Use of mobile phones to conduct interactive, theory-based research on social and behavior change communication in communities affected by Ebola Amanda Berman, MPhil, MSPH Johns Hopkins Center for Communication Programs SBCC Summit Addis Ababa, Ethiopia 8 February 2016

The Challenge Context Outbreak situation Context changing daily Need to obtain relevant data Rapid assessment of knowledge, efficacy, susceptibility, severity, stigma How do we reach respondents? What do we ask? What can we do quickly, acknowledging limitations What needs to be communicated and understood? Who do people trust for information? What sources of information do people get information? What do people know? As Maria Elena spoke about…

Remote & Mobile Communication How do we capitalize on existing technology to initiate successful communication? Advantages: Rapid deployment: messages arrive immediately after sending Scale: # of respondents only limited by access to phone numbers Remote data collection: simultaneous collection of data in multiple, often hard to reach locations Real-time feedback: data arrive immediately after respondents answer Disadvantages: Does NOT replace IDIs, FGDs, or other qualitative methods Only gives a rapid “snapshot” Unique challenges is crafting communication: few questions, 160 characters in length How do we best capitalize on mobile technologies? Advantages as seen here Rapid Scale Remote Real-time Limitations too however Does NOT replace IDIs, FGDs, other methods of qualitative methods

GeoPoll Pre-existing relationships with mobile network operators Access to 1.3m mobile subscribers in Liberia During roll-out phase, building their database Able to produce a national sample that aligned with country statistics Age Sex County Given the time and technical constraints – private company At the time, were in the roll out phase – had access to 1.3m mobile numbers Were in the process of building their database based on demographic and geographic profiles – caught them at the right time! Access to numbers is key – could do in house but much more complicated Significantly cut down on time: received 1,000 completed surveys aligning with desired sample within 6 days of submitting questions

Crafting the Questions Unique challenges 10-12 questions optimal, only 160 characters Crafting questions is key, wording is crucial Challenging to design wording, but needed to do quickly Example: Is Ebola Contagious? A) Yes B) No C) Don’t know Vs. How does Ebola spread? A) Bush meat B) Blood/Vomit/Diarrhea C) Touch/Wash dead bodies D) Don’t know E) Not contagious Unique situation using SMS for surveys – few questions, few characters How do you get the most out of every single question? In the example, the first one would need a follow up question if wanted to know more, in the second you are able to ask both “is it contagious” and “how does it spread” in one question rather than 2

The Questions Trusted sources of information Knowledge – How is Ebola spread? Threat – How likely are you to be infected? Severity – Can people recover from Ebola? Efficacy – How confident are you that you can protect yourself from Ebola Stigma – How likely will you be to welcome back in your community someone who has recovered from Ebola? Trusted source and form of communication Gov, HCW, Teacher, Relig Leader, Trad Leader? Radio, School, Comm Mtg, Health Center, Church/Mosque? Knowledge – How is Ebola spread? Modes of transmission (e.g., air, bush meat, bodily fluids, semen, shaking hands, bodies of the dead?) Threat – How likely are you to be infected? Very, somewhat, not at all Severity – Can people recover from Ebola? Yes, no, don’t know Efficacy – How confident are you that you can protect yourself from Ebola Stigma – How likely will you be to welcome back in your community someone who has recovered from Ebola?

Added for stratcom – theory based – ideational factors

Added for stratcom – questions designed to fit within the model above

Snapshot of Results Skewed towards younger, as would be expected. In general, aligned with national statistics, geographically as well. Note the huge differences among trusted sources and desired source of information.

Shaking hands was being promoted as a behavior to avoid – appears relatively high in almost all counties Touching or washing dead bodies, for example however, is fairly low – around 46% nationally

Implications for designing communication campaigns… Considering household radio and mobile ownership Implications for communication When consider places most in need of information, are they able to be reached? Needs to be taken into account

Conclusions Healthcare workers by far the most trusted sources of information (vs. gov’t, teachers, etc.) Health centers the preferred source of information (vs. community meetings, radio, etc.) Less than half of respondents knew that bodily fluids and contact with dead bodies can transmit Ebola Increased age was associated with increase knowledge Half of respondents felt “not at all likely” to be infected 8 of 10 were “very confident” they could protect themselves Half wanted more information about Ebola prevention, others also wanted information about causes and signs, as well as what happens at ETUs 1. Trusted sources: When asked about trusted sources of Ebola-related information, only 9% chose the government, while 82% chose healthcare workers. About one in ten respondents chose religious leaders, followed by teachers (8%) and traditional leaders (6%) as sources of Ebola-related information. 2. Preferred sources: When asked what would be the preferred source of Ebola-related information, health centers ranked highest (63%) followed by community meetings (53%); 30% wanted information from the radio. 3. How Ebola spreads: When asked about how Ebola is spread, only 45% selected body fluids and 45% selected dead bodies. 96% knew that Ebola is not spread by air. We found that 15.7% of respondents knew all 5 modes of Ebola transmission (bush meat, blood/vomit/diarrhea, semen, saliva, dead bodies) specified in the survey. 76.8% of people knew at least 1 mode of transmission. Knowledge also was influenced by age. Among the following age groups, the percentage of respondents knowing all 5 modes of transmission increased with age: 15-24 years (11.6%), 25-35 years (17.2%), and 35+ years (23.6%). The same held with those knowing any of the 5 modes: 71.8% of 15-24 year olds, 79.8% of 25-34 year olds, and 83.4% of those over 35 years. 4. Perceived susceptibility: Half of all respondents felt that they were “not at all likely” to become infected and about 30% indicated they were very likely to get infected.   5. Self-efficacy: 79% of respondents were “very confident” that they could protect themselves and about 8% indicated not being confident at all. This percentage also seems high but may be the result of increased knowledge about ways in which Ebola spreads, as indicated above. 9. Ebola information: Almost half of respondents wanted more information about Ebola prevention, with about 20% wanting information about the cause as well as signs and symptoms. Approximately 30% of respondents desired information about treatment and what happens at ETUs.   For example – though radio is relatively easy way to communicate (record once, transmit from one location), if people do not trust the message provider, do not have access to radios, and furthermore, trust and prefer other sources of communication – may want to rethink strategy Again, limitations included lack of ability to probe and follow up on questions. However, this rapid assessment can prime the field for further studies and crafting communication materials and programs. First helping to qua health responsentify with Thank you!