The Opposite of Denial: Social Learning at the Onset of the Ebola Emergency in Liberia

Abstract

This study analyzes findings from a rapid-response community-based qualitative research initiative to study the content of Ebola-related communications and the transmission of Ebola-related behaviors and practices through mass media communications and social learning in Monrovia, Liberia during August–September 2014. Thirteen neighborhoods in the common Monrovia media market were studied to appraise the reach of health communications and outreach regarding Ebola prevention and response measures. A World Health Organization (WHO) research team collected data on social learning and Ebola knowledge, attitudes, and practices through focus group–based discussions and key informant interviews over a 14-day period to assess the spread of information during a period of rapidly escalating crisis. Findings show that during a 2-week period, Monrovia neighborhood residents demonstrated rapid changes in beliefs about the source of Ebola, modes of contagion, and infection prevention and control (IPC) practices, discarding incorrect information. Changes in practices tended to lag behind the acquisition of learning. Findings also show that many continued to support conspiracy theories even as correct information was acquired. The implications for community engagement are substantial: (1) Under conditions of accelerating mortality, communities rapidly assimilate health information and abandon incorrect information; (2) Behavior change is likely to lag behind changes in beliefs due to local physical, structural, sociocultural, and institutional constraints; (3) Reports of “resistance” in Monrovia during the Ebola response were overstated and based on a limited number of incidents, and failed to account for specific local conditions and constraints.

From June to August 2014, the West African Ebola epidemic rapidly outpaced the response of national governments and overwhelmed the containment measures taken by international humanitarian and global health organizations like the World Health Organization (WHO), Médecins Sans Frontières (MSF), and other medical humanitarian nongovernmental organizations (NGOs). After an early but arrested outbreak in Liberia on Firestone Plantation in March 2014 (Reaves, Mabande, Thoroughman, Arwady, & Montgomery, 2014), the Liberian government hoped that the threat of the epidemic’s spread had been contained. But in June, July, and August 2014, the epidemic entered into Lofa County, spread along trunk roads into major cities, entered Monrovia (the capital of Liberia), and began to infiltrate remote rural areas connected through capillary networks to major urban centers. In its wake, Ebola was rapidly overwhelming government and NGO clinics, killing health care workers who were disproportionately exposed to the virus, and defying local and international surveillance capabilities.

On August 8, 2014, despite considerable challenges from the West African governments of Liberia, Sierra Leone, and Guinea, the WHO declared the Ebola outbreak in Liberia, Sierra Leone, and Guinea to be a Public Health Emergency of International Concern (PHEIC), and the threat of the epidemic became more apparent to national governments in North America and Europe as cases of Ebola-infected individuals spread beyond Guinea. Efforts to mobilize a response were hampered by a chaotic confusion of voices uncertain how to engage both humanitarian and global health mechanisms towards a common cause. A key source of confusion involved local community response and the need for community mobilization. Within the global health and humanitarian policy communities, there was an ongoing debate over funding priorities. Which was more important: the implementation of high standards for Infection Prevention and Control (IPC) measures like barrier protection, hand washing, early reporting, and isolation and quarantine, or the need to mobilize communities to prevent and respond to Ebola at the household and neighborhood levels (Ansumana, Bonwitt, Stenger, & Jacobsen, 2014; Gostin & Friedman, 2014)? The former option resulted in massive global investment in the construction of centralized Ebola Treatment Units (ETUs); the latter option required a major commitment to community-based social mobilization. Both strategies were pursued (Chan, 2014).

This debate was matched by a wide-ranging set of questions and concerns regarding local communities’ ability to engage with, accept, and adhere to public health messages to control Ebola. Many have commented on how the response to the Ebola epidemic initially infantilized local African populations, exoticized local cultural practices (Moran & Hoffman, 2014; Fairhead, 2014), and questioned the ability of African communities to properly care for its community members if provided with resources. Inadequate efforts to engage local leaders to share information about local conditions and challenges resulted in a global slowness to empower a locally driven response (Marais et al., 2015). Global health and humanitarian response agencies were caught guard. There was a widespread perception local cultural traditions, practices, and resistance would frustrate health communications efforts. Many within the response believed that behavior change would take many months of health communications outreach (Ratzan & Moritsugo, 2014). Compounding existing challenges was the fact that Liberia’s own weak communications infrastructure undermined its ability to respond to the outbreak compared to regional neighbors like Côte d’Ivoire and Senegal (Tokpa, Kaufmann, & Zanker, 2015).

To assess the knowledge, attitudes, and practices of local communities during the Ebola response, the WHO employed a research team to rapidly appraise community access and uptake of information, responsiveness, beliefs, and misperceptions (Omidian, Tehoungue, & Monger, 2014). This research was designed to investigate questions of health communication dissemination in 13 neighborhood sites across Monrovia, Liberia, and included a range of low-resource/high-poverty and middle-income neighborhoods. All sites studied were part of a common media market for governmental and humanitarian information dissemination channels based in or near Monrovia.

This research demonstrates that urban Monrovian neighborhoods learned factual messages and discarded nonfactual messages about (1) the causes of Ebola and (2) protective measures to prevent Ebola spread during the early emergency phase of the current West African epidemic. Social learning theory (Allen and Bergman 1976; Bandura, 1977; Bandura & Walters, 1963) posits that learning can occur purely through observation or instruction in social contexts in the absence of structured pedagogy or direct instruction, as well as through mass media communications (Bandura, 2002).

Social learning and health communications acquisition is accelerated under conditions of mortal threat, like epidemics and public health emergencies, which constituted the conditions for the 2014 West African Ebola outbreak. In August 2014, Monrovia, Liberia certainly met those conditions, with an exponential increase in confirmed, suspected, and probable cases and fatalities between June and August 2014 (see Table 1). During the period of research, there was a concurrent rise in both Ebola- and non-Ebola–related mortality, a collapse of the health care sector in urban Monrovia, an expansion of government-sponsored health communications that relayed confusing messages, and a rise in political and economic strains. The context of the current Ebola outbreak must factor into the specific epidemiological and institutional conditions that informed local contexts of social learning in the Monrovia media environment.

Table 1. Ebola cases and deaths, Liberia and West African region, August 2014

WHO report date	Total cases, Liberia	Total deaths, Liberia	Regional total cases	Regional total deaths
8/28/2014	1378	694	3052	1546
8/21/2014	972	576	2458	1346
8/15/2014	786	348	2115	1076
8/8/2014	554	294	1766	959
7/31/2014	329	156	1322	728
7/24/2014	224	127	1093	660
7/14/2014	142	88	888	539
6/24/2014	51	34	599	338

Urban Liberian neighborhoods shared a common media market but confronted serious problems interpreting new information about Ebola due to problems with mass media campaigns’ credibility and coherence of message. As a result, informal social learning became a key vehicle for locals to acquire credible information about Ebola.

Much is known about how social learning contributes to changes in health behavior, how social learning fits into the broader context of health communications efforts (Nutbeam 2000), and how it works through aggressive social marketing campaigns like those that target HIV/AIDS in West Africa (Obregon & Airhihenbuwa, 2000; Panford, Nyaney, Amoah, & Aidoo, 2001). In this paper, we map the trends in social learning, including: increasing and declining beliefs about Ebola, increasing and declining practices used to prevent Ebola, unchanged beliefs and practices during the research period, and inconsistencies between specific beliefs and specific practices.

This research demonstrates that under extreme public health conditions, local communities can rapidly learn and internalize positive health messages, abandon negative health messages, and refine known health messages, but that political and social factors can impact the health education process and muddy informational messaging. Furthermore, the combination of the formal mass communications campaign and informal social learning processes can have an amplification effect (Telfer, 2015) in crises.

Methods

The analysis presented below is based upon data collected by a WHO research team of one expatriate anthropologist and two Liberian qualitative researchers to collect data at 13 sites during the period August 4–17, 2014, including 9 urban settlements in Monrovia, Liberia, and 4 peri-urban townships in Montserrado and Margibi counties within driving distance to Monrovia.¹ Data collection occurred through focus groups and key informant interviews with residents, leaders, local and regional health officials, and governmental officials. More robust methodologies (like randomized surveys) were unable to be deployed due to IPC constraints that discouraged community encounters and restricted resources. Focus groups were followed by a WHO training about Ebola, which removed the possibility of assessing social learning in communities independent of formal communication experiences. The study was implemented for the purpose of program development and evaluation and public health communication.

De-identified data were analyzed² by a team of public health and anthropological researchers at the University of Florida in October 2014, who thematically identified, coded, and analyzed trends at the community level and correlated trends with key informant interviews and the principal investigator (PI) field notes. Surveyors reported responses related to beliefs and the performance of protective actions in 13 communities over 13 days in a common media market, marking each as a binary value to indicate their presence or absence on the day the survey was taken. We grouped beliefs and behaviors with a slope greater than zero into categories indicating acceptance of messages which encouraged specific beliefs or behaviors; we grouped beliefs and behaviors with a slope less than zero into categories indicating acceptance of messages which discouraged specific beliefs or behaviors; we grouped behaviors with a slope of approximately zero through the first week of the observation period into a category indicating no behavioral change. The findings reported below incorporate both quantitative data from a qualitative coding and analysis of focus group data, and qualitative reports from key informant interviews and field notes. Figure 1 was derived by plotting an average linear relationship between cumulative reports of a presence or absence of messages over time.

Fig. 1. Trends in community-reported beliefs and practices, Monrovia, Liberia, August 2014.

Limitations

Although the communities sampled were consumers of a common media market, it was not possible to engage in naturalistic pretesting and post-testing in order to assess intracommunity change during the 2-week study period. Data were collected by WHO teams during preintervention focus group and interview-based sensitization campaigns to circulate Ebola-related knowledge and practices. Therefore, this data cannot be generalized beyond the limitations of this study. This is consistent with methodological complications confronting social learning research in humanitarian contexts (Apthorpe & Atkinson, 1999).

Findings

In the early weeks of the outbreak, social learning and mass media served as the principle mechanisms for learning about Ebola. Social learning included verbal information sharing, peer-to-peer verbal and text phone communications, public and private conversations, and direct observation of Ebola morbidity and mortality. Mass media and communications included newspapers, radio public service announcements, billboards, social media campaigns through text messages, education activities, and direct education initiatives sponsored by Government of Liberia (GOL) and UNICEF social mobilization teams. In some important ways, social learning outpaced mass media communications in transmitting IPC information, and mass media campaigns seemed to lag behind.

We found rapid and noticeable changes in knowledge about the causes, infection pathways, and modes of prevention against Ebola over a two-week period. Table 2 presents the beliefs and practices reported by focus group participants, and classifies them into “increased acceptance,” “decreased acceptance,” and “no change.” Figure 1 presents a line graph of aggregated trends in increased beliefs, decreased beliefs, increased practices, decreased practices, and constant beliefs and practices.

Table 2. Community-reported beliefs and practices, Monrovia, Liberia, August 2014

Increased acceptance of messages	Decreased acceptance of messages	No change
Beliefs
Bodily fluid; bleeding from pregnant women;	Bats and plums eaten by bats (fruit bats)
vomiting	Organ theft
Bush meat	Poisoned biscuits and candy; poisoned food
Shaking hands; bodily contact	People living in dirty communities^a
Conspiracy theory	Baboons and monkeys
Health workers cause Ebola
Poison in wells; chemicals in water
It’s not Ebola; we don’t believe Ebola exists; myth
Practices
More health communication initiatives to communicate risks	Avoid shaking handsPraying/having faith in God	Hand washingAvoid bush meat; cook food properly
Call a health team when you notice sickness or a strange death	Don’t play with monkeys and batsDon’t touch clothes or share clothes	Avoid body contactAvoid social and public gatherings
Don’t touch sick peopleTake sick people to the hospital	Avoid bodily fluid	Avoid kissing, bathing, or hugging dead bodies
Better equipping of health care workers
Quarantine; build more facilities; isolation centers; testing
Wash body with salt water

^a Clean communities was a part of government messaging.

Changes in Beliefs

At the outset of the data collection period, local respondents tended to conflate their understanding of how Ebola is spread (and through which vectors), the source of Ebola during the current outbreak, the pathway for Ebola’s introduction into Liberia, and the practices that were likely to result in Ebola exposure and transmission under the category of “the source of Ebola.” Three important risk factors: exposure to bodily fluids like vomit, blood, urine, and sweat; bodily contact through caregiving, shaking hands, or intermingling in crowded locations; and handling or consuming bush meat were increasingly reported as causing Ebola. Key informant interviews supported this analysis by indicating that these risk factors were initially distrusted as false “government messages,” but gained credibility with a growing number of neighborhood residents during the study period.

Local rumors and conspiracy theories spread confusing messages about the sources of Ebola early in the epidemic’s arrival in Monrovia. Text messaging campaigns and local news reports suggested that Ebola was brought to Liberia as part of a conspiracy to kill Africans, that the Liberian government was cultivating Ebola in order to extract money from international donors, that foreign governments invented Ebola in a laboratory and introduced it to West Africa to test it for medical experimentation or biological warfare; and that Westerners planted Ebola in monkeys and bats to infect and kill Africans. Among the most widespread and potent rumors was the belief that the media and the Liberian government were lying about the presence of Ebola—that Ebola was a myth. This belief emerged from past experiences with the Liberian government and rebel groups using public health and mass media communications campaigns to spread disinformation in order to gain strategic military advantage, in advance of military attacks. As a result of all these factors, conspiracies had great authority and credibility and indicated local populations’ fear and distrust of governmental and international partners.

During the period of research, popular conspiracy theories in general were reported less frequently. Interviews with response workers have suggested that this decline was associated with reports that Western aid workers were contracting Ebola and an improvement in the relevance and coherence of public health messaging campaigns. Some conspiracy theories shifted as the epidemic and the international response changed form and function, and new ones emerged in response to changes in local conditions. For example, prevention measures taken to control Ebola like the community-based spraying of bleach contributed to the emergence of new conspiracy theories postulating that health care workers were intentionally infecting residents with Ebola through the chlorine sprayers.

Figure 1 suggests that the “stickiness” of conspiracy theories did not inhibit the adoption of key IPC practices. Communities were able to integrate new information about protective health behaviors to prevent the spread of Ebola even as they retained conspiracy theories about Ebola’s source and spread. This finding is supported by anthropological research in Sierra Leone (Chandler et al., 2015), which found that efforts to correct misinformation had a limited impact on epidemic outbreak trends for key cultural and structural reasons.

Changes in Practices

As Figure 1 demonstrates, local understanding of IPC practices rose during the data collection period. By the end of the first week in August, study participants began to report that they would call a health team when they recognized a strange sickness or a death in the community; that they should not touch sick people, and that sick people needed to be taken to a clinic or hospital. However, local residents’ ability to act upon correct knowledge often conflicted with locals’ lack of access to clinics and testing facilities. As Monrovia residents were turned away from hospitals and clinics and emergency phone services went unanswered, people adopted new and sometimes ineffective practices of infection prevention and control, such as washing their bodies with salt water or drinking large quantities of salt water.

At the same time, irrelevant preventive practices for the current context were reported with declining frequency. For example, as Ebola spread through human-to-human contact, rather than animal-to-human transmission, fewer respondents referenced “playing with monkeys and bats” as a risk factor for contracting Ebola.

Overall, during data collection, researchers noted a progressive attitude of seriousness and concern with IPC practices, access to resources, and the implementation of local community measures. Specifically, focus group participants demanded more and better resources like personal protective equipment to protect themselves from Ebola, improved infrastructure, functioning call-in phone lines and ambulances, more beds in hospitals, and improved government communications.

Focus group participants and interviewees also sought additional resources to educate their peers about the presence of Ebola, like door-to-door education campaigns, video clips, and photographic imagery. They also sought information and resources for implementing home-based quarantines, the construction of additional treatment facilities and community-based isolation centers, and access to testing facilities. At the same time, a religious or fatalistic response to the Ebola epidemic showed signs of decline. Communities were less likely to indicate that prayer, faith in God, or other forms of religiosity could protect them from Ebola. This may be associated with a rapid increase in community mobilization that is believed to have had the greatest impact on reversing the course of the epidemic in Liberia.

No Increase/No Decline: Consistently Held Behavior Change Messages

A series of proactive preventive measures were widely circulated in the public media and were intended to help individuals and their families protect themselves from Ebola through specific behavior change and sanitation practices. Communities’ beliefs about these practices were constant during the study and showed neither increase nor decline during the time period studied. These included the beliefs that hand washing (including washing hands after toileting, washing hands in chlorinated water, and washing hands with soap and water); avoiding eating bush-meat or cooking bush-meat properly; avoiding kissing, bathing, or handling corpses; and avoiding bodily fluids would protect against Ebola. Communities’ identification of the need to avoid public gatherings and sporting events as risk factors also remained constant.

The Role of Confused Public Health Messages from the Government

From June to August 2015, numerous sources indicated that Liberian government health messaging campaigns circulated conflicting messages that constituted, as some informants characterized it, “a throw every public health message out and see what sticks” or a “firehose” approach. For example, at the outset of the emergency phase of the epidemic, the Government of Liberia launched a public health campaign that enjoined individuals to discontinue eating bush meat from baboons or monkeys, wash their hands before eating, cook food properly, protect themselves from insect bites (a carryover of antimalarial campaigns), and clean their homes and communities (of pollution, waste, standing water). While several of these messages were indeed effective strategies for malarial control, prevention of water-borne and diarrheal diseases, and containing other epidemic disease vectors, only one message—discontinuing eating bush meat—was specifically targeted towards Ebola. As a result, local populations initially believed that a number of non-Ebola sources of infection, like insects, dirty communities, and baboons or monkeys (neither of which were associated with zoonotic or human-to-human spread of Ebola), were primary sources for Ebola.

Many community members were distrustful of government messages due to historical factors (wartime experiences), but during a rapidly accelerating emergency, government messages also had considerable reach and influence. As shown in this article, incorrect beliefs about the sources of infection changed rapidly during the study period, as government and international actors introduced an aggressive media strategy that focused on consistent and carefully selected messages targeted towards Ebola, which replaced the previous “firehose approach.” However, we believe that it is worth noting that aggressive but imprecise government communications were able to confuse local communities about Ebola sources and vectors for a limited period of time, and it remains unclear how much time was needed to resolve incorrect beliefs attained through government sources.

How Communities Managed Conflicts Between Media Messages and Local Realities

Although respondents, overall, demonstrated an increase in Ebola-related knowledge and information, one anomalous finding suggests that local conditions created conflicts between belief and practice. Over time, Monrovia residents became less likely, rather than more likely, to identify avoiding bodily contact as a practice to protect against Ebola, despite the fact that they increasingly believed that bodily contact and contact with bodily fluids was a cause of Ebola. Other studies suggest that the impracticality of eliminating bodily contact in households where many are physical dependent on older siblings, parents, and elders may be at issue (Abramowitz et al., 2015). One might theorize that the decline in reports of bodily contact as a risk factor may have indicated local constraints around efforts to restrict bodily contact. It might also be possible to infer that respondents were describing then-current practices, rather than a subjunctive framing (should, would, could) of ideal practices.

Conclusion

Since 2014, there has been a dramatic expansion in the scholarship and guidance available for using mass media and communications to intervene in non-Western epidemics, including the emergence of special health communications areas (Goldberg, Ratzan, Jacobson, & Parker, 2015; Roberts, 2015) like community outreach strategies (Boscarino & Adams, 2015; Gilbert & Kerridge, 2015; Santibañezet al. 2015) and technical, technological, and procedural innovations (Goldstone & Brown, 2015). Much literature on public health and behavior change suggests that while health communications can be effective at changing behaviors, real behavior change can require weeks, months, years, or even generations to achieve, and implies, falsely, that many non-Western populations are likely to be disengaged or resistant. These assumptions about resistance to behavior change were widely circulated about Ebola-affected West African communities at precisely the time when this study was conducted, and impacted the quality, quantity, and sophistication of the information that was distributed to Ebola-affected areas at a pivotal moment in the struggle to contain the epidemic. Communities demonstrated the capacity to acquire and validate information through local networks rapidly and efficiently, but health communications experts were not always able to perceive how well social learning was working and therefore could not fully engage its potential.

Low-resource local communities have a very high facility for rapid social learning in extreme health emergencies. Early information missteps were quickly accommodated and “unlearned,” and new, “useful” information was readily adopted late in the period studied. Communities abandoned nonfactual Ebola information and acquired and retained factual Ebola information amidst conspiracy theories, fears about water and food poisoning, fears about the toxicity of spraying, a common dislike of measures like the cremation of Ebola patients’ bodies, and the belief that health workers were complicit in spreading the epidemic.

Across the common greater-Monrovia area media market, the creation of unidirectional (radio, billboards) and bidirectional health communications outreach opportunities (community groups, Internet call-in shows, social media) facilitated the rapid acquisition and retention of accurate Ebola-related information and the discarding of inaccurate health information, in days and weeks, rather than the months suggested by Western experts. The accelerating increase in Ebola-related deaths and a heightened perception of overall community risk may have contributed to the rapid circulation, acquisition, and acceptance of new, correct information about Ebola. While we cannot identify exactly when the shift in beliefs and practices occurred, it is possible to infer that the shift took place when public perceptions of Ebola’s growing threat intersected with the introduction of realistic and useful prevention and response information. Furthermore, local communities believed Ebola-related messages more than at the beginning of the study. While incorrect messages remained in circulation, participant communities developed a consensus about Ebola that prioritized factual over nonfactual messages and therefore demonstrated substantial social learning before they were formally instructed by our research and outreach team. However, local rumors and rumor-driven text messaging campaigns, and government campaigns that disseminated incorrect and misleading messages, complicated—and may have slowed—social learning about Ebola, and may have also introduced unnecessary anxiety, paranoia, and wasteful efforts that undermined trust in public messages.

What is the relationship between social learning, belief, behavior change, and behavior rejection under epidemic conditions? Future research in a wider array of contexts, under different timelines, and with different diseases is needed to be able to draw generalizations or develop a theory of behavior change during emergencies. Global public health response, however, should draw upon what we believe is our most significant finding, which suggests that Ebola behaviour change messages were only adopted and maintained when they were seen as “realistic” or “practical” in daily life. For example, communities widely believed that “no touching” was an effective Ebola prevention strategy, but towards the end of our research period, fewer were adopting it because it was impractical in communities that were heavily dependent on domestic labor to provide care for the sick, elderly, disabled, and youth. We see this cognitive dissonance as a sophisticated and adaptive response to complex conditions, rather than as a rejection of public health messages, or more deleteriously, as “ignorance,” a “lack of education,” or a “lack of human resources.” When cognitive dissonance between belief and practice is observed, it may be that it is the message, not the community, that is to blame for failing to engage with real living conditions.

Moreover, much can be learned from past epidemics, as well as the current Ebola epidemic. We have little understanding of the “stickiness” of beliefs and behaviors under epidemic conditions. Perhaps not changing behaviors is as difficult as behavior change under conditions of intense social learning. Historical and contemporary analyses (Green & Symes, 2015) demonstrate that the circulation of conspiracy theories does not necessarily prevent or conflict with the effective uptake of factual health communications information through social learning networks during an epidemic. People can learn how to protect themselves from disease even while they hold conspiracy beliefs. Conspiracy theories, in this sense, may be seen as part of a critique of the presence of an epidemic and the effectiveness of the response (see research on the locus of control and self-efficacy around health messages and health actions (Rosenstock, Strecher, & Becker, 1988).)

Notes

¹ Specific research locations included nine Monrovia locations: Old Road 1 (Church of Christ), Catholic Hospital community, Soul Clinic community, Say Town Sinkor,·Old Road 2 (Sinkor), St. Paul Bridge, Lakpazee community (Sinkor), Old Road 3, Logan Town. It also included four peri-urban areas near Monrovia: Mboo Statutory District, Duazon (in Margibi County), and Fendell (Montserrado County).

² This research is authorized by the University of Florida Institutional Review Board for the Protection of Human Subjects (IRB-02) #2014-U-1117.