TABLE

Community Engagement Considerations in Rural and Urban Settings, Based on Ebola Experience in Guinea, Liberia, and Sierra Leone

Issue/Factor	Rural	Urban
Socio-demographics (e.g., poverty, literacy, education)	Approaches need to be tailored to socioeconomic status and literacy, but can be managed.	Literacy tends to be higher and English understood more than in rural settings, but still difficult to cater for the diversity in socioeconomic status in densely populated urban settings.
Traditional, social government structures that provide potential for sustainability, but can sometimes marginalize groups of people or other times provide an opportunity for better reach	High	Low
Understanding and correcting rumors	Localized rumors can be settled with local leaders and/or in a community meeting more easily than in urban areas, but still hard if various rumors are circulating.	Very hard to correct misinformation once widely circulated. Mistrust tends to fuel further distortion and undermine efforts to correct misinformation.
Access and reach for supplies and logistics	Easier to distribute than in urban areas, although further away.	Hard to distribute due to congestion/population density.
Partner coordination between regional and local command centers	Very organized and responsive, once up and running.	Hard to cope with very high demand; needs additional contingency and resources.
Data collection and monitoring	Hard because communities can be cautious and it is hard to reach everyone.	Hard due to dense population, difficult living conditions, lack of trust. Data collection and feedback are usually too slow to keep pace with changing situations in communities.
Differences in Preparation, Response, and Recovery phases	Initially Ebola was concentrated in rural areas; response improved with decentralized command centers.	As Ebola intensified, it also reached urban areas and the response struggled to keep pace. Many areas had no prevalence for a long time. Hard to remain vigilant over protracted period.
Interpersonal vs. mass media communication approaches	Mass media (radio) worked well in rural areas (when tailored regarding language, messenger, etc.), with reinforcement from interpersonal approaches (e.g., chiefs, religious leaders, community groups).	Mass media in urban areas is hard to tailor to all needs; interpersonal approaches are very labor intensive for urban settings.
Incentives	Hard; incentives need to be set out clearly across organizations and functions, and consistently followed everywhere, from chiefs to volunteers.	Hard; consistency across organizations and administration is very complicated in densely populated areas.
Capacity of health staff, community mobilizers, and ability to work together in teams	Hard to recruit and support the full range of technical and management skills, local and international staff, etc., especially for long periods.	While more people are available in urban settings, it is still hard to recruit and support the full range of skills needed, especially for long periods.