SURVEY REPORT ‐ OCTOBER 2018 CONTENT · Ebola. A majority of respondents were able to identify...

E a s t e r n D e m o c r a t i c R e p u b l i c o f t h e C o n g o

1ST SURVEY REPORT ‐ OCTOBER 2018 (data from September 2018)

CONTENT

p.3 COMMUNICATION: Awareness about risk and prevention is high. Fewer are informed

about the outbreak situation and state of the response, which is critical to build trust

and overall knowledge.

PATRICK VINCK

PHUONG N. PHAM

ANUPAH MAKOOND

JEAN‐PAUL ZIBIKA

ERIC NILLES p.5 COMMUNICATION: Health professionals are the most trusted source of information

about Ebola but are rarely heard from. Overall trust in sources of information about

Ebola is low.

p.6 COMMUNICATION: Speculations about the reality of the epidemic and its fabrication

for financial or political gains are widespread, especially among women, the poor.

For internal use of those working on the Ebola response. p.7 BEHAVIOR: The epidemic appears to have had, so far, a limited effect on social

interactions, but respondents indicated reduced physical interactions, and most

avoided any risk of exposure to people they suspected were infected or in contact

with infected people.

p.8 MOBILITY: Travels are relatively limited, but higher wealth, education and occupation

as trader are associated with more frequent movements

p.9 BURIAL PRACTICES: Physical contact and exposure of the body of the deceased are

common. Many aspects of safe and dignified burials are unacceptable to

respondents.

p.11 HEALTHCARE: Respondents will turn to hospitals to seek care if they suspect they

have Ebola, but health centers and pharmacies are frequently used. Overall

perception of health professionals is positive. Treatment options are not well known.

p.13 VACCINATION: Vaccines are generally trusted but fewer trust Ebola vaccines.

Perception of risk and lack of clarity in access undermine trust

p.14 TRUST IN THE EBOLA RESPONSE: Trust in institutions is low. While perceptions about

the Ebola response are more positive, few see key actors as contributing to the

response, which may further undermine trust and cohesion.

ABOUT THE SURVEY

This note presents the results of a survey conducted in the cities of Beni and Butembo, North Kivu. A total of 961

randomly selected adult respondents were interviewed over a 10 days period in September 2018. Respondents

were selected using a multistage cluster sampling procedure. We randomly selected 30 avenues in each city. In

each avenue, 16 dwellings were selected using a random geographic procedure. In each dwelling, one adult was

randomly selected for interview. We approached 977 households in the cities of Beni and Butembo to participate in

the survey, of which 10 refused to participate and 6 were empty with no possibility to find members. In the

remaining 961 households composed of 6,094 individuals, we randomly selected 974 adults for interviews. A total

of 10 refused and 3 could not be located. A total of 961 adults (98.3%) were interviewed, 481 in the city of Beni and

480 in the city of Butembo. By design, the survey included 50% women. The average age of respondents was 34

years.

Figure 1: Random selection procedure

Results are representative for each city, with a 5 percent margin of error at a 95 percent level of confidence. The

survey was approved by Brigham and Women’s Hospital Human Research Committee and the Universite Libre des

Pays des Grands Lacs in the Democratic Republic of the Congo. Results are adjusted for the complex design and

weighted for unequal probability of sampling.

Acknowledgment:

We would like to thank the participants and interviewers who made this study possible. Juliet Bedford of

Anthrologica provided invaluable comments on the survey instrument. We would also like to thank Christine Prue

of the CDC who provided analytical insights.

For more information, contact:

Patrick Vinck: pvinck@hsph,harvard.edu Phuong Pham: [email protected]

Vinck P, Pham PN, Makoond A, Zibika JP, Nilles E. Ebola Rapid Survey – Eastern Democratic Republic of the Congo, 1st survey report.

October 2018. Harvard Humanitarian Initiative, Brigham and Women’s Hospital.

30 avenues/ city

16 dwellings / avenue

1 adult / dwelling

977 dwellings approached‐ 10 refused‐ 6 empty

974 adults approached‐ 10 refused

‐ 3 away

961 adults interviewed

Beni: 481Butembo: 480

Men: 481Women: 480

Ebola Rapid Survey | October 2018 3

COMMUNICATION: Awareness about risk and prevention is high. Fewer are informed about the outbreak situation and state of the response, which is critical to build trust and overall knowledge.

All respondents in the cities of Beni and Butembo heard about Ebola in the last week prior to the survey. They

received information frequently ‐ daily for a majority (64%). The percentage of respondents who heard about Ebola

once a week or less was higher among women (13%) compared to men (2%). A large majority of respondents

report having received information about how to protect themselves from Ebola (92%), the symptoms of Ebola

(85%) or where to go for health care for Ebola (80%). Fewer received information about the overall response to

Ebola (64%) and the situation / cases in the province (64%). Providing more general information about response

effort could help generate support for the response and build trust in implementing actors. It may also address key

concerns respondents expressed about the prognostic after contracting the virus and its spread.

Awareness Frequency of information

(Number of days heard about Ebola per week, on average)

8% once a week or less

Topic of information received Beni Butembo

Despite the high level of awareness and frequent flow of information, almost half the respondents rank their

knowledge of Ebola as bad or very bad (49%). Another 43% ranked their knowledge as average, and just 8% said it

was good or very good. Respondents in Butembo ranked their knowledge poorly (58% bad – very bad) more

frequently than those in Beni (22%). This reflects actual knowledge of symptoms and modes of transmission of

Ebola. A majority of respondents were able to identify symptoms of Ebola like vomiting (74%), diarrhea (73%) and

Heard about

Ebola100%

Every day

64%

2 ‐ 6 days / week

27%

Once

6%

Less than once a

week2%

Never

0%13%

2%

Women Men

92%

85%

80%

72%

64%

64%

How to protect yourself from Ebola

Symptoms of Ebola

Where to go for healthcare for Ebola

What to do if a relative / neighbor has Ebola

Overall response to Ebola

Ebola cases in the province

97%

89%

97%

89%

73%

61%

90%

84%

75%

67%

61%

65%

4 For internal use of those working on the Ebola response.

high fever (70%), but less frequently do in Butembo compared to Beni. Similarly, a majority of respondents knew

key modes of transmission of Ebola like physical contact with someone infected with Ebola (74%) or who died of

Ebola virus disease (62%), as well as handling and eating bush meat (55%), but those in Butembo knew modes of

transmissions less frequently than those in Beni.

Self‐reported knowledge about Ebola (% respondents)

Symptoms and transmission modes (% of respondents) Total Beni Butembo

Symptoms

Transmission

Very bad, 1%

Very bad, 8%

Very bad, 6%

Bad, 21% Bad, 50%

Bad, 43%

Average, 56%

Average, 39%

Average, 43

%

Goo

d, 21%

Goo

d, 3%

Goo

d, 7%

Very good

, 2%

Very good, 0%

Very good

, 1%

Beni Butembo Total (weighted)

74%

73%

70%

55%

35%

22%

16%

11%

10%

5%

1%

74%

62%

55%

46%

33%

19%

8%

1%

Vomiting

Diarrhea

High fever

Acute headaches

Bleeding

Weakness

Tiredness

Muscular pain

Stomach / abdomen pain

Other

No response

Physicalcontact with someone infected by Ebola

Physical contact with someone who died of Ebola

Eating / handling bush meat

Contact with objects tuched by someone infected by Ebola

Contact with bodily fluidsof someone infected by Ebola

Sexual contact with someone infected by Ebola

Sorcery

No response

90%

82%

90%

60%

30%

25%

32%

22%

4%

2%

0%

85%

84%

89%

58%

47%

24%

4%

0%

69%

70%

63%

53%

37%

22%

11%

8%

12%

5%

1%

71%

54%

43%

42%

29%

17%

10%

1%


COMMUNICATION: Health professionals are the most trusted source of information about Ebola but are rarely heard from. Overall trust in sources of information about Ebola is low.

As noted, all respondents in the cities of Beni and Butembo heard about Ebola in the last week prior to the survey.

They heard about Ebola from multiple sources, including most frequently their friends and family (89%), local radios

(82%), religious leaders (73%) and national radios (68%). They have less frequently heard from health professionals

like doctors or nurses (53%). Although they hear frequently from these sources, trust in sources of information

about Ebola was relatively low. Just 40% of respondents trusted ‘moderately, a lot or extremely’ their friends and

family as a source of information about Ebola. The percentage trusting formal media was similar, with 46% and 39%

of respondents expressing moderate to high levels of trust in local radios and national radios, respectively. The

most frequently trusted sources of information about Ebola were health professionals (69% moderately ‐

extremely). However, health professionals were less frequently heard from than other less trusted sources. Trust in

authorities and NGOs as a source of information about Ebola was low (23% moderately – extremely for chefs de

quartier, 28% for NGOs). Trust in all sources of information was less frequent in Butembo compared to Beni.

Source of Information about Ebola

(% respondents)

Trust as a source of Information about Ebola

(% moderate to extremely)

Beni Butembo

89%

82%

73%

68%

53%

34%

31%

30%

29%

27%

21%

6%

Friends, family

Local radio

Religious leaders / church

National radio

Health professionals

Internet and social networks

Television

Newspapers / publications

National authorities

Civil society actors

Local authorities

Traditional healers

40%

46%

44%

39%

69%

20%

29%

28%

26%

28%

23%

9%

54%

58%

64%

53%

74%

21%

40%

38%

49%

49%

40%

9%

35%

42%

37%

35%

68%

20%

25%

24%

19%

20%

17%

9%


COMMUNICATION: Speculations about the reality of the epidemic and its fabrication

for financial or political gains are widespread, especially among women, the poor.

Most people have heard statements that the epidemic is not real (86%), or that it was fabricated for financial gains

(85%) or to destabilize the region (86%). Overall, one in four respondents believe that Ebola is not real (25%), and

one in three believe it was fabricated for financial reasons (33%) or to destabilize the region (36%). Women and

poorer respondents are more likely to believe these statements are true. Belief in these rumors appears to be

associated in mistrust in institutions and low adoption of Ebola‐related protective behaviors.

Believe statement is true

(% yes)

Heard statement before

(% yes)

25% believe statement to be true (Ebola is not real)

21% 27% 25% 32% 33% 33%43%

34% 36%

93%84% 86% 89% 83% 85% 89% 85% 86%

Beni

Butembo

Total

Beni

Butembo

Total

Beni

Butembo

Total

Ebola is not real Ebola is fabricated forfinancial gains

Ebola is fabricated todestabilize the region

31%20%

34% 27% 21% 20%

Women

Men

Poorest

quartile … …

Richest

quartile

Gender Wealth


BEHAVIOR: The epidemic appears to have had, so far, a limited effect on social

interactions, but respondents indicated reduced physical interactions, and most

avoided any risk of exposure to people they suspected were infected or in contact

with infected people.

Following the announcement of the outbreak of Ebola in North Kivu, respondents have changed some behavior,

most frequently in direct response to the risk of exposure, for example by avoiding contact with people they

suspect visited Ebola affected areas (73%), people who are infected with Ebola (76%) or people they suspect died

of Ebola (79%). These avoidance behaviors are more frequent in Beni, compared to Butembo, which may be

explained by the higher number of cases in the city of Beni to date. Respondents also indicted reduced physical

interactions like physical contacts with people in general (54%). Few, however, indicated reduced social

interactions, including avoidance of public space. Information and knowledge about Ebola appear to be associated

with increased odds of behavior changes.

Ebola‐related behavior changes (% respondents)

Total Beni Butembo

73%

76%

79%

75%

1%

1%

2%

4%

8%

31%

54%

90%

Avoid contact with people you suspect have visited Ebola affected areas

Avoid contact with people you suspect are infected by Ebola

Avoid contact with the body of a person suspepected to have died of Ebola

Avoid contact with people who had contact with someone infected by Ebola

Avoid visiting extended family members

Avoid visiting neighbors

Stay home more than usual

Avoid going to the church

Avoid taking public transports

Reduce physical interactions with relatives

Reduce physical interactions with others

Washing hands more frequently

Direct exposure

Social interaction

Physical contact

87%

85%

93%

82%

1%

1%

2%

5%

10%

54%

77%

97%

69%

72%

74%

72%

1%

1%

2%

3%

7%

22%

46%

88%


MOBILITY: Travels are relatively limited, but higher wealth, education and

occupation as trader are associated with more frequent movements.

Movements in and out of neighborhood, across the city and across the province and beyond are relatively limited.

Overall, 4 out of 10 respondents (43%) indicated moving across neighboring quartiers more than 4 times a week,

on average. Another 21% moved across neighboring quartiers 2 to 4 times a week, and 14% moved across

neighboring quartiers once a week. The percentage of individuals frequently traveling outside of their quartier

decreased when considering longer movements. Overall 31% of respondents traveled across neighboring territoire

at least occasionally, and 13% travelled beyond neighboring territoire, but within the province. The percentages of

respondents who indicated travelling to other provinces or across the border at least occasionally was small (6%

and 1%, respectively). The frequencies of movement were similar among respondents from Beni and Butembo and

among men and women. However, higher mobility is associated with wealth, higher education level and occupation

as trader or civil servant as opposed to other activities. For example, 42% of the respondents in the wealthiest

quartile moved across neighboring territoire, compared to 23% among those in the poorest wealth quartile.1

Frequency of movement, by distance to the dwelling

Neighboring

quartiers

Within city,

beyond

neighboring

quartiers

Neighboring

territoire

Province, beyond

neighboring territoire

Other province Other country

1 The wealth of household was estimated by assessing their possession of ten nonproductive assets such as a table, a chair or a cellphone. A factor analysis was used to compute a global score of relative wealth. This score was then used to delineate quartiles corresponding to the poorest through the richest households.

43%

21%

14%

16%

6%

22%

16%

18%

24%

20%

1%2%7%

21%

68%

1%2%

10%

87%

1%5%

94%

2%

98%

More than 4 times a week

2 to 4 times a week

Once a week

Less than oncea week

Never


BURIAL PRACTICES: Physical contact and exposure of the body of the deceased are

common. Many aspects of safe and dignified burials are unacceptable to

respondents.

This Ebola rapid survey included several questions around burial practices. Generally, respondents indicated that

burials occur within one or two days of deaths (95%) and that the body is buried by the family itself (96%). When

ask who, if anyone, they notify of the death, respondents indicated that relatives, friends and neighbors are

frequently immediately notified. Administrative and religious authorities, on the other hand are much less

frequently notified, and health professionals are almost never notified. Respondents frequently indicated that

bodies are generally transported to the place of origin of the deceased, even if it is far away (64%). They also

frequently noted that relatives have physical contact with the body (84%) and wash the body (73%). Almost all

respondents noted that the body is publicly exposed between the death and the burial (95%).

DEATH OCCURS → Notifications (% of respondents)

Burial timing

(% of respondents)

Who takes care of

the body?

(% of respondents)

Events during

burials

(% yes)

Transport body to place of origin, even if far away 64%

Family members / friends touch the body of the dead 84%

Family members / friends wash the body of the dead 73%

The body is exposed to the public in the open air before burial 95%

The body stays at home more than a day before burial 34%

96%

81%

68%

17%

17%

1%

Relatives

Neighbors

Friends

Religious leaders

Local administrative authorities

Health professionals / doctors

One day

74%

Two days

21%

More than 2 days

5%

84%

47% 36%9% 4% 2% 0%

Family Friends Neighbors Healthprofessionals

Religiousleader

Localauthorities

No response


Ebola infection can occur from touching the bodies of those who have died from Ebola virus disease. Safe and

dignified practices are promoted to reduce handling of dead bodies and ensure that burials are done by trained

teams. The results, however, suggest that many aspects of safe and dignified burials are not acceptable to a large

percentage of respondents. Overall, just 13% of the respondents would accept that medical staff dress the body

instead of the family, and only 9% would accept having the body stay at a medical facility before burial, rather than

home. Similar low percentages found it acceptable to not have the body visible during the ceremony (4%

acceptable), to not clean the body but use perfume instead (7%) or to have the medical personnel bury the body

rather than the family (2% acceptable). A higher percentage – but still just one in three person‐ found it acceptable

to proceed with the burial without waiting for those relatives traveling from far away. There was little to no

difference between respondents in Beni and Butembo.

Acceptance of burial practices

(% of respondents who find the proposition acceptable)

13%

Medical staff dress the

body instead of the family

5%

The body is not visible

during the ceremony

9%

The body stays at the

hospital / health center

4%

The body is not cleaned,

but a perfume is used.

2%

Medical personnel bury the

body rather than the family

35%

Do not wait for relatives

traveling from far away


HEALTHCARE: Respondents will turn to hospitals to seek care if they suspect they

have Ebola, but health centers and pharmacies are frequently used. Overall

perception of health professionals is positive. Treatment options are not well known.

Respondents largely turn to health professionals for care. Health centers, hospitals and pharmacies are frequently

reported as the place people will go first if they feel sick for any reason (25%, 29%, and 38%, respectively). If they

suspected they had Ebola, respondents would more frequently turn to hospitals for care (75%) compared to other

health service providers. However, in Beni, more respondents noted they would first turn to health centers (47%)

compared to those in Butembo (4%). This likely reflects the overall more frequent reliance on health centers in Beni

compared to Butembo when sick. While many respondents turn to pharmacy when they feel sick (38%), few would

do so if they suspected they had Ebola (1%). Reliance on pharmacies when feeling sick was more frequent in

Butembo than Beni.

Where would you go first for care…

If you are sick (general) If you suspect you have Ebola Total (% of respondents) Total (% of respondents)

Beni Butembo Beni Butembo

Overall, 67% of respondents said they were aware about the existence of a treatment for Ebola. The percentages

were similar in Butembo and Beni. More men (72%) than women (62%) said they were aware of such treatment.

Most respondents who had heard about treatment for Ebola believed those treatments could be obtained at

hospitals (82%) or at health centers (31%). One in ten respondents (11%) did not know where such treatments

would be available. Percentages were similar in Beni and Butembo, except concerning the perceived availability of

treatment at health centers, which was much more frequent in Beni (61%) compared to Butembo (21%). This likely

reflects the much more common use of health centers to seek care in Beni compared to Butembo.

25%

29%

38%

5%

2%

Health Center

Hospital

Pharmacy

Nobody

Other

15%

75%

1%

2%

7%

Health Center

Hospital

Pharmacy

Nobody

Other

59%

24%

17%

0%

1%

Health Center

Hospital

Pharmacy

Nobody

Other

14%

31%

46%

7%

3%

47%

47%

0%

0%

5%

Health Center

Hospital

Pharmacy

Nobody

Other

4%

84%

2%

2%

8%


Awareness and source of treatment for Ebola (% respondents)

Where to get treatment

Overall, respondents are positive about health professionals and their contribution to the Ebola response. Three in

four believe they can protect the population form Ebola (73%), and a higher percentage believe they are preventing

the spread of the virus (83%), compared to a minority who believe they are spreading the virus (7%). Nevertheless,

just 62% trusted health professionals to act in the best interest of the population in their response to Ebola;

another 30% were neutral, and 8% did not trust them to do so.

Perception of health

professionals

Health professionals can protect us from Ebola (% agree) 73%

Health professionals are spreading the virus (% agree) 7%

Health professionals are preventing the spread of the virus (% agree) 83%

Trust health professionals to act in the best interest of the population in

their response to the epidemic

62%

67% aware of treatment for Ebola

31%

82%

13% 11%

Healthcenter

Hospital Other Don't know

DRAFT ‐ Ebola Rapid Survey | October 2018 13

VACCINATION: Vaccines are generally trusted but fewer trust Ebola vaccines.

Perception of risk and lack of clarity in access undermine trust.

Most respondents have heard about vaccines (100%) and believe that they generally work (91%) and are safe

(88%). Most have heard of an Ebola vaccine (88%), more than the percentage of respondents who heard about the

existence of treatment (67%). Only 66% of all respondents believe an Ebola vaccine works and about the same

percentage (63%) would get the vaccine if it was available to them. The main rationale for not taking the vaccine is

the perception that it is dangerous (71%) or does not work (23%), Among other responses (19%) respondents

discussed the lack of clarity about who gets the vaccines, and how and where to get it.

Heard about vaccines in general

(% yes)

Believe vaccines work

(% yes)

Believe vaccines are safe

(% yes)

Heard about Ebola vaccine

(% yes)

Believe Ebola vaccine works

(% yes)

Would take the vaccine if

available? (% yes)

If no, why not?

100% 91% 88%

88% 66% 63%

71%

23%

11%

19%

It is dangerous

It does not work

Not needed

Other reasons

14 DRAFT ‐ For internal use of those working on the Ebola response.

TRUST IN THE EBOLA RESPONSE: Trust in institutions is low. While perceptions about

the Ebola response are more positive, few see key actors as contributing to the

response, which may further undermine trust and cohesion.

For several years, insecurity and lack of services in the region have undermined people’s trust in the government. In

general, only a minority of respondents believe that government authorities at all levels represent their interest

‘well or very well’.

How well do authorities represent the interest of the population (% well – very well)

A higher percentage of respondents trust the government to act in the best interest of the population in their

response to the Ebola epidemic (41%). Nevertheless, this accounts for less than half the respondents and is lower

that the percentage of respondents who trust health professionals to act in the best interest of the population.

Furthermore, while few respondents agreed with negative statements about the government response, a large

percentage were neutral, suggesting at best some doubts about how much the government cares, is able to protect

the population, and acts in their best interests.

Agree Neutral Disagree

Perception of

government response

The government can protect us from Ebola (% agree) 39% 37% 24%

The national government does not care that people get sick of

Ebola 14% 44% 42%

Provincial government does not care about people getting sick

from Ebola 13% 44% 43%

Local authorities (chefs de quartier) do not care about people

getting sick from Ebola 8% 51% 41%

Trust the government to act in the best interest of the

population in their response to the epidemic 41% 37% 24%

Respondents, however, somewhat recognize the contribution to the Ebola response of actors like health

professionals (41% large contribution), the Red Cross (37% large contribution), or the national government (25%

large contribution). However, for all actors considered in this survey, many respondents had no opinion about their

contribution to the response to the epidemic, reflecting the lack of information about the overall response. That is

especially the case in Butembo. Furthermore, at the individual level, few expect direct support from these actors if

they were sick (Ebola or other disease).

Beni, 45%

Beni, 32%

Ben

i, 14%

Beni, 5%

Butembo, 27%

Butembo, 9%

Butembo, 2%

Butembo, 1%Total, 3

2%

Total, 15%

Total, 5%

Total, 2%

Local authorities (chefs dequartier)

City government (mayor) Provincial government National government

DRAFT ‐ Ebola Rapid Survey | October 2018 15

Contribution in the Ebola response

(% respondents)

None

15%

16%

17%

4%

33%

7%

15%

17%

15%

8%

15%

21%

Average

32%

33%

31%

58%

14%

36%

52%

21%

19%

32%

16%

12%

Large

25%

21%

14%

14%

5%

41%

9%

15%

23%

37%

23%

9%

No response

28%

30%

38%

24%

48%

16%

24%

47%

43%

23%

46%

58%

National government

Provincial government

City government

Religious leaders

Traditional leaders

Health professionals

The community itself

National NGOs

International NGOs

The Red Cross

UN agencies

MONUSCO

With support from:

INNOVATION FUND

SURVEY REPORT ‐ OCTOBER 2018 CONTENT · Ebola. A majority of respondents were able to identify...

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