We found that community-based interventions such as community education and mobilisation, survivor reintegration programs, and community-based surveillance systems helped to improve case finding, isolation and treatment as shown in (Reaves et al., 2014; Williams et al., 2015; Li et al., 2016; Fallah et al. 2016). Moreover, community-based interventions improved knowledge, attitudes, and behaviours towards EVD response efforts and helped flatten the EVD epidemic curve (Sepers et al., 2019; Hagan et al., 2015; Jiang et al., 2016). Factors such as survival rates of those infected, testimonials of survivors during their re-integration, risk perception of EVD, and the role of local leaders in garnering community trust helped ensure effective community engagement (Reaves et al., 2014; Carter et al., 2017). In addition, we found that proximity to a healthcare facility, clarity in communication, engagement of community members in safe burials, bottom-up government approaches, donor-community collaborations, level of satisfaction with the EVD response (Kasereka et al., 2019), acceptance or denial of biomedical discourse (Kasereka et al., 2019), and community resilience were also associated with whether any of the community-based interventions we reviewed were successful or not (Reaves et al., 2014; Okware et al., 2015; Capps et al., 2017; Masumbuko et al., 2019; Stone et al., 2016).
Our findings suggest that community-based interventions focused on community education and mobilisation are effective in improving early case detection, isolation, treatment, and significant positive changes in EVD knowledge and attitudes among community members (Reaves et al., 2014; Sepers et al., 2019, Blackley et al., 2015; Hagan et al., 2015; Williams et al., 2015, Li et al., 2016; Fallah et al., 2016; Jiang et al., 2016).
Survivor reintegration programs, jointly championed by community members and private partners such as Firestone Liberia, Inc., also markedly contributed to successful control of EVD outbreak (Reaves et al., 2015; Carter et al., 2017). The return of survivors and the testimonials of excellent Ebola Treatment Unit care that they received were critical in engendering community trust and social mobilisation. In particular, the role of survivor integration efforts in health promotion was even more prominent in countries like Sierra Leone, where survivor testimonials were deemed more effective communication tools than those of the mass media seen by community members as top-down and imposed.
Community-based surveillance systems also helped improve alert reporting, case finding, and eventual isolation (Tiffany et al., 2016; Ratnayake et al., 2015; Sacks et al., 2015; Kasereka et al., 2019). Although, in some instances, these generated false alerts (Ratnayake et al., 2015; Sacks et al., 2015). For example, in Sierra Leone, community-based surveillance helped detect EVD cases even though it produced a side effect of false alerts (Sacks et al., 2015).
These interventions can be scaled-up considerably at the community level to target vulnerable populations such as those geographically remote communities and have unique cultural dynamics. However, such scale-up efforts may come with implementation and long-term sustainability challenges that should be accounted for in advance (Reaves et al., 2014; Sepers et al.,2019; Vinck et al., 2019; Dickmann et al., 2018).
We observed that the reported positive outcomes were much higher for almost all the interventions when there were more components. For instance, joint community mobilisation and palliative care helped to improve case detection and treatment, and a patient's odds of survival significantly than if community mobilisation alone was conducted (Sharma et al., 2014). Also, community education and mobilisation 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 (Blackley et al., 2015; Li et al., 2016). Similarly, the use of cell phones in conducting surveillance performed better than traditional community-based surveillance systems. It may be helpful as a supplementary tool to address the challenges of false alerts generated in conventional surveillance systems. Despite software and internet connectivity challenges, devices such as cell phones can help to improve data access and data collection and accelerate case death reporting (Jia and Mohammed, 2015).
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.42 Future implementation science studies should explore the efficacy of home-based care and its role in accelerating EVD diagnosis and isolation. (Fallah et al., 2014) found that contrary to initial concerns, no healthcare worker or household member of the patient treated at home got infected with the disease. In times of epidemics, this will be important in communities with unique cultural dynamics where infected community members may resist admission to treatment facilities. Such resistance to medical care will increase mortality rates for the infected and put the lives of the non-infected in jeopardy by increasing their risk of community transmission.
Partnerships between private companies and their operating communities, such as those between Firestone Liberia Inc. and community members in Firestone District, Liberia, could serve as a model for how other private companies can contribute to response efforts during epidemics. When the EVD epidemic broke out among some of their staff members and their communities, Firestone Liberia Inc. could successfully engage community members and quickly work with them to reduce EVD cases (Reaves et al., 2014). This shows that multilateral organisations like WHO are not the only non-governmental entities to help stop epidemics. Private for-profit companies also have a role to play. This is especially important given the limited funding available for control efforts in times of outbreaks (Sanogo, 2019).
Community resilience: 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 international community has at its disposal limited funding to implement control efforts. Yet, in the face of financial difficulties, we can learn from the critical roles that community resilience played in flattening the EVD epidemic curve. For instance, during the EVD epidemic, many resilient communities could adopt measures that enable them to support each other long before their health workers arrived (Hanefield et al.,2018). This was particularly important in rural and remote communities where geographic barriers delayed access to treatment. In some communities, resilience achieved through solid 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 (de Vries et al., 2016; Stone et al., 2016). Community resilience has historically proved important in preparing, implementing, and declining outbreaks such as the 1918 Influenza and the ongoing HIV/AIDS pandemic. Investing in initiatives that strengthen community resilience in rural and remote communities in sub-Saharan Africa before and during disease outbreaks may help save lives and be cost-effective.
Barely before the EVD epidemic could become a far thought, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causing coronavirus disease-2019 (COVID-19) emerged. 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 sub-Saharan Africa, where health systems are incredibly fragile. While the WHO currently reports that Africa remains the least affected continent with COVID-19, with 1.5% of the world’s cases, and 0.1% of globally reported deaths, there is no cause for celebration and complacency (Sanogo, 2019). This is because community transmissions are ongoing amidst limited testing capacity in most African countries, particularly in rural and remote communities (Paintsil, 2020). The EVD outbreaks provide a unique opportunity to leverage COVID-19 prevention and control lessons. Existing evidence argues that during the EVD outbreaks, international efforts in Liberia arrived after the epidemic had subsided. Much of the flattening of the epidemic curve was due to significant behavioural changes at the community level (Carrión Martín et al., 2016). In the same vein, community-based interventions should be prioritised as a part of COVID-19 control efforts, with community leaders leading the charge in engaging their community members and enacting bye-laws, where necessary. COVID-19 survivors should also be made a key component of such interventions. Their testimonies may help to engender trust between community members and healthcare workers and encourage health-seeking behaviours. This would minimise chances of community resistant events that may potentially arise in the absence of community engagement (Pronyk et al., 2016). Additionally, individual and communal quarantines during the EVD outbreaks 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 while community-led voluntary quarantine initiatives were successful (Capps et al., 2017).