Ebola crisis in Eastern Democratic Republic of Congo: student-led community engagement

ABSTRACT

The second largest outbreak of Ebolavirus is currently ongoing in Eastern Democratic Republic of the Congo (DRC) and is characterized by lack of compliance with recommended control measures. Trusted local health agents, including medical students, may be valuable social mobilizers in this challenging context. We report a student-led educational campaign to increase community awareness and engagement in EVD control efforts, with evaluation of student and community satisfaction. The outreach was conducted in November 2018, involving 600 students and reaching 5–10,000 community members. Key messages included: ‘Ebola exists in Butembo’ and ‘Bring infected family members to the Ebola Treatment Unit.’ Medical students (n = 355) and community participants (n = 319) evaluated the campaign. Satisfaction was high: 320 (90%) students agreed that medical students could contribute to the EVD response effort, and 233 (73%) community members agreed that the students had helped them understand Ebola in the area. Lower satisfaction scores were associated with intention to hide infected family member from authorities (ρ = −0.25, p < 0.0001), denial of the existence of Ebola (ρ = −0.17, p = 0.0018), and mistrust of the response team (ρ = −0.11, p = 0.042). Both students (77%) and community members (71%) agreed that they were more motivated to combat Ebola as a result of the outreach. In conclusion, medical students can lead to satisfactory community engagement and educational activities during an EVD epidemic. As trusted local health agents, medical students may be valuable allies in building public trust and cooperation in this epidemic.

Background

Ebolavirus Disease (EVD) is an often-fatal hemorrhagic fever that occurs in explosive outbreaks in sub-Saharan Africa. The largest epidemic to date occurred in West Africa in 2014–2016 [1] and the second largest is ongoing in eastern provinces of the Democratic Republic of the Congo (DRC) since its onset in August 2018. EVD transmission in Eastern DRC continues unabated despite intensive control efforts including ring vaccination, containment, and management of infectious cases, contact tracing, and public health messaging. Contextual factors may exacerbate the local epidemic, such as poverty, HIV/AIDS, and ongoing violent conflict following civil and international wars. Fear of EVD within the community may have been magnified by global media attention to the outbreaks in West Africa 4 years earlier. Mistrust of national government and international agencies is prevalent, given enduring security concerns and a perception of an ineffectual response by leaders. Given these challenges, community engagement has been suboptimal, with numerous reports of passive and active resistance to control efforts [2–5].

A cornerstone of disaster management is that the response should begin and end at the local level [6]. Lessons learned during this past EVD epidemic include culturally sensitive approaches community engagement, including safe and dignified burials [7]. Other authors have proposed a multi-stage model for community engagement in an EVD epidemic, including entering communities with humility, reciprocal learning and trust, multi-method communication, development of joint protocols, assessing progress and outcomes, and fostering sustainability [8]. However, in the DRC, as in West Africa in 2014–16, local leaders and health professionals were engaged late in the response, have not been strongly supported [9] and international actors tend to supplant rather than strengthen the local level [6]. Mistrust of response teams, with a prominent presence of foreign national and international responders, has been well documented [10,11] and may obstruct EVD control efforts. Trusted local health practitioners may represent valuable but underutilized ‘social mobilizers’ [12] to lead community education, motivation, and active participation in public health programs. Medical students, armed with vibrancy, accurate classroom knowledge, and understanding of local cultural beliefs or customs, may be helpful players in Ebola public messaging [13]. For example, medical students of Sierra Leone and Guinea launched the ‘Kick Ebola Out’ campaign to educate community members about EVD and reduce stigma or fear of the disease [13].

In response to deficiencies in community engagement activities, medical students from the Université Catholique du Graben (UCG), the leading medical school in Butembo and area, organized an EVD outreach campaign. Butembo is a current hotspot of the EVD outbreak and focal point of ‘social resistance’ [11]. Here we present preliminary findings in support of student-led community engagement, a potential model for future locally driven community engagement activities.

Methods

Ebola educational community outreach

Sponsoring partners of the outreach were the UCG, the Ministry of Health of the DRC, the World Health Organization (WHO), UNICEF, and the Association for Health Innovation in Africa (AFHIA).

Students were provided training (one half day) in the biology, transmission modes, and social dimensions of EVD, together with pragmatic strategy and schedule for the community outreach. Outreach activities included a parade with branded t-shirts and banners through the main streets and market of Butembo, speeches with loudspeaker, one-on-one interactions with community members in public spaces, presentations at faith-based gatherings (Sunday church service), and radio announcements.

Evaluation of outreach: student satisfaction questionnaire

Having participated in the community outreach, students were asked to reflect on their experience and answer a brief 8-item survey. The standardized questionnaire consisted of demographic information and five items related to satisfaction with the outreach, including perceptions of the experience and its utility and impact in reaching community members with the key messages.

Evaluation of outreach: community participant satisfaction questionnaire

A 20-item questionnaire was adapted from past studies of EVD-related knowledge, attitudes, and practices [10,14]. Questions included participant demographics, reactions to the campaign, and satisfaction with the student effort. Further details of the survey questionnaires are provided in the Supplementary Materials.

Results

The outreach campaign was conducted along the following timeline: half-day training session for medical students, 1 November 2018; parade and community outreach, 10 November 2018; public messaging at faith-based assemblies (Sunday church services), 11 November 2018; and evaluations (survey questionnaires) of outreach by community members and students, 12–16 November 2018. Radio announcements were broadcast daily on the program ‘La voix de l’UCG.’ Although the total audience reached was not systematically quantified, we estimate that 600 students were involved and 5–10,000 community members heard the key messages. Images of the training and outreach campaign are shown in Figure 1.

Figure 1.

Pictures of medical student-led Ebola outreach campaign in Butembo, DRC, November 2018. (a). Training session at the Université Catholique du Graben, involving ~600 students from across all years of medical school. (b). Example of two key messages in locally spoken languages French and Swahili: ‘Ebola exists in Butembo’ and ‘Ebola Kills.’ These were printed on banners and T-shirts. (c). Student-led parade through the main streets of Butembo with banners. An estimated audience of 5–10,000 heard the key messages.

A total of 355 medical students evaluated the outreach campaign. The average age of respondents was 22 years (IQR 20–24) and 162 (46%) were female. The distribution of respondents by year of medical school training was 66 (19%), 55 (15%), 99 (28%), 82 (23%), 32 (9%), and 21 (6%) for first, second, third, fourth, fifth, sixth year and beyond, respectively. Student satisfaction and perceived impact of the outreach, based on five questionnaire items, is depicted in Figure 2(a). The five items were statistically significantly correlated (p < 0.0001 for all pairwise rank correlations, Supplemental Table 1) and showed acceptable internal consistency [15] (Cronbach’s alpha = 0.72). Of note, 320 (90%) agreed or strongly agreed that medical students could contribute to the EVD response effort, whereas only 183 (53%) felt that the community had understood the key messages.

Figure 2.

Satisfaction questionnaires evaluating the outreach campaign. (a). Student evaluations included questions about perceived impact, as well as personal reactions. (b). Community participants also provided reactions and ranked their satisfaction with the outreach. For all items, respondents were asked to grade their agreement with the statement on a 5-point Likert scale.

In the week following the outreach activities, 319 community members who had heard the key messages responded to a survey questionnaire. Demographics of the cohort are shown in Table 1. Participant satisfaction with the EVD outreach, measured by five questions, is shown in Figure 2(b). Overall, 167 (53%) of respondents agreed or strongly agreed with all five statements of satisfaction (Figure 2(b)). These items were statistically significantly correlated (p < 0.0001 for all pairwise rank correlations, Supplemental Table 2) and had good internal consistency [15] (Cronbach’s alpha = 0.87). Factor analysis was used to generate a unified construct, a putative score of participant satisfaction.

Table 1.

Demographics and attitudes of 319 community members who participated in student educational outreach.

Characteristic	Total (N = 319)
Demographics
Age (yr), median (IQR)	23 (20–28)
Sex
Female	129 (40)
Male	190 (60)
Educational attainment
No formal education	6 (2)
Primary	34 (11)
Secondary or higher	278 (87)
Occupation
Student	164 (52)
Merchant	45 (14)
Farmer	36 (11)
Government/Police/Military	23 (7)
Nurse/Doctor/Healer	16 (5)
Unemployed	16 (5)
Other	18 (6)
Attitudes toward Ebola following student outreach
Perceived personal risk of EVD
High	95 (30)
Intermediate	88 (28)
Low	75 (24)
I don’t know	61 (19)
Lack of compliance with recommended control measures in case of EVD illness or death in the family
Would not bring family member to treatment center	40 (13)
Would hide family member from authorities	20 (6)
Would wash or touch body	15 (5)
Would not accept official burial team	52 (16)
Denial of biomedical discoursea
Ebola is a fabrication, doesn’t exist in Eastern DRC	37 (12)
Mistrust of response teama
The team has a poor understanding of local conditions	166 (52)
The team is here to make a profit from the epidemic	56 (18)
I don’t trust foreign response team	92 (29)
Local engagementa
Prefer information about EVD from local source than foreign team	132 (42)
The epidemic will continue unless local community is engaged	231 (72)

^aValues represent number (percent) who agreed or strongly agreed with the statements (5-point Likert scale).

Attitudes toward EVD and the response effort are shown in Table 1, showing a substantial minority of respondents with potentially hazardous intentions in case of EVD or death in a family member, mistrust, and preference for local over foreign information sources. Higher satisfaction was associated with increasing respondent age (ρ = 0.13, p = 0.018), but not sex or education level (p > 0.05 for both). Lower satisfaction scores were associated with possible markers of mistrust and noncompliance with recommended control measures: intention to hide EVD infected family member from authorities (p < 0.0001, Supplemental Figure, panel A); intention to touch body of deceased family member with EVD (p = 0.014); denial of biomedical discourse (p = 0.0020, Supplemental Figure, panel B); lack of trust in EVD response (p = 0.033); and perceived profit motive of EVD response team (p = 0.0088, Supplemental Figure, panel C). Higher satisfaction scores were associated with preference for local sources of EVD information over foreign response team (p = 0.00016), and with the view that local engagement would be necessary to end the epidemic (p = 0.013, Supplemental Figure, panel D).

Discussion

Medical students appear to be well positioned to act as ‘opinion leaders’ and ‘social mobilizers’ during the current Ebola epidemic [16]. Given their tacit cultural understanding and biomedical knowledge, they can tailor health messages, build rapport, increase interpersonal communication, empower community members, and promote optimal health outcomes [13]. Here, we described the activities and evaluation (student and participant satisfaction) of a student-driven EVD educational campaign in Eastern DRC in the throes of an epidemic. Having demonstrated the feasibility and high levels of satisfaction, this may be a strategy that could be replicated elsewhere and over time to improve compliance with recommended EVD control measures.

Previous anthropologic research has identified several reasons underlying the lack of compliance with EVD control efforts, which students may be able to address. These factors include rumors, denial of the biomedical discourse, fear, and mistrust of authorities [17,18]. With respect to rumors and denial, we previously described a dynamic syncretism of mythical and biomedical understanding of EVD in affected communities [19]. Medical students may be ideally suited to navigate this complex field of community viewpoints, given their knowledge of disease mechanisms and their awareness of local cultural beliefs. However, community engagement requires more than education and correcting misinformation [20]. Mistrust, prevalent in Eastern DRC [11,21] and other countries affected by large EVD outbreaks [14,22–24], was also a major barrier to compliance [10,21]. Medical students, well known to the community, may be able to circumvent the historically rooted mistrust directed at politicians, government officials, and foreign responders [17]. Some social norms, such as burial practices, may be more adequately addressed in the preparedness phase instead of during the outbreak response phase. Thus, well after the epidemic is over, medical students may be able to play a role as modern agents of change in respectfully addressing or even challenging behaviors within their community that may predispose to infectious disease transmission.

Our descriptive observational study was not designed to assess the effect of the intervention, as this would require a control group (e.g. cluster-randomized study) or pre- and post-intervention assessments (e.g. quasi-experimental design). Moreover, in order to specifically test the impact of a student-led intervention, a control intervention which did not include students would be needed. Nonetheless, we were able to document a high level of satisfaction among the students that delivered the key messages and the community members that heard them. Furthermore, we documented a preference for local over foreign sources of information in 42% of community respondents. Perceptions of the impact of the messages were more circumspect, with only 53% of students agreeing or strongly agreeing that the community had understood the key messages. Given the lack of compliance with recommended control measures observed, the durability of the messaging and need for repeated campaigns also deserves further study. A previous report of student involvement in the EVD response in West Africa described but did not formally evaluate the activities [13]. Another potential impact of the student-led outreach campaign is increasing the motivation of community members, who may otherwise feel disengaged from the foreign-led response. In support of this, a high proportion of both students (77%) and community members (71%) agreed or strongly agreed that they were more motivated to combat EVD as a result of the outreach.

Partners in the outreach campaign included international (WHO and UNICEF) and national (Ministry of Health) agencies. They provided financial support and lent credibility and legitimacy to the educational outreach. On the other hand, the authors note with some irony that our locally driven efforts to sensitize the community were not immediately met with wholehearted support, but also a degree of ‘resistance’ (e.g. procedural objections that our independent efforts had not followed bureaucratic approval chains and the need to adapt some of our key messages to align with partners’ public brand and image). In an epidemic marked by ‘social resistance’ [11] to control efforts, we remark that ‘resistance’ to local engagement may also arise among the very leaders of the public health response. Despite these observations highlighting political intricacies of the EVD response, the authors recognize the valuable work of the international and national partners in this and other public health messaging campaigns.

Our study has several limitations. Beyond parades and presentations, medical students can and do engage in EVD control efforts in many other ways. Often proficient in social media, they can reach wide audiences with accurate information on electronic platforms where misinformation may also abound [11,13]. Thus, a broader study of student activities beyond those described in the present study would be of interest. Qualitative data to complement the survey questionnaires would be of interest and could be feasibly collected on a small random sample of participants to further help illuminate the meaning of findings. We were limited in our study design to a description of student and participant satisfaction, whereas impact would best be measured using a controlled experimental or quasi-experimental design. Outcomes beyond satisfaction, such as knowledge and attitude change, behavior change, and ultimately effects on epidemiologic indices of EVD control would also be desirable. The survey was done in a single urban setting, Butembo, and might not be generalizable to other cities or rural areas. The convenience sample may not accurately represent the views of all segments of the community at large. All data were self-reported, including behavior intentions, attitudes, and satisfaction. Social desirability bias may have affected responses to sensitive or controversial views around denial, mistrust, and non-compliant intentions. The wording of some of the survey items (e.g. ‘I am glad that the students came to talk to us about Ebola’) may have generated biased responses as community members may have been reluctant to respond negatively. Further refinement and validation of survey items are needed to ensure that they are measuring satisfaction, as intended. As an additional step to reduce biased responses, it would be desirable to have a trusted local person who was not on the research team give out and collect the questionnaires.

Conclusion

Our student-driven EVD educational outreach exemplifies principles of local engagement in the struggle against a frightening and stubbornly persistent epidemic. Although our descriptive observational study cannot prove the effectiveness of student-led messaging, high satisfaction scores suggest that educational outreaches were acceptable and appreciated by the community. Local experts in general, and medical students specifically, deserve to participate in the EVD response effort. They should be given opportunities and supported in educating and empowering their neighbors, relatives, and colleagues against EVD. With a potent combination of biomedical knowledge and cultural awareness, they may be able to act as a bridge between foreign response teams and the community, enabling them to join forces to end EVD transmission in the DRC.

Funding Statement

The Association for Health Innovation in Africa (AFHIA), the World Health Organization, and UNICEF provided funds for the outreach campaign. The funders had no role in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript.

Authors’ contributions

KMC conceived the study, supervised and conducted the data collection in the field, and critically reviewed the manuscript. MTH designed the study, performed the data analysis, wrote and critically reviewed the manuscript.

Disclosure statement

No potential conflict of interest was reported by the authors.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Ethics approval and consent to participate

The Comité d’Éthique du Nord Kivu (Centre Hospitalier Universitaire du Graben, Butembo, DRC) approved the study (reference number 005/TEN/2018). Oral consent was obtained from all participants. The ethics committee waived the need for written informed consent for the following reasons: (1) survey questionnaires and focus group discussions (FGDs) carried minimal risk to participants; (2) participation in the survey/FGDs constituted tacit consent; and (3) excessive participant contact, including signing paperwork, was discouraged in the context of an Ebola outbreak with potential for viral transmission by direct person-to-person contact and/or by fomites.

Supplementary material

Supplemental data for this article can be accessed here.