The SBC Working GroupWelcomes You to a Learning Session

on

Combatting Ebola and Similar Outbreaks with Social and Behavior Change Strategies

Global Health Practitioner Conference, Spring 2015Alexandria, Virginia

April 16, 2015

Combatting Ebola and Similar Outbreaks with Social and Behavior Change Strategies

Presenters

• Mathias Pollock, Mercy Corps• Suzanne Van Hulle, Catholic Relief Services• Maya Bahoshy, International Medical Corps• Janine Schooley, Project Concern International

Moderator

• Paul Robinson, International Medical Corps

Emergence of Ebola:

1976-Yambuku, DRC

1976, 79—Nzara, S. Sudan

1977-Tandala, DRC

Group process – 15 minutes1. Jot down one idea of what you think is effective

as SBC initiative for addressing Ebola and similar outbreaks in the futurea) One idea only, please!b) Use one page from note pad on your table and c) Write legibly please

2. Discuss your one idea with your table mates

3. Refine/change your idea if you think necessary

4. Turn in your idea sheet to a volunteer nearby

Saving and improving lives in the world’s toughest places.Saving and improving lives in the world’s toughest places.

Obstacles to Case Reporting

A barrier analysis study of timely reporting of symptomatic family members by heads of households in Montserrado County, Liberia

Global Health Practitioners Conference

April 16th, 2015

Mathias Pollock, Technical Advisor

Saving and improving lives in the world’s toughest places.

E-CAP PROGRAM OVERVIEWObstacles to Case Reporting

Saving and improving lives in the world’s toughest places.

BARRIER ANALYSIS SUMMARY

- Rapid evaluation, mixed-method tool

- Identifies key determinants of behavior

- Perception-based

Obstacles to Case Reporting

Barrier Analysis: What is a determinant? (Food for the Hungry)

Saving and improving lives in the world’s toughest places.

STUDY PARAMETERSObstacles to Case Reporting

• Behavior: Timely case reporting

• 99 individual interviews

(44 Doers and 55 Non-doers)

• 5 Montserrado communities

(New Kru Town, West Point,

Gardenerville, Mount Barclay,

Brewerville)

• Data collection conducted Feb 16th – 18th

Rapid Research Team collecting data in Brewerville (photo: Mercy Corps)

Saving and improving lives in the world’s toughest places.

SELF-EFFICACYObstacles to Case Reporting

WHAT MAKES/WOULD MAKE IT EASY TO REPORT?

41

5

43

7 7

70

7

2520 25

53

11 11

89

713

0

20

40

60

80

100

Pe

rce

nt

resp

on

se

Doers %

NonDoer %

Saving and improving lives in the world’s toughest places.

POSITIVE CONSEQUENCESObstacles to Case Reporting

What are the good things that happen when you report?

52

34

43

20

47

3127

5

0

10

20

30

40

50

60

Patient will getearly Tx

Higher chance ofsurvival

Protectothers/community

Reduce spread ofEbola

% Doers

% Non-Doers

Saving and improving lives in the world’s toughest places.

SOCIAL NORMSObstacles to Case Reporting

WHO DISAPPROVES OF YOU REPORTING?

59

5

16

47

27

18

0

10

20

30

40

50

60

70

Nobody Friends & Neighbors Family members

% Doers

% Non-Doers

Saving and improving lives in the world’s toughest places.

11

25

64

2033

47

0

20

40

60

80

100

Verydifficult

Somewhatdifficult

Not difficult

Access

% Doers % Non-Doers

OTHER SIGNIFICANT DETERMINANTSObstacles to Case Reporting

511

82

1325

60

0

20

40

60

80

100

Very difficult Somewhatdifficult

Not difficult

Cues to Action

Saving and improving lives in the world’s toughest places.

RESULTS SUMMARYObstacles to Case Reporting

• Community leaders (CL) play a critical role but some people have problems accessing them

• Doers perceive “protecting others” and “avoiding the spread” as key motivators for reporting (preventive community altruism)

• Non Doers perceive “friends and neighbors” as disapproving of reporting to #4455 or CL

• Non Doers perceive difficulty in accessibility (lack phone/network)

• While messaging is working, some people are still forgetting to report

ECAP poster targeting holistic community action (photo: Mercy Corps )

Saving and improving lives in the world’s toughest places.

PROCESS LEARNINGObstacles to Case Reporting

Appropriate community entry

Power of stigma

Working w/ local leaders

We have as much to learn from the communities where

we work as we do to teach them!

“Listen, Learn, Act”

Learning to wash hands in Ebola-time (photo: Mercy Corps)

Saving and improving lives in the world’s toughest places.

LIMITATIONSObstacles to Case Reporting

• Limited geographic area

• Relaxed behavior statement

• Survey fatigue

• Time constraints

A survivor educating people about the harmful effects of discrimination. (photo: Mercy Corps)

Saving and improving lives in the world’s toughest places.

PROGRAM RECOMMENDATIONSObstacles to Case Reporting

• Establishing community selected volunteer committee to increase reporting to CL

• Host palava hut conversations with survivor testimonials to dissipate stigma among community members

• Create community maps to identify homes with functioning cell phones in case of emergency

Saving and improving lives in the world’s toughest places.

POLICY RECOMMENDATIONSObstacles to Case Reporting

• Focus on community mobilization from onset of emergencies

• Present messaging through holistic community lens

Community educators for the Center for Liberian Assistance mobilize for a community outreach activities. (photo: Mercy Corps)

Saving and improving lives in the world’s toughest places.

NEXT STEPS

E-CAP II

Follow up barrier analyses (stigma)

Photo voice survivor stories

Obstacles to Case Reporting

The Liberia Crusaders for Peace. (photo: Mercy Corps)

Saving and improving lives in the world’s toughest places.

Obstacles to Case Reporting

CONTACT

Technical Advisormpollock@dc.mercycorps.org

Mathias Pollock, MPH

Thank you for your attentionQuestions?

Rapid Research Team: Marion, Prince, Eunice, Chris, Hermenia, and Marcus

CRS’ Social and Behaviour

Change tools for EVD

prevention

Suzanne Van Hulle & Annisha Vasutavan

Catholic Relief Services

Phases in the Sierra Leone Ebola Response

Phase 1: Learning

Phase 2: Alarm

Phase 3: Acceleration

Phase 1: Learning

Phase 2: Alarm

Phase 3: Acceleration

Comparing SBC activities and

Prochaska’s Stages of Change

Early

Response

Phase

SBC activities Prochaska’s Stage

of Change

1: Learning Public education using

mass media

(IEC materials – Posters,

Pamphlets, Banners, Radio

Discussions, Radio Jingles,

etc)

Pre- contemplation

Early

Response

Phase

SBC activities Prochaska’s Stages

of Change

2: Alarm 1. Community led activities of

positive reinforcement and

social support (district level

authorities working together

with traditional leaders).

2. Public education using mass

media (IEC materials – Posters,

Pamphlets, Banners, Radio

Discussions, Radio Jingles, etc)

1. Preparation/

Action for

initially affected

areas

2. Pre-

contemplation for

newly affected

areas

ER Phase SBC activities Prochaska’s Stages of

Change

3: Acceleration Focus of social mobilization is on

DIALOGUE, targeting influential

change agents .

Activities:

Stakeholder dialogue sessions

with community level change

agents

Training for religious leaders,

traditional leaders, societal

heads etc.

Community dialogue sessions

with representation for a variety

of community members.

Preparation/Action

Case study: Koinadugu District

CRS SBC activities to promote proactive measures to prevent

the EVD outbreak in Sierra Leone

What went well?

• Last district in Sierra Leone to record EVD cases

(mid-October 2014)

• To date, is the district with the 2nd lowest number of cases

in the outbreak (108 cases in total).

KAP Survey Findings – Knowledge of EVD

0102030405060708090

100

Koinadugu

Other districts(Avg %)

0

10

20

30

40

50

60

70

80

90

Handwashing(Soap &Water)

Avoidingphysical

contact withsick people

Participated ina funeral or

burialceremony inthe previous

month

Koinadugu

Other districts insampled in NorthernProvice(Avg %)

KAP Survey Findings –

Prevention behaviors/Behavior change

Challenges

One dimensional interaction

No forum for people to challenge beliefs and ideology

(27.7% of Koinadugu respondents believed that bathing in

salt and hot water can prevent Ebola, & 9.2% believed

that spiritual healers could successfully treat Ebola.)

Weaknesses in early

social mobilization strategies

Shift in CRS’ SBC strategy in the Acceleration phase

Sharing knowledge with communities

Engaging in dialogue

Understanding how various community groups communicate & share information

Understand barriers and motivating factors for certain key behaviors

CRS’ revised SBC strategy:Stream 1:

Community Level Social Mobilization through Influential

Community Change Agents

Identification and training

of community level change agents to be lead trainers

in their respective chiefdoms /districts

Each lead trainer to cascade

training to a further 30

community level change

agents

Community level change

agents to integrate behavior change

messaging in

community level

mobilization sessions

Conduct open

dialogue sessions at community

level to share

experiences

CRS’ revised SBC strategy:Stream 2:

Social Mobilization Rapid Response Teams (RRTs) to carry out SBC activities at

community level

CRS social mobilizers trained on community

engagement, social

mobilization tool kit,

deployment activities, etc

Standard Deployment

10 day blocks in the

field

Emergency Deployment

3-7 days deployment

based on size of

affected community

RRT conduct H2H

sensitization and

community structure

engagement using CRS

Soc. Mob

tool kit

RRTs to conduct regular

community follow ups to check on progress in behavior change

practices

CRS Rapid Response Teams

CRS Social Mobilization Toolkit

Features

Low literacy friendly

Images set in the local context and local languages

Prompts discussion with audience

Focuses on and reiterates (6) key messages through

out discussion

CRS Social Mobilization Toolkit

Rapid Response Team Field Protocol Guide

Video - “Ebola – A poem for the living”

Pictorial flipbook - “Ebola – A poem for the living”

Discussion guide for video and flipbook

Hotline cards – with district alert numbers

Poster

Flipbook

©2015 International Medical Corps

SBC and PSS:Hand in hand to address Ebola

From Relief to Self-Reliance

Maya BahoshyCORE Group GH Practitioner Conference, Spring 2015

All content in this document is the property of International Medical Corps UK and should not be reproduced without prior written consent. This material is protected by copyright. ©2015 International Medical Corps. Materials may not be reproduced without International Medical Corps’ prior written consent.

©2015 International Medical Corps

Our EVD Programming• Ebola Treatment Centers in Liberia (Bong and Margibi County) and

Sierra Leone (Lunsar, Makeni)• Screening and Referral Units in Liberia, Sierra Leone and Guinea• Multi-Agency Training Collaborative training center in Liberia for

healthcare staff from various agencies. Additional training centers in Sierra Leone and Mali.

• Rapid Response teams in Liberia, Sierra Leone and Guinea• EVD Preparedness and response expansion (Mali)• Donors: USAID/OFDA (main), DFID, CIFF, Gates, ECHO, Irish Aid,

Lumpking, Merck, Kaiser, BandAid,

©2015 International Medical Corps

Community Outreach Objectives

1. Address psychosocial needs

2. Support reintegration of survivors

3. Ensure local support and buy-in for ETC

4. Support rebuilding trust in health system

©2015 International Medical Corps

Key Findings/Barriers• To accessing ETC:

• To preventative behaviors:– Fear

– Denial

– Traditional beliefs

– Misconceptions about chlorine and sprayers

– Access to required materials

– Distance

– Perceived quality of treatment

– Mistrust

– Fear of death

– Low action efficacy

– Misconceptions about Ebola

– Poor communication with patients

©2015 International Medical Corps

Community Outreach strategy• Phase 2:

– Trained PSS/SBC dual outreach team

– Increased community engagement

– Key behavior change activities

• Phase 1:

– PSS team

– Needs assessment

– Reactive - pickups

©2015 International Medical Corps

Activities

• Program Launch

• Participatory Data Collection

– Mapping

– Seasonal Diagram

• ETC visits

©2015 International Medical Corps

Activities• Use of survivors for

increased access

• Radio programming

• Continual reflection

©2015 International Medical Corps

Lessons Learnt/Recommendations

• Invest in two way dialogue

• Involve the community and key stake holders from the start

• Ensure cultural appropriateness wherever possible

• Remain dynamic

©2015 International Medical Corps

Lessons Learnt/Recommendations

• Consider the psychological needs and abilities of the target population

• Strengthen the capacity of PSS staff on SBC approaches

• Further research

©2015 International Medical Corps

Thank you

Maya Bahoshy

Social & Behavior Change Officer

mbahoshy@internationalmedicalcorps.org

Janine Schooley

Senior VP Programs, PCI

CORE

Spring Meeting Apri l 2015

CARE GROUPS IN THE

CONTEXT OF EBOLA

In 2010, PCI and ACDI-VOCA (prime), received $40 millionfrom USAID for a 5 year, Title II DFAP for Liberia.

The Liberian Agricultural Upgrading Nutrition and Child Health (LAUNCH) program is designed to increase access to food, reduce chronic malnutrition, & increase access to improved livelihood & educational opportunities in Bong & Nimba counties.

BACKGROUND

PCI is responsible for 2 of 3

Strategic Objectives (SO):

SO2—Reduced Chronic

Malnutrition of Vulnerable

Women & Children

SO3—Increased Access to

Education Opportunities

Care Groups are the primary

platform through which PCI

works to achieve SO2.

There are a total of 158

Care Groups & about 1400

CGVs (i.e. Lead Mothers)

reaching a total of 402

communities.

CARE GROUPS IN LAUNCH

Initial outbreak of Ebola in Liberia with cases coming

from Lofa, a county bordering Sierra Leone & Guinea.

PCI began basic Ebola awareness with Care Groups, using

no additional materials, focused on :

1. Preparing dead bodies, a major risk for transmission

Traditionally Liberians bathe and plait the hair once someone

dies & then bury the dead in the yard with family.

2. Avoiding bush meat

3. No touching!

4. Hand washing

20-40 cases in Bong; 0 in Nimba.

TIMELINE OF EBOLA — MARCH 2014

PCI H&N staff served as “Promoters”, along with general Community Health Volunteers (gCHVs). At the time of the outbreak, staff received training from PCI’s Country Director.

Care Groups continued to meet normally, with CGVs conducting regular meetings and household visits, including basic messages about Ebola prevention as part of their regular meetings.

During this first wave LAUNCH became a member of the National Ebola Task Force &the Case Management sub-committee providing logistical and technical support to the initial training of health workers throughout the country.

CARE GROUPS — MARCH - MAY 2014

The second wave of the epidemic precipitated a consolidated response at the community, district, county & national levels which took precedence over all project health -related initiatives.

Monrovia was hit hard; Six counties exploded with cases including Bong & Nimba.

Nurses, Doctors & Health Care Workers began dying. People started to panic. Health clinics began closing.

In June, the Ministry of Health and Social Welfare ( MoHSW) suspended all non-Ebola related training & travel so that core MoHSW staff could focus solely on the Ebola response.

Care Group activities continued in the communities sharing the same basic Ebola information along with regular lesson plans.

TIMELINE OF EBOLA — JUNE/JULY 2014

The President declared a national State of Emergency in

August, prohibiting public meetings, closed central markets &

sealed international borders impacting food security &

instituted a national curfew.

LAUNCH program—all non-Ebola activities were put on hold;

food distributions ceased, no large gatherings were allowed.

PCI staff remained & by mid August activities were 100%

focused on the Ebola response.

TIMELINE OF EBOLA — AUG/SEPT 2014

PCI contributed to the

development of an Ebola

training guide for staff, based

on WHO & MoHSW training

guidelines.

Training materials were

produced by UNICEF & the

MoHSW for the gCHVs.

PCI printed and bound 4,000

copies as it was a perfect tool for

CGVs.

Tool included signs & symptoms,

how Ebola is spread, what to do

when a family member has Ebola,

etc.

CARE GROUPS — AUG/SEPT 2014

Care Groups in LAUNCH are 8-10 CGVs, a per fect size for continued trainings during Ebola.

CGVs were key in terms of educationto community members, distr ibutionof hand washing buckets, etc.

CGVs protected themselves from Ebola when making household visits.

Not touching anyone (including shaking hands, kissing, hugging), washing their hands with soap or disinfectant after each household, standing at a distance from others, avoiding contact with those who are sick, etc.

Care Groups al lowed us to be in the communit ies & stay connected, relevant & useful throughout when many projects & program activit ies couldn’t continue .

CARE GROUPS — AUG/SEPT 2014

PCI held community video shows on

Ebola. Special permission was

granted to show after curfew. CGVs,

along with gCHVs, led Q&A.

CGVs & gCHVs, supported families

who were quarantined & isolated.

Brought water & food

Helped with farming

By the end of Sept all LAUNCH

communities were mobilized &

educated. Everyone had hand

washing buckets & bleach &

everybody knew Ebola was real.

CARE GROUPS — AUG/SEPT 2014

CONTINUED

Stopped focusing fully on Ebola as staff realized Ebola education only wasn’t sufficient & other issues were also important.

CGVs reviewed old modules (ENA, Maternal Care, etc.)

CGVs focused on nutrition education including the preparation of a local CSB substitute.

PCI began working with the DHO to re-open clinics in Bong.

ANC services are now up & running in all health facil ities in Bong & Nimba. CGVs were key in reestablishing l inks between health facil ities & communities.

LAUNCH commodity distribution began again in October.

CARE GROUPS — SEPT/OCT 2014

The Care Group model is adaptable & flexible, able to be responsive to changing contexts & needs of communities.

PCI successfully used the Care Group approach in reaching & identifying the most vulnerable (both in terms of those at r isk for contracting Ebola, as well as pregnant & lactating women , elderly/disabled, those who lost their caregivers & others who struggled to access regular health services) during the emergency.

PCI has reached over 150,000 community members with Ebola education & prevention messages through the use of Care Groups .

The training of staff working with Care Groups lends itself to the successful use of Care Groups in Ebola as they are already trained in facilitation and outreach – critical in Ebola response.

Care Groups contributes to a full cycle approach, covering Ebola from the community awareness stage all the way to the Ebola Treatment Unit (ETU) level & then re-entering people back into the communities.

CONCLUSIONS

CGVs have been key to the Ebola response! To date, no PCI staff & CGVs

have contracted Ebola.

They are now taking up the task of helping communities adapt & meet the needs of the growing orphan population.

Helping with “re-entry”, minimizing stigma & discrimination of survivors.

Their messages/education & support on Ebola reached men, children, others in the community.

They have been the programming thread throughout!

THANK YOU!

JSCHOOLEY@PCIGLOBAL.ORG

feedthechildren.org

Hot off the press…• The Ebola Viral Disease Care Group Lesson Plans AND

Flipchart (draft for testing) is now available!

Questions & Answers – 10 minutes

• Keep your questions/comments REAL short and sweet

• This is important since we have only a very short time for the next activity – Group Process

Group process – 15 minutes

1. Jot down one idea of what you can do in your organization as SBC initiative to address Ebola and similar outbreaks in the futurea) One idea only, please!b) Use one page from note pad on your table

2. Discuss your one idea with your table mates

3. Refine/change your idea if you think necessary

4. Turn in your idea sheet to a volunteer nearby