Contagious (mis)communication : the role of risk communication and misinformation in infectious disease outbreaks

Abstract: Background: The largest outbreak of Ebola virus disease in history happened between 2014- 2016 in West Africa. In Sierra Leone, one of the three most affected countries, more than 14,000 people got infected and almost 4,000 died. Risk communication and social mobilization efforts aimed to engage with the public and to educate people to prevent further transmission of the virus. Not much is known how being exposed to this type of information influenced people’s knowledge, behaviors and risk perception around Ebola. Misinformation in the Ebola outbreak was widespread, but effective methods to counter real-life infectious disease misinformation have not been studied in a low-income setting. Aims: To determine the role of risk communication in the Ebola outbreak in Sierra Leone and to test the effectiveness of methods to debunk misinformation about infectious diseases. Methods: Four nationwide cross-sectional surveys among the general population of Sierra Leone were carried out at different timepoints of the Ebola outbreak (August 2014, n=1,413; October 2014, n=2,087; December 2014, n=3,540; July 2015, n=3,564). The four surveys were pooled (n=10,604) and the associations between exposure to various information sources and Ebola-specific knowledge, misconceptions, protective behavior and risk behavior were assessed using multilevel modeling. The associations between exposure to information sources and the perceived susceptibility to Ebola (i.e. risk perception), as well as the associations between Ebola-specific knowledge, misconceptions, behaviors and risk perception were measured in the pooled sample of the first three surveys (n=7,039). Qualitative, semi-structured interviews were conducted with 13 Sierra Leonean journalists who reported during the outbreak. Using thematic analysis, their perceived roles were mapped. After the epidemic, a three-arm, prospective, randomized controlled trial (RCT) (n=736) was carried out among adults in Freetown who were in possession of a smartphone with WhatsApp, to test whether 4-episode audio drama interventions could reduce the belief in typhoid-related misinformation. Results: Exposure to information sources was associated with increased Ebola-specific knowledge and protective behavior, but also - to a smaller extent - with misconceptions and risk behavior. Exposure to new media (e.g. mobile phones, internet) and community sources (e.g. religious/traditional leaders) as well as having Ebola-specific knowledge and engaging in frequent hand washing, was associated with increased risk perception. Having Ebolaspecific misconceptions and avoiding burials on the other hand, was associated with lower risk perception (Adjusted Odds Ratio (AOR) 0.7, 95% Confidence Interval (CI) 0.6-0.8 and AOR 0.8, 95% CI 0.6-1.0, respectively). Sierra Leonean journalists adopted various roles over the course of the outbreak; from being skeptical about the existence of an outbreak, to being eye-witnesses themselves. Through training about the virus, they later turned into public mobilizers and instructors, stepping away from their journalistic independence. Results from the RCT showed that the audio drama interventions significantly reduced the belief in typhoid-related misinformation compared to the control group. In Intervention Group A (in which the audio dramas actively engaged with the misinformation) and in Intervention Group 5B (where only the correct information was given), the belief that typhoid always co-occurs with malaria was significantly reduced (Intervention Group A: AOR 0.3, 95% CI 0.2-0.5, Intervention Group B: AOR 0.6, 95% CI 0.4-0.8). Actively engaging with the misinformation, instead of only focusing on the correct information, resulted in the largest reductions in belief in misinformation. Conclusions: The associations between information sources and knowledge, misconceptions and behaviors show the need to have clear, transparent and contextualized information available during the entire course of an epidemic. The mixed findings regarding risk perception and various protective behaviors likely point to the complex interplay between behavior and risk perception, whereby adopting a behavior has an effect on how the risk of disease is perceived. As trusted, community-based sources, local journalists can be vital partners in an outbreak response. Making use of trusted sources is also one of the elements that will likely increase the chances of successfully countering real-life misinformation. Other elements include ensuring that the corrective information is in line with worldviews and repeated exposure to the information. A strategy which actively engages with the misinformation is likely to be more successful in debunking than merely focusing on the correct information. Taken together, the studies show that risk communication and misinformation management should be key pillars in health emergency response and preparedness and should be rooted in communities.