Traveler Insights on the Care Kit and Entry Screening Process

Background: CDC issued guidelines for health departments to monitor travelers coming to the United States from Ebola-affected countries until 21 days after their last possible exposure.  A part of the response was the development and deployment of clear and effective risk communication messages for travelers.

Program background: The Check and Report Ebola (CARE) Kit was developed to help these travelers to perform daily monitoring and reporting of symptoms after their arrival in the United States.  The CARE Kit  includes instructions for travelers for monitoring and reporting possible Ebola symptoms, a detailed illustrated list of possible Ebola symptoms, a digital thermometer with instructions, a 21-day temperature and symptom log, and contact information for public health authorities and healthcare organizations in the event that travelers develop symptoms of Ebola.

Evaluation Methods and Results: CDC wanted to understand if and how current materials (CARE Kits) and approaches (screening process) help travelers to perform active monitoring behaviors.  CDC desired to refine materials and approaches based on traveler insights and suggestions. A mixed-method design was used to assess factors that would affect a traveler’s ability to perform monitoring behaviors, including: perceptions of threat/risk, knowledge of symptoms and self-monitoring behaviors, intention to perform behaviors, self-efficacy, and challenges. During one week in December 2014, in-person interviews were conducted in 3 of 5 airports conducting enhanced entry screening with travelers intercepted after they completed the screening process. Within 3 to 5 days of arrival, travelers who consented to a follow-up phone call were interviewed again.  Travelers had to be 18 years or older and speak English to be eligible. All interviews were recorded and transcribed. Transcripts were thematically analyzed in version 11 of MaxQDA  (VERBI GmBH) using a coding scheme following the instruments. We interviewed 77 of 104 passengers arriving at Atlanta, Newark, and Chicago airports and completed telephone follow-up interviews with 50 of these passengers. All travelers reported receiving and reading a CARE Kit. Many respondents reported that the information was clear, good, or understandable.  Interviews indicated that travelers were well-informed about Ebola and possessed high self-efficacy and motivation for active monitoring. While most travelers indicated that Ebola was a very serious health threat, they did not believe that they were likely to get sick. Although most travelers indicated they knew the purpose of the screening, most said that the purpose was never actually made clear during the screening process. Some respondents reported a lack of clarity about either calling or being called by public health authorities.      Others wanted help addressing stigma from family and friends. Travelers offered many practical suggestions for improving the CARE Kit and screening process.

Conclusions: Feedback from travelers led to specific changes to the CARE Kit. Changes included adding explicit statements about the purpose of monitoring and reporting, clarifying that health departments would be contacting the traveler, and offering tips for addressing stigma.

Implications for research and/or practice: While materials development benefits from applying communication principles and incorporating informal feedback, systematically gathering feedback from the intended audience is important for ensuring clarity.