BackgroundThe mental health impact of the 2014–2016 Ebola epidemic has been described among survivors, family members and healthcare workers, but little is known about its impact on the general ...population of affected countries. We assessed symptoms of anxiety, depression and post-traumatic stress disorder (PTSD) in the general population in Sierra Leone after over a year of outbreak response.MethodsWe administered a cross-sectional survey in July 2015 to a national sample of 3564 consenting participants selected through multistaged cluster sampling. Symptoms of anxiety and depression were measured by Patient Health Questionnaire-4. PTSD symptoms were measured by six items from the Impact of Events Scale-revised. Relationships among Ebola experience, perceived Ebola threat and mental health symptoms were examined through binary logistic regression.ResultsPrevalence of any anxiety-depression symptom was 48% (95% CI 46.8% to 50.0%), and of any PTSD symptom 76% (95% CI 75.0% to 77.8%). In addition, 6% (95% CI 5.4% to 7.0%) met the clinical cut-off for anxiety-depression, 27% (95% CI 25.8% to 28.8%) met levels of clinical concern for PTSD and 16% (95% CI 14.7% to 17.1%) met levels of probable PTSD diagnosis. Factors associated with higher reporting of any symptoms in bivariate analysis included region of residence, experiences with Ebola and perceived Ebola threat. Knowing someone quarantined for Ebola was independently associated with anxiety-depression (adjusted OR (AOR) 2.3, 95% CI 1.7 to 2.9) and PTSD (AOR 2.095% CI 1.5 to 2.8) symptoms. Perceiving Ebola as a threat was independently associated with anxiety-depression (AOR 1.69 95% CI 1.44 to 1.98) and PTSD (AOR 1.86 95% CI 1.56 to 2.21) symptoms.ConclusionSymptoms of PTSD and anxiety-depression were common after one year of Ebola response; psychosocial support may be needed for people with Ebola-related experiences. Preventing, detecting, and responding to mental health conditions should be an important component of global health security efforts.
Perceived susceptibility to a disease threat (risk perception) can influence protective behaviour. This study aims to determine how exposure to information sources, knowledge and behaviours ...potentially influenced risk perceptions during the 2014-2015 Ebola Virus Disease outbreak in Sierra Leone.
The study is based on three cross-sectional, national surveys (August 2014, n = 1413; October 2014, n = 2086; December 2014, n = 3540) that measured Ebola-related knowledge, attitudes, and practices in Sierra Leone. Data were pooled and composite variables were created for knowledge, misconceptions and three Ebola-specific behaviours. Risk perception was measured using a Likert-item and dichotomised into 'no risk perception' and 'some risk perception'. Exposure to five information sources was dichotomised into a binary variable for exposed and unexposed. Multilevel logistic regression models were fitted to examine various associations.
Exposure to new media (e.g. internet) and community-level information sources (e.g. religious leaders) were positively associated with expressing risk perception. Ebola-specific knowledge and hand washing were positively associated with expressing risk perception (Adjusted OR AOR 1.4, 95% Confidence Interval CI 1.2-1.8 and AOR 1.4, 95% CI 1.1-1.7 respectively), whereas misconceptions and avoiding burials were negatively associated with risk perception, (AOR 0.7, 95% CI 0.6-0.8 and AOR 0.8, 95% CI 06-1.0, respectively).
Our results illustrate the complexity of how individuals perceived their Ebola acquisition risk based on the way they received information, what they knew about Ebola, and actions they took to protect themselves. Community-level information sources may help to align the public's perceived risk with their actual epidemiological risk. As part of global health security efforts, increased investments are needed for community-level engagements that allow for two-way communication during health emergencies.
We assessed the effect of information sources on Ebola-specific knowledge and behavior during the 2014-2015 Ebola virus disease outbreak in Sierra Leone. We pooled data from 4 population-based ...knowledge, attitude, and practice surveys (August, October, and December 2014 and July 2015), with a total of 10,604 respondents. We created composite variables for exposures (information sources: electronic, print, new media, government, community) and outcomes (knowledge and misconceptions, protective and risk behavior) and tested associations by using logistic regression within multilevel modeling. Exposure to information sources was associated with higher knowledge and protective behaviors. However, apart from print media, exposure to information sources was also linked to misconceptions and risk behavior, but with weaker associations observed. Knowledge and protective behavior were associated with the outbreak level, most strongly after the peak, whereas risk behavior was seen at all levels of the outbreak. In future outbreaks, close attention should be paid to dissemination of information.
To quantify the potential impact of engaging religious leaders in promoting safe burial practices during the 2014-2016 Ebola virus disease outbreak in Sierra Leone.
We analysed population-based ...household survey data from 3540 respondents collected around the peak of the outbreak in Sierra Leone, December 2014. Respondents were asked if in the past month they had heard an imam or pastor say that people should not touch or wash a dead body. We used multilevel logistic regression modelling to examine if exposure to religious leaders' messages was associated with protective burial intentions if a family member died at home and other Ebola protective behaviours.
Of the respondents, 3148 (89%) had been exposed to faith-based messages from religious leaders on safe Ebola burials and 369 (10%) were unexposed. Exposure to religious leaders' messages was associated with a nearly twofold increase in the intention to accept safe alternatives to traditional burials and the intention to wait ≥ 2 days for burial teams (adjusted odds ratio, aOR: 1.69; 95% confidence interval, CI: 1.23-2.31 and aOR: 1.84; 95% CI: 1.38-2.44, respectively). Exposure to messages from religious leaders was also associated with avoidance of traditional burials and of contact with suspected Ebola patients (aOR: 1.46; 95% CI: 1.14-1.89 and aOR: 1.65; 95% CI: 1.27-2.13, respectively).
Public health messages promoted by religious leaders may have influenced safe burial behaviours during the Ebola outbreak in Sierra Leone. Engagement of religious leaders in risk communication should be prioritized during health emergencies in similar settings.
This study sought understand how the 2014-2016 EVD Virus Disease (EVD) outbreak impacted the nutrition sector in Sierra Leone and use findings for improving nutrition responses during future ...outbreaks of this magnitude.
This qualitative study was iterative and emergent. In-depth interviews (n = 42) were conducted over two phases by purposively sampling both key informants (n = 21; government stakeholders, management staff from United Nations (UN) agencies and non-governmental organizations (NGO)), as well as community informants (n = 21; EVD survivors, health workers, community leaders) until data saturation. Multiple analysts collaborated in a team-based coding approach to identify key themes using Dedoose software. Findings are presented as both quotations and tables/figures.
The EVD outbreak effects and the related response strategies, especially movement restriction policies including 21-day quarantines, contributed to disruptions across the food value-chain in Sierra Leone. System-wide impacts were similar to those typically seen in large-scale disasters such as earthquakes. Participants described an array of direct and indirect effects on agricultural production and food storage and processing, as well as on distribution, transport, trade, and retailing. Secondary data were triangulated by interviews which described the aggregate negative effect of this outbreak on key pillars of food security, infant and young child feeding practices, and nutrition. During the humanitarian response, nutrition-specific interventions, including food assistance, were highly accepted, although sharing was reported. Despite EVD impacts across the entire food value-chain, nutrition-sensitive interventions were not central to the initial response as EVD containment and survival took priority. Culturally-appropriate social and behavior change communications were a critical response component for improving health, nutrition, and hygiene-related behaviors through community engagement.
Infectious diseases such as EVD have far-reaching effects that impact health and nutrition through interrelated pathways. In Sierra Leone, the entire food value-chain was broken to the extent that the system-wide damage was on par with that typically resulting from large natural disasters. A food value-chain approach, at minimum, offers a foundational framework from which to position nutrition preparedness and response efforts for outbreaks in similar resource constrained settings.
To assess the public's knowledge, attitudes and practices about the novel coronavirus in Sierra Leone to inform an evidence-based communication strategy around COVID-19.
Nationwide, cross-sectional ...Knowledge, Attitudes and Practices survey.
56 randomly selected communities in all 14 districts in Sierra Leone.
1253 adults aged 18 years and older of which 52% were men.
We calculated proportions of core indicators (awareness, knowledge, risk perception, practices). A composite variable for knowledge (based on seven variables) was created, and categorised into low (0-2 correct), medium (3-4) and high (5-7). Predictors of knowledge were analysed with multilevel ordinal regression models. Associations between information sources, knowledge and two practices (washing hands with soap and avoiding crowds) were analysed using multilevel logistic regression models.
We found that 75% of the respondents felt at moderate or great risk of contracting coronavirus. A majority (70%) of women did not know you can survive COVID-19, compared with 61% of men. 60% of men and 54% of women had already taken action to avoid infection with the coronavirus, mostly washing hands with soap and water (87%). Radio (73%) was the most used source for COVID-19 information, followed by social media (39%). Having a medium or high level of knowledge was associated with higher odds of washing hands with soap (medium knowledge: adjusted OR (AOR) 2.1, 95% CI 1.0 to 4.4; high knowledge: AOR 4.6, 95% CI 2.1 to 10.2) and avoiding crowds (medium knowledge: AOR 2.0, 95% CI 1.1 to 3.6; high knowledge: AOR 2.3, 95% CI 1.2 to 4.3).
This study shows that in the context of COVID-19 in Sierra Leone, there is a strong association between knowledge and practices. Because the knowledge gap differs between genders, regions, educational levels and age, it is important that messages are specifically targeted to these core audiences.
IntroductionInfectious disease misinformation is widespread and poses challenges to disease control. There is limited evidence on how to effectively counter health misinformation in a community ...setting, particularly in low-income regions, and unsettled scientific debate about whether misinformation should be directly discussed and debunked, or implicitly countered by providing scientifically correct information.MethodsThe Contagious Misinformation Trial developed and tested interventions designed to counter highly prevalent infectious disease misinformation in Sierra Leone, namely the beliefs that (1) mosquitoes cause typhoid and (2) typhoid co-occurs with malaria. The information intervention for group A (n=246) explicitly discussed misinformation and explained why it was incorrect and then provided the scientifically correct information. The intervention for group B (n=245) only focused on providing correct information, without directly discussing related misinformation. Both interventions were delivered via audio dramas on WhatsApp that incorporated local cultural understandings of typhoid. Participants were randomised 1:1:1 to the intervention groups or the control group (n=245), who received two episodes about breast feeding.ResultsAt baseline 51% believed that typhoid is caused by mosquitoes and 59% believed that typhoid and malaria always co-occur. The endline survey was completed by 91% of participants. Results from the intention-to-treat, per-protocol and as-treated analyses show that both interventions substantially reduced belief in misinformation compared with the control group. Estimates from these analyses, as well as an exploratory dose–response analysis, suggest that direct debunking may be more effective at countering misinformation. Both interventions improved people’s knowledge and self-reported behaviour around typhoid risk reduction, and yielded self-reported increases in an important preventive method, drinking treated water.ConclusionThese results from a field experiment in a community setting show that highly prevalent health misinformation can be countered, and that direct, detailed debunking may be most effective.Trial registration numberNCT04112680.
This article describes the development of standard operating procedures (SOPs) for social mobilization and community engagement (SM/CE) in Sierra Leone during the Ebola outbreak of 2014-2015. It aims ...to (a) explain the rationale for a standardized approach, (b) describe the methodology used to develop the resulting SOPs, and (c) discuss the implications of the SOPs for future outbreak responses. Mixed methodologies were applied, including analysis of data on Ebola-related knowledge, attitudes, and practices; consultation through a national forum; and a series of workshops with more than 250 participants active in SM/CE in seven districts with recent confirmed cases. Specific challenges, best practices, and operational models were identified in relation to (a) the quality of SM/CE approaches; (b) coordination and operational structures; and (c) integration with Ebola services, including case management, burials, quarantine, and surveillance. This information was synthesized and codified into the SOPs, which include principles, roles, and actions for partners engaging in SM/CE as part of the Ebola response. This experience points to the need for a set of global principles and standards for meaningful SM/CE that can be rapidly adapted as a high-priority response component at the outset of future health and humanitarian crises.
Experimental Ebola vaccines were introduced during the 2014–2015 Ebola outbreak in West Africa. Planning for the Sierra Leone Trial to Introduce a Vaccine against Ebola (STRIVE) was underway in late ...2014. We examined hypothetical acceptability and perceptions of experimental Ebola vaccines among health care workers (HCWs), frontline workers, and the general public to guide ethical communication of risks and benefits of any experimental Ebola vaccine.
Between December 2014 and January 2015, we conducted in-depth interviews with public health leaders (N = 31), focus groups with HCWs and frontline workers (N = 20), and focus groups with members of the general public (N = 15) in Western Area Urban, Western Area Rural, Port Loko, Bombali, and Tonkolili districts. Themes were identified using qualitative content analysis.
Across all participant groups, not knowing the immediate and long-term effects of an experimental Ebola vaccine was the most serious concern. Some respondents feared that experimental vaccines may cause Ebola, lead to death, or result in other adverse events. Among HCWs, not knowing the level of protection provided by experimental Ebola vaccines was another concern. HCWs and frontline workers were motivated to help find a vaccine for Ebola to help end the outbreak. General public participants cited positive experiences with routine childhood immunization in Sierra Leone.
Our formative assessment prior to STRIVE’s implementation in Sierra Leone helped identify concerns, motivations, and information gaps among potential participants of an experimental Ebola vaccine trial, at the time when an unprecedented outbreak was occurring in the country. The findings from this assessment were incorporated early in the process to guide ethical communication of risks and benefits when discussing informed consent for possible participation in the vaccine trial that was launched later in 2015.
Human behaviour will continue to play an important role as the world grapples with public health threats. In this paper, we draw from the emerging evidence on behaviour adoption during diverse public ...health emergencies to develop a framework that contextualises behaviour adoption vis-à-vis a combination of top-down, intermediary and bottom-up approaches. Using the COVID-19 pandemic as a case study, we operationalise the contextual framework to demonstrate how these three approaches differ in terms of their implementation, underlying drivers of action, enforcement, reach and uptake. We illustrate how blended strategies that include all three approaches can help accelerate and sustain protective behaviours that will remain important even when safe and effective vaccines become more widely available. As the world grapples with the COVID-19 pandemic and prepares to respond to (re)emerging public health threats, our contextual framework can inform the design, implementation, tracking and evaluation of comprehensive public health and social measures during health emergencies.
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