Community engagement in Ebola outbreaks in sub-Saharan Africa and implications for COVID-19 control: A systematic review

Objectives There is a paucity of systematic data on the specic roles community engagement played in preventing and managing the Ebola Virus Disease (EVD) outbreak in Sub-Saharan Africa (SSA). We assessed community engagement's role, benets, and mechanisms to understand its effect on EVD case detection, survival, and mortality in SSA. Implications for COVID-19 prevention and control were also highlighted. Methods We systematically searched for articles between 2010 and 2020 in databases such as MEDLINE and EMBASE. Study types included were randomised trials, quasi-experimental studies, observational studies, case series, and reports. show during the depended on the survival testimonials of risk perception, and community inclusion. Community-based interventions improved knowledge and attitudes, case ndings, isolation efforts and treatment.


Quality Screening
We assessed the quality of articles included using the Joanna Briggs Institute (JBI) Appraisal Checklist and the NIH 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, potential blinding of outcomes in the included studies, and further evaluated these studies to see if authors selectively reported positive or signi cant results and left out negative results. We also assessed the blinding of participants and personnel (patients and treatment providers) and checked to see if some participants knew the intervention or not. Finally, we evaluated studies to see if there was any proportion of subjects whose outcomes were not recorded at the end of the study because of follow-up loss.

Results
Of the 44 articles that were nally included, 19 were cross-sectional and observational studies, 13 were qualitative studies, 3 were pre-post studies with no control groups, 6 were quasi-experimental studies, 2 were opinion pieces that merited inclusion based on our qualitative assessment, and 1 was a metaanalysis as illustrated with the PRISMA table in Figure 1.  Table 1 here A summary of the frequency of these interventions as reported in different studies and the countries where the interventions were implemented are illustrated in Table 2. Table 3 summarises the main factors that impacted the level of community engagement during Ebola response efforts. Some of the key factors that in uenced community involvement were the survival rates of those who were infected (Nyakarahuka et  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 nding, and eventual isolation ( 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 signi cantly than if community mobilisation alone was conducted (Sharma et al., 2014). Also, community education and mobilisation interventions that combined reporting, case nding and isolation, education and training in hygienic burial practices produced better outcomes than when these interventions were deployed alone 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 eld 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 e cacy 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 nongovernmental entities to help stop epidemics. Private for-pro t 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 nancing. 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 nancial di culties, we can learn from the critical roles that community resilience played in attening the EVD epidemic curve.

Conclusions
Governments and international stakeholders should prioritise the goal of engaging community leaders and members before initiating any intervention. During quarantine, communities must have access to necessities such as food, water and medical services, as shown in ( 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 limitations. The overall quality of the studies included in this review was highly variable. Also, many studies had poorly described methods, making it challenging to evaluate biases such as social desirability bias and performance bias.
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. Lessons learned on community engagement during EVD outbreaks can be leveraged in ghting other attacks such as COVID-19. It is imperative to engage community members to execute community-based initiatives for pandemic preparedness and control.

Declarations
Con ict of Interest: The authors declare no con icts of interest.
Funding Source: This research did not receive any speci c grant from funding agencies in the public, commercial, or not-for-pro t sectors.
Ethical Approval Statement: This study was a systematic review and was exempt from ethics approval. The authors gathered and synthesised data from previous studies in which the respective investigators have already obtained informed consent.