p.8 MOBILITY: Travels are relatively limited, but higher wealth, education and occupation as trader are associated with more frequent movements

Transcription

1 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 1 ST 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. 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. 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. PATRICK VINCK PHUONG N. PHAM ANUPAH MAKOOND JEAN PAUL ZIBIKA ERIC NILLES For internal use of those working on the Ebola response. 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.

2 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 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 30 avenues/ city 16 dwellings / avenue 977 dwellings approached 10 refused 6 empty 1 adult / dwelling 974 adults approached 10 refused 3 away 961 adults interviewed Beni: 481 Butembo: 480 Men: 481 Women: 480 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: ppham@hsph.harvard.edu Vinck P, Pham PN, Makoond A, Zibika JP, Nilles E. Ebola Rapid Survey Eastern Democratic Republic of the Congo, 1st survey report. October Harvard Humanitarian Initiative, Brigham and Women s Hospital.

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 (). A large majority of respondents report having received information about how to protect themselves from Ebola (9), 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) Heard about Ebola 100% Once 6% Less than once a week Never 0% 8% once a week or less 13% Women Men 2 6 days / week 27% Every day 64% Topic of information received Beni Butembo How to protect yourself from Ebola 9 97% 90% Symptoms of Ebola 85% 89% 84% Where to go for healthcare for Ebola 80% 97% 75% What to do if a relative / neighbor has Ebola 7 89% 67% Overall response to Ebola 64% 73% 6 Ebola cases in the province 64% 6 65% 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 (2). 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 Ebola Rapid Survey October

4 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 (6), 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) Very bad, Bad, 2 Average, 56% Good, 2 Very good, Very bad, 8% Bad, 50% Average, 39% Good, 3% Very good, 0% Very bad, 6% Bad, 43% Average, 43% Good, 7% Very good, Beni Butembo Total (weighted) Symptoms and transmission modes (% of respondents) Total Beni Butembo Symptoms Vomiting Diarrhea High fever Acute headaches Bleeding Weakness Tiredness Muscular pain Stomach / abdomen pain Other No response 74% 73% 70% 55% 35% 2 16% 1 10% 5% 90% 8 90% 60% 30% 25% 3 2 4% 0% 69% 70% 63% 53% 37% 2 1 8% 1 5% Transmission 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 74% 6 55% 46% 33% 19% 8% 85% 84% 89% 58% 47% 24% 4% 0% 7 54% 43% 4 29% 17% 10% 4 For internal use of those working on the Ebola response.

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. 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 (8), 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 Friends, family 89% 40% 54% 35% Local radio 8 46% 58% 4 Religious leaders / church 73% 44% 64% 37% National radio 68% 39% 53% 35% Health professionals 53% 69% 74% 68% Internet and social networks 34% 20% 2 20% Television 3 29% 40% 25% Newspapers / publications 30% 28% 38% 24% National authorities 29% 26% 49% 19% Civil society actors 27% 28% 49% 20% Local authorities 2 23% 40% 17% Traditional healers 6% 9% 9% 9% Ebola Rapid Survey October

6 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) 2 27% 25% 3 33% 33% 43% 34% 36% Heard statement before (% yes) 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 for financial gains Ebola is fabricated to destabilize the region 25% believe statement to be true (Ebola is not real) 3 20% 34% 27% 2 20% Women Men Poorest quartile Richest quartile Gender Wealth 6 For internal use of those working on the Ebola response.

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. 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 Avoid contact with people you suspect have visited Ebola affected areas 73% 87% 69% Direct exposure Avoid contact with people you suspect are infected by Ebola Avoid contact with the body of a person suspepected to have died of Ebola 76% 79% 85% 93% 7 74% Avoid contact with people who had contact with someone infected by Ebola 75% 8 7 Avoid visiting extended family members Social interaction Avoid visiting neighbors Stay home more than usual Avoid going to the church 4% 5% 3% Avoid taking public transports 8% 10% 7% Physical contact Reduce physical interactions with relatives Reduce physical interactions with others 3 54% 54% 77% 2 46% Washing hands more frequently 90% 97% 88% Ebola Rapid Survey October

8 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 2 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 3 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, 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, 4 of the respondents in the wealthiest quartile moved across neighboring territoire, compared to 23% among those in the poorest wealth quartile. 1 More than 4 times a week 2 to 4 times a week Once a week Less than oncea week Never 2 43% 16% Frequency of movement, by distance to the dwelling 5% 10% 7% % 14% 16% 6% 20% 24% 68% 87% 94% 98% 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. 8 For internal use of those working on the Ebola response.

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. 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) Relatives Neighbors Friends 68% 8 96% Religious leaders Local administrative authorities 17% 17% Health professionals / doctors Burial timing (% of respondents) Two days 2 More than 2 days 5% One day 74% Who takes care of the body? (% of respondents) 84% 47% 36% 9% 4% 0% Family Friends Neighbors Health professionals Religious leader Local authorities No response 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% Ebola Rapid Survey October

10 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 ( 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. Medical personnel bury the body rather than the family 35% Do not wait for relatives traveling from far away 10 For internal use of those working on the Ebola response.

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. 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 (). 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) Total (% of respondents) If you suspect you have Ebola Total (% of respondents) Health Center 25% Health Center 15% Hospital 29% Hospital 75% Pharmacy 38% Pharmacy Nobody 5% Nobody Other Other 7% Beni Butembo Beni Butembo Health Center Hospital Pharmacy Nobody Other 24% 17% 0% 59% 14% 3 46% 7% 3% Health Center Hospital Pharmacy Nobody Other 0% 0% 5% 47% 47% 4% 8% 84% 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 (7) than women (6) said they were aware of such treatment. Most respondents who had heard about treatment for Ebola believed those treatments could be obtained at hospitals (8) or at health centers (3). One in ten respondents (1) 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 (6) compared to Butembo (2). This likely reflects the much more common use of health centers to seek care in Beni compared to Butembo. Ebola Rapid Survey October

12 Awareness and source of treatment for Ebola (% respondents) 8 67% aware of treatment for Ebola Where to get treatment 3 13% 1 Health center Hospital Other Don't know 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 6 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 6 12 For internal use of those working on the Ebola response.

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 (9) 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 (7) 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) 100% 9 88% Heard about Ebola vaccine (% yes) Believe Ebola vaccine works (% yes) Would take the vaccine if available? (% yes) 88% 66% 63% If no, why not? It is dangerous 7 It does not work 23% Not needed Other reasons 1 19% DRAFT Ebola Rapid Survey October

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. 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) Beni, 45% Butembo, 27% Total, 3 Beni, 3 Butembo, 9% Total, 15% Beni, 14% Butembo, Total, 5% Beni, 5% Butembo, Total, Local authorities (chefs de quartier) City government (mayor) Provincial government National government A higher percentage of respondents trust the government to act in the best interest of the population in their response to the Ebola epidemic (4). 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. Perception of government response The government can protect us from Ebola (% agree) The national government does not care that people get sick of Ebola Provincial government does not care about people getting sick from Ebola Local authorities (chefs de quartier) do not care about people getting sick from Ebola Trust the government to act in the best interest of the population in their response to the epidemic Agree Neutral Disagree 39% 37% 24% 14% 44% 4 13% 44% 43% 8% % 24% Respondents, however, somewhat recognize the contribution to the Ebola response of actors like health professionals (4 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). 14 DRAFT For internal use of those working on the Ebola response.

15 Contribution in the Ebola response (% respondents) None Average Large No response National government 15% 3 25% 28% Provincial government 16% 33% 2 30% City government 17% 3 14% 38% Religious leaders 4% 58% 14% 24% Traditional leaders 33% 14% 5% 48% Health professionals 7% 36% 4 16% The community itself 15% 5 9% 24% National NGOs 17% 2 15% 47% International NGOs 15% 19% 23% 43% The Red Cross 8% 3 37% 23% UN agencies 15% 16% 23% 46% MONUSCO 2 1 9% 58% DRAFT Ebola Rapid Survey October

16 With support from: INNOVATION FUND