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Table of Contents
ARTICLE
Year : 2018  |  Volume : 16  |  Issue : 2  |  Page : 79-85

New targets for behaviour change in Ebola outbreaks: Ideas for future interventions


PhD, MS, ScM, Associate Professor, National University, School of Health and Human Services, San Diego, CA; California Southern University, School of Behavioral Sciences, 3330 Harbor Blvd, Costa Mesa, CA, United States

Date of Web Publication30-Jul-2018

Correspondence Address:
Tara Rava Zolnikov
National University, School of Health and Human Services, 3678 Aero Ct., San Diego, CA 92123
United States
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/INTV.INTV_4_18

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  Abstract 


Ebola virus disease (EVD) is an infectious disease with serious individual health and population consequences. While Ebola is extremely contagious, the 2014 outbreak in West Africa was the worst to date. Many strategies were implemented for the containment and treatment of the disease, although some were limited by a lack of focus on social and behavioural factors. These factors must be taken into consideration during intervention development at the levels of individuals, communities and international networks to address issues that could block intervention success. Projects in which social and behavioural understandings are embedded can have long-lasting results not only within affected communities, but also within institutions, with key players, and at a broader level. Ultimately, removing the barriers to outbreak response strengthens health and social systems and could help to prevent EVD infection and reduce transmission worldwide.

Key implications for practice

  • Behaviour-based strategies should include communication through specific groups and subsets of people.
  • This type of communication embedded with social and behavioural understanding can have long-lasting results not only within the community, but also in institutions, key players, and other communities and levels of society.
  • Ultimately, removing the barriers to outbreak response strengthens health and social systems.
  • Being aware of cultural norms and traditions at various levels (individual, community and international) could ultimately help prevent EVD infection and reduce transmission.

Keywords: Behaviour, Ebola, outbreak, public health, socialisation, on Ebola


How to cite this article:
Zolnikov TR. New targets for behaviour change in Ebola outbreaks: Ideas for future interventions. Intervention 2018;16:79-85

How to cite this URL:
Zolnikov TR. New targets for behaviour change in Ebola outbreaks: Ideas for future interventions. Intervention [serial online] 2018 [cited 2018 Nov 20];16:79-85. Available from: http://www.interventionjournal.org/text.asp?2018/16/2/79/237949




  Background on Ebola Top


Ebola virus disease (EVD) in humans is caused by an infection with one of the three Ebola virus strains: Zaire, Sudan and Bundibugyo (Centers for Disease Control and Prevention [CDC], 2015; Gostin, Lucey, & Phelan, 2014). Ebola outbreaks have been recorded in sub-Saharan Africa since 1976 (CDC, 2015); since then, there have been 885,343 confirmed cases of EVD (World Health Organization [WHO], 2014a). The most recent outbreaks of 2014 in West Africa were caused by the Zaire ebolavirus and had a case-fatality rate of 55% (CDC, 2014). Before this outbreak, deaths from EVD had not been recorded in these regions (Gostin et al., 2014). It was the largest and the most widespread EVD outbreak to date, contributing to more than 21,000 cases and 8,000 deaths since January 2014 (CDC, 2014).

There were various factors causing the disease to spread, but one significant factor was the failure of some aspects of the response to sufficiently integrate psychosocial elements, particularly in relation to communication (e.g. health education on containing the outbreak) (Fallah, Skrip, d’Harcourt, & Galvani, 2015; WHO, 2014b). Health and communication infrastructure protecting against EVD locally, community-wide and internationally was neglected in the early stages of the outbreak (DuBois, Wake, Sturridge, & Bennett, 2015; Fallah et al., 2015). Future outbreaks could follow suit unless psychosocial aspects are more comprehensively integrated at these different levels from the beginning. By adding cultural (e.g. honouring dead with goodbye rituals) and subsequent behavioural aspects (e.g. washing the body), an EVD outbreak has a higher likelihood of slowing down or even being completely terminated (Funk, Knight, & Jansen, 2014). In fact, Hewlett and Amola (2003) found that in an earlier EVD outbreak in Uganda, altered perceptions about the response-enabled behaviour to change in ways that contained the outbreak. This was, in some part, accomplished by considering local people’s feelings and knowledge, and working with the affected populations using their cultural practices to help minimise the spread of disease.


  Employed Psychosocial Response Top


From a relatively early stage in the outbreak, a number of organisations recognised that psychosocial support was a crucial element of the response (International Federation of the Red Cross [IFRC], 2014). Mental health and psychosocial support activities played a role with various partners, such as the International Federation of the Red Cross, International Medical Corps (refer Weissbecker et al., 2018) and the World Health Organization. Psychosocial support activities included direct support to affected individuals, making mental health resources available, and providing packages of information for workers. For example, the International Federation of the Red Cross created a briefing package for volunteers, which included folders of information regarding Ebola, stressful situations and psychological response sheets (International Federation of the Red Cross and Red Crescent Societies, 2014). The Inter-Agency Standing Committee (IASC) Reference Group on Mental Health and Psychosocial Support in Emergency Settings created a guide to arm workers with knowledge, strengthen preparedness and create response plans for the psychosocial consequences of EVD (IASC, 2015). The widely-used Psychological First Aid materials (World Health Organization, War Trauma Foundation, & World Vision International, 2011) were adapted for use with populations affected by EVD (World Health Organization, CBM, World Vision International, & UNICEF, 2014), and a wide variety of people involved in the response were trained in the approach, including health workers, social workers and community leaders. However, there is a general acknowledgement that psychosocial elements, especially around community engagement, communication and cultural aspects, were not adequately or comprehensively incorporated into the response, and this had a negative impact on its effectiveness (Cheung, 2015; DuBois et al., 2015).


  More Psychosocial Response Needed Top


International emergency management protocols used in the EVD outbreak in West Africa included behavioural and social interventions (International Federation of the Red Cross [IFRC], 2015; Jácome, 2014; Medicines San Frontiers [MSF], 2008; Rodríguez-Vega et al., 2015; WHO, 2014a), but culturally sensitive communication and response was not fully integrated into the response, and it was not sufficiently based on an understanding of social and behavioural traditions, values and norms, or the involvement of the communities affected. These factors limited the effectiveness of the EVD response (DuBois et al., 2015), and lessons learned from these events can provide information on how to effectively integrate social and behavioural aspects into responses to future EVD outbreaks or other epidemics.

There was considerable confusion, especially during the early stages of the outbreak, about the causes of EVD and how to prevent it, because the top–down communication that took place failed to meet the needs and realities of affected populations. As a result, people responded in ways that contributed to the spread of the disease as well as to the stigmatisation of those affected (Tambo, Lin et al., 2014). For example, in Sierra Leone, infected individuals refused to go to hospitals and were often hidden by relatives who then became infected in turn (Tambo, Ugwu, & Ngogang, 2014). Other risky behaviours included improper burial for those who had died of Ebola, resistance to cremation and disorganised and uncontrolled body collection (Heymann et al., 2015; Pellecchia, Crestani, Decroo, Van den Bergh, & Al-Kourdi, 2015).

There is a tendency for international health organisations to assume a homogeneity in terms of psychosocial and cultural responses to an outbreak such as EVD (WHO, 2014b), while experience shows that communities can respond very differently even within the same country. Community-level beliefs and responses to an outbreak contribute to outcomes through various means including fear, shame, guilt and blame (Van Bortel et al., 2016). It is essential that future responses take these factors into consideration during intervention development (IASC, 2015). Responses at the individual level, community level and in international networks must be addressed to create a fully comprehensive EVD response and to specifically address issues that could block intervention or project success.


  Importance of Theory for Behavior Change Top


To facilitate behaviour change, it is important to first understand its theoretical foundations. Behavioural science theories seek to explain successful means to change or influence behaviour (Ammerman, Lindquist, Lohr, & Hersey, 2002; Noar, Benac, & Harris, 2007). The theories of health behaviour typically contribute to the planning, evaluation and success in intervention design by encouraging individual health (DiClemente, Crosby, & Kegler, 2002; Glanz, Rimer, & Viswanath, 2008).

In the 1950s, the health belief model was a conceptual framework created to understand behaviour, including reasoning behind decisions not to participate in preventative services offered by public health departments (Hochbaum, Sorenson, & Long, 1992). The model was often applied to health concerns and sought to understand health behaviour, practices and the utilisation of health services (Hochbaum et al., 1992). Since the original development, this model has been revised to include general health motivation, perceived susceptibility and severity, benefits and barriers, reasons for action and self-efficacy (Champion & Skinner, 2008; Glanz et al., 2008; Rosenstock, 1974). Essentially, the model was created to help predict health behaviour using individual perceptions, modifying behaviours the and likelihood of action (Glanz et al., 2002) An example of this model and the concepts as they apply to EVD have been provided in [Table 1].
Table 1: Example of health belief model as the concepts apply to EVD (Glanz, 1997)

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Beside the original health belief model, other health theories have been developed to provide a foundation for behaviour change; some include the social cognitive theory, the social ecological theory and the behavioural science theory. The social cognitive theory explains the interaction of personal factors, environmental influences and human behaviour; relevant constructs to interventions include observational learning, reinforcement, self-control and self-efficacy (Bandura, 1986; McAlister, Perry, & Parcel, 2008; Will, Farris, Sanders, Stockmyerl, & Finkelstein, 2004). The social ecological theory provides an understanding of behavioural reactions from individual, interpersonal, organisational, community and public policy regarding the formation of behaviour within the surrounding social environment (Glanz & Bishop, 2010; McLeroy, Bibeau, Steckler, & Glanz, 1988; Sallis, Owen, & Fisher, 2008). The behavioural science theory assumes that human behaviour is inherently integrated in a context of potential barriers that may arise in the field (Glanz & Bishop, 2010). These theories can provide a working framework for programme or intervention design to understand the behavioural implications associated with change. By understanding individuals within their environmental context alongside potentially arising barriers, a more thorough understanding for health behaviour may be used for appropriate EVD intervention development.

Another idea, instead of using a single theory to formulate the basis for behaviour change, is to use selected parts of each theory for a more encompassing or individualised approach to change. For example, principles used in intervention development have been established by Jackson (1997) to include eight theory-based tenets. These include acquiring new behaviours is a process that entails learning through repetition; psychological factors influence peoples’ behaviour; the more benefits occur regarding an experience, the more likely the experience is repeated; behavioural experience can influence individuals’ expectations and values; individuals have an active role in the behaviour change process; social relationships and norms have a large, persistent influence on behaviour; behaviour depends on the context in which it occurs within the environment; and the process of applying behavioural theories should follow research and evaluation methods. These more individualised tenets could contribute to theory-informed practice by embedding behaviour change into intervention design, as displayed by the examples in [Table 2]. These components can then be added to the various levels that need to be included to seek a more comprehensive outreach battling EVD.
Table 2: Example of theory-based tenets as they apply to EVD (Jackson, 1997)

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  Integrating Behaviour Change at Each Level Top


Therefore, how can we integrate behaviour change, and who do we target for intervention efforts? Before we answer that question, let us briefly return to the observable dynamics regarding EVD outbreaks. Fear-driven behaviours are expected in the wake of an Ebola outbreak, but culturally appropriate interventions focused on communication efforts at various levels (individual, community and international) can decrease these behaviours (Smedley & Syme, 2000). Effective communication is paramount in the equation to reduce the spread of EVD, but one message does not fit all. For example, communication between practitioners and policy makers is very different from the communication with the affected communities or with international audiences (Ratzan & Moritsugu, 2014). Social, cultural and economic factors that contribute to health behaviour patterns have sometimes been regarded as an obstacle, but they also have the potential to promote positive change (Glanz et al., 2008; Smedley & Syme, 2000). An example of a behaviour change model focused on communication on each level is shown in [Table 3].
Table 3: Conceptual behaviour change model applied to EVD with a communication focus

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The individual

‘Agents of socialisation’ have the potential to promote appropriate communication for behaviour change while upholding cultural competency. Agents of socialisation are influential people in a particular society who can affect community outcomes. While socialisation is the lifelong process of learning the beliefs, norms and values of a society or particular social group, it is the agents who contribute to providing information and teaching culture. Agents can include families, friends or peers, community members and religious leaders (Bandura, 1986; Calhoun, Light, & Keller, 1997; Healey, 2001). Behaviour is learned from socialisation agents by the means of observation and imitation (Bandura, 1986). The agents of socialisation in sub-Saharan Africa include the extended family that retains the capacity to instil cultural values and norms related to EVD risks and the methods of transmission to younger family members. If the cultural values and norms communicated favour safe practices, this can contribute to behaviour change among large family units, which then avoid behaviours likely to increase EVD transmission. This response then ultimately becomes integrated within the society and acts as a long-term positive behavioural tool for EVD prevention.

One step to the equation of successful change is by changing individual behaviour. A significant amount of human behaviour is developed through observation and modelling (Bandura, 1971), through which individuals learn what they must do to gain positive outcomes and avoid negative ones (Bandura, 1977). By creating these pathways and observing the effects of actions, people can determine appropriate responses in specific settings and adjust behaviour accordingly (Dulany, 1968). Building on this theory, there is the possibility of positive change through the ways in which the agents of socialisation respond to those affected by EVD (including both those who survive and their family members). Those affected by EVD suffer from a variety of psychological and social effects, including stigmatisation, depression, disrupted social support and discrimination (WHO, 2012). It may be possible to change reactions to affected individuals through working with the agents of socialisation. For example, typically when a mother loses her baby, people offer sympathy and kindness instead of casting her aside as a bad omen. This response has been learned and is the observed proper behaviour. Similarly, this type of behaviour change could be relearned in EVD to change the possible outcomes and decrease the spread of disease. Integrating communication from those affected could be a strong message to others, informing them about the disease and potentially reducing stigma and fear, which would contribute to the prevention of further infections. For example, understanding the causes of EVD and the effectiveness of early treatment could lead to people being more open to receiving care in appropriate hospital settings, receiving vaccinations or using prevention tools.

Community

It is at the community-level that protective health practices must be established. With many outbreaks, community-driven behaviour approaches primarily focus on identifying, diagnosing and treating diseases to control its spread (Leung et al., 2005). However, EVD outbreaks are different in that a cyclical pattern of fear arises with a loss of trust in health services, shifts in community leadership due to mortality rates and the loss of services (Van Bortel et al., 2016). Thus, there is a need for a particularly strong focus on the psychosocial responses of the population, and culturally appropriate response to these (WHO, 2012).

Healthcare workers are key figures within communities and can play a crucial role in communication during an EVD outbreak, as well as potentially contributing to behaviour change. There was a focus during the EVD outbreak in West Africa on training and supporting healthcare workers so they could more effectively attend to the health and psychosocial needs of affected individuals (e.g. Hughes, 2015).

International

In an international setting, behaviour change may be much more difficult due to the cultural diversity within and across populations. However, a focus on the international level is significant in EVD outbreaks because the outbreak may eventually spread to these areas, and international aid workers need to be well prepared before arriving to assist in case of such an event (Salaam-Blyther, 2014). The theory of comprehensive approach of ideation may be best suited for all people living outside of the setting to understand the outbreak and formulate a proper response behaviour to it ({2017}). This theory includes understanding behaviour, perceived norms and protection from the disease; feelings of fear, trust and compassion; and behaviours regarding social support and interpersonal communication (Babalola, 2007; {2006}). Applying these principles to communication campaigns would enable targeted messages to be delivered to each specific audience (Slater, 1999), primarily through mass media. This is an area that would need to be further explored, but could be an effective means to communicate appropriate behaviour to a worldwide population.


  Future Directions Top


Ebola virus disease (EVD) has serious individual health and population consequences. The 2014 EVD outbreak in West Africa was significantly more widespread than any prior outbreak. Although various strategies were adopted and implemented for the containment and treatment of the disease, behaviour and social interventions did not form a sufficiently central element of these strategies. As a result, behaviours that contributed to the spread of the disease continued for a long period. Current knowledge on behaviour change was not made full use of, and psychosocial issues were not prioritised. For example, USAID lists the five key targets for interventions in Ebola: food security; health services and health systems; innovation technology and partnerships; governance and economic crisis mitigation; and global health security agenda (USAID, 2017). However, none of these include psychosocial issues, communication or behaviour change.

A response including the psychosocial aspects of EVD can be initiated using any health behaviour change theory. Using theory-informed practice is important for public health intervention development because it provides a scientifically derived foundation for encouraging growth and changing the setting. By including theoretical perspectives on health beliefs and behaviour, there is a greater potential for improving intervention and programme effectiveness by including personalised, culture-based information within the context of the surrounding environment (Burdine & McLeroy, 1992; Hochbaum et al., 1992; van Ryn & Heaney, 1992). That said, behaviour changes do not occur in a vacuum, and strategies should be designed specifically for each audience and reinforced by whichever theoretical model is most appropriate in that context. Strategies should remain flexible to respond to changes as they occur.

The communication of health messages embedded with social and behavioral understanding can have long-lasting results not only within affected communities, but also in institutions, with key players, and other communities or levels of society worldwide (Schiavo, 2014). One suggestion for fostering positive behavioural change is to work directly on outbreak dynamics, prevention and control techniques, contact tracing and containment measures (Tambo et al., 2014). The suggested levels − individuals, community members and international populations − can be embedded through communication efforts through participation, formal and informal education and training efforts (Tambo et al., 2014). These collaborations can eventually lead to timely, effective and detailed reporting on disease incidence and prevalence by health ministries, NGOs, UN agencies, religious leaders, health partners (e.g. CDC, MSF, UNICEF, IFRC), academicians and community members. An awareness of behaviour change in specific contexts and the use of tools that align with each group will ultimately help prevent EVD infections and the spread of other communicable diseases.[58]

Acknowledgements

The author would like to thank Dr. Rebecca Horn for her insightful comments and edits.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Background on Ebola
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