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

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.

Community-based reports of morbidity, mortality, and health-seeking behaviours in four Monrovia communities during the West African Ebola epidemic.

The goal of this study was to assess morbidity, mortality, and health-seeking behaviours during the 2014 Ebola outbreak in Monrovia, Liberia. This study examined commonly reported symptoms of illness, pre-clinical diagnostic practices, typical healthcare-seeking strategies, and health resources available to populations, in order to identify salient needs and gaps in healthcare that would inform local emergency response efforts. Semi-structured interviews were conducted with household members in four Monrovia neighbourhoods. Researchers used a multi-stage cluster approach to recruit participants. Within 555 households sampled, 505 individuals were reported sick (69%) or recently sick (38%) or deceased (7%). Common self-diagnoses included malaria, hypertension, influenza, typhoid, and Ebola. The most cited health-seeking strategy was to purchase medications from the private sector. Respondents also obtained healthcare from community members known to have medical experience. Findings suggest that non-formal healthcare systems played an important role in managing morbidity during the West African Ebola virus disease (EVD) outbreak. Lay community members engaged in complex assessments of health symptoms and sought biomedical care at rates perhaps higher than anticipated during the response. This study highlights how informal networks of healthcare providers can play an important role in preventing and curbing future emerging disease outbreaks.

Community-centered responses to Ebola in urban Liberia: the view from below.

BACKGROUND: The West African Ebola epidemic has demonstrated that the existing range of medical and epidemiological responses to emerging disease outbreaks is insufficient, especially in post-conflict contexts with exceedingly poor healthcare infrastructures. In this context, community-based responses have proven vital for containing Ebola virus disease (EVD) and shifting the epidemic curve. Despite a surge in interest in local innovations that effectively contained the epidemic, the mechanisms for community-based response remain unclear. This study provides baseline information on community-based epidemic control priorities and identifies innovative local strategies for containing EVD in Liberia. METHODOLOGY/PRINCIPAL FINDINGS: This study was conducted in September 2014 in 15 communities in Monrovia and Montserrado County, Liberia--one of the epicenters of the Ebola outbreak. Findings from 15 focus group discussions with 386 community leaders identified strategies being undertaken and recommendations for what a community-based response to Ebola should look like under then-existing conditions. Data were collected on the following topics: prevention, surveillance, care-giving, community-based treatment and support, networks and hotlines, response teams, Ebola treatment units (ETUs) and hospitals, the management of corpses, quarantine and isolation, orphans, memorialization, and the need for community-based training and education. Findings have been presented as community-based strategies and recommendations for (1) prevention, (2) treatment and response, and (3) community sequelae and recovery. Several models for community-based management of the current Ebola outbreak were proposed. Additional findings indicate positive attitudes towards early Ebola survivors, and the need for community-based psychosocial support. CONCLUSIONS/SIGNIFICANCE: Local communities' strategies and recommendations give insight into how urban Liberian communities contained the EVD outbreak while navigating the systemic failures of the initial state and international response. Communities in urban Liberia adapted to the epidemic using multiple coping strategies. In the absence of health, infrastructural and material supports, local people engaged in self-reliance in order to contain the epidemic at the micro-social level. These innovations were regarded as necessary, but as less desirable than a well-supported health-systems based response; and were seen as involving considerable individual, social, and public health costs, including heightened vulnerability to infection.