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

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.