Where Does Ebola Come From? Communicating Science as a Matter of Life and Death – Part 1 of 2

*This post originally appeared in PLOS | blogs.

When I was in Liberia in June this year, just one month after the country had been declared “Ebola-free,” I noticed how often I heard the phrase “that was before Ebola” or “that was after Ebola”. The Ebola outbreak that began in 2014 brought unspeakable horror to a country still rebuilding after the war. News of new cases in late June 2015 again catapulted the country into high alert. In September 2015, the country was once more declared Ebola-free, but not for long. Ebola’s return in mid-November 2015 has produced yet another high alert.

Thus the realization is growing that it is not “before Ebola” or “after Ebola”, it is during Ebola. Ebola is with us, with the people of West Africa.

Days since last case (CDC)


August 2014

  • Liberia’s President, Ellen Johnson Sirleaf declares a state of national emergency.
  • The WHO declares Ebola an “international public health emergency”

May 2015

  • Liberia is declared Ebola-free. Liberians heave a collective sigh of relief

July 2015

  • A handful of new Ebola cases emerge.

September 2015

  • The WHO once again declares Liberia free of Ebola virus transmission in the human population.

November 2015

  • Three new cases of Ebola are confirmed. More than 160 people are being monitored for signs of the diseases

Source: http://www.cdc.gov/vhf/ebola/outbreaks/history/chronology.html

Before the 2014-25 Ebola outbreak that took 11,000 West African lives and made Ebola a worldwide concern, people in Liberia spoke of an event being “before the war” or “after the war.” Liberians lived through two conflict periods, the First Liberian Civil (1989 – 1996) and the Second Liberian Civil War (1999–2003).  “References to before the war and after the war is a heuristic that individuals use to frame or situate the horrors of the war and what it entails. What might be unspeakable”, says Dr. Janice Cooper, who heads up the Carter Center in Monrovia’s mental health program. “It is a reference to which we can collectively relate”.

Billboards in Kakata in Margibi County, Liberia, where new Ebola cases were recorded in June and July 2015.

Billboards in Kakata in Margibi County, Liberia, where new Ebola cases were recorded in June and July 2015.

When Ebola re-emerged in Liberia in late June 2015, there were no panicked scenes, no people collapsing in the streets. According to the Dec. 2nd 2015 WHO situation report, a monthly case tracker, the June/July outbreak was confined to six cases. But the euphoria and pride Liberians felt at having defeated the disease was over. In its place, new questions emerged about what it all meant.

Translating Complexity

At Internews, a media development organization, where I serve as Global Health Media Advisor, we had navigated this complexity alongside local Liberia-based journalists for whom we provide training to help them respond to the Ebola crisis – and who then go on to produce their reports in various media, most often working on a shoestring. We also partnered with the humanitarian community to provide two-way communication channels to affected communities.  Early in 2015, Internews set up DeySay, a rumor tracker that detects and manages Ebola-related rumors, which are coordinated and analysed for trends at a central hub in Monrovia. The tracker has picked up on wild speculation that the government of Liberia was profiteering from Ebola and recorded widely held beliefs that the disease is not real. Distrust in government is rooted in the years of civil war and conflict preceding Ebola. Also, early on in the outbreak, many people resisted treatment for Ebola because early presentation of the disease is with symptoms similar to malaria or even flu. Malaria is endemic in Liberia, and so often the (Ebola) symptoms seemed like those of a familiar disease.

We would analyse the rumor and say: what’s the piece of information that is missing here? Where is the misunderstanding coming from? And then we provide that piece of information to our journalists and social mobilizers and religious leaders on the ground. It’s about really understanding where it’s coming from,” says Anahi Iacucci, Internews Senior Innovation Advisor, who led the Information Saves Lives project in Liberia and deployed DeySay.

In this way, DeySay has been a valuable journalistic tool used by Liberia-based reporters in the Internews training program. As rumors were collected with the DeySay tracker, myths were debunked by providing a factual correction or explanation as illustrated below:

  • Rumor from Sinoe County:  There are people who are refusing to take their children to the hospital for the Polio and vitamin A immunization campaign because they believe that the government is using the campaign as a way to infect people with Ebola.
  • Well-sourced and accurate response: From the 26 nation-wide Polio and vitamin A immunization campaign: Children below the age of 5 were given free drops in the mouth to protect them from the polio virus. The polio immunization campaign was not organized by the government to infect people with the Ebola virus. With the vaccination, young children are protected against the virus, to ensure that Liberia will continue to be polio free.
  • Rumor from Nimba County: A woman in Nimba County was arrested after she refused health workers trying to give her child the Polio and vitamin A vaccine. She said the vaccine would infect the child with the Ebola virus.
  • Well-sourced and accurate response: A parent has the right to refuse the immunization of his child. No one should be arrested for refusing to take part in the immunization campaign.

Beyond tracking rumors, Internews is also partnered with GeoPoll in a project that traces the most frequently asked questions around Ebola. During all phases of the crisis – during Ebola’s peak in July to October 2014, in the Ebola-free phase as well as after its resurgence in July 2015 – the most enduring question has been: Where does Ebola come from?  

The Medical Forensics of Ebola

Like the people of Liberia, scientists have also been asking this question; specifically, where did the new Ebola cases in Liberia come from, in late June, seven weeks after the country had been declared Ebola free, and again, in mid-November, ten weeks after the country had again been declared Ebola free.  Although their present focus is on West Africa, the question of where Ebola originated has bedeviled virologists since the virus was first identified in 1976. In time this strain would be dubbed Zaire virus. Subsequently, additional strains of the virus emerged, named for the areas where they occurred.  Later in 1976, Sudan virus was identified, a strain of the virus with a lower fatality rate than Zaire virus. Ivory Coast Ebola virus, isolated in 1994, showed slightly different characteristics again. In the period 1989–2007, three additional Ebola subtypes have been identified, Reston virus, Taï Forest virus and Bundibugyo virus. The strain of the virus present in the multiple outbreaks in West Africa since March 2014 is simply called Ebola virus.

So, where did the new cases in June 2015 come from?

A simple headline, released by Liberia’s Ministry of Health and Social Welfare, sums up a complex scientific investigation.

“Ebola virus genomes from latest flare-up rule out introduction from Guinea or Sierra Leone.”

The government’s news release further outlines the players and medical forensics that led to this conclusion:

“A joint team – including the Liberian Institute for Biomedical Research (LIBR), the United States Army Medical Research Institute for Infectious Diseases (USAMRIID) and the Liberian Ministry of Health – has sequenced the EBOV isolated from the index case in this cluster.”

As Tolbert Nyenswah, the Head of Liberia’s Incident Management System (IMS) later explained, “The form of the virus present in June was of a mutation present in Liberia, not neighboring countries. Both sequences are identical and are consistent with this cluster representing a continuation of the EBOV outbreak in Western Africa, as opposed to a separate introduction from a reservoir population.”

Say What?

Through-out the epidemic, viral sequencing had shown different mutations of the current strain found in West Africa, thus enabling scientists to identify the origin of a single infection as being a version circulating in localized parts of Liberia, Sierra Leone or Guinea. This resolution of the Ebola DNA detective story helped put an end to the common rumor that the new Ebola cases came from across the border, from Guinea or Sierra Leone. Or did it?  As the science on Ebola has unfolded, those most affected have been trying to make sense of the complex procedures utilized in scientific laboratories to arrive at such conclusions. However, this language is not easy to follow if you’re new to molecular genetics. So, the question local journalists repeatedly faced was How can we make sure this critical information is broadly understood by the people? 


Internews trainee Eric Opa Doue of Echo Radio, which provides Ebola news in Rive Cess County, Liberia. Photo by: Andre Smith/Internews

“This news is in deep science, not in English,” says Eric Opa Doue, a community radio journalist in the Internews health training program who holds a degree from the Ghana School of Journalism.

“I first need to digest and simplify it, then send it to the translation department at my station, to ensure the message is correctly deciphered in Kru and Bassa languages for my audience, so that everyone will understand. For example, Opa Doue asks, “what does the following sentence (from the Liberian government’s news release) mean – in plain language:

‘The sequence groups closely with previous isolates from Liberia and is distinct from the viruses currently circulating in Sierra Leona and Guinea.’”

Most importantly, local Internews reports focused on the fact that this scientific finding ruled out cross-border transmission from Sierra Leone or Guinea. It also ruled out rumors, including that the boy died from eating infected dog meat. In essence, the message became the fact that this was the same Ebola they’d been dealing with since 2014.

“Ebola Deeply”

Ebola Deeply, an independent global digital media project led by journalists and technologists whose goal is to “build a better user experience of the story by adding context to content,” also took on this challenge. Work such as their two-part series Unlocking Ebola’s Secrets has been helpful to Internews trainees and others following and attempting to explain this story. To produce this report, the Ebola Deeply team visited Liberia’s genome sequencing center where researchers examined the genome of viral samples taken from the 17-year old boy who died in the town of Smell no Taste in Margibi County. There they learned that by using genome sequencing, the scientists were able to determine that the viral strain in the boy’s body was genetically similar to that circulating in this area of Liberia last year. The viral forensics had shown that the virus which killed the 17-year-old young man in June 2015 and which caused Ebola to re-emergence in a small pocket in his town in Margibi County, had the same signature as the virus present in his area earlier in 2015.

As the Ebola Deeply journalists explained in Unlocking Ebola’s Secrets, the process of genome sequencing is like “turning the pages of the virus’s personal diary”.

Learning (More) from Ebola

Toward the end of July 2015, the WHO’s Dr Bruce Aylward and colleagues from the US Centers for Disease Control and the Liberian Ministry of Health told humanitarians responding to the Ebola crisis that the world of science is braced for a period of immense learning.  The West African Ebola epidemic has been the most devastating the world has seen. More than 11,000 people have died, and, connected to this scale and to an increasingly more efficient Ebola response, is the fact that this epidemic has left behind the largest number of Ebola survivors ever – people who have been infected, but who did not die of Ebola. To families, these are loved ones who are still with them; to science, this is an opportunity to unravel some of the many questions about Ebola that remain unanswered.

hands-e1449500801203What scientists like Aylward are now saying about Ebola are things that could not have been tackled in the horror and haste of the humanitarian crisis, when the entire focus was about saving lives and preventing transmission to caregivers from those who were dying.

In part two, I discuss what is being learned about new modes of Ebola virus transmission and the public health messages that are being prepared and implemented to communicate the implications for the people of Liberia.

Ebola Survivor Comic Book to Be Distributed to Liberian Schools

teeThe Health Communication Capacity Collaborative (HC3) is supporting the printing and distribution in Liberian schools of a comic book featuring a fictional soccer star that survived Ebola.

Plans call for distributing 3,500 copies in schools along with a teacher guide, as well as selling it commercially. Developed by a team of graphic artists and storytellers in Liberia, the Ebola edition of “Tabella Tee – International Soccer Star” chronicles the latest turn in Tee’s inspiring life.

The comic book details how Ebola is transmitted by having Tee consider how he was infected in the first place. It then lists signs and symptoms of Ebola as Tee describes his own illness and his hesitancy to seek help. He eventually uses the national hotline number in Liberia to get the help he needs.

As a survivor, Tee experiences some stigma when he returns to his community, but he is welcomed after his family learns he is no longer infectious. The engaging visuals and story were designed to educate as well as entertain readers.

The next issue of the comic book will focus on the spread of Ebola throughout Tee’s community.

The Power of Behavior Change

USAID-ebola-burial-practicesThe journal Nature has a special on Ebola, collecting all its reporting on the virus in one place. One of those articles, Models overestimate Ebola cases, is on the failure of mathematical models to accurately predict the epidemic’s course. In an interesting letter responding to that article, the authors credit “altered cultural perception” that allowed for behavior change, changing the course of the epidemic for the better.

Below is the text of the response. The letter, along with others from the November 26th issue, can be found here on Nature’s website.

Ebola: the power of behaviour change

Without including social, cultural and behavioural responses to the Ebola epidemic, models may overestimate outbreak size (Nature 515, 18; 2014).

Behavioural response, triggered by an epidemic, can slow down or even stop virus transmission (see S. Funk et al. Proc. Natl Acad. Sci. USA 106, 68726877; 2009). Indeed, altered cultural perception in response to the disease enabled people’s behaviour to change in ways that helped to contain outbreaks in the past (see B. S. Hewlett and R. P. Amola Emerg. Infect. Dis. 9, 12421248; 2003).

Reports from Foya in Liberia indicate that the outbreak there is now in decline. A local information campaign to change funeral practices and other behaviours seems to have paid off.

More aid and more personnel are urgently needed, but so is the involvement of local communities and the provision of information that can help to contain this epidemic.

Sebastian Funk, Gwenan M. Knight London School of Hygiene & Tropical Medicine, London, UK.
Vincent A. A. Jansen Royal Holloway University of London, Egham, Surrey, UK.


Ebola is Real: Using Theory to Develop Messaging in a Health Crisis

Question: What is the difference between these two messages?

“Ebola is real! If you get it, you’ll die!”
“Ebola is real! If you seek treatment you have a fifty-per-cent chance of recovery?”

Answer: Theory. The Extended Parallel Process Model, or EPPM, to be exact.

These messages come from a great article in the New Yorker on the use of “culture makers” (i.e. entertainers, community leaders) in Ebola communication. The article describes the experience of a staff member from NGO Search for Common Ground, Mike Jobbins, with Ebola communication in Liberia at the start of the epidemic:

Ebola is Real messaging

Photo by Elizabeth Serlemitsos

“In Liberia, Jobbins told me, his local colleagues faced an initial wave of government sloganeering that amounted to “Ebola is real—if you get it, you’ll die!” The campaign, he said, sent “a terrible message, especially in a war-affected population where there is already so much fatalism.” The group offered up an alternative, as Jobbins remembers it: “How about, ‘Ebola is real, and if you seek treatment you have a fifty-per-cent chance of recovery?’ ” He added, “You have to hit that sweet spot of treating it seriously enough that people listen and act, but not so seriously that people become fatalistic.”

What Jobbins is describing is the impact of theory on messaging. The first message, “Ebola is real! If you get it, you’ll die!” aims to communicate the real and deadly threat of Ebola. But unfortunately the message doesn’t respond to the fact that when we are confronted with scary, threatening things that we can’t control we tend to put our head in the sand and pretend the threat doesn’t exist. This all-too-human tendency is described by the EPPM. The theory, however, also gives a solution: although we tend to respond to fear of things we can’t control with avoidance, we respond to fear of things we can control with action. This small bit of theoretical understanding clears the way for a new message: “Ebola is real! Seek care and you can survive!”

In the EPPM, the fear is called “threat,” and the belief that one can do something to avoid the threat is called “efficacy.” This Threat/Efficacy relationship is like an equation that must be balanced on either side of an equal sign: the threat we communicate must be balanced by a do-able action the audience can take to avoid the threat. Too little fear with lots of efficacy results in apathy; too much fear with too little efficacy results in avoidance. The sweet spot is symmetry, where just enough fear meets plenty of efficacy and they result in action.

Using theory in health messaging doesn’t have to be a massive undertaking, and you don’t have to be a researcher to do it. What theory does for health communication is provide a road map to your work. It explains what you hope will happen, and why. It gives structure to your thinking, and in the worst of times a little structure and guidance can be very useful to keep you from wandering too far off the path.

Okay, so you can use the Extended Parallel Processing Model for everything, right? It is the only theory you’ll ever need, correct? Well, no. If you try it on another health issue you’ll see why. Take family planning. On the surface, EPPM seems to work – increase the perceived threat of unintended pregnancy, increase perceived ability to use contraception, and you have increased contraceptive use. Except that babies aren’t viruses, and women don’t like thinking of them as threats to be avoided. Instead, women often would rather think of babies as blessings, even when they don’t particularly want to be blessed with a baby right now. That calls for a different theory, one that predicts behavior based on how a woman thinks and feels. Ideation is one such theory – here is a video about how it is used in the promotion of family planning.

So if one theory does not cover all behavior change communication, how do you find out which one will best help you design your intervention? Here are a couple of tools. First is this nice Theory Picker from the CDC. It gives an overview of the major behavior change theories, including:

It also can walk you through a series of questions to see which theory might best fit your problem. I tried this with Ebola, and the old “garbage in, garbage out” truism applies. When I tried to answer the questions with just “Ebola prevention” in mind I couldn’t answer questions like: “Many audience members already believe that the consequences of the behavior would be more positive than negative.” But when I thought more specifically of one single behavior (I picked safe burial) the Picker did, indeed, give me the EPPM as one of the top two options to consider. The Picker seems to be a nice tool to explore theory in a really practical way.

For a deeper look at some of the theories and their application, here is a collection of short research briefs. And if the theories of behavior change aren’t enough for you, and you want to get into the theories that guide which media to use to communicate which messages, try this guide on media selection.

What Can Be Done to Reduce Stigma and Help Communities Get Beyond Fear

i_am_a_liberian_500In ancient Greece, slaves and traitors and other undesirables were marked or branded to show their lowly status and allow people to shun them. From that practice we get the word stigma, or mark. Today we use the word to describe the discrimination and social shunning people experience for myriad different reasons – sexual orientation, disease status, weight, ethnicity. As Ebola has spread, so has the stigma associated with the disease. People touched by Ebola – who themselves have it or have had it, who care for people with it, or who come from countries suffering from it – are marked.

A few things suggest why stigma has followed Ebola in a way that it hasn’t for, say, influenza, which kills far more people every year all over the globe.

  • Novelty. We humans don’t like what we don’t know. We tend to distrust new people, technologies, and diseases more than we distrust known, dangerous, but familiar things.
  • Fear. Being afraid can make us act in ways we otherwise wouldn’t, pushing away others in need of care because their disease frightens us so badly.
  • Other-ness. When things are frightening and new, it is comforting to be able to say “I can’t get it, because I’m not like her.” It either creates an “Us versus Them” dynamic to create mental separation between those at risk and those not (even if only in the imagination) or it exacerbates existing Us versus Them dynamics with previously stigmatized groups (think injection drug use and homosexuality at the start of the HIV epidemic).

The reaction of many in the US is illustrative of the Novelty/Fear/Other-ness dynamic: – Ebola is frightening, new to the US, and is brought to us from far away by them. Perhaps it should be unsurprising that the family of the Liberian man who died of Ebola in Dallas has experienced stigma and shunning, and that nurses, doctors, journalists, and aid workers of all types coming back from Liberia, Sierra Leone, and Guinea have also been excluded, quarantined, and feared. That Liberians, Sierra Leoneans, Guineans, and Nigerians – and their children – living in the US have experienced shunning and humiliation is appalling. The much more deadly impact of stigma, however, is in the countries where Ebola is epidemic.

Why does stigma matter so much in countries facing epidemics? It is because stigma leads to hiding of the disease, and that leads to further transmission. If people are afraid of a disease not just for itself, but for what people will do to them (or not do for them) if they have it, they are less likely to report symptoms and seek care. Stigma also limits communities’ ability to care for children who are sickened or orphaned by the disease and it prevents communities from welcoming survivors back into the fold. Survivors are potential game-changers in their communities, able to care for people with the virus without falling ill again. It is essential that communities find ways to welcome them home. In Liberia, at least, there is anecdotal evidence that stigma is receding as correct knowledge grows and survivors come home. This article in the Washington Post illustrates both the stigma and the resilience of a community working to care for kids impacted by Ebola.

Other health conditions face stigma, too, and we can learn from those experiences. The comparison everyone is making is to HIV/AIDS, of course, but other epidemics may have more relevance. For example cholera, like Ebola, is communicable, deadly, pops up in difficult to extinguish epidemics, and its sufferers and survivors experience stigma. In Haiti, not only the people with cholera experience stigma, but so do the people who are integral to preventing it, the men who clean and maintain latrines. The IRC has developed some key messages and materials to battle stigma and these illustrate the simplicity of the messaging and desired action response: cholera is a disease like any other; help people, but protect yourself; cholera can’t be spread by shaking hands.

From a communication perspective, what can be done to reduce stigma and help communities get beyond their fear to care for their own? What messages and channels should be the focus? Here are some areas for messaging:

  • Communicate correct knowledge on transmission and risk (a person who isn’t sick isn’t a risk to me, even if the person has recovered from Ebola)
  • Increase people’s sense of self-efficacy for prevention (I know what I can do to protect myself and my family)
  • Promote the role of people who have survived Ebola (survivors are assets to my community)
  • Care and compassion for children who have lost their care givers (we are all responsible for taking care of the community’s children)

As with any communication, the message you need to convey and the audience you are trying to reach will guide you in figuring out how to communicate. For example, mass media campaign type work can help with correct knowledge, but isn’t very effective for transmitting complicated information; entertainment education can help model change and promote pro-social behavior, but can be time consuming to produce and air; community mobilization can work to organize people to respond, and provides opportunities for dialogue with religious and cultural leaders. All of these channels (each with their strengths and limits) are more powerful when they are used together, because multi-channel interventions extend reach and are mutually reinforcing.

Ebola, Hand-washing and Oral Rehydration Therapy

The question of Ebola communication has focused mainly on, well, Ebola. But beyond knowledge of how the virus is spread and what to do if you get it, there are practices and skills that public health people have been communicating about for decades that can help with prevention and, possibly, survival. Two big ones are hand-washing and Oral Rehydration Therapy (ORT).

Hand-washing is one of those crucial life-saving practices that doesn’t get as much attention as it deserves, and which is not always as simple as it seems due to lack of access to clean water and soap. Even when it is simple, it often isn’t done, as anyone spending time in an airport restroom can attest. No one is suggesting that hand-washing alone is going to get the virus under control. Indeed, there is no research yet on the exact role hand washing plays in halting the spread of Ebola. Regardless of how effective hand-washing is in preventing the spread the virus, we do know that it is crucial in preventing the spread of other diseases, like influenza, that can look like Ebola. The fewer people going to doctors with flu in the coming months – whether in Baltimore or Bamako – the better.

So how to communicate on hand-washing at a time like this, or any time? Jeffrey Sachs has an article on hand-washing in the age of Ebola, and a program to teach kids to wash their hands five times a day. Since hand-washing is a habitual behavior it makes sense to get kids early, and kids also bring healthy habits home to share with their families.

Hand-washing has also been promoted as part of integrated health programs that support multiple healthy behaviors and the health services that support them. This is a poster from Nigeria, one of a series on hand-washing:
It has a simple, direct message, a call to action, and clear visuals. In other outbreak situations we have also turned to communication to promote hand-washing as a key tool in stopping the spread of disease, such as H1N1 – here is an example of a material from Egypt that gets a little extra help from a cute Sesame muppet.


Another old-school intervention that could be helpful now is Oral Rehydration Therapy. ORT (also known as oral rehydration salts or oral rehydration solution) may have a more direct effect on Ebola survival, though again there is little evidence to show what role ORT can or should play in the community setting. Given the uncertainly, what we can communicate is the use of ORT when anyone is sick with diarrhea and vomiting – the same message public health authorities have been giving for years. For families waiting for care at an Ebola Treatment Unit for their loved ones in affected countries, knowing to spike the water with ORT could make a difference to survival. In Nigeria, doctors who lived through their infections with Ebola attributed their survival to the early and copious use of ORT.

There are reports of people using coconut water for hydration in Sierra Leone and elsewhere. Coconut water has the advantages of being clean (unless contaminated when opening the coconut) and having some minerals and sugars. However, previous studies show it does not have sodium or enough glucose to be used instead of the sugar/salt solution.

How to use ORT has been communicated in different ways over the years. That old stand-by of community health workers and Peace Corps Volunteers, Where There is No Doctor, gives the following recipe for “Rehydration Drink”: a half level teaspoon of salt and eight level teaspoons of sugar in a liter of clean water. It should taste no saltier than tears. You can add fruit juice or coconut water for added oomph.

This simple, classic poster from India (from 1990!) illustrates ORT communication.

IND1 poster
Communication for ORS doesn’t have to be a print material, either: check out this cup with instructions written on it.

cup with instructions

And finally, communication on both hand-washing and ORT is encouraged and facilitated by the WHO. Here is link to quick messages and tweets on Ebola, hand-washing, and ORT. The messages are downloadable as print ready posters, including one with the recipe for oral rehydration solution.

The Art of Adaptation When Adapting Communication Materials in a Hurry

If you Google “brochure” and “family planning,” you get page after page of links to brochures, most of them to reputable materials you can use. But replace “family planning” with “Ebola,” and there aren’t so many options.

The outbreak, and our response, is simply too new. If you are in need of a brochure (or poster or radio spot or whole communication strategy) for Ebola – and you need it now, of course – you are going to have to build one. Luckily, you won’t have to do it from scratch.

There are communication materials for Ebola, and the Ebola Communication Network is making sure that they are being shared. But even if you find something that you think might meet your communication needs, you still are going to have to adapt it. Why? Because communication materials work best when they are specifically designed with an audience, topic and action in mind.

With-symptoms1For example, this nice poster was developed by the Ministry of Health and Social Welfare (MOHSW) and UNICEF in Liberia. Let’s say you want to use it somewhere else. Would it work? Could you just change the hotline number and the country logo and order a print run? Here are some things to consider before you do.

1. What is my goal? What do I want people to know and do?

These are the first questions to ask. If the material doesn’t clearly and directly address the knowledge, behaviors or beliefs that you want to change, you are going to have to do an adaptation. This poster, for example, would be appropriate if your goal is for people to know the symptoms, call for help when they are sick and allow care by health care workers. This poster is appropriate in an active epidemic context where people have access to Ebola Treatment Units. But if you are working in a context where there are currently no Ebola cases but the community needs to prepare for a possible epidemic, the messaging will change to awareness of the signs and symptoms, rather than seeking care. In other words, your communication goal is going to be different in different places, and it will need to change over time as the situation changes, and your materials will need to change as well.

2. Is it right for my audience?

On a very basic level, you need to be sure that the people you are trying to reach can access and understand the information. If you are trying to reach poor women in an urban slum, because they are the family caregivers, you’ll need to be careful that the material is appropriate for a low literacy audience, and that the materials appeal to and catch the eye of the people who need to see it. So first define your audience, and then make sure the material is accessible and understandable to them. Two areas in particular are important when adapting for specific audiences:

Language: People are most likely to absorb the message of a material if the language is the language spoken in their home and community. Even if someone can speak English (or French, or what have you), the material might be more effective in a native tongue, especially if the material contains information that is influenced by culture. That creates a trade off: translating into multiple local languages and creating distribution plans for different sets of materials is more expensive and more time consuming than producing material in one language, and having one plan for its dissemination. But a material that isn’t understood or is ignored because it is perceived as coming from outside the community isn’t going to work, and that is an even bigger waste of time and money.

Images: Like language, pictures matter. If the material has graphics of people, houses, food, etc. they should look like the people, houses and food of the community for which the material is designed. Sometimes the graphics are simple enough that specific cultural or geographic cues aren’t noticeable, but often they are vitally important and getting it wrong can cause offense.

3. Is the information correct for my context?

Information that is correct in one context may be dead wrong in another. Carefully review the material to make sure that the information lines up with what local authorities are advising. Make sure hotline numbers, addresses and names of service providers are locally adapted.

4. Does the material have key messages?

Even if the information is generally what you want to communicate, materials are most effective when they have a few key messages. The Liberia poster is a good example of focus on a few key messages: the symptoms of Ebola and the steps to take if you have it. Sometimes communication materials can get too wordy or have too much information to absorb. Stick to a few key messages and if there is more information that is essential to communicate, put it on another material and distribute as companion pieces or try a different format.

There are many situations where a print material (or a radio PSA, or other short form mass communication) isn’t the appropriate way to communicate information. Complicated, in-depth information or information that contradicts cultural norms is best conveyed inter-personally or using video. This allows for back-and-forth communication with a trusted source (in the case of interpersonal communication) or at least modeling of behavior (in the case of a video). An example of complicated information would be how to care for sick family members at home while waiting for help. The instruction is best done by community health workers, while a print material or PSA could be used to encourage people to talk to those workers to get more information.

A sub-category of the key message is the “call to action,” which is the behavior you want people to take as a result of exposure to your material. This should never be ambiguous to you or your audience. Examples might be: “if someone in your family has a fever, call for care” or “protect yourself and your family, don’t touch dead bodies.” You should test the exact language of your call to action with the community to be sure you get it right.

So, say you have found a material that seems very close to what you need for your intervention. You have determined that it is appropriate for your audience, translated it into a few local languages and adjusted the language so it has a few key messages and a call to action that fits your context. Can you send it to the print house? Nope, not yet. One last important step.

5. Pre-test.

Before you invest time and money in producing materials, you need to be sure the audience understands them and reacts to them the way you intend. A pre-test doesn’t need to be formal or conducted by researchers. Here is a guide to conducting pretesting. When it comes to pretesting, do what you can do. Don’t decide to do none at all because you can’t do it the way the book tells you to. Any feedback is better than none.

Finally, a plea. If you are developing Ebola communication materials, or adapting existing materials, please share them with the Ebola Communication Network so others can adapt them all over again.

Communication Plays a Critical Role in Ebola Crisis

© 2005 Emmanuel Esaba Akpo, Courtesy of Photoshare

© 2005 Emmanuel Esaba Akpo, Courtesy of Photoshare

During a capacity building workshop in Freetown, Sierra Leone, this past June, the mood was understandably tense as Ebola continued to spread from the East. Tea-break conversations became heated about regional responses to it. While no one agreed on how long it would last or the toll it would ultimately take, one thing was universally accepted: there was a strong need for social and behavior change communication (SBCC) in communities.

One of the workshop participants, Reverend Alimamy Kargbo of the Inter-religious Council of Sierra Leone and Chair of the Global Fund Country Coordinating Mechanism in Sierra Leone, put it this way, “We are troubled and confused about the rate of the spread and the major reason for the spread has been denial [of Ebola]  and not taking heed of instructions issued by the Government and other health workers,” he said. “Now that many people have accepted the reality of its existence and its deadliness, it is as they say ‘out of control’ and still beyond the scope of government to contain it.”

The SBCC challenges related to Ebola are many: the virus can be transferred through local customs and practices such as funerary preparations, including washing the dead, and by eating bush meat that carry the virus. Improper handling of Ebola victims by family members and health workers and avoidance of hospitals and health centers are also major causes of the spread.

“People are too afraid to go to the hospital or health facilities for fear that they will be diagnosed with Ebola,” Kargbo continued, and since there is no known cure, going to a health facility is not an attractive option for many. “Besides, some nurses and health workers are running away for fear of contracting the disease as little or no protective gear are available in some health facilities.”

The Harvard Business Review (HBR) and the World Bank blog both ran articles this week on the critical need for SBCC in Guinea, Liberia, Sierra Leone and other countries in the region where Ebola may be spreading, highlighting entertainment-education (EE) as one approach that helps people consider changing current behaviors and attitudes. As the articles point out, EE has been used with good results for other health issues such as HIV/AIDS, malaria, and nutrition.

The HBR cited drama theory research from Lawrence Kincaid, a health communication expert with Johns Hopkins Bloomberg School of Public Health Center for communication Programs (JHU.CCP), which is a leader in the field of SBCC and entertainment-education. Kincaid has found that “audiences empathize with characters and vicariously live their conflicts through them, even riding with them through their change of mind.” Like many communication strategies, the ones for Ebola, according to the World Bank article, include a variety of communication vehicles such as text messaging via mobile phones, community mobilization and door-to-door outreach.It also reported that UNICEF and partners are engaging in participatory theater to spread messages, giving message-driven theater performances in communities and bus terminals.

“The more that people are transported into the world of the narrative, the more they feel immersed in the story, the more likely they are to change their beliefs to be more consistent with those expressed in the world of the narrative,” said researcher Melanie Green, in a quote from the HBR.

As of August 4, there have been 1,711 infections and 932 deaths from Ebola in these countries, and even more have been affected by the toll the virus is taking on people’s everyday lives. Last week, the World Health Organization declared the outbreak a global health emergency. SBCC must be a critical component of any global public health strategy to stop Ebola from spreading further in the region – or the world.

“I hope that we start our communication programs sooner rather than later in countries that may be affected in the coming days such as Nigeria, before people are too fearful or panicked,” said Caroline Jacoby, Senior Program Officer with JHU.CCP who teaches a course called Entertainment Education for Behavior Change and Development in Johns Hopkins Bloomberg School of Public Health. “Shifting long-held practices and behaviors is difficult, but once people start taking the appropriate actions to keep themselves, their families and their communities safe, these actions can start becoming the ‘norm,’ and have an impact on lives.”

Reprinted with permission from the Health Communication Capacity Collaborative on August 14, 2014