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      Fears and Misperceptions of the Ebola Response System during the 2014-2015 Outbreak in Sierra Leone

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          Abstract

          Background

          Future infectious disease epidemics are likely to disproportionately affect countries with weak health systems, exacerbating global vulnerability. To decrease the severity of epidemics in these settings, lessons can be drawn from the Ebola outbreak in West Africa. There is a dearth of literature on public perceptions of the public health response system that required citizens to report and treat Ebola cases. Epidemiological reports suggested that there were delays in diagnosis and treatment. The purpose of our study was to explore the barriers preventing Sierra Leoneans from trusting and using the Ebola response system during the height of the outbreak.

          Methods

          Using an experienced ethnographer, we conducted 30 semi-structured in-depth interviews in public spaces in Ebola-affected areas. Participants were at least age 18, spoke Krio, and reported no contact in the recent 21 days with an Ebola-infected person. We used inductive coding and noted emergent themes.

          Findings

          Most participants feared that calling the national hotline for someone they believed had Ebola would result in that person’s death. Many stated that if they developed a fever they would assume it was not Ebola and self-medicate. Some thought the chlorine sprayed by ambulance workers was toxic. Although most knew there was a laboratory test for Ebola, some erroneously assumed the ubiquitous thermometers were the test and most did not understand the need to re-test in the presence of Ebola symptoms.

          Conclusion

          Fears and misperceptions, related to lack of trust in the response system, may have delayed care-seeking during the Ebola outbreak in Sierra Leone. Protocols for future outbreak responses should incorporate dynamic, qualitative research to understand and address people’s perceptions. Strategies that enhance trust in the response system, such as community mobilization, may be particularly effective.

          Author Summary

          To decrease the severity of epidemics in countries with under-developed health system capacity to control outbreaks, lessons can be drawn from the Ebola outbreak in West Africa. This is the first study, to our knowledge, to use qualitative research methods to understand community members’ perceptions of using the Ebola response system during the outbreak in Sierra Leone. We conducted this study in two of the most populous districts during a time when there were still a high number of Ebola-related fatalities, and the Ebola response system had been scaled up. While national household surveys demonstrated high levels of intent to use the response system at the time, epidemiological reports suggested that there were delays in seeking testing and treatment. Our use of semi-structured in-depth interviews, as well as an ethnographer with experience in Sierra Leone, enhanced our ability to elicit people’s fears and misperceptions. Concerns about the response system clustered around three key themes: fears of calling the national hotline, negative perceptions of the chlorine spray, and misperceptions about the Ebola laboratory test and the need to re-test. These fears and misperceptions likely delayed people from seeking care. Our results lend support to the argument that trust in the public health response system was integral to citizens’ use of the system. We make several recommendations for how trust could have been enhanced during the Ebola outbreak. Protocols for future outbreaks should incorporate dynamic and qualitative research both to understand perceptions of the response system and to use these data to inform a more effective response.

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          Most cited references15

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          Ebola: limitations of correcting misinformation.

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            Reputation, relationships, risk communication, and the role of trust in the prevention and control of communicable disease: a review.

            Population-level compliance with health protective behavioral advice to prevent and control communicable disease is essential to optimal effectiveness. Multiple factors affect perceptions of trustworthiness, and trust in advice providers is a significant predeterminant of compliance. While competency in assessment and management of communicable disease risks is critical, communications competency may be equally important. Organizational reputation, quality of stakeholder relationships and risk information provision strategies are trust moderating factors, whose impact is strongly influenced by the content, timing and coordination of communications. This article synthesizes the findings of 2 literature reviews on trust moderating communications and communicable disease prevention and control. We find a substantial evidence base on risk communication, but limited research on other trust building communications. We note that awareness of good practice historically has been limited although interest and the availability of supporting resources is growing. Good practice and policy elements are identified: recognition that crisis and risk communications require different strategies; preemptive dialogue and planning; evidence-based approaches to media relations and messaging; and building credibility for information sources. Priority areas for future research include process and cost-effectiveness evaluation and the development of frameworks that integrate communication and biomedical disease control and prevention functions, conceptually and at scale.
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              Organization of patient care during the Ebola hemorrhagic fever epidemic in Kikwit, Democratic Republic of the Congo, 1995.

              In contrast with procedures in previous Ebola outbreaks, patient care during the 1995 outbreak in Kikwit, Democratic Republic of the Congo, was centralized for a large number of patients. On 4 May, before the diagnosis of Ebola hemorrhagic fever (EHF) was confirmed by the Centers for Disease Control and Prevention, an isolation ward was created at Kikwit General Hospital. On 11 May, an international scientific and technical committee established as a priority the improvement of hygienic conditions in the hospital and the protection of health care workers and family members; to this end, protective equipment was distributed and barrier-nursing techniques were implemented. For patients living far from Kikwit, home care was organized. Initially, hospitalized patients were given only oral treatments; however, toward the end of the epidemic, infusions and better nutritional support were given, and 8 patients received blood from convalescent EHF patients. Only 1 of the transfusion patients died (12.5%). It is expected that with improved medical care, the case fatality rate of EHF could be reduced.
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                Author and article information

                Contributors
                Role: Editor
                Journal
                PLoS Negl Trop Dis
                PLoS Negl Trop Dis
                plos
                plosntds
                PLoS Neglected Tropical Diseases
                Public Library of Science (San Francisco, CA USA )
                1935-2727
                1935-2735
                18 October 2016
                October 2016
                : 10
                : 10
                : e0005077
                Affiliations
                [1 ]School of International Service, American University, Washington, District of Columbia, United States of America
                [2 ]Center on Health, Risk and Society, American University, Washington, District of Columbia, United States of America
                Armed Forces Health Surveillance Center, UNITED STATES
                Author notes

                The authors have declared that no competing interests exist.

                • Conceived and designed the experiments: TY SS.

                • Performed the experiments: TY SS.

                • Analyzed the data: TY EN SS.

                • Wrote the paper: TY EN SS.

                Author information
                http://orcid.org/0000-0001-9611-1714
                Article
                PNTD-D-16-00234
                10.1371/journal.pntd.0005077
                5068712
                27755553
                511cf811-b291-48f6-bdb0-58727319ac19
                © 2016 Yamanis et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 25 February 2016
                : 27 September 2016
                Page count
                Figures: 2, Tables: 0, Pages: 12
                Funding
                Funded by: American University Provost Office and the American University Center on Health, Risk and Society
                Award Recipient :
                This study was funded by the American University Provost Office, the American University School of International Service, and the American University Center on Health, Risk and Society. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Categories
                Research Article
                Medicine and Health Sciences
                Tropical Diseases
                Neglected Tropical Diseases
                Viral Hemorrhagic Fevers
                Ebola Hemorrhagic Fever
                Medicine and Health Sciences
                Infectious Diseases
                Viral Diseases
                Viral Hemorrhagic Fevers
                Ebola Hemorrhagic Fever
                Physical Sciences
                Chemistry
                Chemical Elements
                Chlorine
                People and places
                Geographical locations
                Africa
                Sierra Leone
                Medicine and Health Sciences
                Public and Occupational Health
                Engineering and Technology
                Transportation
                Ambulances
                Medicine and Health Sciences
                Diagnostic Medicine
                Signs and Symptoms
                Fevers
                Medicine and Health Sciences
                Pathology and Laboratory Medicine
                Signs and Symptoms
                Fevers
                Biology and life sciences
                Organisms
                Viruses
                RNA viruses
                Filoviruses
                Ebola Virus
                Biology and Life Sciences
                Microbiology
                Medical Microbiology
                Microbial Pathogens
                Viral Pathogens
                Hemorrhagic Fever Viruses
                Ebola Virus
                Medicine and Health Sciences
                Pathology and Laboratory Medicine
                Pathogens
                Microbial Pathogens
                Viral Pathogens
                Hemorrhagic Fever Viruses
                Ebola Virus
                Biology and Life Sciences
                Organisms
                Viruses
                Viral Pathogens
                Hemorrhagic Fever Viruses
                Ebola Virus
                Biology and Life Sciences
                Organisms
                Viruses
                Hemorrhagic Fever Viruses
                Ebola Virus
                Medicine and Health Sciences
                Health Care
                Health Services Research
                Custom metadata
                Unfortunately, making data publicly available would breach compliance with the protocol approved by our IRB, and thus the IRB will not approve public access to our data. Data are from the Sociocultural Aspects of Ebola in Sierra Leone study whose authors may be contacted at yamanis@ 123456american.edu .

                Infectious disease & Microbiology
                Infectious disease & Microbiology

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