1. Social and Behavior Change Communication: Insights from Multiple KAP Surveys in Sierra Leone
Mohamed F. Jalloh, MPH
Epidemiologist / Behavioral Scientist Ebola Affected Countries Office, Division of Global Health Protection Centers for Disease Control and Prevention

2. Worst Ebola outbreak in history…

3. Photo Credit: Dan Martin, CDC

4. Overview
Aug ’14
n=1413
Oct ’14
n=2087
Dec ’14
n=3540
July ’14
n=3564
First case of Ebola in Sierra Leone was detected in May 2014; population knew very little about Ebola
Conducted 4 cross-sectional surveys in SL
Multi-staged cluster sampling
2004 Census List of Enumeration Areas served as the sampling frame for random selection of clusters
In each cluster 20 households were selected using systematic random sampling
In each selected household, two interviews were conducted (HH head + woman/young person)
Data collected by trained teams (KAP-1 paper; rest on programmed tablets)
Collaborative effort by: SL MoHS, NERC, FOCUS 1000, CDC, UNICEF, and CRS

5. Summary of key findings
Overall - high awareness and knowledge of Ebola
Misconceptions regarding Ebola declined over time
Intentions to seek medical care improved over time
Attitudes toward safe burials improved over time
Discriminatory attitudes toward Ebola Survivors initially declined but persisted throughout the epidemic
August 2014: 9 in 10 respondents held at least one discriminatory attitude
October ’14 – July ‘15: 4 in 10 respondents held at least one discriminatory attitude
Self-reported protective behaviors improved

6. Multiple channels of receiving Ebola information…radio most popular
Exposure to info sources associated with correct knowledge and protective behavior
Strong dose-response
Strongest association found after the peak of the outbreak
Info exposure also associated with incorrect knowledge and harmful behavior (but with lower point estimates)

7. From Data to Action
KAP data used in real-time to inform various response efforts
National Soc Mob Strategy / Evaluation Framework
National Messaging Guide – “Act Against Ebola”
Big Idea of the Week
Community-led Ebola Action through the Social Mobilization Action Consortium
social mobilizers, religious leaders, traditional healers, radio stations
Highlighted need for supply side (e.g. ambulances) to meet created demand
Informed rapid behavioral assessments (RBAs) and other qualitative assessments

8. What we know… What we don’t know…
Behavior change is complicated and human behavior is not always rational
KAP data strongly suggest that behaviors changed in SL during the epidemic
Epidemiological data, call center data, and burial data, also suggest that behaviors changed
Changes in behaviors contributed to ending the epidemic
Social mobilization not scaled up in SL until after the peak of epidemic
Social mobilization more targeted and intensified in the active-transmission areas
How pathways of behavior change vary during the epidemic
Effect of social learning and intrinsic factors on behavior change
Effect of ‘Fear of loss’ on behavior (Loss Aversion Theory)
Effect of messaging framing (loss vs gain frame)
Relative effect of witnessing the impact of the epidemic versus messaging

9. What can we draw from health behavior theories, existing literature, and Ebola for SBCC during future epidemics?
Behavior change interventions are more effective when targeted at multiple levels of the social ecology – need to go beyond individual level to address interpersonal, community, and policy level factors as well
Messenger just as important as the message – need to identify influential and trusted messengers
Framing of messages can influence behavior change – need for rapid message testing (iterative)
Identification of gaps in knowledge, attitudes, and practices – feasible to conduct rapid KAPs, even in the midst of such a horrific outbreak