CDC and Partners use Data-Driven Communication Interventions to Fight Ebola 

Alongside medical and public health approaches to combat Ebola, CDC and its partners have employed interventions that influence public opinion and result in behavior changes so that communities and families have accurate information and are willing to use it to protect themselves against disease.

“We know that Ebola is a behavioral problem,” said Mohamad Falilu Jalloh, program manager for FOCUS 1000, a CDC partner and nongovernmental public health agency in Sierra Leone.

It fell to Jalloh, a Sierra Leonean educated in the United States, to return to his homeland to design and execute national studies to pinpoint the public’s knowledge and opinions about Ebola. Supported by CDC Foundation, CDC, UNICEF, Catholic Relief Services, eHealth Africa, and other partners, the studies conducted by FOCUS 1000 have served as an important foundation for campaigns to teach people about health risks and to convince a once-skeptical public that changing behavior is critical to stopping the spread of disease. These studies also provided crucial insight into the best ways to disseminate information to the public.

The studies are called “KAPs,” short for “knowledge, attitudes, and practices.” As Jalloh knew, in the early days of the outbreak there was little existing information on people’s knowledge of and attitudes toward Ebola. ”We need to have a base line of what people know, are thinking, and doing to inform the social mobilization and behavior change communication efforts,” Jalloh said.

By May 2015 -- the one-year anniversary of Sierra Leone’s outbreak – three KAP studies had been completed. Together, they demonstrated that knowledge of the disease is not enough to motivate people to take steps to protect against Ebola. Instead they indicated a need for clear, convincing messages and community engagements that described concrete disease prevention steps and addressed deeply-held cultural norms, such as those at odds with safe burial practices.

The First KAP Study

Guided by results from the first KAP study conducted in August 2014 and with assistance from CDC, Sierra Leone unveiled a program called “ACT Against Ebola” to provide clear and specific information about the disease to communities. The program was based on “ACT Against AIDS,” which had been used successfully for years to inform the public and change practices to diminish the grip of AIDS on the public.

Partners in the national social mobilization efforts were trained on the ACT Against Ebola messages. “CDC was able to really use the KAP to come up with ACT Against Ebola, and it was a turning point for social mobilization and messaging on Ebola prevention in Sierra Leone,” Jalloh said. The program also enhanced the Sierra Leone’s ability to connect people with crucial information.

Information from the first KAP study was used to create messages to encourage changes in public behavior, including specially tailored messages on the radio. Enlisting religious leaders helped to further amplify and validate key behaviors. This strategy increased public knowledge and influenced behaviors – especially around shifting cultural and religious norms for burial practices, which normally involved the touching or washing of the corpse.

The Second KAP Study

CDC experts with experience in KAP surveys helped Focus 1000 develop more effective questionnaires for the second, and third, studies, expanding the number of people surveyed and devising a system for analyzing the data so it would reveal national, regional, and –even some district-level results.

Data from the second KAP study, conducted in October 2014, with associated focus groups, confirmed suspected links between the outbreak and specific community behaviors. For example, focus group participants identified one of the barriers to adhering to safe burial practices--indicating a strong dislike for the black burial bags used by safe burial teams. They explained that black bags were associated with paupers’ graves. When the color of the bags used by burial teams were changed to white, that helped overcome resistance to safe burial practices.

With the data in hand and clear correlations highlighted, the KAP study results were presented to the National Ebola Response Center (NERC) in Sierra Leone. The information was shared with burial teams, and several members of the FOCUS 1000 team went to radio programs and communicated the data for use in programming.

Through the second KAP study, “we demonstrated resistance to [safe] burial [practices] and where it was more prevalent – at the time that was in Western Area and the Northern Province. We then were able to triangulate that information with epi data to confirm that they were the same places where we were seeing a lot of new cases.” Jalloh said.

One answer was to provide clear information in a public manner.

“There was a press briefing... to help journalists know how to communicate and translate the findings to promote the recommendations about safe, dignified burials; seeking medical treatment early,” Jalloh said.

The KAP studies also used important technical advances, one of which was moving from a paper-based system to the use of handheld computer tablets during the second study in October 2014. That switch both increased the speed by which data was collected and improved the accuracy of the data.

The Third KAP Study

By the time the third KAP study began in late December, survey teams were now very familiar with putting data directly into the tablets. The CDC Foundation underwrote the cost of the tablets and upgrade. Jalloh said the benefits were immediate. “Very clean data comes out in a rapid, real-time fashion,” Jalloh said. Speed improved too. By no longer having to input data from paper, about two to three weeks was saved on every study. At a time when the epidemic was fast-changing, the speedy turnaround was invaluable to informing the on-the-ground strategies and interventions.

A focus groups conducted in April 2015 also revealed that many people were alarmed when ambulances arrived with their sirens blaring. The sound was unfamiliar and produced anxiety. With that knowledge, ambulance drivers were told to approach with their sirens off, and move slowly to show respect for the dead.

The change has closed data gaps, Jalloh said and “strengthened our capacity, our focus areas, and data management... . We were able to rapidly collect data on key indicators on knowledge, attitudes, and practices. That meant it could be analyzed in a matter of days when it would have taken months before.”

The combination of better data and faster results was a critical piece of the larger roadmap needed to defeat Ebola. Information drawn from KAP studies helped those fighting Ebola better understand dangerous behaviors that were obstacles to controlling the epidemic and with that information, a powerful tool for saving lives.