The purpose of health education of behavior change communication (BCC) is to share ideas such that all sides of the communication process learn to act in ways that better control and prevent disease and promote health. Both community members (clients) and health workers (providers) need to change behavior is their interaction to become a health promoting dialogue.
This dialogue becomes easier when all parties share some common perceptions about the issue at hand. Both health workers and community members can usually agree that malaria often presents with high body temperature. Also both usually agree that malaria can be disruptive of daily life and even be deadly.
But there are differences. While both may agree that there are different types of malaria, the health worker may mention different species of Plasmodium such as falciparum, ovale, vivax, malariae and now even knowlesi. The community member may think of yellow malaria, heavy malaria, aching malaria, and ordinary malaria. These differences may put acceptance of interventions to control malaria into jeopardy. Fortunately, current downward trends in malaria incidence imply that our communicants have more in common than not.
Along comes Ebola Viral Disease in West Africa, which has killed around 3000 people in Guinea, Liberia, Sierra Leone and Nigeria at this writing. The disease has never been seen on that side of the continent before. It is spreading more rapidly than it even did in its previous East and Central African outbreaks. How does one communicate with people – both community members and health workers – about a disease they have never seen before?
The following encounter reported by BBC shows the initial confusion.
Not infrequently in the last few weeks I’ve encountered people complaining of a headache or a night of intense sweating. They slide off to the hospital and reappear a day or two later with a bag full of drugs, and they laugh it off. “Oh yeah, there are so many mosquitoes at this time of year,” they say. Better it be ‘normal’ malaria than death (Ebola).
The confusion results in harmful changes in treatment seeking behavior according to the The Pacific Northwest Conference of The United Methodist Church.
Misinformation and denial are keeping sick people from getting help. Some people are hiding from government officials and medical teams because they fear that if they go into quarantine, they will never see their loved ones again. Since the early symptoms of malaria and Ebola are similar, many malaria patients are not getting treatment. This crisis jeopardizes the progress toward improving access to health care generally.
In his blog, Larry Hollen summarizes the dilemma as follows: Both diseases disproportionately affect the poor and ill-informed Because Ebola and malaria have common early symptoms, such as fever, headache and vomiting, there may be confusion about the cause of illness among both those who are ill and health care providers.
Efforts to communicate the nature and dangers of Ebola have proceeded anyway. Posters, billboards, radio spots and even local volunteers with bullhorns, armed with information from the ministries of health or NGOs remind people that Ebola can kill and that people must report to a health facility for testing and care.
This top-down approach to communication often meets skepticism and suspicion. The messages also do not match reality when people find health centers closed due to loss of staff or health workers reluctant to see febrile patients fearing that they may have Ebola, not malaria. A health education dialogue cannot take place under such circumstances.
In fact suspicion is the order of the day. Sierra Leone and Liberia have emerged not long ago from brutal civil wars that not only destroyed must health and other infrastructure but killed much of their populations and alienated those who survived. Reinforcing this suspicion and distrust are militaristic approaches in both countries to contain the poor populations most affected.
False rumors are spreading that the international donors who are slowly rallying resources to fight the disease are actually the ones who may have created and started the spread of Ebola. It is unfortunately not surprising under such circumstances that a health education team going to a remote village in Guinea were killed.
Some positive approaches to Ebola communication have been documented including the use of trusted community health workers making door-to-door visits in Sierra Leone. More effort is needed to plan a more inclusive dialogue among all parties in order to halt the Ebola epidemic. Dialogue can start from the known – like the similarities with malaria – and move into the unknown. Drugs and vaccines will not be enough, if trust and good communication are lacking.