Whether Plague, SARS, H1N1, MERS, Zika or, now again, Ebola, emerging pathogens continue to challenge us in public health (Shah, 2016).
Ebola virus disease (EVD), described as a behavior-driven epidemic is caused by an infection with one of the three Ebola virus strains: Zaire, Sudan and Bundibugyo (CDC, 2015; (Gostin, Lucey, & Phelan, 2014). Ebola outbreaks have been recorded in sub-Saharan Africa since 1976 (Centers for Disease Control and Prevention [CDC], 2015); since then, there have been 885,343 confirmed cases of EVD (World Health Organization [WHO], 2014a). The 2014-2016 West Africa outbreaks was the largest and the most widespread EVD outbreak to date, contributing to more than 21,000 cases and 8,000 deaths (WHO, 2014b). Before this outbreak, deaths from EVD had not been recorded in these regions (Gostin et al., 2014).
Various factors caused the disease to spread, but a significant one was the failure of some aspects of the response effort to sufficiently integrate psychosocial elements, particularly in relation to behavior change communication at the individual, inter-personal, and community level (Zolnikov, 2018). Evidence abounds that cultural practices such as burial rituals and subsequent behavioral aspects (e.g. washing the body), contact with a patient’s body (dead or alive); or bodily fluids, including blood, vomit, saliva, urine or feces; or personal items used by the patient like bedding and clothes; played a major role in infection transmission and maintaining a reproduction number > 1 (Althaus, 2014; Zolnikov, 2018).
As the 2014-2016 outbreak in West Africa showed us, an effective response in real time to these outbreaks always requires the use of social and behavior change interventions even while other solutions (vaccines, treatments, etc.) are explored. Although various strategies were adopted and implemented for the containment and treatment of the disease, behavior and social interventions did not form a sufficiently central element of these strategies. As a result, behaviors that contributed to the spread of the disease continued for a long period. Current knowledge on behavior change was not made full use of, and psychosocial issues were not prioritized. For example, USAID lists the five key targets for interventions in Ebola: food security; health services and health systems; innovation technology and partnerships; governance and economic crisis mitigation; and global health security agenda (USAID, 2017). However, none of these include psychosocial issues, communication or behavior change.
These lessons appear to have been poorly learnt however, as the first line of response for the ongoing outbreak in the Democratic Republic of the Congo (DRC) that started in May 2018 was vaccinations with an experimental, “never before used”, unlicensed rVSV-ZEBOV Ebola vaccine – a monoclonal antibody cocktail that was cleared for compassionate use in the outbreak. Quickly shaping up as the seventh largest Ebola outbreak in history, as of 2 October 2018, a total of 162 confirmed and probable EVD cases, including 106 deaths, have been reported-resulting in a global case fatality ratio (CFR) of 65.4% (WHO, 2018).
The optimism that vaccination of cases, their close contacts, and front-line medical workers would result in a break in infection transmission chains is fast fading with the identification of five new confirmed cases on 6 October 2018 (Wise, 2018). This higher-than-normal daily increase (the usual reporting average is 1-2 new confirmed cases per day) has been blamed on community resistance to disease response efforts (Wise, 2018).
While vaccinations are ongoing and health systems in the DRC are undergoing an overhaul, it’s instructional that socio-behavioral interventions were all that was available in 2014. In fact, (Hewlett & Amola, 2003) found that in an earlier EVD outbreak in Uganda, altered perceptions about the response-enabled behavior to change in ways that contained the outbreak. This was, in some part, accomplished by considering local people’s feelings and knowledge, and working with the affected populations using their cultural practices to help minimize the spread of disease; including handwashing, notifying community leaders when sick, not touching the sick or dead, and safe burial practices (Hewlett & Amola, 2003).
Behavior change interventions have been successfully applied to existing threats like HIV/AIDS, malaria, malnutrition, child survival, maternal mortality, and recently to emerging threats like Zika too. Although vaccines may disrupt future EVD outbreaks, social mobilization and local initiatives will promote behavior change among affected populations, also contribute to epidemic containment (Abramowitz, Hipgrave, Witchard, & Heymann, 2018).
Can a behavioral epidemiology framework be used to evaluate the quality of available evidence on SBS health-related behaviors as evidence-based interventions in the control Ebola outbreaks?
The behavioral epidemiology framework developed by Sallis et al (Sallis, Owen, & Fotheringham, 2000) identifies a sequence of research categories about health-related behaviors that describes five main phases as follows; 1–establish links between behaviors and health; 2–develop measures of the behavior; 3–identify influences on the behavior; 4–evaluate interventions to change the behavior; 5–translate research into practice (Sallis et al., 2000).
Their framework builds upon the initial work of Greenwald and Cullen; Flay; Oldenburg, Hardcastle, and Kok (Sallis et al., 2000). Sallis et al used their behavioral epidemiology framework to evaluate content fields and disciplinary perspectives of articles published in four journals and classified their findings into the phases of research (Sallis et al., 2000).
I propose to use this behavioral epidemiology framework lens to evaluate available evidence on health-related behaviors as evidence-based interventions for the control of Ebola outbreaks.
Through a systematic search of peer reviewed and gray literature, I intend to identify articles published between 1978 and 2018 with the following MeSH search string: ‘hemorrhagic fever, ebola'[MeSH Terms] OR ‘ebolavirus'[MeSH Terms] OR ebola[Text Word] AND ‘Risk Reduction Behavior'[Mesh] OR “Behavior change”[Text Word] that discuss intrapersonal, interpersonal, and community level behavior change interventions. Thereafter, I will code my findings into categories using and expanding on the coding categories, rules, and inclusion/exclusion criteria proposed by Sallis et al and Abramowitz et al (Abramowitz et al., 2018; Sallis et al., 2000).
Outline my systematic review methods and findings in a manuscript detailing the stage of behavioral intervention research for EVD control. Mature research areas are expected to have more studies in the latter phases. This classification process and my findings will help public health researchers identify where we have a dearth of research and why they are worth exploring, minimize duplication of effort in research, and encourage more research in intervention areas that we know to be effective, specifically socio-behavioral ones.