A Model for Engaging Communities in Infectious Disease Prevention and Control in Informal Urban Settlements: Lessons from Ebola

The 2014 Ebola outbreaks in Freetown, Sierra Leone and West Point, Liberia, cast in stark relief the critical, yet often neglected, role of informal urban settlements at the intersections of place and health, particularly in... [ view full abstract ]

The 2014 Ebola outbreaks in Freetown, Sierra Leone and West Point, Liberia, cast in stark relief the critical, yet often neglected, role of informal urban settlements at the intersections of place and health, particularly in infectious disease prevention and control (IPC). When informal settlements are discussed in relation to disease outbreaks, the understandable focus is on the deep poverty, crowding, inadequate health infrastructure and related factors making urban slums ripe for public health emergencies. As the Ebola outbreaks illustrated, however, a missing link in disease control in informal settlements often lies in the failure to adequately apply principles of community engagement. These include the early, active and sustained involvement of affected communities, and their trusted leaders, networks and lay knowledge, in helping inform more socially and culturally appropriate IPC approaches.
We draw on experiences of health care workers and residents in Freetown and other urban settlements; organizations including CDC, WHO and the Infection Control Africa Network; and leaders in community engagement, informal settlement mapping, and infectious disease control, to present an eight step model for creating within informal settlements environments emphasizing reciprocal learning and trust, bidirectional communication, asset and risk mapping and planning for sustainability. We illustrate successful efforts including the engagement of traditional healers and their union in Freetown, during the last months of Ebola, to successfully break final transmission chains. We further illustrate how often minor adjustments to the IPC protocol, taking into account the “community protocol” (cultural values, customs and practices) were able to improve community receptivity and discourage harmful practice such as the hiding of ill family members.
We conclude with lessons learned for a more community-engaged approach to IPC in informal urban settlements, and efforts underway with WHO to test the model’s applicability to the prevention and control of measles and other infectious diseases.