ABSTRACT
Introduction:
Rumors and misperceptions were a persistent challenge in the response to the 2014–2016 Ebola Virus Disease (EVD) outbreak in West Africa. This study aimed to document organizational approaches to identifying and addressing rumors and provide practical recommendations for future outbreaks.
Methods:
We conducted semistructured interviews with 34 individuals who participated in the EVD response in Liberia and/or Sierra Leone. Interviews focused on the general organizational approach and organizational response to specific rumors. Interviews were recorded and transcribed verbatim.
Results:
Most respondents reported that rumors were considered an organizational priority and their importance increased over time. Formal rumor identification systems using community-level reporters were described in Liberia and Sierra Leone as well as varied informal systems. A wide range of approaches was used to address rumors including Community Led Ebola Action, Community Led Total Sanitation, drama performances, Ebola Treatment Center/Unit-based approaches, radio, leveraging community leaders as an information source, and organization change. Interpersonal and community-led approaches were described most often. Staff whose professional roles did not involve rumor management reported informally addressing rumors with colleagues and beneficiaries. Rumors reflecting valid concerns with the EVD response, such as potential infection in health care facilities, were addressed through organizational change and improvement.
Discussion:
Interpersonal and community-led approaches were considered effective by participants and hold promise for future outbreaks. Informal systems developed at Ebola Treatment Centers/Units highlighted how these facilities may be utilized as an information hub. Professionals who interact with beneficiaries, especially local staff, are likely to address rumors informally and organizations may benefit from considering local staff an asset in rumor management. Rumors alerted responders to issues in the EVD response, but this may not be the most efficient mechanism to receive and address concerns.
INTRODUCTION
The 2014–2016 Ebola Virus Disease (EVD) outbreak in West Africa was devastating. In Guinea, Liberia, and Sierra Leone there were 28,616 confirmed, probable, and suspected EVD cases and 11,310 deaths.1 Although numerous risk and emergency communication manuals, guidance, and trainings existed at the start of the outbreak, persistent communication challenges highlighted gaps in these approaches.2 A coordinated response to the outbreak did not begin until approximately 6 months after the first human contact with the Ebola virus3 and inadequate and inappropriate communication early in the outbreak proved counterproductive.4–6 Early messaging, for example, overemphasized the importance of bushmeat in transmission while underemphasizing the comparatively higher risk of human-to-human transmission.7,8
Rumors, misperceptions, and community resistance presented significant obstacles in controlling EVD spread.4,5 Rumors, defined as “unverified and instrumentally relevant information statements in circulation that arise in contexts of ambiguity, danger, and potential threat,”9 can be problematic, but are an expected and adaptive response to frightening and ambiguous situations.10 Information is necessary for planned action and when it is unavailable or not trusted, people may come together to pool information in an attempt to develop a reasonable understanding of a situation.9–11 Rumors are not traditionally viewed as an information source but do reflect fears, hopes, and concerns of the populations in which they circulate. As such, they can be an invaluable resource for informing communication approaches and outbreak response.
This study aimed to capture the range of approaches used to identify and address rumors during the 2014–2016 EVD outbreak in Liberia and Sierra Leone. Guinea was excluded because the interview guide drew on rumors previously identified in Liberia and Sierra Leone, and rumor data were not available for Guinea.
Although program descriptions describing formal organizational responses to rumors exist,4,5,12,13 this study sought to describe both informal and formal approaches used by EVD responders in a variety of roles, locations, and organizations to identify and address rumors to provide practical recommendations for rumor identification and management in future outbreaks. Rumors continue to be of interest in public health as illustrated by their impact on the ongoing COVID-19 pandemic.14,15 To better understand how to identify and manage rumors, it is important to identify lessons learned from previous outbreaks and encourage innovation. In particular, studying informal rumor identification and management techniques practiced by EVD responders with direct community contact can provide unique insights into bottom-up approaches to identifying and addressing rumors.
Studying informal rumor identification and management techniques can provide unique insights into bottom-up approaches to addressing rumors.
METHODS
This was a cross-sectional qualitative study.
The study was reviewed and approved by the Tulane University Social-Behavioral Institutional Review Board. Participants provided oral informed consent.
Sample
Participants were recruited via Facebook and Twitter posts on the lead author’s personal pages, the lead author’s professional networks, and the CORE Group, Global Alliance for Nursing and Midwifery, and Healthcare Information for All listservs. Snowball sampling was used to reach the target sample size of 30 to 50 or until saturation was reached.
Thirty-four individuals who participated in the EVD response in a professional capacity in Liberia or Sierra Leone participated in the study. Of these, 16 participants worked in Sierra Leone, 14 worked in Liberia, and 4 worked in both countries. Twenty participants were international staff and 14 were local staff. Individuals aged younger than 18 years and/or unable to communicate in English were excluded.
Data Collection
First, participants completed a short survey about the organizations they worked with during the EVD response. The survey was available on the Health Insurance Portability and Accountability Act (HIPAA)-compliant Johns Hopkins University instance of Qualtrics.
Then, participants completed semistructured interviews on organizational response to common rumors about EVD. Interviews were conducted in person, by phone, or via their preferred digital platform (e.g., Skype, WhatsApp, Zoom). Interviews conducted via Skype and Zoom were audio-recorded using platforms’ integrated recording capacity. All other interviews were recorded via QuickTime Player version 10.5 on a laptop computer. Audio recordings were labeled with a participant code and transcribed verbatim.
Data collection took place between September 24, 2019, and June 24, 2020.
Data Analysis
Survey data were downloaded from Qualtrics and analyzed in Microsoft Excel. Interview transcripts were analyzed in Dedoose version 8.3.21 using individual-level thematic content analysis based upon an a priori analysis plan (Table 1). Two coders reviewed the first 20 interview transcripts to develop a codebook based on emerging themes. Each transcript was coded by 1 coder and reviewed by a second coder who identified code discordance. Coders discussed discordant codes until reaching consensus. Participants were not provided with a rumor definition but were rather asked how they defined rumors. This was an intentional approach to allow participants to describe their experience based on their own understanding of rumors and how they were addressed.
Analysis Plan for Semistructured Interview Responses of Participants Who Were Asked About Their Organization’s Response to Rumors During the 2014–2016 Ebola Virus Disease Outbreak
RESULTS
Participant Background and Rumor Perception
Of participants who completed the organizational characteristics survey (n=30), 17 worked for 1 organization during the outbreak, 11 worked for 2 organizations, and 2 worked for 3 or more organizations. In total, participants reported working at 40 organizations (Table 2).
Characteristics of Organizations Employing Interview Participants Who Were Asked About Their Organization’s Response to Rumors During the 2014–2016 Ebola Virus Disease Outbreak, by Country
The professional and educational backgrounds of participants varied and included international development, emergency response, public health, and clinical care, with international development and public health being the most common. Many participants had experience in multiple areas.
Organizational Response to Rumors
Rumor Priority
At an organizational level, the importance of identifying and addressing rumors varied. Some participants reported a high-priority level but also described how the priority level varied between departments. Several participants indicated that rumors were a low priority in their organizations. Increasing priority of rumors over time emerged as a common theme. Table 3 presents illustrative quotes regarding rumor priority.
Participant Quotes Regarding Rumor Priority From Interviews on Organizational Response to Rumors During the 2014–2016 Ebola Virus Disease Outbreak in Liberia and Sierra Leone
Rumor Identification
Of the 34 participants, 13 described a formal rumor identification system. Formal systems described in Liberia and Sierra Leone consisted of a national network of community-level individuals reporting rumors via mobile phone. Additionally, a few participants also mentioned formal systems reviewing mass media to identify rumors. However, although the formal systems were national, several participants were unaware of their existence.
Formal rumor identification systems in Liberia and Sierra Leone used a national network of community-level individuals reporting rumors.
Many participants discussed how organizations identified rumors with informal or ad hoc methods, most often through in-person communication between staff and community members. In some cases, staff members who were told about rumors worked in social mobilization or communication roles, although in some cases local staff were asked about rumors even if their professional role did not include any formal communication responsibilities. For example, a local staff working with an international nongovernmental organization focused on creating business opportunities described how he was frequently asked about rumors. Some participants also described other systems used to identify rumors of EVD cases but not other types of rumors. Table 4 presents illustrative quotes regarding the rumor identification processes.
Participant Quotes Regarding Rumor Identification From Interviews on Organizational Response to Rumors During the 2014–2016 Ebola Virus Disease Outbreak in Liberia and Sierra Leone
Rumor Management
Participants described a wide range of rumor management approaches using interpersonal communication and mass media channels. Participants emphasized that using multiple communication channels was vital to ensure that people in remote or isolated areas were reached, as well as the importance of different complementary approaches (e.g., radio, community meetings, drama) that allowed for wide distribution of information as well as gave people opportunities to ask questions and raise concerns.
Interpersonal communication approaches were discussed most often and were generally implemented at the community level. In Sierra Leone, one such approach was a participatory methodology called Community-Led Ebola Action. One participant described how this approach was used to address fears and rumors about personal protective equipment and ambulances. Participants described a similar approach that was used country-wide and coordinated through a consortium. Another international staff member in Liberia discussed how Community-Led Total Sanitation, the approach on which Community-Led Ebola Action was based, was adapted for community engagement in Lofa County, Liberia. Community-Led Ebola Action16 and Community-Led Total Sanitation17,18 have previously been described in detail in the literature. These approaches emphasize the capacity of communities to develop their own solutions to challenges that meet scientific standards for outbreak control as well as the importance of demystifying situations and objects that cause fear. Another community engagement approach used musical and drama performances. Participants also discussed the importance of listening to questions and concerns from the community, gathering accurate information, and sharing that information with the community to close the communication loop.
Community-level communication approaches emphasize communities’ capacity to develop solutions to challenges that meet scientific standards for outbreak control and help demystify situations and objects that cause fear.
Informal interpersonal communication efforts were also frequently discussed, especially those that took place in the Ebola treatment center/unit (ETC/ETU) context. Another international staff member working at an ETC/ETU described a more formal approach to using downtime to provide education and reduce misinformation. Although this approach used interpersonal communication to start, it later expanded to mass media. These approaches illustrated the potential for the ETC/ETU to be a setting for information sharing and addressing rumors.
Radio was the most common medium for mass media approaches, but billboards, posters, and social media were also mentioned. Interactive radio programs were generally seen to be the most effective mass media efforts. One international staff member working in Liberia and Sierra Leone and described other radio programming and efforts to work with journalists to reduce and address rumors.
Consistent messaging was discussed as a key attribute to both mass media and interpersonal communication approaches. In Sierra Leone, participants described a standard messaging guide that was produced by a Social Mobilization Action Consortium, while in Liberia participants reported that official messaging was centrally approved. Although consistent messaging was considered important to effective communication, several participants also discussed how initial messaging about the high likelihood of death from EVD was actually counterproductive and caused people to hide EVD cases. This illustrated the importance of considering the potential unintended effects of messaging.
A common theme in participants’ discussions of both interpersonal and mass media rumor management approaches was the importance of delivering information through trusted sources. The first step described for identifying trusted sources in communities was entering a community in a culturally appropriate way. One international staff member working in Sierra Leone discussed the need to be cautious in entering communities; approaches that worked in some communities may not work in others. After entering a community, participants discussed approaches to identifying trusted community members and then using those people to share information as community members may be more likely to accept information from a trusted source.
While the majority of rumor management approaches discussed were focused on communication, several participants also provided examples of organizational changes. For example, several participants discussed how family access to the ETC/ETU was increased over time and decreased rumors. Some organizational changes were made in direct response to a rumor. For example, bags used for safe burials were modified to allow family and friends to see the face of the deceased in response to rumors that these bags were filled with rocks, which illustrated the importance of transparency in reducing rumors.
Several participants discussed how traditional beliefs could affect communication and rumor management. One international staff member working in Sierra Leone described how this appeared to contribute to the persistence of the rumor that EVD was not real. In contrast, a local staff member also working in Sierra Leone described how they took traditional beliefs into account to lead to desired health behaviors. This contrasting approach illustrated that traditional beliefs, even those that are inconsistent with the biomedical explanation of disease, may not be inconsistent with behavior change goals.
Another theme that emerged in several interviews was how to address rumors that the participants felt were based on truth, at least in part. Participants mentioned rumors of people profiting from EVD, chlorine being dangerous, nepotism in ETC/ETU hiring, and health workers transmitting EVD as having some basis in truth. Participants generally indicated that when addressing these rumors the best approach was to acknowledge the element of truth. Table 5 presents interview quotations for emergent rumor management themes and summarizes the key insights for rumor management approaches.
Participant Quotes and Key Insights Regarding Rumor Management From Interviews on Organizational Response to Rumors During the 2014–2016 Ebola Virus Disease Outbreak in Liberia and Sierra Leone
Organizational Response to Specific Rumors
A common rumor in Sierra Leone was that health workers were spreading EVD. Participants mentioned identifying the rumor in several different ways.
A common rumor in Sierra Leone was that health workers were spreading EVD.
Five of the 9 participants who discussed this rumor believed that there was some truth to this rumor, but several believed the fears may have been overstated. Despite participants believing that there was some element of truth to the rumor, they also recognized that it was very damaging and led to the stigmatization of health workers and decreased health-seeking behavior.
The primary approach to addressing this rumor was organizational change and improvement of infection prevention and control procedures. As 1 participant put it:
You can't message your way out of something like that. —International staff, Sierra Leone
Interpersonal communication approaches and mass media campaigns were also used to complement organization change efforts. Table 6 presents illustrative quotes describing the organizational response to this rumor.
Participant Quotations Regarding Organizational Response to Rumors of Health Workers Spreading Ebola Virus Disease in Sierra Leone
DISCUSSION
Rumor identification systems using mobile phones and large networks of social mobilizers appeared to be effective for gathering rumors, but interviews seemed to indicate that there was limited awareness of these systems. This indicates a need for improved coordination and communication about rumor identification and management efforts. It is also worth considering how information from rumor identification systems can be used to improve outbreak response. While rumors and misinformation are often considered within the purview of communications, rumors are also an important information source regarding how operations can be improved. This was illustrated by the operational changes that several organizations made in response to rumors in the community.
It also was a consistent theme that EVD responders heard and responded to rumors even if this was not part of their professional role. This was especially common among local staff. This presents a potential risk as staff members may respond in a way that exacerbates a negative rumor but also presents an opportunity. Organizations can use their internal communication structures to encourage staff members to report these rumors and provide the necessary information and skills to respond to them. For example, it could be beneficial to allocate a portion of time during staff meetings to discuss questions, concerns, and rumors that staff are hearing from the communities they work with. Alternatively, an organization could appoint a focal person to which that community feedback could be directed. Social and behavior change training (effective communication, facilitation, negotiated behavior change, etc.) could be beneficial to prepare staff members to respond to rumors. These efforts should take into account existing workloads and be cognizant of situations where this would cause an undue burden on staff members.
Organizations can use their internal communication structures to encourage staff members to report rumors and provide the necessary information and skills to respond to them.
The use of mass media messaging and interpersonal communication at a community level to address rumors is not a new idea. Many EVD responders discussed how the 2014–2016 EVD outbreak was a learning experience and that both mass media and interpersonal communication approaches steadily improved as the outbreak went on. However, this type of approach may underutilize rumors as an information source. The results of this study illustrate how rumors highlighted issues within the response that were later addressed, but this process was ad hoc as there was not a structure in place for community members to share rumors or feedback directly with those who could address their concerns.
Despite this challenge, numerous examples of how community feedback was used to improve the outbreak response were described. One of the most striking examples was the rumor that health workers were spreading EVD. This rumor was perceived by several EVD responders as having some basis in truth and is supported by evidence of nosocomial transmission during the outbreak in Sierra Leone.19,20 As such, the primary response to this rumor was no communication or messaging, but rather improving infection prevention and control procedures in ETC/ETUs and health centers. Rumors that indicated mistrust of ETC/ETUs were seen by most EVD responders as being understandable given that in the early part of the outbreak family members or friends often went to the ETC/ETU and were never seen again. Increasing access to ETC/ETUs and modifying burial practices to allow safe family participation was perceived by participants to successfully reduce rumors, but more importantly, led to a more compassionate response that respected the humanity of those affected by the outbreak.
Limitations
This study had several limitations. EVD responders working with large international nongovernmental organizations were overrepresented in the sample due to the use of snowball sampling and the author’s own professional network. The lead author had worked in Sierra Leone during the 2014–2016 EVD outbreak, which resulted in higher levels of interconnection between participants who had worked in Sierra Leone and may have contributed to more similar opinions among those participants. No incentive was provided for participating in the study so it is likely that participants were motivated primarily in their own interest in the topic, which may have led to some sampling bias. To encourage openness and honesty in participant interviews, participants were not asked to provide the name of the organization(s) they worked with. However, as organization names are not included in the data, it is not possible to take into account duplication in the organizations represented. The data were also limited due to the long amount of time that had passed between the EVD outbreak and the time of interviews.
CONCLUSION
This study provides an overview of how rumors affected the 2014–2016 EVD response at an organizational level. While participants believed rumors had a clearly negative impact on health-seeking behavior, they were also instrumental in improving the EVD response. This study illustrates that rumors should be a key consideration in outbreak responses from the start of an outbreak response and should be considered in all aspects of the response, not only as an issue to be addressed via communication.
Acknowledgments
We would like to thank the Ebola Virus Disease responders for their service during the 2014–2016 outbreak and for volunteering their time to participate in this research. We would also like to thank Lina Moses, Dominique Meekers, and Janet Ruscher for their feedback and guidance on this research and Alisha Thompson and Ryan Blyth for their work transcribing interviews.
Author contributions
AJB conceived of the research, recruited study participants, collected interview data, led the data analysis, and drafted the manuscript. BK analyzed interview data and reviewed and revised the manuscript. DWS provided supervision and feedback on study design, data collection, and analysis and reviewed and revised the manuscript.
Competing interests
None declared.
Notes
Peer Reviewed
First published online: August 17, 2021.
Cite this article as: Brandt AJ, Katalenich B, Seal DW. Qualitative review of organizational responses to rumors in the 2014–2016 Ebola virus disease outbreak in Liberia and Sierra Leone. Glob Health Sci Pract. 2021;9(3):654-667. https://doi.org/10.9745/GHSP-D-21-00203
- Received: March 6, 2021.
- Accepted: July 15, 2021.
- Published: September 30, 2021.
- © Brandt et al.
This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. To view a copy of the license, visit https://creativecommons.org/licenses/by/4.0/. When linking to this article, please use the following permanent link: https://doi.org/10.9745/GHSP-D-21-00203
In this issue
Statistics from Altmetric.com
Jump to section
Related Articles
Cited By...
- No citing articles found.