‘When Ebola enters a home, a family, a community’: A qualitative study of population perspectives on Ebola control measures in rural and urban areas of Sierra Leone

Abstract

Background

During the West Africa Ebola outbreak, cultural practices have been described as hindering response efforts. The acceptance of control measures improved during the outbreak, but little is known about how and why this occurred. We conducted a qualitative study in two administrative districts of Sierra Leone to understand Ebola survivor, community, and health worker perspectives on Ebola control measures. We aimed to gain an understanding of community interactions with the Ebola response to inform future intervention strategies.

Methodology/Principal findings

Participants (25 survivors, 24 community members, and 16 health workers) were recruited purposively. A flexible participatory method gathered data through field notes and in-depth, topic-led interviews. These were analysed thematically with NVivo10© by open coding, constant comparison, and the principles of grounded theory. The primary theme, ‘when Ebola is real’, centred on denial, knowledge, and acceptance. Ebola was denied until it was experienced or observed first-hand and thus health promotion was more effective if undertaken by those directly exposed to Ebola rather than by mass media communication. Factors that enabled acceptance and engagement with control measures included: access to good, proximate care and prevention activities; seeing that people can survive infection; and the co-option of trusted or influential local leadership, with bylaws implemented by community leaders being strongly respected. All participants noted that dignity, respect, and compassion were key components of effective control measures.

Conclusions

Successful control approaches need strong community leadership, with the aim of achieving collective understanding between communities and health workers. Health promotion for communities at risk is best conducted through people who have had close interaction with or who have survived Ebola as opposed to reliance on broad mass communication strategies.

Author summary

The scale of the 2014–15 Ebola epidemic was unprecedented and led to over 11,000 deaths in Sierra Leone, Liberia and Guinea. What is distinct about the findings of this study is the knowledge gained from experiences and reflections of communities, health workers and Ebola survivors living in the midst of an outbreak of this magnitude. To this point cultural practices were seen to both spread the disease and hinder response efforts, yet little was known about how and why affected communities engaged with Ebola control measures. We talked with people to understand their perspectives with the aim of improving responses to future disease outbreaks. Our findings show people believed ‘Ebola is real’ and adapted to control measures when they were directly affected by the disease. Factors supporting acceptance of and adherence to controls were treatment quality; proximal care; first-hand observation that people can survive the disease; and the participation of local leaders and community knowledge in the response. Dignity, respect, and compassion were essential for control measures to be accepted and effective. Health messaging is best conducted at household level through local leaders or people who have experienced Ebola first-hand, rather than mass media which was the initial approach.