The Lancet Infectious Diseases: Low levels of public trust during violent conflict may have thwarted attempts to control Ebola

March 27, 2019

A quarter of people surveyed during active 2018 Ebola outbreak in the Democratic Republic of Congo believed the virus was not real, and would not accept vaccination against infection

Mistrust and misinformation can stop people taking measures to prevent the spread of Ebola virus disease (EVD), increasing the likelihood that they refuse vaccination, according to a study with nearly 1,000 people published in The Lancet Infectious Diseases journal.

The study highlights the vital importance of understanding that, among people who have learnt from experience to distrust authority, how and by whom health messages are communicated can be just as important as what is said.

Of 961 adults interviewed, only 349 thought that local authorities could be trusted to represent their interests and 230 believed rumours that the Ebola virus does not exist. Among individuals who believed the virus was real, those who thought the risk of contracting the virus was high were less likely to seek care or to accept vaccination. This might be due to fear that a medical setting could expose them to the virus. At the same time, most respondents reported taking individual measures such as washing their hands more frequently (885 of 961) and avoiding contact with people suspected to have Ebola (757 of 961).

Higher trust was positively correlated with seeking care and accepting vaccination.

The research was conducted in the cities of Beni and Butembo at the epicentre of an active Ebola outbreak in the east of the country. It is a highly insecure, densely-populated environment. Violent conflict over two decades has resulted in thousands of deaths and injuries, including attacks against civilians and targeted attacks on EVD response teams. Delayed presidential elections have contributed to an unstable political situation.

It was already known that violence leads to a collapse of trust and that trust is important for compliance with changes in behaviour to reduce health risks. However, this is the first study to more precisely define how misinformation and mistrust on an individual level can undermine the response to an infectious disease outbreak.

"Medical responses alone are not enough to stop the spread of Ebola," says Dr Patrick Vinck from Harvard University, USA, who led the research. "Ebola responders are often from outside local communities, so building trust via local leaders and service providers should be a cornerstone of efforts to engage with people to control outbreaks. This is particularly important in conflict zones where information about outbreaks can become politicized." [1]

Interviews were conducted in September 2018, a month after the country declared its tenth EVD outbreak. Most respondents had heard false rumours about the EVD outbreak. While one in four believed in the statement that Ebola does not exist (230/961 people or 26%), an even higher proportion believed that the outbreak was fabricated for financial gains (312/961, 33%), or was fabricated to destabilize the region (371/961, 36%) [2]. Nearly a fifth (171 respondents) believed all three statements. Among those who believed in all or any misinformation statements, trust scores in EVD information, government and health professionals were significantly lower. The belief that EVD does not exist was linked to lower adoption of behaviours to prevent its spread, as well as people being more than 15 times less likely to seek formal health care and five times less likely to accept vaccination.

Confidence in vaccines in general was high, with 899 people believing that they work. It was lower in relation to Ebola vaccines specifically. Only 641 believed that EVD vaccines work and only 589 reported that they would accept vaccination, while 59 were unsure. The reasons cited for not accepting vaccination included that it was unsafe (225 out of 313 people), that it didn't work (75 of 313) and that it was not needed to avoid contracting the virus (45 of 313).

All people who took part in the survey felt that local authorities were more trustworthy than provincial and national levels of government. This might reflect the fact that they have greater visibility and access and are directly involved in delivering services. Health professionals were more frequently trusted than authorities, though the authors note that they did not distinguish between government, private, and humanitarian health providers. Additional differences in trust might exist depending on these affiliations.

The researchers point to several limitations, including that the study was conducted in urban environments. In other affected areas, particularly those that are rural, perceptions might be different. All data were self-reported, including behaviour changes and it's possible that participants act differently to the behaviour they report to researchers. This can lead to over-reporting of the extent to which individuals take precautions to prevent the virus spreading.

Writing in a linked Comment, Joe Trapido from the London School of Economics, UK, says: "The strength of the paper by Vinck and colleagues is the attention given to ordinary people." He adds: "Extensive participant observation fieldwork might not be an immediate option here, but more qualitative knowledge might be useful: what it is about how a rumour acts in a social context that makes it harmful? In many cases, I suspect that establishing common ground on the basis of genuine attempts at communication, as shown in the Article by the extensive questioning of local people, might be more important in securing positive outcomes than dispelling misinformation."

This study was funded by the Harvard Humanitarian Initiative Innovation Fund. It was conducted by researchers from Harvard University, USA, the Free University of the Great Lakes Countries in the Democratic Republic of the Congo, and Anthrologica, UK.

The labels have been added to this press release as part of a project run by the Academy of Medical Sciences seeking to improve the communication of evidence. For more information, please see: if you have any questions or feedback, please contact The Lancet press office

[1] Quotes direct from author and cannot be found in text of Article

[2] Please note that the percentages don't exactly match the numbers of people as data were weighted to reflect the unequal probability of sampling between the two cities.


Peer-reviewed / Observational study / People

The Lancet

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