Community Perspectives about Ebola in Bong, Lofa and Montserrado Counties of Liberia: Results of a Qualitative Study

"Strategic health communication can play a key role in stopping the outbreak, primarily by helping community members recognize and identify how they can modify their religious and cultural practices and behaviors — such as not directly touching loved ones who are ill or by changing the way persons who die from Ebola are treated and buried — so they and their families can prevent themselves from getting the disease."

This 30-page report discusses findings of an assessment to better understand community perceptions related to responses to the Ebola virus outbreak in Lofa, Bong, and Monteserrado counties in Liberia, with a focus on communication. The assessment was conducted by the Health Communication Capacity Collaborative (HC3) at the Johns Hopkins Center for Communication Programs (CCP) for the United States Agency For International Development (USAID) to assist the Government of Liberia (GOL) and its partners to understand community attitudes, norms, and practices related to the Ebola outbreak; the changes that have taken place since the outbreak started; as well as ongoing challenges and concerns. The results are intended to inform ongoing and future activities on social and behaviour change communication (SBCC) in response to the Ebola epidemic in Liberia.

Specifically, the study sought to create an understanding of the following:

• "What are the attitudes, community norms and practices that are related to Ebola?
• How do these attitudes, norms and practices vary within and across study counties?
• How have these attitudes, norms and practices changed over time?
• What factors were responsible for changes in attitudes, norms and practices over time?
• Which groups of people in the community continue to be most affected by Ebola and what are the reasons for their higher vulnerability?
• What are community perspectives on community readiness, collective efficacy and community resources to take appropriate actions related to Ebola prevention, care and treatment (including safe disposal of corpses)?
• How does the community relate to individuals who have recovered from Ebola and their families?"

This study used qualitative methods to assess community attitudes and norms related to Ebola in the three counties.

To mention just a few examples of some of the findings, the assessment found that communication activities across all counties had contributed to improving knowledge about Ebola prevention and treatment, countering misconceptions, addressing stigma, and promoting health seeking behaviours. Findings showed that community leaders played a very important role as both a communication channel, and in helping communities act on their knowledge, for example organising health services to assist person showing symptoms of Ebola. Likewise, community task forces were an important part of the response as they helped motivate people to adapt prevention and treatment behaviours. One of the key contributing factors to the rapid spread of the disease that communication helped to address was very deeply held tradition that required families to wash and bury their own dead. Throughout the communities interviewed as part of the assessment, traditional practices that put people at risk of Ebola have mostly stopped, and communication is cited as a key factor in changing these norms and practices.

On the other hand, the assessment pointed to continued challenges. For example, there are still some pockets of denial due to misinformation, and some specific groups, such as youth, are more reluctant to change their social behaviours. Along with the prevention information already received, respondents stated that communities would like more information, such as about "vaccines, contact tracing and information about whether Ebola case numbers are decreasing and when the epidemic is likely to be over. There is also an interest in understanding better the origins of Ebola and how it spread to Liberia." The most credible sources of information were cited as religious or community leaders, health workers, community task forces, survivors, and local media/radio programmes.

The report concludes that correct knowledge of Ebola, its transmission, and prevention measures has improved, but there is still a need for information campaigns, particularly tailored for certain groups, such as youth. "Respondents have identified communication with leaders, health workers and community members as an important tool for both identifying Ebola cases and promoting prevention measures. Communication and information networks, approaches and processes have been established in these communities to strengthen the response to the epidemic."

The report offers several recommendations:

• "Community education and information resources must continue to dispel rumors and myths about Ebola. Target groups with specific information needs must also be considered to increase prevention behaviors among those with increased vulnerability, such as youth."
• "Involving community and religious leaders in the fight against Ebola be an effective strategy for mobilizing the community around a common cause."
• "Community task forces should continue to be part of the response to Ebola and other health issues. They can also become strong grassroots networks for dispersal of correct and accurate information."
• "Communication can play an important role in educating people about emergency planning and what they should and should not do during an outbreak, and how to respond when there is no access to the national hotline."
• "There is need for community education to correct prevailing myths and rumors about Ebola transmission and on what it means to be Ebola-free. Activities and messages designed to promote compassion for Ebola survivors and orphans are very relevant."

"Keeping Liberia Ebola-free should be communicated as a priority and responsibility for all in Liberia."

• "Exploring factors responsible for the low prevalence of Ebola in the low disease burden counties may be a useful research endeavor...There should be continuous monitoring of the after-effects of Ebola prevention messaging and how it has impacted community norms and behaviors."