‘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

BackgroundDuring 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 findingsParticipants (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.ConclusionsSuccessful 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.

An assessment of Ebola-related stigma and its association with informal healthcare utilisation among Ebola survivors in Sierra Leone: a cross-sectional study

“…Further analysis of the enacted stigma subscales revealed verbal abuse was more likely to occur among EVD survivors residing in urban locations when compared to those living in rural areas. Our finding may be explained by the fact that adherence to local bylaws to prevent stigma and discrimination by the community was more prevalent in rural areas compared to urban areas [59]. Also, previously identified urban-rural community differences in knowledge and perception of, and attitude towards, EVD may also explain our finding [60].…”

Hygiene programming during outbreaks: a qualitative case study of the humanitarian response during the Ebola outbreak in Liberia

“…A possible way to incentivise or create demand for new interventions is to change perceptions around 'experimenting' e.g. using methods that have already gained traction such as 'social learning' methods [61], or approaches that involve working more closely with communities [62][63][64]. Small scale pilots of different approaches are needed to generate more evidence of what works in emergencies and outbreaks.…”

“Social distancing: barriers to its implementation and how they can be overcome – a rapid systematic review and synthesis of qualitative studies”

“…Here, the lack of trust in government and authorities (21,23,24,30,33), stigmatisation (23,26,33,38) as well the inadequacy of timing (18) and channels of communication (21,28,31,36,44). Inadequate preparedness (29,31,37), and a lack of legislation and penalties (22,24,26,33,44) were found to be additional barriers.…”

“…Data from the studies included in this review indicate that it is important to address stigmatisation and the psychological burden of measures like quarantine. (20,22,25,(30)(31)(32)38,40) Building trust in government and authorities as well as promoting confidence in the implemented measures are further opportunities for improvement (21,23,24,26,30,33,39,43,45). Addressing solidarity, social responsibility and community collaboration promotes adherence and is a critical element of the response (21)(22)(23)26,27,30,31,33,39).…”

“…Ultimately, the most central theme identified across studies is the critical importance of good communication (23,25,26,28,29,(31)(32)(33)(34)(35)(36)(37)(38)(39)44,45 (34)(35)(36)(37), and information should be context specific and relevant to people's lives. Further important aspects identified were transparency, good timing, clarity and uniformity (18,23,25,(34)(35)(36)(37).…”