Evidence Briefs

Provide a synthesis of the best available evidence on a variety of priority topic areas as identified by leading infectious disease experts. We systematically explore the published literature using a comprehensive search strategy to identify relevant research on infection prevention, management, and control. For more information on our search strategy of the published literature, click here.
McMaster University

Behavioural and emotional responses

Mar 28, 2017

Author(s): Stephanie Vendetti-Hastie, RN, CIC, Kristin Read, MPH, & Dr. Maureen Dobbins, PhD, RN
Expert Reviewer(s): Dr. Mark Loeb, MD, MSc, FRCPC & Dr. Dominik Mertz, MD, MSc

The OutbreakHelp Evidence Briefs aim to provide short summaries of the available evidence related to priority topic areas identified by leading infectious disease experts. Content for the Evidence Briefs were developed using a comprehensive and systematic search of the academic literature from inception to December 31st 2015 (more recently published information on this topic may be available here). All results were screened for relevance using pre-defined inclusion and exclusion criteria. Included articles must have met the following criteria: 1) specific to the topic of Ebola Virus Disease (EVD), 2) human research or research with real-world applicability, 3) study in a peer reviewed journal, and 4) published in either English or French. Articles identified as relevant were tagged with priority topic areas and assessed for quality using abbreviated versions of appropriate critical appraisal tools; a 5-star rating scheme was applied to articles as relevant. Relevance screening, category tagging, and critical appraisal were independently conducted by two raters and conflicts were resolved through discussion. A thematic analysis was performed on included articles by charting and then categorizing common concepts and topics discussed in the literature. Results are summarized in a narrative. The following Evidence Brief discusses psychosocial considerations focusing specifically on evidence related to different types of behavioural and emotional responses to EVD as well as the factors that may have an influence on these types of responses.

Main Message

Widespread media attention about EVD influences public awareness, interest and anxiety. In turn, these emotional responses to the EVD outbreak influence behavioural responses which may have an impact on infection prevention and control interventions. The internet in general, and social media platforms in particular, are key sources of information for the public, including healthcare providers. It is recommended that these platforms be utilized to provide factual, timely and transparent messaging to the public, especially in areas experiencing EVD outbreaks.

Behavioural Responses to EVD

In a systematic review of peer-reviewed scientific publications and media portrayals (print and internet), behavioural and emotional responses to the 2014 EVD outbreak in Nigeria were described. These responses included fear, hysteria, stigma and discrimination, anger and greed, as well as other behaviours that were considered irrational (Ogoina, 2016). There are wide-ranging behavioural responses to EVD outbreaks which can be triggered by the fears, misconceptions, myths and limited knowledge of EVD (Ogoina, 2016).


Negative consequences of enforcement of quarantine for asymptomatic contacts of positive cases are described in a 2015 qualitative study conducted in several small communities in Liberia affected by EVD. Participants (n= 432) reported that quarantine increased levels of stigmatization and triggered a process of public labelling creating fear, panic and disenfranchisement of minority groups. People with non-EVD illness avoided seeking care to avoid stigmatization. Food and other essential supplies were not readily available and forced those under quarantine to be non-compliant with imposed measures and created socio-economic distress (Pellecchia, Crestani, Decroo, Van den Bergh, & Al-Kourdi, 2015).

Upon completion of a mission in Africa, an EVD first responder’s public health co-workers (n=178) were surveyed regarding their attitudes and intended practices prior to the responder returning to the workplace. Despite the responder having no contact with an EVD patient, 18% of co-workers surveyed were uncomfortable with the person returning to the workplace and 7.9% reported they might not come to work if the responder was present. Staff members reporting being uncomfortable with the responder returning to work were 11 times more likely to work in noninfectious disease program areas (OR=10.7, p=0.003) and were three times more likely to have education below a bachelor’s degree (OR = 2.7, p=0.039). No other respondent characteristics were significantly associated with comfort or discomfort (Chan, Daly, Talbot, 2015).

Community and workplace stigma is similarly described in a qualitative study among 30 African residents of Hong Kong following reporting of the EVD outbreak in West Africa by Hong Kong mass media. All participants had at least some form of education (1 university, 15 entered secondary school, 13 finished primary school, 1 entered primary school) and reported at least one chronic condition. The stigmatization that participants experienced in turn, shaped their perceptions of EVD. More than half of the participants reported that EVD was a disease of retribution, a punishment by God affecting those who behave badly. Nearly half of participants reported that EVD was introduced to Africa by Westerners who had brought bad spirits to Africa when travelling (Siu, 2015).

Misconceptions and Mistrust

Misconceptions and mistrust characterize several narrative studies that describe common cultural and politico-economic beliefs regarding EVD among some local populations.

A 2015 paper that explores conversations with local health care worker candidates and basic EVD course trainers in Sierra Leone describes common EVD beliefs among local populations:

·       EVD is a punishment from God, a supernatural force or curse, only non-believers become infected

·       Bathing in salt water prevents EVD which is spread through the air

·       EVD is caused by sorcery/witchcraft

·       EVD survivors are zombies

·       Health care settings should be avoided, they are the cause of illness and you do not come out alive

·       Ambulance drivers are paid a bounty for dead bodies (Davies, Bowley, & Roper, 2015).

Similar themes were reflected in a 2003 study from the Republic of Congo that attempted to gain an understanding of local people’s perspectives and explanations of EVD so that they could incorporate them into biomedical response models. Beliefs described included sorcery, Euro-American coercion and poisoning by powerful sects (Hewlett & Amola, 2003). The authors described that although local beliefs and practices were strong, people used multiple explanatory models and health care systems at the same time in an effort to stop virus spread. Some indigenous control measures were consistent with those of the biomedical model. The results of this study were supported in a 2003 descriptive study from Uganda where illness such as EVD are explained through cultural models of spirits and gods (Hewlett & Amola, 2003).  

The theme of mistrust also echoes in a 2015 study among Liberian community leaders who were participants in the mass drug administration (MDA) for neglected tropical diseases program. During interviews 37.1% reported that there were fears within the community regarding the potential link between EVD and MDA. People believed that those involved in EVD response might spread the disease or the MDA medicines themselves may cause the disease (Bogus, et al., 2016). 

A two-part online study of U.S citizens in 2015 assessed the risk perception and public trust in information that was communicated to them regarding the EVD 21 day quarantine period. The purpose of the study was to examine whether openness about post-21 day symptoms would attenuate negative reactions from participants. Results suggested that informing Americans about the small likelihood of an incubation period extending beyond 21 days would not increase perceived risk and distrust, and might diminish negative reactions should a case occur beyond 21 days and be reported by the media. Authors suggest that early communications about unpleasant infectious disease facts may increase trust in public health response (Johnson & Slovic, 2015).

Factors Influencing Emotional and Behavioural Response


A review of the database of Google trends from January 2006 to October 2014 revealed that EVD was the most searched term in Nigeria during the outbreak from 1 August 2014 to early October 2014, and the web interests generated by EVD surpassed all prior web interests generated by other news topics (Ogoina, 2016). Twelve studies described below discuss the role of the media in EVD outbreaks.

The nature and extent of coverage about EVD in three widely circulated US daily newspapers was examined in a 2015 study. The total number of articles identified in the one month analysis period was 301. Content focused on: death tolls and cases that occurred in the United States (39%), the outbreak in Africa (33.6%), death rates (20%), precautions taken by institutions (17%), travel risks/screening at airports (17%), poor handling of cases (15%), and preparedness/lack of (15%). Other topics covered less frequently included precautions the public could take (4.0%), role of volunteers (3.3%), ethical issues (3.0%), ruling out a case (2.0%), discrimination (2.0%), US oversight (1.7%) and possibility of virus mutation (1.7%) (Basch, Basch, & Redlener, 2014). News coverage was also found to be a source of social media and internet contagion. A 2015 study conducted in the U.S. examined whether or not the news coverage was a significant factor in the temporal patterns in Ebola-related internet and Twitter data using a mathematical contagion model. The authors found significant evidence of contagion, with each Ebola-related news video inspiring tens of thousands of Ebola-related tweets and internet searches (Towers, et al., 2015).

In the midst of the 2014 EVD outbreaks, Twitter was examined to provide a snapshot of EVD related tweets for the purposes of monitoring trends of information spread and to determine public knowledge and attitudes. Results of the study demonstrated 42,236 tweets mentioning the EVD outbreak were posted and disseminated to over 9 billion people over the 8 day period of data collection. Four main public topics of concern were discussed in tweet content: risk factors, causes of EVD (including transmission), infection prevention education, health information (signs, symptoms), disease trends, spread and location (name of locations, information about spread) and compassion (prayer for countries in Africa). Communication was stimulated by public concern and mirrored news alerts. The authors observed EVD-related tweets increasing in frequency and fear intensity from Africa, Europe and North America with the growing number of cases (Odlum, & Yoon, 2015).

Twitter was also the subject of investigation in another 2015 study in the United States that used textual analytics to identify topics and extract meanings from unstructured text data tweets that occurred during a live CDC Twitter chat about EVD.  The greatest concerns revealed by the quantity of themes and tweets were about the virus itself, its lifespan and symptoms and how it was transmitted. Fear of travel followed as the second largest theme, which included air travel in general and specifically to Africa (Lazard, Scheinfeld, Bernhardt, Wilcox, & Suran, 2015).

In a similar 2015 study, the content of the CDC Facebook page, specifically user comments and meta-data, was examined to look at audience engagement with online health information. In total, 836 posts and 35, 973 comments from 14, 305 unique users were analyzed, including 157 posts and 22,948 comments specific to EVD. The CDC submitted fewer posts about EVD than about non-EVD topics, but audience engagement with EVD posts was significantly higher with 57.93% of users commenting on EVD posts as opposed to non-EVD posts (32.23%). Men were significantly more likely to comment on EVD than non-EVD posts and submitted more comments per user (Strekalova, 2016).

Media as source of information

In a 2015 online study of 212 U.S. residents, EVD risk perceptions and knowledge were measured. The internet (92%) and media (86%) were identified as major sources of new information about EVD in the past year. The internet was rated as the most trustworthy source (µ =6.2 SD = 1.9), followed by government (µ=5.9, SD=2.34) and the media (µ =5.4, SD=2.2). The respondents provided low rates of worry (µ =2.3, SD=1.9) and personal risk (µ =1.7, SD = 1.4) although EVD was perceived as a serious problem (µ =8.5, SD=2.2) (Rolison & Hanoch, 2015).

In a 2015 cross-sectional study among health care providers (n=258) in Sudan, 68.6% reported hearing about EVD from classical media (television, radio and newspaper), social media (25.2%) and medical websites (23.3%). False information reported by respondents included airborne transmission (53.1%), insect transmission (20.2%), that a licensed vaccine (16.7%) and specific EVD treatment (8.6%) is available. Overall, 91.1% of respondents never attended any training sessions on EVD (Alfaki, Salih, Elhuda, & Egail, 2016).  Similar results were found in a community based cross-sectional qualitative and quantitative study of residents in two states of Nigeria (n=582) reporting that the media was the first source of EVD information, with television accounting for 32.4% and radio at 27.1% (Ughasoro, Esangbedo, Tagbo, & Mejeha, 2015). Similary, television, radio and news were found to be important sources of information on EVD in other studies (Ganguli, Chang, Weissman, Armstrong, & Metlay, 2015; Gidado, et al., 2015).

EVD knowledge, perceived risk of infection and source of information was also surveyed among 150 Australian pilgrims planning on attending Hajj in 2014. Seventy-eight percent reported the mass media as their main source of information, followed by the internet at 9%, general practitioners at 6% and others at 5% or less. Forty percent of pilgrims had no accurate knowledge of EVD transmission and 40% acknowledge the risk of EVD at Hajj, but had no fear of contracting it (45%) (Alqahtani, et al., 2015).

Malaysian university students and staff (n=458) were surveyed regarding knowledge and perceptions toward EVD. Source of knowledge of EVD was reported as internet for 80.4% for students and 58.9% for staff. Median knowledge score was low (< 50%), with staff from the medical clinic having higher knowledge (61.5%, p=0.002) and science based students having more knowledge (46.2 %, p <0.0001) than students in other programs. The internet was found to be the most commonly accepted method for provision of education about EVD (27.2%) and a combination of internet, TV shows and awareness campaigns were found to be the most acceptable way to provide EVD education among staff (41.9%) (Abubakar & Sulaiman, 2015).

YouTube was also evaluated as a source of information on EVD. In a study, 118 videos were critically appraised and categorized as misleading (26.27%) or useful (73.3%).  Independent users were more likely to post misleading videos (93.55% vs 29.89%, OR=34.02, 95% CI=7.55-153.12, P<0.001) whereas news agencies were most likely to post useful videos (65.5% vs 3.23%, OR=57.00, 95% CI = 7.40-438.74, P<0.001) (Pathak, et al., 2015).

Image-sharing platforms were also explored to characterize public discourse about EVD. Nine distinct themes emerged, with themes differing across the various platforms. Jokes about EVD were the most prevalent theme on Instagram (42%), whereas images primarily representing health care workers and other professionals providing care were depicted on Flickr (46%). The authors concluded that social media platforms are used in different ways and understanding this can inform future uses of these platforms for message dissemination by healthcare professionals and researchers (Seltzer, Jean, Kramer-Golinkoff, Asch, & Merchant, 2015).


Stigmatization, mistrust and misconceptions related to EVD were highlighted throughout the literature which highlights the need for clear and concise communication that is culturally appropriate in order to address these inter-related issues. The internet, social media, and YouTube provide a platform for the dissemination of tailored messages in order to increase knowledge and improve control methods on the transmission of EVD.


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