and motorcade air jingles provided an indirect form of communication to the public.  This type of sensitisation was useful for achieving a wide reach to reinforce key control messages but it did not allow for a two-way dialogue about the epidemic. How do you know if someone listening to the radio changes their behaviour?

Direct sensitisation, on the other hand, such as performing door-to-door campaigns and organizing community meetings to discuss the disease went further in appeasing fears and providing clarity about the causes of the epidemic and how to control it.  This requires more capacity but it can increase the public’s ability to recognize Ebola and adhere to prevention practices.

Direct individual communication, however, was not so straight-forward. Due to the fear surrounding control efforts, one agency found that many households went to hide when their teams approached their homes. In some cases, the presence of the sensitisation teams led to increased suspicion, and this hampered their ability to get the messages across or even access certain households. Another agency realised that their day-time visits were missing important family members due to the farming season. Still another realised that house-to-house visits did not specifically target young people, who are particularly vulnerable to the disease. A fourth found that the traditional broadcast approach of motorcades was not actually getting the message across. All these challenges needed quick solutions.

One of the most important lessons was that direct individual sensitization needs to come from the right people.  Residents were more receptive when the messages were delivered by trusted community members and community health workers who lived in their districts. The panic and confusion associated with the disease made it crucial for the information and guidance to come from familiar and respected sources. When going door-to-door, for instance, it was much more effective to have known members of the community approach the home first. Evening visits also found more people at home, and carrying out activities in schools, cinemas, football pitches and other public places helped to reach more young people. One agency even took an integrated approach to motorcades, getting Ministry of Health and Sanitation staff to accompany the motorcades to answer the questions of people passing by, which greatly improved knowledge transfer over the traditional broadcast approach. In Freetown, the WaSH consortium also broke precedence to provide a one-time payment of 10,000 Le to community health workers as an incentive for urgent mobilisation. All of these programmatic changes helped share life-saving knowledge more effectively.

A little about the results

A KAP endline survey of 600 respondents by ActionAid in the Bo and Kono districts assessed the effectiveness of media coverage and communication on behaviour change.  Overall, there was a clear increase in the awareness of Ebola and how it is transmitted and prevented. This was further corroborated through Save the Children’s KAP survey, which found that after the 45 day project, there was an increase from 39% to 85% of households correctly able to identify Ebola prevention methods.

However, ActionAid also found that there was no significant improvement in the time it takes for potential cases to seek care.  The responses roughly stayed the same with 33% claiming they would treat the symptoms at home for 3-4 weeks and 54% saying they would immediately go to a doctor.  In other words, people’s awareness is increasing but sustained efforts are needed to change actual behaviour.

Whether the sensitisation activities are effective in shifting behaviour and reporting suspected cases is of critical importance.  Resources are stretched and time is of the essence.

Anecdotally, the Start Fund projects did observe some specific short-term changes, such as lower attendance at funerals, increase in hand washing and using gloves, decrease in hand shaking and increase in precautions from frontline health workers when caring for patients.   These are encouraging signs but attention should continue to be focused on identifying the specific sensitisation actions which led to these outcomes and behavioural changes.

[1] As of 6 September, these numbers have been reported to WHO from the Ministries of Health of Guinea, Liberia and Sierra Leone.

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