The Development of Standard Operating Procedures for Social Mobilization and Community Engagement in Sierra Leone During the West Africa Ebola Outbreak of 2014–2015

Abstract

This article describes the development of standard operating procedures (SOPs) for social mobilization and community engagement (SM/CE) in Sierra Leone during the Ebola outbreak of 2014–2015. It aims to (a) explain the rationale for a standardized approach, (b) describe the methodology used to develop the resulting SOPs, and (c) discuss the implications of the SOPs for future outbreak responses. Mixed methodologies were applied, including analysis of data on Ebola-related knowledge, attitudes, and practices; consultation through a national forum; and a series of workshops with more than 250 participants active in SM/CE in seven districts with recent confirmed cases. Specific challenges, best practices, and operational models were identified in relation to (a) the quality of SM/CE approaches; (b) coordination and operational structures; and (c) integration with Ebola services, including case management, burials, quarantine, and surveillance. This information was synthesized and codified into the SOPs, which include principles, roles, and actions for partners engaging in SM/CE as part of the Ebola response. This experience points to the need for a set of global principles and standards for meaningful SM/CE that can be rapidly adapted as a high-priority response component at the outset of future health and humanitarian crises.

Acknowledgments

We are grateful for contributions from the following critical reviewers: Samuel Sesay (Sierra Leone Ministry of Health and Sanitation); Roeland Monasch, Kshitij Joshi, and Rafael Obregon (UNICEF); Lucille Knight (formerly of UNICEF); Amanda Crookes (Handicap International); Patricia Moscibrodzki (Icahn School of Medicine at Mount Sinai); and Fatou Wurie (Evidence for Action-MamaYe Campaign).

The development of the Sierra Leone Standard Operating Procedures for Social Mobilization and Community Engagement was a collaborative process including input from the following key partners: Ministry of Health and Sanitation and District Health Management Teams; United Nations agencies (UNICEF, United Nations Mission for Ebola Emergency Response, World Health Organization, United Nations Population Fund, International Labour Organization); Social Mobilization Action Consortium composed of partners including BBC Media Action, Centers for Disease Control and Prevention, Focus 1000, GOAL, and Restless Development; ABC Development; Action Aid; Action Contra la Feme; BRAC; Catholic Relief Services; Caritas; Care International; CADA; CAWeC; Child Welfare Society; CHRISTAG; Concern; Conservation Alliance; eHealth; ENGIM; Help SL; Evidence for Action-MamaYe Campaign; FAWE; First Response Liberia Ambulance; Forut; Handicap International; Health for All Coalition; International Rescue Committee; ISLAG; KADDRO; Johns Hopkins University; Médecins Sans Frontières; NRD-SL; Oxfam; Partners in Health; People’s Advocacy Network; Plan; Real Women; RODA; Save the Children; Sierra Leone Red Cross and International Federation of the Red Cross; UPHR-SL; World Hope International; Voice of Women; World Vision; and others.

Notes

¹ For instance, comprehensive Ebola knowledge increased from 39% in August 2014 to 69% in July 2015 (Focus 1000, 2014). During this same period discriminatory attitude decreased from 95% to 41%, and hand washing with soap and water (to avoid Ebola infection) increased from 66% to nearly 90%. Similarly, the proportion of respondents objecting to SDMB for a deceased family member decreased from more than 30% in October 2014 to just 11% in December 2014, the period when the upward Ebola epidemiological curve stalled and began a slow downward trend going into January 2015 (Jalloh et al., 2016).

² The initial four pillars under the Emergency Operations Center were (a) coordination/finance/logistics; (b) epidemiology/surveillance and laboratory; (c) case management, infection control, and psychosocial support; and (d) social mobilization/public information.

³ The expanded seven pillars under the National Ebola Response Center were (a) surveillance, contact tracing, and labs; (b) case management and infection prevention and control; (c) logistics and supplies; (d) SDMB, including management of ambulances; (e) child protection, psychosocial support, and survivors; (f) media and communication; and (g) social mobilization.

⁴ Organizations involved in the SM Pillar included MOHS and District Health Management Teams; United Nations agencies (UNICEF, United Nations Mission on Emergency Ebola Response, World Health Organization, United Nations Population Fund, International Labour Organization); Social Mobilization Action Consortium composed of partners BBC Media Action, Centers for Disease Control and Prevention, Focus 1000, GOAL, and Restless Development; ABC Development; Action Aid; Action Contra la Feme; BRAC; Catholic Relief Services; Caritas; Care International; CADA; CAWeC; Child Welfare Society; CHRISTAG; Concern; Conservation Alliance; eHealth; ENGIM; Help SL; Evidence for Action-MamaYe Campaign; FAWE; First Response Liberia Ambulance; Forut; Handicap International; Health for All Coalition; International Rescue Committee; ISLAG; KADDRO; Johns Hopkins University; Médecins Sans Frontières; NRD-SL; Oxfam; Partners in Health; People’s Advocacy Network; Plan; Real Women; RODA; Save the Children; Sierra Leone Red Cross and International Federation of the Red Cross; UPHR-SL; World Hope International; Voice of Women; World Vision; and others.

⁵ The National SM Pillar contained four subcommittees: (a) Coordination, Monitoring, and Evaluation (UNICEF, MOHS coleads); (b) Messaging and Distribution (Centers for Disease Control and Prevention, MOHS coleads); (c) Capacity Building (WHO, MOHS, coleads); and (d) Vulnerable groups (Handicap International, UNICEF). The Social Mobilization Action Consortium provided national- and district-level secretariat services.

⁶ People with visual or hearing impairment cannot access information in the same way as the general population. Different methods were needed to reach certain groups outside of the mainstream (e.g., commercial sex workers or people with disabilities). Different languages and low literacy levels also needed to be factored in to effectively reach different groups and communities.

⁷ SMAC includes partners BBC Media Action, Centers for Disease Control and Prevention, Focus 1000, GOAL, and Restless Development. Working within the strategy of the MOHS’s National SM Pillar, SMAC supported a network of 2,366 community mobilizers, 1,989 religious leaders, and 36 radio stations working across all districts in Sierra Leone (SMAC, 2015).

⁸ New confirmed cases decreased from a peak of 537 new cases in the week commencing November 24, 2014, to 184 new cases in the week commencing January 5, 2015 (WHO, 2015b).

⁹ In April 2015, two additional workshops were held in Koinadugu and Kono districts, where there were recent confirmed cases. These did not inform the development of the SOPs and are not included in this analysis.

¹⁰ These included district representatives from UNICEF, United Nations Mission for Ebola Emergency Response, U.K. Department for International Development,, WHO, the Institute of Medicine, and the Centers for Disease Control and Prevention.

¹¹ Western Area does not have Paramount Chiefs; however, several ward councilors did attended. Unlike the other workshops, the Western Area workshop was only one day and did not include detailed action planning and mobilizer mapping. Ward-level action plans and ward-level mobilizer micromapping was instead done in smaller meetings over subsequent weeks.

¹² For example, full training might include a full one-week pre-engagement training, including hands-on practice, as well as ongoing remedial/short-term trainings by experienced facilitators.

¹³ Between November 2014 and June 2015 more than 4,500 community alerts (sick and death) were made by SMAC community mobilizers through their community-based surveillance efforts, which included alerts called by SMAC-supported community champions, community mobilizers, and religious leaders.

¹⁴ The Community-Led Ebola Action (CLEA) methodology was developed by SMAC partners Restless Development and GOAL. It aims to empower communities to do their own analysis and take their own action to become Ebola free. CLEA triggers collective action by inspiring communities to understand the urgency and the steps they can take to protect themselves from Ebola (SMAC, 2014).