Threat, Trust, and Tools for Action: What Matters in Helping Travelers from Ebola-Affected Countries to Follow Government Monitoring and Reporting Guidelines?

Background:  Prominent models of human behavior, such as the Health Belief Model, the Precaution Adoption Process Model, Reasoned Action models, and Social Cognitive Theory, generally converge to suggest that adherence to behavioral recommendations reflects not only people’s knowledge, but also factors such as perceived credibility of message source, social norms, and the availability of appropriate tools to perform the behavior. People appear more likely to share information with government agencies, for example, when they believe agencies are trustworthy. Persuading audiences also requires careful consideration of existing beliefs. In light of these considerations, the recent Ebola outbreak in West Africa has posed challenges and opportunities to investigate adherence to monitoring recommendations, which are important to the domestic Ebola response.

Program background:  As part of the Ebola response, CDC developed communication supports to assist travelers from affected countries in complying with U.S. monitoring requirements until 21 days after their departure from an Ebola-affected country. Specifically, CDC developed and implemented the CARE+ (Check and Report Ebola) Program, which features CARE Ambassadors who meet inbound travelers to explain how to participate in state-implemented active monitoring programs.

Evaluation Methods and Results:  Since October 2014, five U.S. airports (Chicago O’Hare (ORD), Newark Liberty (EWR), Atlanta Hartsfield-Jackson (ATL), John F.  Kennedy International (JFK), and Dulles International (IAD)) have implemented enhanced screening for Ebola, and since December 2014, these airports have also implemented the CARE+ program. Data collection is currently under way of inbound travelers arriving at JFK and IAD, which comprise a majority (about 70%) of passengers arriving from affected countries. Travelers had to be 18 years or older and speak either English or French to be eligible. We developed a systematic convenience sample by inviting inbound travelers screened for Ebola to a voluntary in-person intercept interview. All intercept interview participants were asked to also participate in two follow-up telephone interviews, one scheduled for 3-to-5 days following the initial interview and a second scheduled within two days of the end of their monitoring period. This longitudinal design allowed us to model future behavior as a function of antecedent perceptions. Data collection will be completed by the end of July 2014. We will report distribution of traveler monitoring behavior, use of monitoring tools, perceptions of threat and trust, and current salience of Ebola, among other variables. We will also model traveler self-monitoring behavior as a function of knowledge and trust in information sources.

Conclusions:  Adherence to recommended monitoring behavior is expected to be a function of multiple variables.

Implications for research and/or practice:  Support initiatives to improve communication with those screened in response to communicable disease outbreaks should consider not simply presenting disease-related facts, but also assess the context in which the information is provided, including how affected people view public health institutions offering messages. Assessing travelers’ knowledge and beliefs, along with the impact of people or media that can influence those beliefs, is potentially important in developing outreach efforts to address global communicable disease concerns such as Ebola.