Social Mobilization Lessons Learned: The Ebola Response in Liberia

“One of the key lessons learned during the first wave of the outbreak was that behavior and prevention must be considered alongside biomedical approaches, and messaging must consider the context and impact of messaging on populations.”

The primary aim of this report is to document and analyse the key social mobilisation efforts that contributed to the response during the 2014–2015 West African Ebola outbreak. More specifically, the report looks at the work of the Ebola Response Social Mobilization Pillar, one of six technical working groups/pillars that were established as part of the Incident Management System (IMS), which included: case management, contact tracing, safe burials, surveillance, laboratory, and social mobilization, each with clearly defined lines of authority and accountability within the system. The report highlights what worked, some of the challenges, as well as lessons learned from the social mobilisation response, which was considered key to the overall Ebola outbreak response.  The report is based on key Ministry of Health (MOH) and partner documents (published and unpublished), journal articles, partner blog posts, interviews with key stakeholders, data collected through MOH and partner activities, and analysis of project documents.

The body of the report is divided into two sections. The first four chapters of the report give an overview of the state of Liberia’s health system, which was still being rebuilt after two long and destructive civil wars when the outbreak occurred. It looks at how social mobilisation activities, such as door-to-door campaigns, radio shows, and other community initiatives, were utilised to share and distribute MOH-approved messages and materials and to help to create and support focused dialogue within communities. Some of the projects and approaches highlighted in the report include the adaptation of CONCERN Worldwide’s Care Group model, the Ebola Community Action Platform (ECAP)’s utilisation of ECAP/PSI’s Listen! Learn! and Act! methodology, the Health Communication Capacity Collaborative (HC3) and Internews’s DeySaySMS Rumor Tracker, HC3/CCP’s Bridges of Hope toolkit, and the MENTOR Initiative’s three-level approach for social mobilisation in Monrovia. The first section of the report also looks at how the Ebola Response Social Mobilization Pillar fits in with the whole response system, and how it is structured into different working groups that have distinct roles relating to communication and media.  The importance of social mobilisation research, monitoring, and evaluation activities is highlighted, such as assessing the need for social mobilisation in hot spot areas to identify problems, gaps, and solutions.  

The second half of the report identifies the success factors, key challenges, and lessons learned from the outbreak, as well as recommendations for preparedness activities moving forward. The following were identified as factors that worked well: 

1. Establishing Systems and Structures for Partner Coordination at the National Level - The establishment of the social mobilization (SM) pillar and structure facilitated a more systematic way of planning and monitoring activity and progress that supported greater clarity and precision in reporting to the Incident Management System (IMS), and made it possible for convening partners to implement community-based activities and channel their support for health promotion and social and behavior change communication (SBCC).
2. Community Engagement and Empowerment - The engagement of community leaders—chiefs, traditional healers, Zoes, prominent traditionalists, religious leaders, and women and youth leaders—was instrumental in educating communities and residents, increasing understanding and widespread acceptance of Ebola procedures by key community leaders, and developing a greater connection between chiefs and health officials in all areas where there was training, including the collection and exchange of contact information.
3. Use of Innovative Approaches/Methodologies for Community Mobilisation - These appoaches and methodologies are discussed in the first section of the report and are briefly mentioned above.

The report outlines some of the challenges which included: partner coordination and communication; local partner engagement; community resistance or challenges working in communities; limited research/data from the field; logistical/financial constraints, and working in difficult terrain/challenging environments. For example, in relation to coordination, the report explains that, as more implementing partners arrived to provide support, a significant concern was how to best coordinate partner approaches, particularly messaging. Organisations had multiple - and sometimes differing, conflicting, and/or duplicative - messages and approaches to helping. This situation occurred at the national, county, and even at the district levels, and harmonisation of these efforts was an ongoing challenge.

The report discusses lessons learned emerging out of the research, which are just briefly listed here:

1. Community Engagement and Ownership Are Key
2. Utilize Ebola Survivors in Social Mobilization and Community Activities
3. Invest in Capacity Building of Community Structures and Systems Strengthening at All Levels
4. Systematic, Sustainable, and Targeted Approaches Work
5. Develop Standards for Incentives for Community Work
6. Coordination and Communication Are Essential in an Emergency Response that Requires Constant Adaptation
7. Facilitate Two-Way Communication with Communities
8. Work in Collaboration with the Local Media
9. Deliver Consistent Messages and Do Not Oversimplify

The following is a list of the recommendations for preparedness activities moving forward, which are only briefly touched on here:

1. Maintain Clear and Consistent Messaging - Positive reinforcing messaging is more effective for facilitating desired behaviour change than fear-arousing messages. Also, it is crucial to emphasise the importance of standardised consistent information that addresses community concerns and answers the questions “why” and “how.” For example, a significant challenge in the early days of the outbreak was convincing the population to believe messages that stated that one could survive Ebola. The first messages exclaiming that “Ebola Kills” frightened the population, making it considerably more difficult to gain their trust when the messages changed.
2. Establish Clear Channels for Communication - If possible, provide a deeper explanation of disease prevention in the context of germs and transmission, not just “don’t touch.” Community surveys have found that many people believe that hugging or handshaking is what caused/transmitted Ebola. They did not understand that it is not the act of hugging that transmits the disease, but the fact that the other person is sick and contagious.
3. Support Continuous Community Engagement - Community engagement should be a continuous activity, not one limited to only emergency situations. It is important to have a functional early warning system in place, so that when emergencies occur, they can be addressed and managed quickly and effectively. This system should include disease surveillance.
4. Promote Key Preventive Behaviours in Community - The promotion and support of key preventative behaviours is important for long-term disease prevention and should not be limited to outbreak situations. Supportive mechanisms for prevention must be in place, from the provision of water and sanitation in schools and communities to special health education programmes in schools. Without these efforts, it is more difficult to underscore the value of handwashing and other hygiene behaviours and to encourage their continuation.
5. Set Up Effective Reporting and Data Systems - For example, quantitative reporting could enhance the appreciation for social mobilisation and health promotion activities because it puts this aspect of the response on a common footing and into a common language with other functions, such as epidemiology.
6. Build Capacity of the Local Media - Consistent investment in local media capacity must go hand in hand with all other efforts on the road to recovery, stability, and preparedness in the region.
7. Improve Partner Coordination and Communication - For example, coordination and communication should run through the MOH, and the National Health Promotion Division (NHPD) needs to be visible and vocal in taking a leading role in advocating for the establishment of social mobilisation and community engagement structures. Also, knowledge and information must be shared and agreed upon. Terms, such as “social mobilisation,” “community engagement,” and “health promotion,” should have agreed-upon definitions that are correctly and consistently used.
8. Establish Risk Communication System/Protocols - Develop a risk communication/preparedness communication strategy or plan, establishing an early and clear intervention plan for different line ministries that uses intersectoral approaches at community, institutional, and government agencies, creating a network for communication, supervision, and coordination.
9. Facilitate Strategic Cross-Border and Inter-Cultural Activities - Organise intercultural forums amongst stakeholders from Guinea, Liberia, and Sierra Leone to synchronise cross-border prevention coordination.