Human Behavior Change to Prevent Pandemics

Applying One Health to reduce pandemics through community behavioral change and develop interventions in critical emerging disease hotspots.

Dr. Peter Daszak, President and Disease Ecologist, EcoHealth Alliance

As the COVID-19 pandemic continues to levy a heavy health and economic toll worldwide, a preventive approach to emerging infectious disease (EID) emergence has been recognized as a more effective approach, costing 100 times less than a responsive approach, to safeguarding global health. 

Three-quarters of EIDs are zoonotic in origin, meaning that contact between humans and animals created a pathway for a pathogen to spillover. As societies worldwide rapidly urbanize, human communities, their livestock, and wildlife are being pushed together in ways that foster contact opportunities. Additionally, over 30% of EIDs are linked to land-use change, and those whose livelihoods depend on the land and wildlife (e.g. through bushmeat trade and consumption) are our first-line of defense against new pathogens entering human populations. However, these populations also comprise uniquely vulnerable socioeconomic segments of society and are often under-prioritized in EID prevention efforts. We aim to solve this problem by characterizing and quantifying local high-risk behaviors and empowering community members to mitigate risk with science-based knowledge and tools.

1) High-Risk Communities

The social science component of our project ensures community experiences and perceptions comprise the data that will inform behavioral interventions. Many of these communities rely on forest products for their livelihoods ( e.g. bushmeat, timber), leading to frequent contact with wildlife recognized as disease reservoirs. By using the lived experiences and value systems of participants to tailor our research tools, we will generate results of maximal value for successful and appropriate local programs. 

2) Local Scientists 

The capacity to prevent the next pandemic exists within the communities living in high-risk areas. Local One Health practitioners can and must lead the way in assessing the landscape of risk and facilitating local involvement in building meaningful mitigation solutions. Our team has a demonstrated history of implementing rigorous capacity-building alliances that foster solid research methodologies and public engagement with social scientists, laboratory scientists, and clinicians from over ten countries. 

3) Global Scientists

The approach and data generated by our project will serve international one health practitioners, including health, ecologists and epidemiologists in the long-term. Our proposal will refine and fill gaps in baseline disease prevalence data, contact rates, and types, serving as a springboard for future pandemic risk forecasting work.

Projects in the pandemic prevention space inherently provide a public good. Preventing a spillover event from happening in a remote forest of West Africa equates to protecting public health globally. 

Specifically, we will generate a novel approach and bank of intervention resources that will be made open-source and usable by both local and global researchers and practitioners. The behavioral drivers of pandemics are not well understood, and we will be adding important information to the scientific knowledge base around this topic. If our pilot is successful at reducing risk, we will make the model accessible to anyone so that it can be adopted and scaled in other hotspot areas. We expect several peer-reviewed publications to result from this project. 

Additionally, this project will strengthen the global capacity of local researchers and practitioners to mitigate spillover risk. From our community-focused One Health interventions, to the skills and resource strengthening of our local scientific partners in the three regions, the increased global awareness and agency in understanding the interlinkages between humans, animals, and the environments will be our most treasured service.

The first outcome of our project will be effective interventions tailored specifically to mitigate the risk of identified zoonotic viruses and responsive to local risk factors. This will be facilitated by our research activities, which will allow us to monitor changes in sero-prevalence in our target population and the knowledge, attitudes, skills, and practices driving or preventing viral spillover.

Out of this, we will build towards our key outcome of decreasing spillover risk in the community due to protective and sustained changes in knowledge, attitudes, skills, and behaviors. This hinges on using the post-intervention assessments to further refine the pilots to be effective beyond the life of the project. A critical component of this outcome will be community report-backs (which we have successfully managed in Liberia), workshops with Internews reporters to share the findings more broadly, and the development of the online hub to make our intervention’s resources widely available. 

In addition to our mobilization of capacity-building materials created through PREDICT-2, EcoHealth Alliance is also a member of USAID’s One Health Workforce - Next Generation, and can link local staff with resources developed under this project for sustained skills development.

A critical component of the successful implementation, sustainability, and most importantly, transformational change of our project is lasting behavior change. Our emphasis on collaborating with, supporting, and strengthening the skills of our local One Health partners is not only the appropriate way of going about this work, but the touchstone of our impact. In the first three years, our project will focus specifically in Liberia, South Africa, and Indonesia. However, our goal is to ultimately scale our innovative approach to one that can be applicable and influential in other regions around the world at high disease risk. The unique nature of our project equips local actors in the first three regions with science, perspective, and the necessary resources to prevent the emergence of the next pandemic while remaining sensitive to topics such as people’s relationships with their changing worlds and how their livelihoods might adversely impact their health. Since our solution is to carefully, meaningfully, and unhurriedly engage with our target community to secure local and national buy-in, this methodical approach lends itself to worldwide applications, as will be demonstrated by the outputs of our activities in our initial target regions.

Our ultimate measure of success is preventing future pandemics. However, as we cannot measure an event’s absence, we look towards capacity-building and knowledge, attitude, skills, and behavior change. We will monitor successful completion of program activities using SMART guidelines.

Activity 1: Capacity-strengthening exercises tailored to each team’s needs

Indicator 1: 100% of team members successfully complete capacity-building workshops, measured by post-workshop assessments in Year 1

Activity 2: Sero-surveillance assessing communities' viral history and investigations of behavioral risk factors using survey, interview, and focus group tools, adapted with collaborators

Indicator 2: 100% of target participant number complete consented assessments participation in Y1. Target number will be indicated in approved protocol documents outlining site-specific targets and determined by LQAS method

Activity 3: Develop and pilot intervention for each region

Indicator 3: Complete 3 intervention pilots throughout the three geographies in Y2

Activity 4: Post-intervention assessment analyzing impact on viral transmission and changes in knowledge, attitudes, skills, behaviors

Indicator 4: 100% of target number participant number complete consented participation in sero-surveillance, behavioral risk surveillance, and impact assessments in Y2. Target number will be indicated in approved protocol documents outlining targets and determined by LQAS method

We anticipate and are prepared to make COVID-19 adaptations in data collection protocols to maximize the safety of both respondents and staff. When possible, the study team will conduct enrollment and data collection in open air settings without compromising privacy. The research team will wear proper personal protective equipment and offer masks and hand sanitizer to participants. The research team will adhere to all local COVID-19 protocols determined by the host government. While misinformation surrounding COVID-19 will not directly impact our program design, it is another reason why so much time at the beginning of the program’s roll-out is dedicated specifically to community engagement, and why Internews collaboration will be crucial in sharing evidence-based information with the broader public.

Another challenge we often encounter is interacting with communities who speak a language different than the national language. Our strategy will be to ensure that individual(s) who speak both the local language and national language are included on the core local team and as a part of any intervention phase (e.g. train-the-trainers). Having a team with this kind of relationship with our target communities will also ensure that our outreach, research tools, interpretations, and activities are all culturally informed and responsive.

EcoHealth Alliance maintains a network of over 100 local collaborators at the community, nonprofit, academic, private sector, governmental, and intergovernmental levels around the world in over 30 countries that often serve as implementing partners. A list of EHA’s organizational partners may be found here: www.ecohealthalliance.org/partners.

Our proposal uses established research practices in disease surveillance to springboard into novel scientific waters. We believe that our solution can  change the face of global pandemic risk and aligns with the Trinity Challenge's mission. Our challenge has always been to find a supporting partner with the vision to help tackle this global challenge with equal parts ambition, creativity, and science. We believe that the Trinity Challenge, Reckitt, and Internews all have a long-view towards pandemic risk reduction and embody these values. 

Our proposal, which most aligns with the Challenge Areas 1b., 1c., and 2a., will determine and limit the risk of key zoonotic viral threats and the risks they pose to communities. As noted previously, the barriers we anticipate encountering are related to language and culture. The Trinity Challenge’s facilitation of partnerships with global subject matter experts - namely Reckitt and Internews - will allow us to appropriately design and refine our research tools and programs to reflect and be responsive to local needs. The local networks and history of community engagement in West Africa, South Africa, and Southeast Asia brought by us and our two partners will ensure that our solution makes a real impact.

We intend to collaborate with Reckitt and Internews, who will participate in our project in the following ways:

• Reckitt will provide guidance in assessment tool development and subject matter expertise in water, sanitation, and hygiene-related content for One Health educational materials during the intervention development phase, in addition to providing overall advisory guidance.

• Internews will provide contextual expertise in data collection tool refinement, assist with the communication of detailed scientific community findings at a broader scale, and provide overall advisory guidance. With their expertise in subject matter related to One Health in Southeast Asia and their network of reporters, they will be invaluable partners in building contextually adapted surveys and sharing news of this program and its findings to outlets that will enable our solution to reach a broad audience and increase its impact.

Through our solution, we intend to cultivate long-lasting relationships to further our solution’s goals and our partners' influential work around the world.