Unraveling the effects of the Ebola experience on behavior choices during COVID-19 in Liberia: a mixed-methods study across successive outbreaks

Abstract

Background: The burden of the COVID-19 pandemic in terms of morbidity and mortality differentially affected populations. Between and within populations, behavior change was likewise heterogeneous. Factors influencing precautionary behavior adoption during COVID-19 have been associated with multidimensional aspects of risk perception; however, the influence of lived experiences during other recent outbreaks on behavior change during COVID-19 has been less studied.

Methods: To consider how the direct disease experience ("near misses") and behavior change during the 2014-2016 Ebola virus disease (EVD) outbreak may have impacted behavior change during the early waves of the COVID-19 outbreak in West Africa, we analyzed data from a mixed-methods study that included a phone-based survey and in-depth interviews among vaccinated Liberian adults. Logistic regression via generalized estimating equations with quasi-likelihood information criterion (QIC)-based model selection was conducted to evaluate the influence of the interaction between and individual effects of the outbreak (EVD and COVID-19) and the "near-miss" experience on adoption of individual precautionary behaviors. Thematic analysis of interview transcripts explored reasons for differential behavior adoption between the two outbreaks.

Results: At the population level, being a "near miss" was not associated with significantly different behavior during COVID-19 versus Ebola; however, overall, people had lower odds of adopting precautionary behaviors during COVID-19 relative to during Ebola. Participants who report near miss experiences during Ebola were significantly more likely to report having a household member test positive for COVID-19 (p<0.001). Qualitatively, participants often reflected on themes around more proximal and personal experiences with Ebola than with COVID-19; they also commented on how EVD led to better preparedness at the systems level and within communities for how to behave during an outbreak, despite such awareness not necessarily translating into action during COVID-19.

Conclusions: The results suggest that perceived proximity and intensity to disease threats in space and time affect behavioral decisions. For successive disease threats, comparisons of the present outbreak to past outbreaks compound those effects, regardless of whether individuals were directly impacted via a "near-miss" experience. Measures, such as risk communication and community engagement efforts, that gauge and reflect comparisons with previous outbreaks should be considered in response strategies to enhance the adoption of precautionary behavior.

Keywords: Behavior during outbreaks; Ebola outbreak; Liberia; Pandemics; SARS-CoV-2; Social and economic consequences; Vaccination behavior.

Fig. 1

Role of successive outbreaks in modifying risk perception and behavior choices. Individual behavioral decisions occur under the influence of personal experiences and other individual-level factors within the context of community- and national-level factors such as local (e.g., community) rules, collective efficacy, and/or national policies that vary in stringency of implementation. The proximity and perceived severity or intensity (i.e., morbidity and mortality) of the situation are particularly influential factors in low-resource settings. For Liberia, decision-making around the adoption of precautionary behavior during COVID-19 was moderated by comparisons with the Ebola experience

Fig. 2

Relative behavior change for individual precautionary measures during Ebola versus during COVID-19. Behaviors were self-reported by participants as being undertaken at the same frequency, more often, or less often, relative to before the outbreak (Ebola or COVID-19). Results are further stratified by whether participants had close experience with disease in their families or households during the Ebola outbreak—that is, those who had a household member test positive for Ebola (yes) versus those who did not (no)

Fig. 3

Results of multiple logistic regression analysis via GEEs for each precautionary behavior. The odds ratio of adoption of the behavior and the 95% confidence intervals are presented. Covariates represented in the figure reflect those that were selected in the model via QIC model selection as being most contributory to explaining the outcome behavior. The odds ratio for the COVID-19 outbreak represents the odds of behavior adoption during COVID-19 relative to during the Ebola outbreak. The odds ratio for the “near miss” represents the odds of behavior adoption by those with a close experience with disease during the Ebola outbreak relative to by those without a close experience

Fig. 4

Reasons for getting the COVID-19 vaccine by EVD “near-miss” group. Participants indicated all factors that motivated them to get the COVID-19 vaccine, such that each percentage represents the percentage of participants in each “near-miss” group reporting a particular factor as part of their decision-making process. For differences between groups that were statistically significant at p < 0.05, they are noted by ***

Fig. 5

Willingness to accept Ebola vaccine if offered by local authorities. Participants reported whether they would be willing to accept a future prophylactic Ebola vaccine if it was available to them. The findings are presented for overall sample and by near miss status, both for EVD near misses and COVID-19 near misses