Rural populations exposed to Ebola Virus Disease respond positively to localised case handling: evidence from Sierra Leone

Abstract

At the height of the Ebola epidemic in Sierra Leone in November 2014, a new decentralized approach to ending infection chains was adopted. This approach was based on building local, small-scale Community Care Centres (CCC) intended to serve as triage units for safe handling of patients waiting for test results, with subsequent transfer to Ebola Treatment Centers (ETC) for those who tested positive for Ebola. This paper deals with local response to the CCC, and explores, through qualitative analysis of focus group data sets, why communities see CCC in a positive light. The responses of 562 focus group participants in seven villages with CCC and seven neighbouring control villages without CCC are assessed. These data confirm that CCC are compatible with community values concerning access to, and family care for, the sick. Mixed reactions are reported in the case of \"safe burial\", a process that directly challenged ritual activity seen as vital to maintaining good relations between socially-enclaved rural families. Land acquisitions to build CCC prompted divided responses. This reflects problems about land ownership unresolved since colonial times between communities and government. The study provides insights into how gaps in understanding between international Ebola responders and local communities can be bridged.\n\nAuthor SummaryControl of Ebola Virus Disease requires facilities where patients can be isolated and treated safely, without risk to medical personnel or family members. In the 2014-15 Ebola epidemic in Sierra Leone emphasis was at first placed on large field hospitals known as Ebola Treatment Centers (ETC). These were often located far from areas where new cases were being discovered. Patients were distrustful of their purpose and slow to report, and the disease continued to spread. Six months into the epidemic a new approach was tried, based on much smaller and more rapidly constructed centres (Community Care Centres (CCC) located where new cases were occurring. This paper examines community reactions to the CCC. There was a much greater sense of community ownership of these small, localised centres, and reporting times improved. Families were able easily to visit and observe activities, even though restricted from crossing red lines. The staff were often local and provided trustworthy information on the progress of patients. Families were able to prepare home food for patients, and this was thought to improve their morale and chances of survival. CCC were also appreciated for treating other disease, and not only Ebola. Referral of patients to ETC was easier to accept when the outcome of an Ebola blood test was known. There were some differences of opinion over \"safe burial\" procedures and acquisition of sites for the CCC, but on balance CCC were well accepted by communities, and were seen locally as a positive development in Ebola control.