NewMixed Methods Approach for Monitoring Community Perceptions of Ebola and Response Efforts in the Democratic Republic of the Congo

Background: Efforts to contain the spread of Ebola in the eastern Democratic Republic of the Congo (DRC) during the 2018–2020 epidemic faced challenges in gaining community trust and participation. This affected implementation of community alerts, early isolation, contact tracing, vaccination, and safe and dignified burials. To quickly understand community perspectives and improve community engagement, collaborators from the DRC Red Cross, the International Federation of the Red Cross, and the U.S. Centers for Disease Control and Prevention explored a new method of collecting, coding, and quickly analyzing community feedback. Methods: Over 800 DRC Red Cross local volunteers recorded unstructured, free-text questions and comments from community members during community Ebola awareness activities. Comments were coded and analyzed using a text-coding system developed by the collaborators. Coded comments were then aggregated and qualitatively grouped into major themes, and time trends were examined. Results: Communities reported a lack of information about the outbreak and the response, as well as concerns about the Ebola vaccination program and health care quality. Some doubted that Ebola was real. The response used the feedback to revise some community engagement approaches. For example, 2 procedural changes that were followed by drops in negative community responses were: using transparent body bags, which allayed fears that bodies or organs were being stolen, and widening the eligibility criteria for Ebola vaccination, which addressed concerns that selectively vaccinating individuals within Ebola-affected communities was unfair. Discussion: This system is unique in that unstructured feedback collected by local volunteers in the course of their work was rapidly coded, analyzed, and given to health authorities for use in making course corrections throughout the response. It provides a platform for local voices to be heard throughout an emergency response and provides a mechanism for assessing the effects of program adjustments on community sentiments. INTRODUCTION By June 21, 2020, the Democratic Republic of Congo (DRC) had reported 3,470 probable or confirmed cases of Ebola virus disease (EVD) since the beginning of the outbreak in 2018. Of these, 2,287 persons died and 1,171 recovered. On July 30, 2018, the DRC Centers for Disease Control and Prevention, Atlanta, GA, USA. b International Federation of the Red Cross and Red Crescent Societies, Geneva, Switzerland. Correspondence to Giulia Earle-Richardson (evy8@cdc.gov). Global Health: Science and Practice 2021 | Volume 9 | Number 2 332 Ministry of Health led a coalition of international agencies, governments, andnongovernmental organizations in a coordinated Ebola response, despite a uniquely challenging context of political conflict and violence. The response focused on 4 main interventions to stop EVD spread: (1) identifying possible cases and isolating, testing, and treating the patients quickly at EVD treatment centers; (2) finding, quarantining, and monitoring people who had exposure to an EVD case for 21 days (as well as people having had contact with those contacts); (3) offering vaccination to contacts and their contacts; and (4) conducting safe and dignified burials* in outbreak-affected communities. As part of this response, local Red Cross volunteers in Ebola-affected communities undertook risk communication and community engagement activities (e.g., community meetings, “phone-in” radio shows, mobile “cinema” presentations) and made home visits in selected communities. During these activities, volunteers recorded any comments from community members about Ebola, such as questions, beliefs, observations, rumors, or suggestions for improving the government-led response to the epidemic. Prior Efforts With Community Engagement and Community Feedback in Epidemic Response Although the concepts are not new in humanitarian settings, community engagement has been slower to be fully incorporated into epidemic response structures, despite growing evidence that community engagement strengthens epidemic control. The hesitation to embrace community engagement in epidemic emergency response may stem from the fact that authentic engagement requires an investment of time and resources in understanding community needs, as well as awillingness to change epidemic control strategies based on community feedback. Understanding community needs through some form of community listening (e.g., surveys, focus groups, interviews, rapid ethnography) must be done in a very compressed timeframe and often in extremely challenging field conditions. Even when it is accomplished, engagement only succeeds if social scientists can get actionable information into the hands of decision makers who are willing to be advised in their work. Ideally, community engagement in emergency response is supported by a regular “feedback loop,” in which community reactions to epidemic control activities are continuously monitored and addressed. Context of the North Kivu, DRC Ebola Outbreak The Ebola epidemic that began in North Kivu province of DRC in 2018 was described by the country’s minister of health as “the longest, most complex and deadliest” in the country’s history. The urban location of the early cases contributed to its persistence, as did the social and political turmoil in the region. According to the World Health Organization (WHO), therewere 420 attacks on health facilities in eastern DRC during the outbreak period, and security reviews identified 140 armed groups active in the area. Kidnappings and killings of civilians were also frequently reported. As a result, for much of the North Kivu Ebola response, WHO-led operations were located hundreds of miles from where cases were occurring. Mistrust of the national government is widespread, as the North Kivu region has long been a stronghold of political opposition. This mistrust intensified in December 2018, when the government excluded several areas in North Kivu from voting in national elections due to the Ebola outbreak. The Rapid Community Feedback Collaborators While gathering community feedback was not a new idea for IFRC as it looked to support the Red Cross of DRC in Ebola control, it needed a way to systematically and rapidly gather feedback to apply qualitative analytic methods to produce reports that could offer specific, actionable recommendations. The CDC Ebola Response Social and Behavioral Science task force had recently created a similar rapid assessment system to support the Zika emergency response in Puerto Rico and the U.S. Virgin Islands in 2016. The Red Cross of DRC was a trusted local partner, which had been promoting health and assisting with health emergencies and epidemics for many years. In August 2018, the DRC Red Cross, IFRC, and CDC collaborated to create a method for entering free-text notes into a Microsoft Excel spreadsheet and coding them to allow for rapid aggregation, analysis, and reporting. The current analysis identifies the major themes of community concern during the *Safe and dignified burials are burials performed by specially trained Ebola response teams, in which participants are protected from the still-infectious body, but also can follow traditional practices to the extent possible. In the context ofan epidemic, understanding community needs must be done in a very compressed timeframe and often in extremely challenging field conditions. New Mixed Methods Approach for Monitoring Community Perceptions of Ebola www.ghspjournal. org Global Health: Science and Practice 2021 | Volume 9 | Number 2 333 2018–2020 Ebola outbreak in DRC and describes how the information was used by the Red Cross and Ebola response leaders to better address community concerns.