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number of times each day. Furthermore, coordination of burial teams across 14 districts is needed. • To increase community acceptance of safe, dignified medical burials, it is recommended to make an important alliance with religious and traditional leaders in the community. • Because additional Ebola deaths cannot be avoided given the magnitude of the Journal of Health and Social Sciences 2020; 5,1:073-090 The Italian Journal for Interdisciplinary Health and Social Development 83 ongoing epidemic, burial teams can perform safe community burials when space is available for additional cemeteries. Social mobilization and community outreach interventions from NGOs A number of NGOs were dedicated to controlling the disease on the ground. Of these NGOs, MSF and Samaritan’s Purse were notable during the Ebola outbreak for their sacrifice and dedication. They were the pioneers who responded at the earliest stage of the Ebola outbreak while others were reluctant to respond or did not quite know what to do. A few days after Ebola was identified in March 2014, MSF opened an ETC in the town of Macenta, Guinea [32]. After Ebola patients had been identified in more than 60 separate locations across three countries—Guinea, Liberia, and Sierra Leone—Bart Janssens, MSF director of operations, warned that “the epidemic is out of control” and asked the WHO to deploy the massive resources necessary to contain the epidemic [66]. Social mobilization and community outreach programs were considered key components of increasing awareness of the Ebola virus and educating people about changing certain behaviors and burial practices [67]. For example, when the Liberian government and the WHO implemented a pilot training program in Lofa County, NGOs such as MSF, Samaritan’s Purse, the Liberian National Red Cross Society, and IFRC conducted independent ‘train-the-trainer’ sessions for awareness outreach campaigns [67]. Through these programs, more than 700 Liberian health workers (70% of the county’s health workforce) were retrained to refresh their knowledge of basic infection prevention and control measures [68]. Additionally, they learned the heightened measures required for the Ebola outbreak to perform safe, dignified burials in the communities [68]. DISCUSSION The need for a strategic approach to future disease outbreak Although the governments, intergovernmental organizations, NGOs, and communities eventually coordinated with one another to control the disease, the Ebola outbreak resulted in heavy casualties. Widespread cooperation among stakeholders from various entities was inhibited by resistance, mainly from villagers, which seriously hampered the Ebola response in the early stages of the epidemic. The Ebola outbreak in West Africa demonstrated that even if scientifically effective and efficient methods are available, they are unlikely to be implemented successfully unless they are culturally and religiously accepted [37]. For example, even if the WHO’s safe and dignified burial guidelines considered ‘culture’, they acknowledged only Christian and Islamic traditions [53]. Public health is not just about governmental or organizational superstructure; rather, it must also have an impact on attitudinal and behavioral changes in the traditions and daily lives of the people of West Africa [69]. Thus, effective science and health communication, as well as community engagement tailored to the local circumstances, should be key strategies for successful outbreak control [70]. In addition, spiritual wellbeing should be considered as another source of happiness, in addition to three dimensions of health—physical, mental and social wellbeing—defined by WHO [71, 72]. The need for designing and implementing health communication theory framework Figueroa suggested that theory-based frameworks, such as the ideation model and pathways frameworks, should be considered important tools to guide how research and communication activities are conducted [73]. Kincaid et al. presented the most recent version of the ideation model representing a metatheory of health communication toward ‘a wide broad range of communication, social and behavioral change theories and their interrelationships’ [75]. In this model, psychosocial variables, which influence health behavior changes and determine the practice of a recommended behavior, are grouped into three domains: cognitive, emotional, and social. Journal of Health and Social Sciences 2020; 5,1:073-090 The Italian Journal for Interdisciplinary Health and Social Development 84 For community-based preventive programs, Manguvo and Mafuvadze proposed that traditional leaders also be assigned to monitor and implement preventive measures to halt the spread of Ebola [37]. As Manguvo and Mafuvadze described [37], when a disease outbreak occurs, health officials, traditional and religious leaders, and traditional and spiritual healers should jointly launch community-based awareness campaigns. These campaigns should specifically target all types of leaders who have a strong voice and decision-making power that community members respect and follow. After the community leaders are well informed, they will be willing to educate people in their communities about the importance of safe burials. Christian and Islamic leaders can also
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