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Corresponding author: Shadrack O. Frimpong, Department of Public Health and Primary Care, University of Cambridge, Forvie Site, Robinson Way, Cambridge CB2 0SR, United Kingdom.
Department of Pediatrics, Yale School of Medicine, New Haven, USADepartment of Public Health and Primary Care, University of Cambridge, Cambridge, UKDepartment of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, USA
# Yale Pediatric Infectious Disease, Yale New Haven Hospital, 20 York Street, New Haven, CT 06510, USA.
Elijah Paintsil
Footnotes
# Yale Pediatric Infectious Disease, Yale New Haven Hospital, 20 York Street, New Haven, CT 06510, USA.
Affiliations
Department of Pediatrics, Yale School of Medicine, New Haven, USADepartment of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, USADepartment of Pharmacology, Yale School of Medicine, New Haven, USASchool of Management, Yale University, New Haven, USA
Interventions to address disease outbreaks cannot be a “one-size-fits-all”.
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Community interventions improved knowledge and attitudes, and response efforts.
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Level of involvement depended on survivor testimonials and Ebola virus disease risk perception.
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Combined interventions were more successful than singular interventions.
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Community engagement during Ebola can be applied to COVID-19 and future outbreaks.
ABSTRACT
Objectives
There is a paucity of scoping data on the specific roles community engagement played in preventing and managing the Ebola virus disease (EVD) outbreak in sub-Saharan Africa. We assessed the role, benefits, and mechanisms of community engagement to understand its effect on EVD case detection, survival, and mortality in sub-Saharan Africa. The implications for COVID-19 prevention and control were also highlighted.
Methods
We searched for articles between 2010 and 2020 in the MEDLINE and Embase databases. The study types included were randomized trials, quasiexperimental studies, observational studies, case series, and reports.
Results
A total of 903 records were identified for screening. A total of 216 articles met the review criteria, 103 were initially selected, and 44 were included in the final review. Our findings show that effective community involvement during the EVD outbreak depended on the survival rates, testimonials of survivors, risk perception, and the inclusion of community leaders. Community-based interventions improved knowledge and attitudes, case findings, isolation efforts, and treatment uptake.
Conclusion
Although the studies included in this review were of highly variable quality, findings from this review may provide lessons for the role of community engagement in the COVID-19 pandemic's prevention and control in sub-Saharan Africa.
The Ebola virus is the etiological agent of the Ebola virus disease (EVD), a hemorrhagic fever that occurs in epidemics in the West and Equatorial Africa [
]. The virus was named after the river ‘Ebola’ in the Democratic Republic of Congo, where the first EVD outbreak occurred in 1976. According to Khalafallah et al. [
], it is an enveloped, negative-sense, single-stranded RNA virus belonging to the genus Ebolavirus and the Filoviridae family. There are five species of Ebola viruses: Zaire, Bundibugyo, Sudan, Côte d'Ivoire (Taï Forest), and Reston [
]. It is transmitted among humans through close contact with blood or bodily fluids from an infected individual or animal. The main clinical manifestations of EVD are fever, myalgia, abnormal inflammatory responses, dehydration, electrolyte imbalance, hemorrhage, and sometimes death [
]. A recent outbreak in 2013-2016 in West Africa was the most widespread to date, killing over 11,000 individuals, with a case fatality rate of over 40% [
]. A successful community engagement requires the active involvement of community members in program design, leadership, implementation, and monitoring and evaluations [
]. Interventions that engage communities to decentralize power and decision-making and create a shared responsibility to design culturally appropriate and sustainable programs.
Community engagement is crucial in improving population health and empowers communities to be responsible for their health [
]. Historically, community-based approaches have been effective in addressing complex health challenges. For instance, the HIV equity initiative successfully worked with community members in Haiti's lower Central Plateau to improve HIV treatment uptake [
]. This was achieved by assigning patients to specific community health workers who monitored the patients’ medication adherence, met with patients monthly, and provided patients with social support, such as paying school fees for children whose parents were HIV-positive. By engaging the local government, the HIV equity initiative could change behaviors associated with the spread of new infections.
It is well established that interventions to address public health challenges cannot be “one-size-fits-all” and must be tailored to their specific regions and contexts [
]. Although the role of community engagement in disease conditions, such as HIV/AIDS, tuberculosis, and maternal and infant care, has received much attention, there are limited scoping data on the specific roles it played in the prevention and management of the EVD outbreak in SSA. Consequently, there is a knowledge gap in how community engagement can be applied to address other outbreaks in SSA, such as future EVD outbreaks and the ongoing COVID-19 pandemic.
This review aimed to examine the effects of community engagement on EVD case detection, survival, and deaths in SSA and to assess key factors and attributes of successful community engagement. Our findings will inform the best community engagement practices for controlling and preventing similar outbreaks.
Materials and methods
Search strategy and eligibility criteria
This study was a scoping review. We searched key electronic databases, including MEDLINE and Embase, and identified relevant articles on PubMed, Google Scholar, Google, and ResearchGate. The eligibility criteria entailed a broad array of studies, including randomized trials, quasiexperimental studies, observational studies, case series, and reports, with participants, such as communities and individuals in African countries afflicted with EVD, including health care providers and governmental and nongovernmental organizations. The articles must also be published in English. The search terms included one or more of the following: community-based prevention and care, community surveillance systems, community health workers, local community leaders, community members, and local medical staff, social mobilization, or community implementation. Date restriction from 2010 to 2020 was imposed on the search because this period also recorded the two most severe outbreaks, with 28,616 cases and 11,310 deaths in the 2013-2016 outbreak and 3470 cases and 2280 deaths in the 2018-2020 outbreak [
]. Furthermore, these outbreaks happened at pandemic scales in multiple countries, including Liberia, Sierra Leone, Guinea, Nigeria, Senegal, the Democratic Republic of Congo, and Uganda. The multiplicity of countries and the high number of EVD cases and deaths made 2010-2020 a preferred period suitable for this review's purpose of assessing community engagement during the Ebola outbreaks in different SSA country contexts.
Article selection and information extraction
We evaluated all titles and abstracts to determine their relevance and eligibility. Literature that did not meet the eligibility criteria was excluded. Where there was not enough information to decide based on the abstract and title, we obtained the full text and reviewed it accordingly to decide. Copies of the full text of potentially relevant references were obtained and reviewed to ensure they met the eligibility criteria. Where necessary, differences in opinion were resolved by discussion among the authors who have varied expertise on the topic.
The authors performed the information extraction process, and any discrepancies were discussed. For each article, the following information was documented: author(s), year of publication, country, study design, type of intervention, community engagement factors (if any), and main outcome(s).
Quality screening
We assessed the quality of articles included using the Joanna Briggs Institute Appraisal Checklist and the National Institute of Health Quality Assessment Tools for Observational and Cross-Sectional Studies (Supplementary Tables). In each assessment, we screened for sources of selection bias, such as convenience sample or location, and potential blinding of outcomes in the included studies. We further evaluated these studies to see if authors selectively reported positive or significant results and left out negative results. We also assessed studies to see if there was any proportion of subjects whose outcomes were not recorded due to loss of follow-up. We evaluated the studies to see if the outcome measures (dependent variables) were clearly defined, valid, reliable, and implemented consistently across all study participants. Finally, we evaluated the qualitative studies for ethical approval and the inclusion of participant voices.
Results
Literature selections
Our search results generated studies that were mainly observational and quasiexperimental; we identified 896 titles from the search conducted in all databases and seven from the reference list of the screened studies, culminating in a total of 903 records; 680 studies were excluded mainly because they did not use any of the interventions stated in our eligibility criteria. After screening titles and abstracts, 216 full texts were reviewed and screened further (Figure 1). Of the 216 full texts reviewed, 103 were initially selected, whereas 113 articles did not meet inclusion criteria based on the full-text screening. A total of 44 articles were finally included because they met all the eligibility requirements, whereas 59 articles were not included based on issues regarding their methods, key findings, and contributions. Of the 44 articles, 19 were cross-sectional and observational studies, 13 were qualitative studies, three were pre-post studies with no control groups, six were quasiexperimental studies, two were opinion pieces that merited inclusion based on our qualitative assessment, and one was a meta-analysis, as illustrated with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses table in Figure 1.
Table 1 summarizes the findings of community-based interventions and their significant outcomes. There were 33 different studies from six different countries, with most of them conducted in Liberia and Sierra Leone. Of the 33, there were 15 different types of community-based interventions, many of them focused on community-based education and mobilization [
Rapid assessment of knowledge, attitudes, practices, and risk perception related to the prevention and control of Ebola virus disease in three communities of Sierra Leone.
The Ebola virus disease outbreak in Tonkolili district, Sierra Leone: a retrospective analysis of the viral haemorrhagic fever surveillance system, July 2014–June 2015.
Using a mhealth tutorial application to change knowledge and attitude of frontline health workers to Ebola virus disease in Nigeria: a before-and-after study.
Behind enemy lines: a perspective on Ebola from Sierra Leone. How the use of interpersonal communication made a difference in the fight against Ebola (an operational intervention).
A summary of the frequency of these interventions, as reported in different studies, and the countries where the interventions were implemented, is illustrated in Table 2.
Table 2Outcomes of community-based interventions by intervention type, country, and components.
Community education; alert reporting; contact tracing; social mobilization.
Improved EVD case detection, zero infection of healthcare workers, no unsafe burials, and EVD-free goal was achieved four months earlier in participating communities than the entire Sierra Leone.
Rapid assessment of knowledge, attitudes, practices, and risk perception related to the prevention and control of Ebola virus disease in three communities of Sierra Leone.
The Ebola virus disease outbreak in Tonkolili district, Sierra Leone: a retrospective analysis of the viral haemorrhagic fever surveillance system, July 2014–June 2015.
Potential impact of improving access to data and case detection; yet has limitations of software malfunctioning; and technical literacy, and data privacy concerns.
Using a mhealth tutorial application to change knowledge and attitude of frontline health workers to Ebola virus disease in Nigeria: a before-and-after study.
Improvement of knowledge of Ebola; reinforcement of positive attitudes of avoiding contact with Ebola patients, eating bush meat, and risky burial practices.
Postintervention, there were rapid positive changes in beliefs about EVD, yet this lagged behind practices, and many people still supported conspiracy theories.
Statistically significant positive changes in EVD recognition, transmission, and mitigation. EVD knowledge gained through intervention was retained after one year.
Behind enemy lines: a perspective on Ebola from Sierra Leone. How the use of interpersonal communication made a difference in the fight against Ebola (an operational intervention).
We and the nurses are now working with one voice": how community leaders and health committee members describe their role in Sierra Leone's Ebola response.
Social and cultural factors behind community resistance during an Ebola outbreak in a village of the Guinean Forest region, February 2015: a field experience.
Community education about survivor's Ebola-free status; community celebration event; survivor given medical certificate and encouraged to share their experience in ETU; broadcasting of event via radio; in-kind donation to survivor from Firestone.
Helped to improve community acceptance of EVD response, and the consequent trust reduced EVD spread.
CBS, community-based surveillance; CCCs, community care centers; CEM, community education and mobilization; CHW, community health workers; CLTS, community-led total sanitation; ETU, Ebola treatment unit; EVD, Ebola virus disease; mHealth, mobile health.
Community education and mobilization initiatives included community involvement in radio campaigns, culturally sensitive burials, alert reporting, contact tracing, case finding, isolation, and treatment uptake. Most of the interventions targeting the involvement of community members in alert reporting, case finding, and isolation led to gradual, and in some cases, immediate complete cessation of the EVD epidemic in the communities, in which they were implemented [
]. For instance, in Sierra Leone, community-based education and mobilization efforts contributed to the detection of 70.8% of 72 EVD cases by trained local community members [
]. In these three Sierra Leonean communities, where the intervention was piloted and community-based measures were modeled to reduce 77 EVD cases, the EVD-free goal was attained 4 months earlier than the entire country [
]. Other interventions, which focused on educating community members on the importance of conducting safe burials and culturally appropriate ways to include community members in burial processes, improved hygienic burial practices, EVD awareness and case detection, and an overall decrease in EVD spread [
The rapid spread of EVD across geographic boundaries necessitated the development of interventions that could quickly detect, report, and treat incident cases at the community level [
]. In response, community-based surveillance systems were implemented to minimize the exponential spread of the outbreak. This was achieved by training community members to find cases, report alerts, and isolate cases where necessary. Mainly conducted in Sierra Leone, many of these initiatives improved case detection, even though many of them generated data that were false alerts [
]. Yet, surveillance facilitated data collection from communities that are rural and remote and are also usually difficult to reach to obtain data for response efforts [
The Ebola virus disease outbreak in Tonkolili district, Sierra Leone: a retrospective analysis of the viral haemorrhagic fever surveillance system, July 2014–June 2015.
]. In Sierra Leone's Tonkolili district, the EVD surveillance system further helped collect crucial information, such as case fatality ratios, hospitalization rates, and common risk factors observed in different chiefdoms [
The Ebola virus disease outbreak in Tonkolili district, Sierra Leone: a retrospective analysis of the viral haemorrhagic fever surveillance system, July 2014–June 2015.
Integration of community members into the formal health care system
To involve community members directly in response efforts, certain interventions in Sierra Leone, Liberia, and Guinea focused on hiring and training community members as health workers and letting them work together with formal health care workers and community leaders [
]. Such concerted approaches improved community trust relations and EVD outcomes overall.
Survivor integration programs
Survivor integration programs, initiatives that transitioned EVD survivors back into their communities, contributed to EVD prevention and control efforts. In Liberia, private companies, such as Firestone LLC, established reintegration programs focused on pre-entry community education, entry events, and, later, survivor engagement [
]. These programs began by educating community members that the survivor is indeed Ebola-free and poses no threat of infecting anyone. Next, they worked with community leaders to organize community events, during which they formally welcomed the survivor back into the community and congratulated them with certificates for their resilience during recovery. During such celebratory events, survivors were encouraged to use the platform to educate their fellow community members about their experiences in the health facilities or ETUs.
The survivors also highlighted the dignified care they received and encouraged community members to see the health workers as genuine allies in the fight against the epidemic. Firestone LLC then donated a reintegration package to the survivor to assist them in their livelihoods as they readapt to normal living in their communities. Similar reintegration programs were conducted in Guinea [
Social and cultural factors behind community resistance during an Ebola outbreak in a village of the Guinean Forest region, February 2015: a field experience.
] by organizations, such as The Alliance for International Medical Action (ALIMA), where EVD survivors formed an integral component of control efforts at the community level. Such survivor reintegration efforts helped to improve community compliance with EVD control activities, such as contact tracing, and consequently, an increase in case detection and management in Guinea [
Social and cultural factors behind community resistance during an Ebola outbreak in a village of the Guinean Forest region, February 2015: a field experience.
]. Similarly, in Sierra Leone, such reintegration programs increased the number of patients admitted to Ebola management centers and reduced the number of people encountering dead bodies [
The factors affecting household transmission dynamics and community compliance with Ebola control measures: a mixed-methods study in a rural village in Sierra Leone.
The quarantine in communities took two main forms: the quarantine of residents who were EVD-infected and the bounded quarantine of an entire community. For many residents who were EVD-infected and were quarantined, some communities provided them with food and water and supported their livelihoods by engaging healthy young men to assist them with their farming activities, such as crop harvesting [
]. These efforts helped to reduce the EVD-related stigma that people usually face during quarantine. Regarding bounded quarantines of communities, both the approaches and outcomes were mixed. In Liberia, the government imposed a military-style quarantine in West Point, leading to protests, injuries, and various other forms of social resistance [
]. Yet, in the same country, community members in Mawah Village, Bong County, voluntarily decided to quarantine themselves by placing restrictions on entries and departures, regulating their river crossings, and closing their markets; these led to zero reported EVD cases [
In response to rising EVD cases in Sierra Leone, and the limited capacity of ETUs, the United Kingdom's Department for International Development partnered with several private and public entities to establish CCCs to augment the capacity of ETUs [
]. However, the evidence on the impact of CCCs is mixed. Some scientists claim that the proximity of CCCs to the community-led to rapid case isolation and helped to reduce fear and stigmatization [
]. For instance, EVD case isolation was higher in CCCs than in other facilities (85% vs 49%; odds ratio = 6.0; 95% confidence interval = 4.0, 9.1), which contributed to a 13-32% reduction in the EVD reproduction number [
]. Others argue that CCCs did not significantly contribute to the epidemic's decline because the general EVD curve had already flattened before many CCCs were opened [
In Guinea, Sierra Leone, and Nigeria, mobile health and technology-based tools were used to collect and analyze contact tracing data, conduct surveillance, gather essential geographic information, and disseminate EVD information [
Using a mhealth tutorial application to change knowledge and attitude of frontline health workers to Ebola virus disease in Nigeria: a before-and-after study.
Using a mhealth tutorial application to change knowledge and attitude of frontline health workers to Ebola virus disease in Nigeria: a before-and-after study.
Using a mhealth tutorial application to change knowledge and attitude of frontline health workers to Ebola virus disease in Nigeria: a before-and-after study.
]. The application also reinforced positive attitudes of avoiding the following: contact with patients with Ebola, eating bush meat, and risky burial practices, shown by increases between pre- and postintervention scores from 83-92%, 57-64%, and 67-79%, respectively [
Using a mhealth tutorial application to change knowledge and attitude of frontline health workers to Ebola virus disease in Nigeria: a before-and-after study.
We also found evidence from single studies that highlighted community-based interventions, such as active surveillance and health education, community-based ETUs [
Behind enemy lines: a perspective on Ebola from Sierra Leone. How the use of interpersonal communication made a difference in the fight against Ebola (an operational intervention).
]. These interventions were reported to contribute to EVD prevention and control efforts in distinct ways, such as reducing the risk of infection, improving case finding, isolation, and treatment uptake [
Behind enemy lines: a perspective on Ebola from Sierra Leone. How the use of interpersonal communication made a difference in the fight against Ebola (an operational intervention).
Table 3 summarizes the main factors that impacted community engagement during the Ebola response efforts. Some of the key factors that influenced community involvement were the survival rates of those who were infected [
The factors affecting household transmission dynamics and community compliance with Ebola control measures: a mixed-methods study in a rural village in Sierra Leone.
When Ebola enters a home, a family, a community’: a qualitative study of population perspectives on Ebola control measures in rural and urban areas of Sierra Leone.
Rapid assessment of knowledge, attitudes, practices, and risk perception related to the prevention and control of Ebola virus disease in three communities of Sierra Leone.
Understanding the role of community resilience in addressing the Ebola virus disease epidemic in Liberia: a qualitative study (community resilience in Liberia).
When Ebola enters a home, a family, a community’: a qualitative study of population perspectives on Ebola control measures in rural and urban areas of Sierra Leone.
The factors affecting household transmission dynamics and community compliance with Ebola control measures: a mixed-methods study in a rural village in Sierra Leone.
Social and cultural factors behind community resistance during an Ebola outbreak in a village of the Guinean Forest region, February 2015: a field experience.
Ebola epidemic in war-torn Democratic Republic of Congo, 2018: acceptability and patient satisfaction of the recombinant Vesicular Stomatitis Virus - Zaire Ebolavirus Vaccine.
Ebola epidemic in war-torn Democratic Republic of Congo, 2018: acceptability and patient satisfaction of the recombinant Vesicular Stomatitis Virus - Zaire Ebolavirus Vaccine.
Rapid assessment of knowledge, attitudes, practices, and risk perception related to the prevention and control of Ebola virus disease in three communities of Sierra Leone.
The factors affecting household transmission dynamics and community compliance with Ebola control measures: a mixed-methods study in a rural village in Sierra Leone.
When Ebola enters a home, a family, a community’: a qualitative study of population perspectives on Ebola control measures in rural and urban areas of Sierra Leone.
When Ebola enters a home, a family, a community’: a qualitative study of population perspectives on Ebola control measures in rural and urban areas of Sierra Leone.
Social and cultural factors behind community resistance during an Ebola outbreak in a village of the Guinean Forest region, February 2015: a field experience.
The factors affecting household transmission dynamics and community compliance with Ebola control measures: a mixed-methods study in a rural village in Sierra Leone.
When Ebola enters a home, a family, a community’: a qualitative study of population perspectives on Ebola control measures in rural and urban areas of Sierra Leone.
Understanding the role of community resilience in addressing the Ebola virus disease epidemic in Liberia: a qualitative study (community resilience in Liberia).
The factors affecting household transmission dynamics and community compliance with Ebola control measures: a mixed-methods study in a rural village in Sierra Leone.
The factors affecting household transmission dynamics and community compliance with Ebola control measures: a mixed-methods study in a rural village in Sierra Leone.
When Ebola enters a home, a family, a community’: a qualitative study of population perspectives on Ebola control measures in rural and urban areas of Sierra Leone.
Ebola epidemic in war-torn Democratic Republic of Congo, 2018: acceptability and patient satisfaction of the recombinant Vesicular Stomatitis Virus - Zaire Ebolavirus Vaccine.
Ebola epidemic in war-torn Democratic Republic of Congo, 2018: acceptability and patient satisfaction of the recombinant Vesicular Stomatitis Virus - Zaire Ebolavirus Vaccine.
Understanding the role of community resilience in addressing the Ebola virus disease epidemic in Liberia: a qualitative study (community resilience in Liberia).
In rural and remote areas where geographic barriers delayed access to treatment uptake, many communities were able to adapt measures that enabled them to support each other long before their health workers arrived [
Understanding the role of community resilience in addressing the Ebola virus disease epidemic in Liberia: a qualitative study (community resilience in Liberia).
]. In some communities, resilience achieved through strong social cohesion, respect for community culture, social capital, and robust community leadership, as opposed to foreign aid that is top-down in nature, proved to be the best option to stop an outbreak [
Understanding the role of community resilience in addressing the Ebola virus disease epidemic in Liberia: a qualitative study (community resilience in Liberia).
An important factor that influenced the involvement of community members in the EVD response initiative was the perception of the risk of Ebola. Those who did not believe they were at risk were less likely to change their attitudes and behaviors [
Rapid assessment of knowledge, attitudes, practices, and risk perception related to the prevention and control of Ebola virus disease in three communities of Sierra Leone.
]. Community members were more likely to engage in EVD response activities if they had already seen someone in their community get infected. Furthermore, community involvement in an EVD response depended on the satisfaction levels of community members regarding the reaction and their knowledge of the biology and infectivity of EVD [
Survival rates of affected and testimonials during their reintegration
In addition, many families refused response efforts, such as treatment uptake due to the fear of the stigma they may experience when other community members learn that their relative has been infected. They also had concerns about rumors that the body parts of people sent to ETUs were dismembered and used for rituals [
]. For such families, what helped to allay their concerns and encouraged them to participate in the response was seeing survivors return from the ETUs and share their experiences of how they were given dignified care and attention by the health workers in the ETU [
The role of local leaders in garnering community trust
Another crucial factor that drove successful community engagement was local leadership and its role in gaining community trust. In many communities, especially those that were rural and remote, the buy-in of local chiefs and other leaders was the defining factor of whether an intervention became successful [
]. When community leaders were put at the forefront of an EVD response, they played active roles in encouraging their community members to participate and also enacted communal bye-laws to enforce and promote essential response components, such as quarantine, contact tracing, and surveillance [
]. On the other hand, when community leaders were not involved, and instead, government top-down approaches, such as policing and military strategies were used, community members resisted through protests and refused to participate in the response [
Proximity to the health care facility and clarity in communication
Other community-level factors pertaining to health care access and communication challenges hampered the community engagement efforts. In many communities, proximity to a treatment facility improved health care services utilization because individuals did not have to walk long distances to access medical care, and those whose family members were infected and in care could easily visit them and see them with standardized hospital restrictions [
When Ebola enters a home, a family, a community’: a qualitative study of population perspectives on Ebola control measures in rural and urban areas of Sierra Leone.
]. Another factor that hampered EVD response activities was the mismatch between public health information from the mass media and the community experience [
The factors affecting household transmission dynamics and community compliance with Ebola control measures: a mixed-methods study in a rural village in Sierra Leone.
]. For instance, in Uganda, health communication suggested that community members should not eat monkeys; yet, there were no monkeys in many communities [
The absence of community involvement in burial processes led to the prevailing notion that EVD response team members were using dead patients for rituals; in many communities, there were strong initial challenges of effectively conducting safe burials without considering local cultural barriers and traditions [
Social and cultural factors behind community resistance during an Ebola outbreak in a village of the Guinean Forest region, February 2015: a field experience.
]. Many community members were not allowed to witness the final burial rites of their loved ones, and burial teams handled the corpses of their deceased family members in a traditionally respectful manner. Others decried that they did not know what happened to the bodies of their dead relatives [
]. Consequently, many began to suspect that health workers and response team members were selling body parts of their relatives for rituals and magic, which made many community leaders hesitant to recommend their community members to seek medical care at ETUs [
Trust problems and breakdown of social cohesion were noted in countries like Liberia, where the government gave top-down instructions to isolate bodies and cremate dead ones [
]. Again, in Liberia, the government-imposed quarantine without implementing educational campaigns, provision of access to social services, and local leadership involvement. Such state-enforced quarantine led to the mandatory prohibition of movement, raised condemnation, strengthened the stigmatization of citizens infected with EVD, and created socioeconomic distress [
]. However, not all quarantines were government imposed, some were voluntarily adopted by community members themselves, and they successfully reduced EVD cases [
The fight against the Ebola outbreak was not one that national governments wielded alone. They had the support of allies, such as private companies, nonprofit organizations, and multilateral organizations. In Liberia, private partners, such as Firestone LLC, participated in response efforts in their communities by conducting radio announcements and community meetings to mobilize community members for their response efforts [
]. Others, such as ALIMA, also established ETUs within communities. In the Democratic Republic of Congo, the International Conservation and Education Fund produced videos to educate residents of 15 villages about EVD and its risk factors [
]. Multilateral organizations, such as the World Health Organization and its partners, including the United Kingdom Department for International Development, also joined the fight by establishing Ebola CCCs to augment ETUs [
]. The concerted efforts of organizations, such as the International Federation of the Red Cross, the United States Agency for International Development, the Center for Disease Control and Prevention, Samaritan's Purse, Medicins Sans Frontiers, and the United Nations, in EVD control measures in Liberia are also well documented [
This review shows that community-based interventions, such as community education and mobilization, survivor reintegration programs, and community-based surveillance systems, helped to improve case finding, isolation, and treatment uptake; improved knowledge, attitudes, and behaviors toward EVD response efforts; and contributed to EVD prevention and control efforts. Factors, such as survival rates of those who were infected, testimonials of survivors during their reintegration, risk perception of EVD, and the role of local leaders in garnering community trust, helped to ensure effective community engagement. Also, we found that proximity to a health care facility, clarity in communication, engagement of community members in safe burials, bottom-up government approaches, donor-community collaborations, and community resilience, were also associated with whether any of the community-based interventions we reviewed were successful or not.
Successful interventions that should be considered for scale-up
Our review findings suggest that community-based interventions focused on community education and mobilization effectively improve early case detection, isolation, treatment uptake, and significant positive changes in EVD knowledge and attitudes among community members. Survivor reintegration programs, jointly championed by community members and private partners, such as Firestone LLC, also markedly contributed to the decline of the EVD epidemic. The survivors’ return and the testimonials of excellent ETU care they shared were critical in engendering community trust and social mobilization. Community-based surveillance systems also helped improve alert reporting, case finding, and eventual isolation, despite the false alerts they generated.
Generally, community education and mobilization efforts were the most implemented and successful interventions, followed by survivor reintegration, integration of community members as paid or volunteer support for formal health care workers, and community-based surveillance systems. Survivor integration efforts’ role in health promotion was even more prominent in countries such as Sierra Leone, where survivor testimonials were deemed as more effective communication tools than those of the mass media, which were seen by community members to be top-down and imposed. These interventions should be scaled-up considerably at the community level to target vulnerable populations, such as those communities that are geographically remote and have unique cultural dynamics as well. However, such scale-up efforts may come with implementation and long-term sustainability challenges that should be accounted for in advance [
Strength in numbers: combined interventions fared better
We observed that the reported positive outcomes for almost all the interventions were much higher when there were more components. For instance, joint community mobilization and palliative care helped to improve case detection, treatment uptake, and a patient's odds of survival significantly than if community mobilization alone was conducted [
]. Also, community-based education and mobilization interventions that combined reporting, case finding and isolation, education, and training in hygienic burial practices produced better outcomes than when these interventions were deployed alone [
]. Similarly, community-based surveillance initiatives that used cell phones performed better than those that did not use cell phones. Technologies, such as cell phones, may be helpful as supplementary tools to address the challenges of false alerts generated during community-based surveillance [
As a community-based intervention, the joint field blood draw and point-of-care diagnostics initiative and its success shed light on the potential of combining home-based care and point-of-contact diagnostics [
]. Even though there is limited evidence, the opportunity to further experiment with the intervention and investigate its role in accelerating EVD diagnosis and isolation should not be ignored. According to Fallah et al. [
], contrary to initial concerns, no health care worker or household member of the patient treated at home got infected with the disease. In times of outbreaks, this is particularly important in communities with unique cultural dynamics, where the infected community members may resist admission to treatment facilities. Such resistance to medical care will increase the infected patient's mortality rates and jeopardize the lives of the noninfected individuals by increasing their risk of community transmission.
Public-private partnerships
Partnerships between private companies and their operating communities, such as those between Firestone LLC and community members in Firestone District, Liberia, could serve as a model for how other private companies can contribute to response efforts in epidemics. When the EVD epidemic broke out among some of their staff members and their communities, Firestone LLC could engage the community members successfully and quickly work with them to reduce EVD cases [
]. This shows that multilateral organizations, such as the World Health Organization, are not the only nongovernmental entities that can help stop epidemics and that private, for-profit companies also have a role to play. This is especially important given the limited funding that is available for control efforts in times of epidemics [
Kampala manifesto: building community-based One Health approaches to disease surveillance and response-The Ebola Legacy-Lessons from a peer-led capacity-building initiative.
Community resistance, the sense of self-responsibility and agency that community members wield in addressing their challenges, also played a crucial role in slowing the epidemic. One of the biggest challenges in global health today is inadequate health financing. This problem is particularly heightened during emergencies, such as epidemics, where the global community has limited funding at its disposal to implement control efforts. Yet, in the face of financial difficulties in such times, we can take some lessons from the important roles that community resilience played in EVD prevention and control efforts and in the decline of outbreaks, such as the 1918 influenza and the ongoing HIV/AIDS pandemic [
]. Investing into initiatives that strengthen community resilience in rural and remote communities in SSA before and during disease outbreaks may also help save lives and financial resources.
Future directions
Although the single-study interventions were reported to contribute to EVD prevention and control efforts, we cannot comment on their applicability to future epidemics conclusively. This is due to the small study sample sizes (n = 1). Therefore, we recommend that more similar interventions are done and subsequent studies conducted to enable future unbiased review of their effectiveness and applicability for future epidemics. Of particular note are community vaccinations and their modes of implementation. For instance, although single-study results show that there was high acceptability for the administration of the rVSV-ZEBOV vaccine for 90 recipients, its large-scale administration may be hindered by factors, such as low institutional trust and community beliefs in EVD misinformation [
Ebola epidemic in war-torn Democratic Republic of Congo, 2018: acceptability and patient satisfaction of the recombinant Vesicular Stomatitis Virus - Zaire Ebolavirus Vaccine.
]. Past ethical concerns with mass antimalarial vaccinations, and recently, the outrage against some French scientists who disparagingly spoke about Africans as “guinea pigs” for vaccinations, may further compound the difficulty of large-scale vaccinations [
]. Additional studies on such community-based vaccinations will provide robust evidence to investigate their implementation's acceptability, effectiveness, and fidelity.
Beyond the mixed evidence surrounding the impact of CCCs on EVD case isolation and treatment uptake, existing data from published studies also do not agree on the role of community involvement in their implementation. For instance, although Carter et al. [
] argued that the local community members who donated land and free labor had no say in the planning process of their construction. In addition, organizations, such as Medicins Sans Frontiers, have voiced their lack of support for CCCs, commenting on their displeasure with their modes of design and operation [
]. Given the significant amount of funding and resources spent on their construction, further research studies must be conducted to ascertain the best ways CCCs can be successfully operated during disease outbreaks.
Implications for covid-19 control
Before the EVD pandemic could become a far thought, viruses could not wait to bring about another pandemic, COVID-19, on humanity. With millions of lives affected and hundreds of thousands of deaths recorded, proper measures must be put in place to stem the pandemic, especially in parts of the world like SSA, where health systems are fragile. Although the World Health Organization currently reports that Africa remains the least affected continent with COVID-19, with 1.5% of the cases and 0.1% of reported deaths worldwide, there is no cause for celebration and complacency [
]. As a viral and infectious disease, the EVD pandemic provides a unique opportunity to leverage COVID-19 prevention and control lessons. Existing evidence argues that during the EVD pandemic, international efforts in Liberia arrived after the epidemic had subsided and that much of the flattening of the epidemic's curve was due to significant behavioral changes at the community level [
]. In the same vein, community-based interventions should be prioritized as a part of COVID-19 control efforts, with community leaders leading the charge in engaging their community members and enacting bylaws, where necessary. COVID-19 survivors should also be included in such interventions because their testimonies helped to engender trust between community members and health care workers and encouraged health-seeking behaviors. This would reduce the chances of community resistance events that may arise without community engagement [
In addition, individual and communal quarantines during the EVD pandemic could shed light on how to ensure that COVID-19 quarantines and lockdowns are similarly effective. Top-down approaches, such as state-enforced, military-style quarantines, elicited protests, violence, and deaths. whereas community-led voluntary quarantine initiatives were successful. Consequently, government leaders and international stakeholders should prioritize engaging community leaders and members before initiating any intervention. During quarantine, communities must have access to necessities, such as food, water, and medical services [
]. Finally, given the paucity of funding in the global health landscape during the COVID-19 pandemic, there is a great need to focus on community resilience in rural and remote places and engage private partners’ efforts, just as Firestone LLC and ALIMA did during the EVD pandemic.
Limitations
Our review sheds light on the impact of community-based interventions during the EVD epidemic and factors associated with successful community engagement. Nonetheless, it is not without its limitations. The overall quality of the studies included in this review was highly variable and made the findings susceptible to several biases. First, the challenge of publication bias could have influenced the results of this study. The tendency of published literature to mainly report cases where community engagement led to an intervention success means that engagement efforts that failed to achieve significant success were not retrieved during the search findings. Also, many studies had poorly described methodologies, making evaluating biases, such as social desirability and performance bias, challenging. Finally, the different approaches that the studies used to assess the strength of the association between community engagement factors and their outcomes further made it difficult for any causal inferences to be made.
Conclusion
Several community-based interventions were instrumental in controlling EVD outbreaks, and their implementation successes or failures were hinged on myriads of factors that hampered community engagement efforts. The lessons learned on community engagement during EVD outbreaks can be leveraged in addressing other outbreaks, such as COVID-19. Engaging community members to implement community-based initiatives for pandemic preparedness and control is imperative.
Declaration of competing interest
The authors have no competing interests to declare.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Ethical approval
This study was a scoping review and was exempt from ethics approval as the authors gathered and synthesized data from previous studies in which informed consent was already obtained by the respective investigators.
Acknowledgments
The authors would like to thank Francis Arthur-Holmes, Kris Hilton, Sharon Attipoe-Dorcoo, Priya D. Bhirgoo, Frida Aloo, and Angela Kumirai for their helpful edits and comments.
Author Contributions
SOF conceptualized and wrote the original draft. EP made substantive contributions to the concept and edited the paper.
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