Applying COMBI to Ebola Control in Yambio, Southern Sudan

This publication details the on-the-ground Communication-for-Behavioural-Impact (COMBI) strategies used with Ebola virus in Southern Sudan in April 2004. As described here: when the outbreak was detected, the World Health Organization (WHO) "Early Warning Alert and Response Network (EWARN) - a mechanism to identify, confirm and respond to suspected outbreaks within 24 to 48 hours - was set in motion. The District Commissioner very quickly set up a crisis management committee to oversee the response with four technical sub-committees: case management, surveillance, social mobilization and logistics/security. Members of the management committee included heads of county departments e.g. health, education, church and local government leaders as well as key agencies: WHO, UNICEF [United Nations Children's Fund], CDC [Centers for Disease Control and Prevention] and MSF [Médecins Sans Frontières]....

The social mobilization sub-committee coordinated the work of 21 social mobilizers - teachers, pastors, and volunteers with previous community mobilization experience of polio and measles campaigns." Posters were distributed to health centres, and letters and briefing papers were sent to all church and government leaders requesting their support.

A rapid situational analysis was carried out with listening exercises including key informant interviews and focus group discussions with the social mobilisers, health staff, surveillance officers, and local people in market places and churches. Information gathering included observation of daily lives that might identify: appropriate communication settings, channels, and influentials; trusted and credible sources of information; and ways to promote collective action.

There was agreement on a focus of 3 key preventative behaviours. The COMBI framework was used to develop an integrated multi-faceted mobilisation and communications strategy to be implemented by the existing social mobilisation team as described here:

"The COMBI blend of communication interventions:

1. Public advocacy/ mobilizing decision makers and administrative structures
   • Support was intensified from the county administration through the commissioner to chiefs and church leaders, requesting them to specifically focus on addressing distressing rumours.
   • Church leaders were requested to remind people of the key behaviours during their regular sermons during the crisis period and to let people know that they would be informed by the health authority as soon as the crisis was over and normal practices could be resumed.
   • The social mobilizers developed a rota of visits to all church denominations and spoke at the very large gatherings about the outbreak what was being done, the need for vigilance, collective action and the necessity of early reporting and diagnosis. It was also highlighted that care takers of sick people were particularly at risk.
2. Community mobilization
   • Meetings were held with chiefs and local communities, including traditional healers in areas with high numbers of potential cases. People were encouraged to ask questions and these were lively sessions. Ebola survivors also spoke and many questions were directed at them. 
   • When possible, following meetings, house-to-house mobilization was conducted. And in all cases, the mobilizers personally handed out information material which also gave them the confidence to approach individuals and provide a reason to engage others in "conversation".
   • Market places were also targeted with public address, leaflets and “conversations” by the mobilizers.
   • Teachers were provided with an orientation on Ebola control and posters for their schools. 
3. Personal selling (mobilizing local networks and advocates)
   • The social mobilizers were provided training in basic communication techniques, which covered verbal and non-verbal communication, answering difficult questions, and how to use the public address system. Previously, the microphone was kept inside the van which was a barrier to community members asking questions. Subsequently, the microphone was taken outside and given to others. The credibility of the social mobilizers was also being questioned as they were doing local shopping at the same time as conducting community dialogue. This practice was stopped, so they concentrated on the work in hand. Training was also provided to the mobilizers by the health staff where they could ask the questions they were being asked by communities that were not covered on the question-and-answer sheets they had been given. They were also taken to see the isolation ward (from the outside) and they could see for themselves the structure and the process so they could explain better any concerns that community members may have had.
   • They were provided with distinct T-shirts so people could easily recognize that they were part of the control efforts and were Ebola control team members. It enhanced their credibility in the eyes of communities as well  increased their self-confidence and pride in what they were doing.
   • Leaflets were produced and distributed in the local language. What was significant about them was that they addressed the most basic questions and rumours people had, it also had an artist’s drawing of the isolation ward so people knew what the isolation ward looked like and that the fence was low enough that families could see and talk to patients without touching. It also had photographs and testimonies of people who had been treated in the isolation ward for Ebola and had survived urging families to protect themselves and each other during the crisis.
   • Pastoral counselling from the local bishop was provided to families that had multiple deaths. This was about building empathy and allowing families to express and share their grief rather than being met with inquisitive questions and providing blood samples.
4. Promotional materials and advertising
   • Banners were placed in local market places, health centres and churches as triggers to remind people to be vigilant during the crisis period.
   • Evening announcements were carried out by the social mobilizers at a time when people had returned home from cultivating their land.
   • All materials were branded in one colour so that people could associate the colour with the control programme.  The chosen colour also traditionally meant hope and the coming of something good."

The document concludes with: "One of the major lessons learnt from Sudan in 2004 was that effective community and consumer engagement is the foundation for developing appropriate and relevant social mobilization/communication strategies and outbreak control interventions.

Communication is not about providing messages but is a process with an outcome (outbreak control) and therefore promotes a dialogue among all those involved in outbreak response beginning with affected community members.  Effective listening and engagement can help strengthen relationships, build trust, and enhance transparency. However, the real challenge is in how we respond to the information and insights provided through this process and transform them into appropriate actions. Once the outbreak ended, the local authorities had an official ceremony to acknowledge the efforts of those who were part of the response operations. Those who had died were remembered and local personnel were given certificates and thanked for their commitment and dedication."

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