Tag Archive for: Ebola News

Communication Research on SARS and Its Application for Ebola Stigma

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Contending with the Ebola outbreak in West Africa has presented an enormous challenge for public health response. However, the decreasing incidence of cases in certain regions of West Africa masks a looming challenge—namely, how do we manage the stigma attached to Ebola survivors as populations recover from this public health crisis?

A poster warns travelers about Severe Acute Respiratory Syndrome (SARS) at Soekarno Hatta International airport in Jakarta, Indonesia. The poster was produced by the Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs, as part of the KUIS and STARH projects. © 2004 Catherine Harbour, Courtesy of Photoshare

A poster warns travelers about Severe Acute Respiratory Syndrome (SARS) at Soekarno Hatta International airport in Jakarta, Indonesia.
© 2004 Catherine Harbour, Courtesy of Photoshare

During and after an outbreak of emergent infectious disease, fear is itself a contagious agent. Indeed, overcoming psychological contagion is among the most difficult dimensions of public health recovery. The gruesome physical manifestations of Ebola present a perfect recipe for contagious fear, not only among those infected by the disease, but also toward those same individuals should they survive it. This is a painful paradox.

Individuals who survive Ebola develop antibodies that can save the lives of others who are infected. Despite this clinical reality, these antibodies do nothing to protect survivors from long-term ostracism and psychological scars. Prior experience of SARS is illustrative* as it painfully highlighted the power of an emergent infectious disease to stigmatize those who manage to physically recover from it; thus, introducing psychological wounds that can endure long after the infection resolves.

Against this backdrop, health communication efforts can and must play a central role in mitigating stigma toward survivors of Ebola (and other new potential infectious disease outbreaks on the horizon). As communication researcher Peter Sandman has aptly noted, risk perception is the sum of the actual hazard and the outrage (sometimes referred to as ‘dread’ or ‘fear’) accompanying that hazard.

Accordingly, effective risk communication to reduce stigma among Ebola survivors needs to address not only the clinical facts of the disease, but also the sense of dread directed toward those who have been infected by it and who must resume their lives if they’re fortunate enough to have survived. Communication research on SARS has highlighted the importance of health communication campaigns targeted for those at risk of stigma and ostracism, as part of a broader societal-level health communication campaign. Disease survivors at risk of stigma range from members of the general public to health practitioners who may become infected in the course of treating others. Enlisting trusted agents, such as faith-based community leaders, to deliver de-stigmatizing risk messages can aid such vital communication efforts.

Of course, addressing disease-survivor stigma entails recognizing its existence. Ongoing monitoring of traditional and social media content is thus needed to help public health authorities and other risk communication purveyors identify emergence and patterns of stigma at local, national and regional levels. Research can further increase situational awareness of stigma’s prevalence through focus groups, key informant interviews and/or quantitative surveys.

Stigma can have profound economic and quality-of-life impacts on those who experience it and these impacts regrettably can become part of the “new normal” following such outbreaks. In turn, this maladaptive “new normal” can have significant and tragic social justice-related effects on those who have already directly faced the ravages of a terrifying illness. Effective outbreak-related risk communication messaging therefore needs to focus explicitly on de-stigmatizing survivors, to create a constructive new normal without discrimination based on history of illness. In that critical regard, targeted risk communication to reduce stigma toward Ebola survivors can thus help to decrease the very real potential of long-term psychosocial insult on top of physical injury and illness.

*Additional References:

Person et al: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3322940/
Verma et al.: http://www.annals.edu.sg/pdf200412/verma.pdf
Lee et al.: http://www.ncbi.nlm.nih.gov/pubmed/15913861
Siu: http://www.ncbi.nlm.nih.gov/pubmed/18503014

Ebola, other Health Threats Challenges Resilience of Fragile Health Systems

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The total number of Ebola cases crossed the 23,000 mark this week.

Phebe-Hospital-in-Bong-County

Phebe Hospital in Bong County, the tertiary hospital for the county. Photo courtesy of Anna Helland.

It’s a big number, and yet it still fails to show the total damage of the Ebola epidemic – not just the deaths, but the loss of trust, traditions and fragile health systems. NPR has a lovely multimedia piece on one Liberian community traumatized by Ebola that does show that toll. What is striking in the piece is not so much the trauma, though, but the resilience. Amid the trauma, we see the face and hear the words of a woman whose husband and his other wives have died of Ebola, and she is left to care for all of their children. “The same love their mothers gave to me, I give to them,” she says. I had to read that sentence twice to grasp that it wasn’t the love the mothers used to give to their children that she now tries to provide, but that she is dipping into a deep well of love these women had for each other. In the same story a man talks about what happened in his village and their work to pull themselves back together. He says “If my neighbor’s not happy, I’m not happy.”

Another NPR story profiles a grandfather who survived Ebola in an ebola treatment unit (ETU), and then stayed in the ETU to nurse his beloved five year old granddaughter through the disease. These are stories of family and community resilience and love, and they are moving and inspiring.

It would be so nice to conclude that because families are strong, and communities are resilient, that they will survive and thrive and we therefore haven’t failed them.

But the same NPR multimedia piece has photos of the community’s clinic, staffed by a nurse. There used to be a community health worker, too, but he died of Ebola. These photos give some idea of the fragility of the health structure in contrast to the resilience of the community.

How fragile are the health systems in Liberia, Sierra Leone and Guinea?

  • The U.S. has 2.5 doctors for every 1,000 people. Liberia has 1 doctor for every 100,000 people.
  • Sierra Leone, Liberia and Guinea rank 5, 8, and 13 in the global maternal mortality rate, reflecting an abysmal lack of access to and use of trained health providers during birth.
  • The infant mortality rate in Sierra Leone, Liberia and Guinea had fallen dramatically in recent years, but their rates are still some of the highest in the world. In Liberia about 1 in every 10 infants dies before the first birthday.
  • Per capita spending on health in Sierra Leone is $205, in Guinea it is $67, and in Liberia it is $102. If we stay in the “L” section of the WHO’s list of health indicators, we see that Lithuania spends $1,426 per capita, Lebanon spends $979, and wealthy Luxembourg spends $6,341 per person.

All of this before Ebola. And it isn’t as if these countries have inherently high rates of maternal and infant death; these rates are clear reflections of health care systems that don’t fully serve their populations, for a whole host of reasons.

Ebola has shone a harsh light on the fact that our global resilience to a virus like Ebola rests on the resilience of the health systems in Liberia and Sierra Leone and Guinea. There is no isolation, there are no islands, when it comes to global health. Perhaps it was tempting to think there were, and that the fragility of the Liberian health system was a tragedy only for Liberians. Other diseases and tragedies have illustrated our interconnectedness over the years – HIV/AIDS, SARS, avian flu, terrorism – but I wonder if this is the first time we have really seen how all countries are really only as resilient as that system built on that little clinic, staffed by that one nurse, in that village at the end of a dirt road in West Africa.

ebolandresiliency

Ebola Survivor Comic Book to Be Distributed to Liberian Schools

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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.

Grand Imam of Guinea Taking New Role as Ebola Messenger

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Guineas-Grand-Imam-EbolaA recent National Public Radio (NPR) story that aired on January 26 revealed how the Grand Imam of Guinea – a country still struggling with Ebola as rates begin to drop in Liberia and Sierra Leone – stepped up to the challenge of taking on a new role as Ebola messenger. Engaging faith leaders to promote important messages about Ebola and particularly safe burials has been a critical strategy for governments and health organizations working to end the virus’ spread.

Liberia, Guinea and Sierra Leone have all taken steps to convene faith leaders both nationally and locally to train them on Ebola facts and how they can support elimination goals.

According to the story, reported by Ofeibea Quist-Arcton and titled Guinea’s Grand Imam Pulls No Punches in His Ebola Message, “The Grand Imam is certain he and other religious leaders will gain the confidence of people currently in denial about Ebola. But he admits it’s a battle. To succeed, you have to find the right medium for the message.” The story goes on to say that the American Ambassador of Guinea, Alex Laskaris, “linked up with the Grand Imam” to get involved in Ebola. According to Laskaris, “This is old-school, pre-digital diplomacy…It’s making contact eye to eye, person to person, sitting under the mango tree. And it’s also listening to people’s fears and finding out what is motivating young people to throw stones, women to bar us from entering their houses.”

Read the blog article and/or listen to the podcast on NPR’s website.

Encouraging Condom Use or Abstinence for Ebola Survivors

Encouraging Condom Use or Abstinence for Ebola Survivors

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Of all the searing images that have come from the Ebola epidemic, the ones that stay with me are the ones that show the loneliness of the disease. The child dying on the floor, the people standing behind yellow caution tape, the impenetrable barrier of the protective suit that prevents the sick from feeling the touch of a caring human hand. How do people endure this kind of isolation? And how must it feel to survive Ebola, to survive this loneliness, and then to face more isolation and loneliness when you return home?

condom-ebola-survivors

Sexual transmission of Ebola is real.

Of course stigma is one cause of isolation for survivors, but another is becoming increasingly clear: sexual transmission of Ebola is real, and we must ask survivors to be very careful not to pass Ebola to a sex partner. They must use a condom or abstain from sex for weeks – both of which are options that put a barrier (however thin and beautifully packaged!) between a traumatized Ebola survivor and a welcome, needed act of intimacy and love.

So how do you communicate about protecting your lover (or yourself) from Ebola? There are a couple of pieces of good news here. First, we actually know quite a bit about communicating with people about sexual behavior, particularly about using condoms. Second, men can pass Ebola to their partners for seven weeks. This may seem like an eternity to a man recovering from the kind of isolation that Ebola wreaks, but the risk does end and life can go back to normal, unlike sexual behavior for someone with, say, HIV.

There are many successful HIV prevention programs that focus on changing sexual behavior in different ways to mitigate risk. Here is a link to some HIV/AIDS program examples, most of which address sexual behavior for different audiences.

These materials and strategies won’t work if just applied to Ebola in Sierra Leone, of course. This recent study from Sierra Leone on the mental health impact of Ebola (done by the International Medical Corps in the Port Loko District) gives some insight into the ways in which materials for survivors and their sexual partners might be best designed, even though the study is small. The main idea I took away was – again – the weight of loneliness, loss, grief, fear, stigma and isolation that sufferers and survivors bear. It would be unconscionable to inadvertently make that burden worse by producing materials that reinforce separation, rather than connection.

If I were designing materials for Ebola survivors about sexual transmission, what would I keep in mind? I think one overriding theme comes through, maybe best illustrated by the images on condom packages. Are they covered with serious health messages? No. We save that for cigarette packages. Instead they are covered with pictures and words that evoke the act of love, in all its human permutations, depending on the brand and its intended market. In other words, you can’t sell condoms with HIV or Ebola. You sell condoms with sex. Likewise, we won’t be able to “sell” condom use and abstinence for Ebola survivors with fear and trembling. You can’t make intimacy about fear – you have to make intimacy about love, even when love means abstaining from the act of it, if only for a time.

Shedding New Light on Ebola Stigma Through an Old Christmas Song

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ebolastigmapostAlthough we won’t hear about Rudolph the red-nosed reindeer for another 11 months, I’ll be thinking about him for a while. Last month I attended mass at St. Therese Parish of Seattle led by Maurice Mamba. Father Mamba’s spoke passionately about the exclusion Rudolph faced from the other reindeer because of his differences. Rudolph, of course, was accepted after his special trait helped in a way none of the other reindeer could. The point was, Father Mamba said in his Congolese accent, it’s important to accept others as they are, no matter how different they may be.

The story reminded me of the two years (2003-2005) I spent in Zambia and the stigma people living with HIV faced there. I also thought about Father Mamba’s home country which experienced an outbreak of Ebola last year in September as well as the epidemic raging now in West Africa. I thought about the people in Sierra Leone who were prohibited from celebrating Christmas outside their homes.

As reported by Reuters, Kadija Kargbo, a man living in the Sierra Leone capital of Freetown, was somber about Christmas: “We want to avoid contact because of this deadly disease. It’s necessary but I am not really happy. Normally we have a lot of fun with family and friends, but we just have to stay home.”

Also not far from my mind were the stigmatized Ebola survivors, many of whom lost family members in addition to suffering from the virus themselves. You can read some of their stories in a Social Mobilisation Action Consortium resource, developed to show showcase their trials and tribulations, but also their hope for the future. A survivor named Juliana, a student from the town of Bo, shared her story:

I went to the hospital and the test showed I had Ebola so I was admitted to the treatment centre. After some time in the treatment centre, I started to get better until one day they did the test and it showed I no longer had Ebola and could be discharged. Now I feel healthy in my body but my mind is struggling because I lost my cousin, my fiancé and my 11-month old son to Ebola. In the community people are scared to come close to me, but they are happy I am alive. People are surprised. They say hello, but they don’t touch me or want to share meals with me. This is difficult for me. I hope that soon people will realize that Survivors no longer have Ebola, and are immune. In this way, Survivors are actually the safest people to be around.

Stories like Juliana’s are at once heart-wrenching and inspiring. I hope she fully regains her neighbors’ acceptance and her peers welcome her back. Since surviving Ebola, Juliana, like Rudolph, has a special trait that can make her a leader in her community. As Father Mumba has shown, people who are different, when fully accepted, can shed new light on an old song.

Follow #ISurvivedEbola for more stories of life after Ebola
Follow @JarretCassaniti for commentary about public health and politics

Anthropology and Ebola Communication

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Health communication has often drawn from the discipline of marketing in conceptualizing how we do what we do, especially when it comes to health issues where people need to use a product or service. Health marketing is concerned primarily with what people do. Another discipline that is increasingly recognized as crucial to the fight against Ebola is anthropology. If marketing is concerned with what people do, anthropology is concerned with why they do it –the “internal logic” of a cultural practice or system.

Bong County, Liberia - October 9, 2014: An Ebola response team from the Bong County Ebola treatment unit educates a town in Bong Mines about Ebola. Their ambulance has already collected many people from this town. Several have died, but there has been at least one survivor who has returned. Photo by Morgana Wingard

Bong County, Liberia – October 9, 2014: An Ebola response team from the Bong County Ebola treatment unit educates a town in Bong Mines about Ebola. Their ambulance has already collected many people from this town. Several have died, but there has been at least one survivor who has returned. Photo by Morgana Wingard

Anthropology uses a practice called the ethnographic method to understand cultures through interviews and observation. For health communication practitioners based outside target communities, maybe one of the most valuable contributions of anthropology is its role in “translating” between the communities, helping outsiders understand what is going on in a society and what it means to the people who live there. As we’ve seen in this Ebola epidemic, the medical/crisis response/government communities don’t always fully understand the concerns and world view of the impacted communities, or maybe simply don’t appreciate what a profound impact that worldview can have on health workers’ attempts to stop the spread of disease.

Many health communication professionals do use ethnography in their daily work, of course. We conduct or use ethnographies, and work to understand how cultures are put together, and how people in those societies understand themselves, so that we can introduce new ideas or behaviors about health that will prevent illness. Understanding culture has long been standard best practice for communicating about reproductive health, HIV and malaria, to name a few. In a crisis, though, often the thing that is possible to do quickly is the thing that gets done. Ethnography is not quick, or at least it may suffer if it is done quickly (here is a fascinating blog series of whether rapid, “corporate” ethnology done to understand markets is useful). There is evidence that the first phases of the Ebola response did not use an anthropological perspective, and that it is urgently needed now. One simple example from a Washington Post year-end “What Have We Learned About Ebola” article  is the color of body bags: in Liberia, white is the color of mourning, and the color of the shroud used to bury bodies. But the body bags used for Ebola victims were black, and people didn’t want their loved ones buried in them. So they started using white body bags, instead. It is this assumption that what doesn’t matter to oneself (the color of a body bag) doesn’t matter to other people that gets us into hot water. We don’t know what we don’t know, but anthropology can help us find out.

To learn more about how culture is influencing the Ebola epidemic, read the articles (listed below) written by anthropologists or with an anthropological perspective. Also, here is a nice overview of what anthropology has helped us learn about Ebola transmission, called Anthropology in the Time of Ebola.) National Public Radio also has an article on “the missing experts,” i.e. anthropologists.

Articles written by anthropologists or with an anthropological perspective:

Africa United in the Fight Against Ebola

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As the largest Ebola epidemic in history continues to afflict portions of West Africa, the need to control the spread of the virus is greater than ever.

wevegotyourbackEbola is a threat to people, health systems and economies around the globe. But West African communities in particular are being hammered by Ebola as a result of already-strained healthcare systems, mistrust of healthcare workers and fear and stigmatization of those infected. One major aspect to halting the epidemic is to ensure that healthcare workers, patients, and the public receive accurate information that dispels myths, promotes prevention methods and outlines resources for those affected by Ebola.

To aid in that effort, a new health communications campaign, Africa United is being announced today by the CDC Foundation, actor Idris Elba and a global team of African soccer stars, international health organizations and corporations.

For Africa United, Elba and a team of professional soccer stars, who have ties to West Africa, appear in new public service announcements (PSAs). The first PSA, titled “We’ve Got Your Back,” is aimed at engendering solidarity for healthcare workers who are on the front lines working to protect the public from Ebola. Other PSAs convey important Ebola prevention messages, coordinated with U.S. Centers for Disease Control and Prevention staff in West Africa.

Yaya Touré, an Ivorian professional soccer player, who appeared in one of the PSAs said, “I wanted to support this campaign for so many reasons. I could not sit back without doing something to help fight Ebola. It is important we don’t treat this as something we just discuss with work colleagues or simply follow on the news for updates—instead our focus should be to do something.”

I am very proud of the CDC Foundation’s backing of this important effort, and I appreciate the support of the many organizations who have come together and donated their time, voice, creativity and skills to make this communications campaign possible. This collaborative effort is an example of why public-private partnerships are crucial in uniting organizations to work together to address public health challenges—including the spread of Ebola.

To learn more about Africa United and to view the educational materials, visit www.WeAreAfricaUnited.org.

*This post originally appeared on the CDC Foundation website and was shared with the Ebola Communication Network by the Africa United Campaign.

The Power of Behavior Change

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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, 6872–6877; 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, 1242–1248; 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

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Question: What is the difference between these two messages?

“Ebola is real! If you get it, you’ll die!”
and
“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.