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Public knowledge, perception and source of information on Ebola virus disease, Lagos Nigeria, September 2014 S. Gidado1, A. Oladimeji1, A. Roberts2. P. Nguku1, N. Waziri1, F. Shuaib3. O. Oguntimehin4, E. Musa5, C. Nzuki6, A. Nasidi7, P. Adewuyi1, T. Aba1, A. Olayinka1, O. Odubanjo1, Gabriele Poggensee1, O. Babalola1, N-FELTP Residents1 1. Nigeria Field Epidemiology and Laboratory Training Programme, Abuja, Nigeria 2. Department of Community Health, Lagos University Teaching Hospital, Idi-Araba, Lagos, Nigeria 3. Ebola EOC/Federal Ministry of Health, Abuja 4. Lagos State Primary Health Care Board, Lagos 5. World Health Organization, Abuja 6. United Nations Children’s Fund 7. Nigeria Centers for Disease Control, Abuja Ebola virus • Highly infectious hemorrhagic virus • Case fatality rate of 25 – 90% • First discovered in 1976 • Outbreak in West Africa • Ebola in Nigeria   First case reported on 23rd July, 2014 Public fear and anxiety 3/17/2016 Nigeria Epidemiology and Laboratory Training Programme 2 Information and EVD outbreak • Inaccurate and unofficial information • Harmful and ineffective preventive measures  Bath and drink large quantities of salt water – Deaths reported in Nigeria (WHO, 2014) • Undermine outbreak control efforts • Gap in public knowledge and perception of Ebola   Sources of information on Ebola Generate useful information http://www.who.int/mediacentre/news/ebola/15-august-2014/en/ 3/17/2016 Nigeria Epidemiology and Laboratory Training Programme 3 Objectives • Assess the level of public knowledge and perception of EVD • Determine sources of public information on Ebola • Assess behavioural modifications during EVD outbreak 3/17/2016 Nigeria Epidemiology and Laboratory Training Programme 4 Study Setting • Population = 21 million • Administrative Nigeria   Lagos State 3/17/2016 Districts = 20 Wards = 245 • Highly heterogeneous, cosmopolitan city • International airport and seaport Nigeria Epidemiology and Laboratory Training Programme 5 Study design and population • A cross-sectional study  August 2014 • Inclusion criteria  Adults  Residing in Lagos  Four weeks prior to the study 3/17/2016 Nigeria Epidemiology and Laboratory Training Programme 6 Sample size • Using the formula n = {(Z2p(1-p)/d2) • Assumption      n = sample size Z = normal variate corresponding to 1.96 for a confidence level of 95% p = proportion of individual with knowledge is assumed, 0.5 d = standard error or precision level of 0.05 non-response rate 10% • Minimum sample size per LGA is 423 3/17/2016 Nigeria Epidemiology and Laboratory Training Programme 7 Sampling technique Multistage sampling 3 Senatorial zone 20 LGAs or Districts STAGE 1: Selection of LGAs 12 LGAs or Districts Random sampling Probability proportionate to size 138 Wards STAGE 2: Selection of Wards Random sampling Probability proportionate to size 78 Wards STAGE 3: Household and respondents Systematic sampling 68 Respondents in each ward Total minimum sample size = 5304 3/17/2016 Nigeria Epidemiology and Laboratory Training Programme 8 Data collection • Semi-structured, interviewer administered questionnaire  Socio-demographic characteristics  Knowledge and perception of Ebola infection  Sources of information on Ebola  Behavioral modification during the outbreak • Pretest • Trained interviewers 3/17/2016 Nigeria Epidemiology and Laboratory Training Programme 9 Grading of Knowledge domain Domain Correct Wrong Touching blood fluid from a person who is sick of EVD 2 0 Contact with a person who is sick of EVD 2 0 Contact with fomites of a person who is sick of EVD 2 0 Close participation in burial rites of a person who died of EVD 1 0 Animal to man 1 0 Total 8 0 Fever 2 0 Any other correct sign/symptom 1 0 Any other correct sign/symptoms 1 0 Total 4 0 Regular hand washing with soap and water 2 0 Regular use of hand sanitizers 2 0 Avoiding contact with an EVD case or suspect 2 0 Not actively participating in burial rite of a person who died of EVD 1 0 Avoiding crowded places/events 1 0 8 0 Mode of transmission of Ebola virus Signs and Symptoms Preventive measures 3/17/2016 Total Nigeria Epidemiology and Laboratory Training Programme 10 Grading of knowledge Knowledge Maximum Poor Good domain score knowledge knowledge Mode of transmissions 8 0–3 4–8 Symptoms and signs 4 0–1 2–4 Preventive measures 8 0–3 4–8 General score 20 0–9 10 – 20 3/17/2016 Nigeria Epidemiology and Laboratory Training Programme 11 Perception regarding EVD • Do you think Ebola virus is a problem in Lagos? • Do you think you can contract Ebola Virus Disease? • Do you think government is doing enough to contain the Ebola Virus Disease outbreak? 3/17/2016 Nigeria Epidemiology and Laboratory Training Programme 12 Data entry and analysis • Data entry and analysis using Epi-Info 3.5.4 • Results    Frequencies and proportions Associations between variables Level of significance p < 0.05 3/17/2016 Nigeria Epidemiology and Laboratory Training Programme 13 Ethical considerations • Non research determination granted for the study  Emergency operation center incident management team • A response to public health emergencies  Part of the EVD outbreak response • Informed consent 3/17/2016 Nigeria Epidemiology and Laboratory Training Programme 14 Socio-demographic characteristics (n=5322) Characteristics Number of respondents Age distribution (in years) ≤ 20 503 21 – 30 1946 31 – 40 1563 41 – 50 815 > 50 495 Sex Male 2785 Female 2537 Religion Christianity 3747 Islam 1507 3/17/2016 Nigeria Epidemiology and Laboratory Training Programme Percentage 9.5 36.6 29.4 15.3 9.3 52.3 47.7 70.4 28.3 15 Socio-demographic characteristics (n=5322) Characteristics Number of respondents Highest level of formal education No formal education 145 Primary 680 Secondary 2826 Post-secondary 1671 Occupation Trader 2021 Skilled worker (Artisan) 1185 Student 709 3/17/2016 Nigeria Epidemiology and Laboratory Training Programme Percentage 2.7 12.8 53.1 31.4 38 22.3 13.3 16 Knowledge of EVD transmission (n=5322) Percentage OA23 *Multiple responses for each parameter 3/17/2016 Nigeria Epidemiology and Laboratory Training Programme 17 Slide 17 OA23 for consistency, maintain one decimal place for all data labels Olufemi Ajumobi, 3/ 10/ 2016 Knowledge of signs and symptoms (n=5322) Percentage 3/17/2016 Nigeria Epidemiology and Laboratory Training Programme 18 Preventive measures from EVD (n=5322) Percentage 3/17/2016 Nigeria Epidemiology and Laboratory Training Programme 19 Good knowledge of EVD (n=5322) Percentage 3/17/2016 Nigeria Epidemiology and Laboratory Training Programme 20 Factors associated with poor EVD knowledge (n=5322) Variable Educational level Primary and below Post primary Sex Female Male Districts with EVD cases No Yes LGA location Rural Urban 3/17/2016 Knowledge Poor Satisfactory OR (95%CI) p-value 545 2576 280 1921 1.5 (1.2-1.7) < 0.01 1558 1563 979 1222 1.2 (1.1-1.4) < 0.01 2491 630 1695 506 1.2 (1.0-1.3) 0.02 567 2554 386 1815 1.0 (0.9-1.2) 0.56 Nigeria Epidemiology and Laboratory Training Programme 21 Perception on EVD • EVD is a problem in Lagos state – 3778 (71%) • Felt they cannot contract EVD – 3246 (61%) • Government efforts not enough – 692 (13%) • • • • Get the drug or Vaccine Close international borders Scale up mobilization, public health messages Provide hand sanitizers to the public • Undecided on government effort (11%) 3/17/2016 Nigeria Epidemiology and Laboratory Training Programme 22 Sourcing for information and good knowledge (n=5322) • Association exist between searching for information and good knowledge, OR 2.7 (1.9 - 3.8) • Searching multiple sources of information is 3 (1.9 – 5.0 ) times more likely to have good knowledge 3/17/2016 Nigeria Epidemiology and Laboratory Training Programme 23 Behavioural modification during the EVD outbreak (n = 5322) Started Stopped 2162 (41%) respondents 3084 (58%) started stopped engaging in one doing at least one or more of these activities or more of these activities • Regular hand washing • Handshaking & Hugging • Eating bush meat • Unnecessary contact 3/17/2016 • Improve hygiene • Use salt water and kola nut (6%) Nigeria Epidemiology and Laboratory Training Programme 24 Discussion • Gap in public knowledge and perception of EVD exist as shown in Sierra Leone study (2014) OA27 where only 39% has comprehensive knowledge • Our study reported 19% with comprehensive knowledge OA28 • Gaps may be attributed to the fact that Ebola outbreak has never occurred in Nigeria • Knowledge influence perception and behaviour 3/17/2016 Nigeria Epidemiology and Laboratory Training Programme 25 Slide 25 OA27 '2014' was that yea of publication or the year study was conducted? mention name of author e.g. Babalola et al. 2015 Olufemi Ajumobi, 3/ 10/ 2016 OA28 Ebola is a rare disease and should remain so. could the gaps be due to medium used for disseminating infomration about Ebola in Nigeria? were the uneducate targeted? what of those who didnt have access to electronic or print media? were tradiitonal means of disseminating information used? were appraoches targeted based on level of education, locality, etc were messgaes tailored to appropriate audience? what is there in literature? Olufemi Ajumobi, 3/ 10/ 2016 Conclusion • Targeted public health messages should be widely disseminated • • • • Raised public knowledge Corrected misconception Discouraged stigmatization Motivated positive behaviour 3/17/2016 Nigeria Epidemiology and Laboratory Training Programme 26 Recommendation • Accurate and appropriate information • Promptly disseminated • Through locally relevant source • Promote positive behavioural modification 3/17/2016 Nigeria Epidemiology and Laboratory Training Programme 27 Public health actions • Information disseminated • Utilized for public health measures • Published in journal 3/17/2016 Nigeria Epidemiology and Laboratory Training Programme 28 Public health actions 3/17/2016 Nigeria Epidemiology and Laboratory Training Programme 29 Acknowledgement • Ebola EOC/Federal Ministry of Health, Abuja • Nigeria Field Epidemiology and Laboratory Training Programme, Abuja, Nigeria • Association of Public Health Practitioners of Nigeria Lagos State Chapter • Ebola Containment Trust Fund 3/17/2016 Nigeria Epidemiology and Laboratory Training Programme 30 3/17/2016 Nigeria Epidemiology and Laboratory Training Programme 31 References 1. WHO | Ebola virus disease. WHO. http://www.who.int/mediacentre/factsheets/fs103/en/ (accessed Oct 22, 2014). 2. WHO | WHO Statement on the Meeting of the International Health Regulations Emergency Committee Regarding the 2014 Ebola Outbreak in West Africa. WHO. http://www.who.int/mediacentre/news/statements/2014/ebola20140808/ en/ (accessed Oct 22, 2014). 3. Dixon MG, Schafer IJ, Centers for Disease Control and Prevention (CDC). Ebola viral disease outbreakWest Africa, 2014. MMWR Morb Mortal Wkly Rep 2014; 63: 548–51. 4. Centers for Disease Control and Prevention. 2014 Ebola Outbreak in West Africa. 2014 http://www.cdc.gov/vhf/ebola/outbreaks/2014westafrica/index.html (accessed Oct 22, 2014). 5. Shuaib F, Gunnala R, Musa EO, et al. Ebola virus disease outbreak Nigeria, July september 2014. MMWR Morb Mortal Wkly Rep 2014; 63: 867–72. 6. Mwesiga A. Reporting epidemics: newspapers, information dissemination and the story of Ebola in the Ugandan district of Luweero. Pan Afr Med J 2011; 9: 43. 7. Borchert M, Mutyaba I, Van Kerkhove MD, et al. Ebola haemorrhagic fever outbreak in Masindi District, Uganda: outbreak description and lessons learned. BMC Infect Dis 2011; 11: 357. 8. Lagos State Government. 2013; published online Sept 1. http://www.lagosstate.gov.ng. 9. Oyeyemi A, Ogunnowo B, Odukoya O. Patent Medicine Vendors in Rural Areas of Lagos Nigeria: Compliance with Regulatory Guidelines and Implications for Malaria Control. Trop J Pharm Res 2014; 13: 163–9 10. Lwanga SK, Lemeshow S, Organization WH. Sample size determination in health studies : a practical manual. Dťermination de la taille d’ un čhantillon dans les ťudes sanomťriques: manuel pratique 1991. http://apps.who.int//iris/handle/10665/40062(accessed Oct 22, 2014). 11. Lakhani A, Mahmood H, Laeeq A, et al. Viral hemorrhagic fever in Pakistan: awareness among health care personnel. JPMA J Pak Med Assoc 2002; 52: 214–7. 12. Çilingiroğlu N, Temel F, Altıntaş H. Public’s knowledge, opinions and behaviors about CrimeanCongo Hemorrhagic Fever: An example from Turkey. Kafkas Univ Vet Fak Derg 2010; 16: S17–22. 13. World Medical Association Declaration of Helsinki. Ethical principles for medical research involving human subjects. Bull World Health Organ 2001; 79: 373–4. 14. Janjua NZ, Razaq M, Chandir S, Rozi S, Mahmood B. Poor knowledge predictor of nonadherence to universal precautions for blood borne pathogens at first level care facilities in Pakistan. BMC Infect Dis 2007; 7: 81. 15. Fasina F, Shittu A, Lazarus D, et al. Transmission dynamics and control of Ebola virus disease outbreak in Nigeria, July to September 2014. Euro Surveill Bull Eur Sur Mal Transm Eur Commun Dis Bull 2014; 19. 16. Hewlett BS, Amola RP. Cultural contexts of Ebola in northern Uganda. Emerg Infect Dis 2003; 9: 1242–8 17. Ogunsola F, Balogun M, Aigbefo S, et al. Perception and practice of hand washing in Kuramo Community, Lagos, Nigeria. Int J Infect Control 2013; 9. DOI:10.3396/ijic.v9i1.006.13. 18. Scott B, Curtis V, Rabie T, GarbrahAidooN. Health in our hands, but not in our heads: understanding hygiene motivation in Ghana. Health PolicyPlan 2007; 22: 225–33. 19. Barrett R, Brown PJ. Stigma in the time of influenza: social and institutional responses to pandemic emergencies. J Infect Dis 2008; 197 Suppl 1:S34–S7. 20. Survivors of Ebola outbreak in West Africa battling new ‘disease’ of stigma. CTVNews.http://www.ctvnews.ca/health/survivorsofebolaoutbreakinwestafricabattlingnewdiseaseofstigma1.1794523 (accessed Oct 22, 2014). 3/17/2016 Nigeria Epidemiology and Laboratory Training Programme 32 Perception regarding EVD Do you think Ebola Virus Disease is a problem in Lagos?  Yes  No  I don’t know 17a. If no, specify (Do not read options, tick what is mentioned. Multiple responses allowed) It is just being exaggerated People just want to make money with Ebola drug There are only few cases I do not believe that there are cases of EVD  Other (please state) If yes, specify (Do not read options, tick what is mentioned. Multiple responses allowed)  It is a deadly disease  It has no cure  It is highly infectious It is an attack by the Western world It creates a lot of panic  Other (please state) Do you think you can contract Ebola Virus Disease?  Yes  No  I don’t know If no, why not? Do you think government is doing enough to contain the Ebola Virus Disease outbreak?  Yes  No  I don’t know If no, what other things do you think government should do in order to contain the Ebola disease outbreak? 3/17/2016 Nigeria Epidemiology and Laboratory Training Programme 33 Practice of proper hand washing Part of the hand (n = 5322) Percentage Wash palm only 87 Wash palm and back of hand 83 Wash palm, back of the hand and fingers 38 Wash palm, back of the hand, fingers and fingernails 21 Wash palm, back of the hand, fingers, fingernails and base of thumbs 12 Wash all parts of the hand 2 3/17/2016 Nigeria Epidemiology and Laboratory Training Programme 34 Sources of EVD information (n=5322) Percentage 3/17/2016 Nigeria Epidemiology and Laboratory Training Programme 35 Information source and good knowledge Poor Variables Good (%) (%) OR Source information (n=5322) Yes 24 76 2.7 No 11 89 Sources of information (n=3459) Multiple 29 71 3.1 Single 11 89 3/17/2016 95% C. interval pvalue 1.9 3.8 < 0.01 1.9 5 < 0.01 Nigeria Epidemiology and Laboratory Training Programme 36 EVD Related healthcare seeking behaviors "Advice to someone with "If I Have EVD symptoms" Health seeking behaviour EVD symptoms" (%) (%) Visit the hospital 72 73 Call the Ebola helpline 19 16 Prayers 13 14 Hide/Stay at home 4 3 Do nothing 3 0 Seek religious healers 3 3 Self-prescribed treatment 1 2 3/17/2016 Nigeria Epidemiology and Laboratory Training Programme 37 Suspected case of Ebola • Any person, alive or dead, suffering or having suffered from a sudden onset of high fever and having had contact with • a suspected • probable • confirmed Ebola- a dead or sick animal • Any person with sudden onset of high fever and at least three of the following symptoms • Headaches, vomiting, anorexia / loss of appetite, diarrhea, lethargy, stomach pain, aching muscles or joints, difficulty swallowing, breathing difficulties, hiccup • Any person with inexplicable bleeding , sudden and inexplicable death 3/17/2016 Nigeria Epidemiology and Laboratory Training Programme 38