Table 1 Description of the 5 theory-based steps used in standard programme design compared to our findings of what was done during the Liberian Ebola outbreak

Assessment - programme designers gathering existing knowledge about the target behaviours, audience, and context

Existing research and resources on hygiene behaviour were not utilised.

In the absence of clear evidence humanitarians struggled to define key hygiene behaviours.

Understanding behaviour – formative research is undertaken to develop a deeper understanding of behaviour at the current time

Assessments focused on the availability of infrastructure rather than behavioural barriers or determinants.

Programme design - iteratively creating and pre-testing the intervention package with your target audience.

The design process was rushed with actors feeling the need to act.

Programmes primarily focused on providing hygiene products and teaching people about Ebola transmission and preventative behaviours.

Hygiene messages were standardised across the country. This was viewed as minimising risk and confusion but it also meant that messaging was often not contextualised to different experiences within the country.

Opportunities may have been missed to utilise alternative behaviour change techniques, particularly emotional or psychological determinants of behaviour.

Programme delivery – training and supporting staff as they delivering activities as intended.

Programmes were seen as more successful when they used ‘trusted messengers’ and created a dialogue with community members.

Evaluation – process and impact evaluation of the project.

Monitoring primarily focused on identifying regions where there was community denial or health facilities infection control.

Organisations monitored inputs and activities rather than outcomes or impact.

There was no systematic monitoring of hygiene knowledge, awareness, or behaviour