New Mixed Methods Approach for Monitoring Community Perceptions of Ebola and Response Efforts in the Democratic Republic of the Congo

Abstract

Background: Efforts to contain the spread of Ebola in the eastern Democratic Republic of the Congo (DRC) during the 2018-2020 epidemic faced challenges in gaining community trust and participation. This affected implementation of community alerts, early isolation, contact tracing, vaccination, and safe and dignified burials. To quickly understand community perspectives and improve community engagement, collaborators from the DRC Red Cross, the International Federation of the Red Cross, and the U.S. Centers for Disease Control and Prevention explored a new method of collecting, coding, and quickly analyzing community feedback.

Methods: Over 800 DRC Red Cross local volunteers recorded unstructured, free-text questions and comments from community members during community Ebola awareness activities. Comments were coded and analyzed using a text-coding system developed by the collaborators. Coded comments were then aggregated and qualitatively grouped into major themes, and time trends were examined.

Results: Communities reported a lack of information about the outbreak and the response, as well as concerns about the Ebola vaccination program and health care quality. Some doubted that Ebola was real. The response used the feedback to revise some community engagement approaches. For example, 2 procedural changes that were followed by drops in negative community responses were: using transparent body bags, which allayed fears that bodies or organs were being stolen, and widening the eligibility criteria for Ebola vaccination, which addressed concerns that selectively vaccinating individuals within Ebola-affected communities was unfair.

Discussion: This system is unique in that unstructured feedback collected by local volunteers in the course of their work was rapidly coded, analyzed, and given to health authorities for use in making course corrections throughout the response. It provides a platform for local voices to be heard throughout an emergency response and provides a mechanism for assessing the effects of program adjustments on community sentiments.

Red Cross volunteers in the Democratic Republic of the Congo talking to families in Bunia about Ebola and gathering information about their questions and concerns. These types of interactions will help improve how humanitarian actors, including Red Cross, address community concerns. © 2021 Corrie Butler/International Federation of Red Cross

Red Cross volunteers in the Democratic Republic of the Congo provide a sensitization campaign in the biggest market in Bunia. This is a regular activity with communities, providing critical information about Ebola and how to prevent other major diseases. © 2020 Corrie Butler/International Federation of Red Cross

FIGURE 1

Community Feedback Comments in Ebola-Affected Health Zones^a by Health Zone, Month, and Monthly Ebola Case Counts and Deaths,^b Eastern Democratic Republic of the Congo, August 2018 to February 2020 (N=292,232) Abbreviations: HZ, health zone. ^aHealth zones include Goma, Rwampara, Kalunguta, Masereka, Musienene, and Kayna. ^bEbola deaths may be cases that were diagnosed in previous months. Thus, in some months the number of deaths may be greater than the number of cases.

FIGURE 2

Frequencies^a of Comments Related to Ebola Response Activities,^b Beni Health Zone, September 2018 to February 2020^c Abbreviations: ETC, Ebola testing center; EVD, Ebola virus disease. ^aFrequencies are expressed as 4-week rolling averages of the percentage of all weekly comments within each code. ^bThree additional codes—recommendation to improve health care, comments about responders, and questions about burials—are not shown because they did not show any appreciable change over the period. Another code, contact tracing, received too few comments overall to show over time. ^cThere were 2 time segments: November 16–29, 2019, and December 21, 2019 to January 4, 2020, in which no data were collected.