Integrating Social & Behavior Change for Disaster Preparedness, Response, and Recovery -- Meyer and Nijiru

1. J E A N M E Y E R C A P P S , B S N M P H
H A R O N N J I R U , M P H
COMMUNITY ODF STATUS AND EBOLA VIRUS DISEASE
(EVD) IN
LOFA COUNTY, LIBERIA

2. BACKGROUND
• The need to measure health impacts of WASH interventions
long recognized
• At the time, scientific evidence-base of impact of CLTS on
health was weak in spite of abundant empirical observations
• Community-based EVD prevention had not been studied prior
to the outbreak
• Project was not designed for research, but provided some
opportunities to compare differences between CLTS and non-
CLTS communities

3. IWASH
• Funded by USAID and implemented by NGO
(Global Communities) with Government of Liberia
(GoL)
• CLTS in last two years of 4-year project
• New CLTS activities ended with the Ebola outbreak
in early 2014

4. CLTS IN IWASH
• Liberia has a formal CLTS protocol (developed with
iWASH assistance).
• EVD outbreak before larger communities could be
“triggered”
• 98 of 115 communities “triggered” for CLTS became
ODF and validated by GoL

5. EBOLA (EVD) IN LOFA COUNTY
• Entered Liberia through
an adjoining district in
March 2014
• 928 reported EVD cases,
648 EVD-attributed
deaths
• NL had, reported no EVD
deaths in ODF
communities, but deaths
in non-ODF communities

6. PURPOSE
In early 2015, WHO called for documenting Lesson Learned from
community experiences with EVD in Lofa County
This study sought to:
• 1) validate claims of no EVD cases in CLTS ODF communities
• 2) determine if CLTS-specific interventions were the likely
explanation of differences
• 3) control for possible confounders
• 4) Identify areas for additional study

7. METHODOLOGY
Retrospective study where CLTS was implemented by iWASH
prior to epidemic
• Literature and Data Review
• Household Survey
• Key Informant Interviews (KII)
•
• Focus Group Discussion (FGD) both genders (14 EVD and
Non-EVD communities)

8. HOUSEHOLD SURVEY
• 551 Household Interviews in local languages,
including all tribes, religions and clans
• Cross-sectional
• Community size and proximity to Ebola and ODF communities considered
• Households per community: proportionate
• Sampling
• Communities: simple random sampling
• Individual HH: systematic random sampling

9. GEOGRAPHICAL DISTRIBUTION OF
HOUSEHOLDS
Communities
already
identified
Voinjama
District
260
Households
23
Communities
Kolahun
District
291
Households
20
Communities
Number of households studied = 551

10. FINDINGS
Non-beneficiary
Households
n=312

11. IWASH/CLTS INFLUENCE ON RESULTS
54.2%
45.8%
91.5%
8.5%
No NL training NL training
No Ebola Got Ebola

12. HOUSEHOLDS USING A LATRINE
61%
47%
69%
29%
22%
0%
10%
20%
30%
40%
50%
60%
70%
80%
ODF no Ebola CLTS + Ebola CLTS no Ebola nonCLTS + Ebola NonCLTS no Ebola
Households(%)
Intervention

13. ODF COMMUNITIES SAID THEY WERE PRACTICING
PROTECTIVE BEHAVIORS PRIOR TO THE OUTBREAK.

14. QUALITATIVE FINDINGS
• No differences in responses ranking trusted Ebola
info sources: radio, NGOs, health workers, etc.
between communities
• EVD communities said denial or ignorance of Ebola
as a “real” disease made them resist early
information about prevention and response.

15. ANALYSIS
• No cases of EVD in ODF communities
• CLTS communities (“triggered” but not validated as
ODF) were 17 times less likely to have cases of EVD
• Diarrhea, intestinal worms and ringworm prevalence
lower in ODF communities
• Strong inverse correlation between CLTS/ODF and EVD
(R = - 0.6)
• Strongly infers that the CLTS effect not due to chance.

16. LESSONS LEARNED
• The community must take the initiative and sustain the effort with their
own resources
• NL network developed through CLTS guaranteed trusted linkages to
individual communities
• Communities develop their own ways to sustain behaviors (e.g. “fines”)
• Partnership with GoL and traditional leadership led to acceptability
• The GoL CLTS methodology (developed with GC technical assistance) is
sound for the Liberian context.
• Monitoring throughout the process was very important for successful ODF

17. • How can lessons learned be incorporated into both WASH
and community health programs?
• Where are the appropriate integration points in national
programs (health, public works, etc.?)
• What were the key factors?
• Improved communication channels?
• Resilience?
• Can “Trust” between communities and responders be measured?
• Will “enthusiasm” be maintained?
• Are CLTS communities "positive deviants”?

18. IMPLICATIONS FOR FUTURE PROGRAMS
• Good foundations based on communities’ own met
needs are an effective basis for public health
emergency response
• Strong CLTS protocols and validation (“no
shortcuts!”) extremely important
• Effective government-NGO implementation
partnerships important

19. RECOMMENDATIONS FOR WASH AND
HEALTH PROGRAMS
• Disease prevalence (CDD, etc.) baseline studies
and final studies are needed to confirm CLTS and
other WASH interventions impact on health
• Public health and WASH disciplines need a
common language and indicators for stronger
programming and measurement
• More dialogue between disciplines is needed

20. WAY FORWARD
• CLTS/ODF is only the “first step” of the Sanitation
Ladder. (Does nothing for access to clean water)
• Better coverage of access to clean water still
needed to increase WASH impact on health
• Women’s involvement as CLTS implementers
needs more emphasis; Literacy as a criteria is a
barrier in NL selection. Lessons from MNCH
programs can be applied to overcome gender
barriers

21. Q U E S T I O N S ?
THANK YOU!