what does the public know about ebola
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American Journal of Infection Control xxx (2015) 1-7
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American Journal of Infection Control
journal homepage: www.aj ic journal .org
American Journal of Infection Control
Major article
What does the public know about Ebola? The public’s riskperceptions regarding the current Ebola outbreak in an as-yetunaffected country
Anat Gesser-Edelsburg PhD a,*, Yaffa Shir-Raz PhD a, Samah Hayek MPH, DrPH a,Oshrat Sassoni-Bar Lev MAb
aHealth Promotion Department, School of Public Health, University of Haifa, Haifa, IsraelbDepartment of Communication, University of Haifa, Haifa, Israel
Key Words:Ebola epidemicKnowledge and risk perceptionsHealth care and nonhealth care workersUncertainty trust and irrationalityCitizen science and mental models
* Address correspondence to Anat Gesser-EdelsPromotion Department, School of Public Health, UKhoushy Ave, Mount Carmel, Haifa 3498838, Israel
E-mail address: [email protected] (A. Gesser-Funding support: The research leading to these
from the European Union Seventh Framework Progragrant agreement no 612236.
Conflicts of interest: None to report.
0196-6553/$36.00 - Copyright � 2015 by the Associahttp://dx.doi.org/10.1016/j.ajic.2015.03.005
Background: The unexpected developments surrounding the Ebola virus in the United States provide yetanother warning that we need to establish communication preparedness. This study examines what theIsraeli public knew about Ebola after the initial stages of the outbreak in a country to which Ebola has notspread and assesses the association between knowledge versus worries and concerns about contractingEbola.Methods: Online survey using Google Docs (Google, Mountain View, CA) of Israeli health care pro-fessionals and the general public (N ¼ 327).Results: The Israeli public has knowledge about Ebola (mean � SD, 4.18 � 0.83), despite the fact that thedisease has not spread to Israel. No statistically significant difference was found between health careworkers versus nonhealth care workers in the knowledge score. Additionally, no statistically significantassociation was found between knowledge and worry levels. The survey indicated that Israelis expectinformation about Ebola from the health ministry, including topics of uncertainty. More than half of theparticipants thought the information provided by the health ministry on Ebola and Ebola prevention wasinsufficient (50.5% and 56.4%, respectively), and almost half (45.2% and 41.1%, respectively) were unsure ifthe information was sufficient.Conclusion: The greatest challenges that the organizations face is not only to convey knowledge, but alsoto find ways to convey comprehensive information that reflects uncertainty and empowers the public tomake fact-based decisions about health.
Copyright � 2015 by the Association for Professionals in Infection Control and Epidemiology, Inc.Published by Elsevier Inc. All rights reserved.
Ebola communication chaos
The unexpected developments surrounding the Ebola virus inthe United States provide yet another warning that we need toestablish communication preparedness, according to an editorial inthe Journal of Health Communication.1 Ratzan and Moritsugu dis-cussed communication chaos regarding the Ebola crisis, including
burg, PhD, Head of Healthniversity of Haifa, 199 Aba.Edelsburg).results has received fundingmme (FP7/2007-2013) under
tion for Professionals in Infection C
lack of understandable, reliable, and actionable information fromnetwork news, newspapers, and social media. The current Ebolacrisis demonstrates that communication, which should be a centralweapon against diseases,2 is still not central enough in the au-thorities’ arsenal.
Trust, empowerment, rationality, and uncertainty
Risk communication literature defines 4 components of aneffective dialog with the public during epidemic crises: trust,empowerment, rationality, and uncertainty. Regarding trust,studies show that when the public feels it has no control over thesituation, trust in government organizations becomes key in thepublic’s reception of the risk management approach.3
ontrol and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
A. Gesser-Edelsburg et al. / American Journal of Infection Control xxx (2015) 1-72
Media and scholars have criticized the Centers for DiseaseControl and Prevention (CDC) for projecting overconfidence withregard to Ebola generally, and specifically regarding US hospitals’capacity to manage the disease.4,5
When 2 nurses in a Dallas hospital contracted the disease, criticscited the CDC’s assurance that “U.S. hospitals can safely managepatients with Ebola disease.” According to Rosenbaum,5 the CDCsaid the nurses probably contracted the disease because of a pro-tocol breach. However, it turned out there was no protocol, whichmade things even worse.
Regarding empowerment, the literature refers to the authorities’exercise of power. Optimally, they should empower the public tomake decisions about risks for themselves.6 According to Ratzanand Moritsugu,1 in the Ebola crisis, the public remained afraid andconfused, mainly because of multiple spokespeople, incoherentinformation, and an overly general message that did not addresssubpopulations.
Regarding rationality, governments and organizations haveoften explained the public’s failure to follow certain recommen-dations as irrational. Current studies show that individuals makedecisions not because they are irrational but because they evaluaterisk according to its relevance to their lives.7,8 The public’s behaviorin a crisis is driven by sometimes contradictory motives: rationalityversus emotionality9 and seeking official sources of security versusthinking independently.
Regarding uncertainty, unpredictability and lack of controlcharacterize uncertain situations of communicating risk to thepublic during crises. Uncertainty is characterized by unpredict-ability and lack of control regarding uncertain situations ofcommunicating risk to the public during crises. Maxim et al10 notedthat laypeople raise more and different uncertainties than thosecommunicated by researchers.
Sandman and Lanard emphasize the need to proclaim uncer-tainty: “When imperfect, tentative information is all you have, thenimperfect, tentative information is what you must give people sothey can decide how best to cope.”11 In a health crisis, the majorcommunication challenge is providing timely information thatexplains how the public should protect itself.
In the current crisis, uncertainty concerns fundamental ques-tions, such as how the Ebola virus is transmitted. This question iscentral when communicating about Ebola and is connected to theissue of precautionary measures. Leading health authorities (WorldHealth Organization and CDC) and local health authorities conveythe message that the virus spreads through direct contact withblood or other body fluids or with contaminated objects and ma-terials, but is not airborne, and that infected people are not con-tagious until they develop symptoms.12-14 Alongside this officialline, the media has highlighted Ebola researchers who claim thatairborne transmission cannot be ruled out.15,16 Others warned thateven if the virus is not presently airborne, it could become so.17
The Pentagon issued a requirement for a 21-day quarantine forall service members who had contact with Ebola patients.18 Despitecriticism, for example a New England Journal of Medicine editorialclaimed that it “is not scientifically based, is unfair and unwise,”19
the editorial was still published, making the messages confusing.
Citizen science, deficit model, and public knowledge
The deficit model20 attributes public skepticism to science andtechnology or hostility to a lack of understanding. It is associatedwith a division between experts who have the information andnonexperts who do not.
The second approach stems from the concept of citizen scienceand is more optimistic about the public’s knowledge. The termwas
used to describe expertise among those traditionally seen asignorant laypeople.21
Citizen science does not view the public and experts in dichot-omous termsdas those lacking knowledge versus those possessingit. As such, “.‘laypeople’ are not viewed as tabulae rasae, asdisinterested or ‘innocent’ of the issues.but as the very embodi-ment of knowledge about the practical world.”22
Media’s role: relevance and severity
Today, various bodies ofworkpaycritical attention to themedia’srole in risk communication. The spread of Ebola fromWest Africa toWestern countries has led to an increase in the health organizations’alertness and media coverage throughout the world. The public’sability to absorb information from the media and conduct a dialogdepends on how the organizations address the public’s states ofrelevance and severity. The health belief model suggests that if thepurpose is to prepare the public for a threat, people must believethat it is relevant to their world and that it is severe.23
OBJECTIVE
Therefore, the purpose of this study is to examine what the Is-raeli public knew about Ebola after the initial stages of the outbreak(mid-September to November 2, 2014) in a country to which Ebolahas not spread. Our overall goal is to assess the association betweenknowledge about Ebola (spread, vaccine, treatment, and preven-tion) versus worries and concerns about contracting Ebola. Inaddition, we analyzed differences between health careworkers andnonhealth care workers in their knowledge about Ebola versusworries and concerns about contracting Ebola. We also examineduncertainty in this context.
Theoretical framework
We examined the public’s knowledge in light of the 2 opposingapproaches: the deficit model, which assumes that the public hasless knowledge than health care workers, and citizen science,which does not view the public and the experts in dichotomousterms. The study uses the 2 approaches as a conceptual basis toexamine the public’s knowledge. We examined whether the pub-lic’s and health care workers’ knowledge levels influence theirworries and concerns.
Hypothesis
The current study has 2 hypotheses. The first is that no differencewill be found between the health care workers and public with re-gard to knowledge levels about Ebola. The second hypothesis is thatthere is an association between knowledge level about Ebola andlevel of worries and concerns regarding contracting Ebola in Israel.
METHOD
Data collection
An online survey (N ¼ 327) within a cross-sectional study wasconducted to examine degree of knowledge about Ebola among theIsraeli public. The data had to be collected quickly. Ongoing newsabout the disease could affect people’s attitudes and beliefsregarding Ebola; therefore, the survey was created and distributedvia Google Doc online software (Google, Mountain View, CA) frommid-September to November 2, 2014. This platform enablescreating interactive online questionnaires and distributes them viae-mails or social media outlets.
Table 1Demographic characteristics (N ¼ 327)
Characteristic Value
Age, y 39.7 � 14.02 (19-89)SexMale 114 (35.6)Female 206 (64.4)Missing 7
Health care workerYes 70 (21.8)No 250 (78.1)Missing 7
Education�High school 29 (9.0)>High school 43 (13.4)Academic degree 250 (77.7)Missing 5
NOTE. Values are mean � SD (range), n (%), or n.
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The survey was distributed in 3 central ways. First, it wasdistributed through snowball sampling,24 where the first wave ofrespondents distributed the questionnaire link to others, viae-mail and social media outlets, mainly Facebook. This enabled usto reach mostly laypeople, without medical or public health ed-ucation. Second, it was distributed through the official Web site ofan Israeli university, which also enabled us to reach students andpeople, most of whom are laypeople, to compare them to healthcare workers. By using both of these techniques, we were able toachieve a relatively large sample quickly. Finally, the questionnairewas distributed to health care professionals by sending the linkthrough the University of Haifa School of Public Health mailing listto ensure that a sampling of health care professionals would takethis survey along with a sampling of the general public.
Questionnaire
The questionnaire was based on a literature review dealing withthe recent studies on Ebola. As we wrote in the questionnaire, noaudience studies were conducted yet; therefore, our study was apioneer in the field.
The main purpose of the questionnaire was to measure theknowledge of the general public and health care workers regardingEbola. The questions were developed around these issues. Thequestionnaire related to the levels of knowledge and concern asmain components in the literature regarding risk perception.25
Regarding the level of knowledge, we included questionsdealing with the definition of Ebola, its transmission routes, whocan contract Ebola, is there any specific treatment or vaccine forEbola, and the severity of Ebola. Regarding the level of concern, weincluded questions dealing with the risk of an Ebola outbreak inIsrael and worry about contracting Ebola.
Another component we included was expectation from theMinistry of Health. We chose to examine to what extent do thepublic want to receive more information from the Ministry ofHealth on Ebola and to what extent do people feel that the Ministryof Health provided comprehensive information on the subject.
The questionnaire opened with an explanation about the surveyand assured the confidentiality and anonymity of the respondents.The questionnaire examines knowledge about Ebola, extent ofconcerns or worries regarding Ebola, and what Israelis expect fromthe Israeli Ministry of Health regarding Ebola.
Level of concern
The study includes the 2 following dependent variables thatmeasure the level of concerns/worries:
1. To what extent are you afraid of contracting Ebola?: a cate-gorical variable with 3 levels (low, medium, and high).
2. To what extent are you afraid that Ebolawill spread to Israel?: acategorical variable with 3 levels (low, where the risk is <50%;medium, where the risk is 50%; and high, where the risk is>50%).
Independent variables consisted on different measures
Knowledge scoreThe knowledge score was the sum of the score of 5 questions
that includes information about the individual’s general knowledgeabout Ebola; if the respondent answered correctly, then the answerwas counted in the score. The questions that assessed the knowl-edge level are the definition of Ebola, transmission route, who canbe infected, if there is any treatment for the disease or prevention,and to what extent Ebola is a serious disease.
Expectations from the Israeli Ministry of Health
This variable includes 5 questions that assess Israelis’ expecta-tions from the Ministry of Health. These questions included infor-mation on interest in receiving information from the Ministry ofHealth, and if so, what kind; and if the Ministry of Health hasprovided sufficient information about Ebola, treatment, andprevention.
Demographic characteristics
Demographic characteristics included age, sex, profession(health care worker or nonhealth care worker), and education.
Analysis
First, participants’ characteristics were summarized using fre-quencies, means, and SDs. Second, we compared the differences ofseries of bivariate analyses (ie, c2 test for categorical variables, t testfor continuous variables) to determine the difference betweenhealth care workers versus nonhealth care workers in knowledgelevel about Ebola.
Finally, we used ordinal logistic regression to assess the asso-ciation between knowledge level about Ebola and our dependentvariables while considering differences in demographic character-istics. We presented the adjusted odds ratio (AOR), with 95% con-fidence interval (CI). All the statistical analyses were conductedusing SAS version 9.3 software (SAS Institute, Cary, NC). Two-sidedP values < .05 were considered statistically significant.
Ethics committee approval
This research has been approved by the University of HaifaFaculty of Social Welfare and Health Sciences Ethics Committee forHuman Research (approval no. 259/14).
RESULTS
The study garnered 327 responses. The average age of partici-pants was 39.7 years; the youngest participant was 19 years, andthe oldest was 89 years. More than half of the respondents werewomen (64.4%), and most had academic degrees (77.7%) and werenonhealth care workers (78.1%) (Table 1).
The mean of the knowledge score � SD was 4.18 � 0.83. Therange of the scorewas 2-5. This indicates that every respondent hadat least 2 out of 5 correct answers. The study shows that Israeliswere knowledgeable about Ebola during the period in question.
Table 2Distribution of knowledge, worry, and expectation from the Ministry of Health inIsrael (N ¼ 327)
Measure/Question Value
KnowledgeDefinition of EbolaAn infection transmitted from person to person 306 (94.4)It is not a contagious infection 2 (0.6)Do not know 16 (4.9)Missing 3
Transmission routeFluid (eg, blood, saliva, feces, etc) 170 (52.6)Air droplets 82 (25.4)Do not know because scientists are uncertain 33 (10.2)Do not know 38 (11.8)Missing 4
Who can contract EbolaImmigrants or international workers from Africa 26 (8.1)Everyone 294 (91.3)Pregnant women and children 1 (0.3)Health care workers (doctors, nurses, etc) 1 (0.3)Missing 5
Treatment for Ebola or vaccineThere is a specific treatment for Ebola 34 (10.6)As of today, there is neither a vaccine nor anyspecific treatment for Ebola
224 (70)
As of today, there is no specific treatment forEbola, but there is a vaccine
29 (9.1)
Do not know 33 (10.3)Missing 7
Severity of EbolaFatal disease 244 (76.3)It is a dangerous disease that can be fatal,only for people at risk
37 (11.6)
Ebola is dangerous, but it is possible to recover 25 (7.8)Ebola is not dangerous at all 0Do not know 14 (4.4)Missing 7
Knowledge scoreKnowledge score for correct answers 4.18 � 0.83 (2-5)
WorryRisk of an Ebola outbreak in IsraelHigh (>50%) 24 (7.4)Medium (50%) 98 (30.3)Low (<50%) 201 (62.2)Missing 4
Worry about contracting EbolaHigh 73 (22.6)Medium 108 (33.4)Low 142 (43.9)Missing 4
Expectation from the Ministry of HealthReceiving more information from the
Ministry of HealthYes, just in case we have reported cases in Israel 109 (33.6)Yes, now 190 (58.6)Not interested to get any kind of information 25 (7.7)Missing 3
If you answered yes to the previous question,what kind of information would you like?What to do to prevent the transmission 43 (14.7)Everything related to Ebola, treatment,andprevention (also subjects that includescientific uncertainty)
157 (54)
Everything related to Ebola, but just for topicsthat have scientific certainty
91 (31.3)
Missing 36Extent of agreement that the Ministry of
Health provided comprehensive informationon EbolaStrongly agree 8 (2.5)Agree 25 (7.8)Not sure 145 (45.2)Disagree 99 (30.8)Strongly disagree 44 (13.7)Missing 6
(continued)
Table 2Continued
Measure/Question Value
Extent of agreement that the Ministryof Health providedcomprehensive information onEbola preventionStrongly agree 3 (0.9)Agree 24 (7.5)Not sure 132 (41.1)Disagree 117 (36.4)Strongly disagree 45 (14)Missing 6
NOTE. Values are n (%), n, or mean � SD.
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Almost all of the participants knew that Ebola is an infectiontransmitted from person to person (94%), more than half of theparticipants (52.4%) reported that it is transmitted through bodyfluids, and 25.4% incorrectly reported that it is transmitted via air.Of the participants, 10.2% reported that there is uncertaintyregarding transmission route. Of the participants, 90% reported thatanyone could contract Ebola, and 70% reported that there is notreatment or vaccine. Most (76.3%) of the participants answeredthat Ebola is fatal (Table 2). Most of the participants reported a lowlevel of worry about contracting Ebola (43.6%) and a low level(<50% risk) of worry about contracting the disease in Israel (62.2%).The survey indicated that Israelis have specific expectations fromthe Ministry of Health. They expect updates on Ebola (58.6%) andupdates on topics of uncertainty (54%) related to Ebola. Almost halfof the participants thought the information provided by the Min-istry of Health on Ebola and its prevention was insufficient (44.5%and 50.4%, respectively), and almost half (45.2% and 41.1%,respectively) were unsure if it was sufficient (Table 2).
As a result of the bivariate analyses for assessing the associa-tion in the knowledge score between levels of worry about con-tracting Ebola or having an outbreak in Israel, we found that thereis no statistical difference between knowledge score and worrylevels of the 2 dependent variables (P > .05) (data not shown).Additionally, bivariate analysis shows that there are no statisticaldifferences between health care workers versus nonhealth careworkers in the overall knowledge score (P > .05). When weassessed each item related to knowledge, we found that there is asignificant statistical difference between health care workersversus nonhealth care workers regarding knowledge of who couldcontract Ebola and whether there is any Ebola treatment or vac-cine (Table 3).
The results showed that there is an association between age, sex,and medium level of worry of contracting Ebola. Older people areless likely to worry about contracting Ebola. For a 1 year increase inthe age of the participants, the odds of a medium level of worry are0.97 lower than the low level of worry of contracting Ebola(AOR ¼ 0.97; 95% CI, 0.95-0.99). Women are more likely to worrythan men. Women are twice more likely than men to worry at amedium level (AOR¼ 2.19; 95% CI,1.3-4.27). However, the study didnot find any association between age and high level of worry orbetween sex and high level of worry. The knowledge and knowl-edge score for health care workers and education were not signif-icantly associated with any level of worry (Table 4).
Furthermore, when we assessed the association betweenknowledge score and worry level of contracting Ebola in Israel,we could not find any significant association between knowledgeand worry level regarding an Ebola outbreak in Israel. Addition-ally, age, sex, being a health care worker, and education were notsignificantly associated with knowledge and worry level(Table 4).
Table 4Ordinal logistic regression for the association between knowledge level and worry level for Israelis to contract Ebola and for Ebola to break out in Israel
Demographic characteristics
Worried to be infected Worried to find Ebola cases in Israel
High Medium Low High Medium Low
Age 0.98 (0.94-1.02) 0.97 (0.95-0.99)* Ref 1.00 (0.97-1.02) 0.99 (0.97-1.01) RefP value .273 .009 .923 .542
SexMale Ref Ref Ref Ref Ref RefFemale 2.39 (0.75-3.59) 2.19 (1.3-4.27)* 0.94 (0.46-1.96) 1.38 (0.72-2.65)P value .139 .020 .883 .331
Education�High school Ref Ref Ref Ref Ref Ref>High school NS 1.04 (0.29-3.78) 0.88 (0.19-4.11) 0.80 (0.19-3.36)P value .538 .220 .693Academic degree NS 0.59 (0.20-1.75) Ref 0.43 (0.11-1.63) 0.46 (0.14-1.57) RefP value .157 .085 .110
Health care workerHealth care worker Ref Ref Ref Ref Ref RefNonhealth care worker 1.99 (0.51-7.85) 1.56 (0.75-3.27) 1.75 (0.70-4.43) 1.84 (0.72-3.07)P value .324 .235 .228 .290
Knowledge score 1.05 (0.56-1.97) 1.18 (0.82-1.72) Ref 0.88 (0.58-1.34) 1.04 (0.71-1.51) RefP value .875 .377 .555 .848
NOTE. Values are odds ratio (95% confidence interval) or as otherwise indicated.NS, odds ratio included a wide interval that yielded an insignificant outcome because of the small numbers in the high level category of the worry level; Ref, reference.*P value is statistically significant at P < .05.
Table 3Differences between health care workers versus nonhealth care workers in the overall knowledge level, of who could contract Ebola, and Ebola treatment or vaccine
Measure/Question Health care workers Nonhealth care workers c2 test or t test* P value
Overall knowledge level (score), mean � SD 4.15 � 0.82 4.28 � 0.83 �1.13 .259Infected with Ebola 9.19 .027y
Immigrants or international workers from Africa 1 (1.4) 25 (10.1)Everyone 68 (97.1) 221 (89.5)Pregnant women and children 0 1 (0.4)Health care workers (doctors, nurses, etc) 1 (1.4) 0
Treatment for Ebola or vaccine 8.63 .035y
There is a treatment for Ebola 3 (4.3) 31 (12.6)As of today, there is no treatment for Ebola, but there is a vaccine
for Ebola6 (8.7) 22 (8.9)
As of today, there is neither a treatment for Ebola nor a vaccine 57 (82.6) 163 (66.3)Do not know 3 (4.3) 30 (12.2)
NOTE. Values are n (%), n, or as otherwise indicated.*P value is statistically significant at P < .05.yFor categorical variables the c2 test is used, and for continuous variables the t test is used.
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DISCUSSION
The study indicates that Israelis were knowledgeable aboutEbola during the questionnaire time frame. This finding emphasizesthe concept of citizen science21 that states that the public isknowledgeable regarding environmental and health topics. Ac-cording to this approach, the public does not lack knowledge as isstated in the deficit model.20 Rather, the analysis-acceptabilitydistinction fails to recognize the potential multiple sources ofknowledge regarding risk issues.
This finding stands out because there have been no instances ofthe disease in Israel and in light of the finding that most partici-pants thought the information provided by the Israeli Ministry ofHealth on Ebola and Ebola prevention was insufficient. The public’sknowledge can be explained by the flood of news media, especiallysocial media.26 Studies of the impact of public warnings aboutemerging diseases in uncertain situations have shown that they canreceive much news coverage.27 The mass media are a leadingsource of health information for the public and can influencehealth-related beliefs, attitudes and behaviors.28,29
Furthermore, this study underscores that scientific informationcannot be limited messages because we assume that the public isconstantly exposed to information through the media.
Another interesting finding is that not only is the publicknowledgeable, but differences were found between health careprofessionals and the public regarding Ebola. A bivariate analysisshows that there is no difference between health care workers andnonhealth care workers in their knowledge score. When weassessed each item regarding knowledge level, we found that therewas no statistically significant difference in most of the knowledgeitems (ie, transmission route, severity of the disease).
These findings undermine the deficit model’s assumption thatpublic health professionals have greater access to scientific infor-mation and are more likely to understand it. We can interpret it inlight of the fact that health care workers, similar to the public, areexposed to information mainly via the media. Because Ebola hasnot reached Israel, it is possible that health care workers, doctors,and nurses have been exposed to few, if any, professional discus-sions to which the general public had not been exposed.
In addition, this study reveals that we must take into accountthat health care professionals do not have the comprehensiveknowledge of virologists. This group is often viewed as expert,whereas it is actually a subgroup of the general public. The differ-ence between health care professionals and the public was re-flected in only 3 findings: in 3 out of 7 items, the study found astatistically significant difference between health care and
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nonhealth care workers (ie, who can be infected and whethertreatment exists). Health care workers might knowmore about thenonexistence of a vaccine because if a vaccine was developed theywould be informed by the health authorities.
Also of interest is the breakdown of the findings as to ways ofcontracting Ebola. When respondents were asked how Ebola iscontracted 52.4% answered body fluids and 25.4% incorrectly re-ported airborne. About a quarter of respondents chose airbornecontagion, including health care workers, despite health organi-zations’ official position.12-14 This indicates that the public is stillexposed to alternative voices in the media about uncertainty con-cerning the possibility of airborne Ebola transmission.15,16 (Our goalwas to indicate that the public is aware of a certain debate aroundthe issue of transmission. This debate surfaced in the media andgained wide exposure both in traditional and new media. For thisreason, we deliberately presented media articles because thesearticles are the sources accessible to the public.) Some studies andarticles suggest that the issue of transmission comprises uncer-tainty and deserves further research.30-35 Nevertheless, this un-certainty is not reflected in the health authorities’ messages.
Furthermore, ambiguous messages from authorities reflected inthe media may have influenced the range of answers given in thesurvey, including the 10.2% who replied “I do not know becausethere is uncertainty among scientists” and the 11.8% who respon-ded “I do not know.” These ambiguous messages include the po-sitions of the World Health Organization, CDC, Pentagon, US Army,and Israeli Health Ministry.15-18,36
The findings regarding the question of the ways of contractingEbola are significant because they indicate the importance ofproviding the public with practical information about preventingthe disease. The survey indicates that the respondentswill not knowhow to protect themselves in the event of an outbreak in Israel.Furthermore,when asked if theywanted to receive information thatexpresses scientific uncertainty, 54% of respondents said yes. Thisfinding is consistent with risk communication studies about un-certainty, which indicate that the public wants full transparency ofinformation, including updates about uncertainty and disagree-ments between experts.11,37 As Sandman and Lanard38 point out,“confident statements that turn out wrong exacerbate public fear.”
A noteworthy finding is the lack of correlation between re-spondents’ level of knowledge and their concerns regarding anEbola outbreak in Israel. As a result of the bivariate analyses toassess the difference in knowledge levels across the different levelsof concern about contracting the disease and concerns about con-tracting the disease in Israel, we found that there is no statisticaldifference between knowledge and worry levels for the 2 depen-dent variables. This finding is not surprising because according to astatistical approach, one can assume that the chances of outbreakor infection are small. The fact that Ebola did break out in Westerncountries challenges this view. In the context of the survey findings,the Israeli public might still view Ebola as a distant and irrelevantthird-world disease and may believe it has low relevance. This isconsistent with studies of public apathy and in accordance with thehealth belief model23 when the threat is not immediate.39,40 Inaddition, this finding emphasizes other studies that contend thatpublic risk perception is rational and embodies attitudes, relevance,contextuality, and emotions regarding the risk.7,8 The public’sbehavior in a crisis is to seek official sources of security whiletending to think independently.9
The question is how the public can be prepared for an outbreak.More generally, how can the world be prepared for a disease that isstill defined as a third-world disease but threatens to spread?When respondents were asked: To what extent do you agree thatthe health ministry provided comprehensive information aboutEbola prevention?, 56% answered they did not feel they received
comprehensive information, and 41% were unsure. This findingmight indicate that concepts of transparency, inclusion, and trustbuilding,3 basic risk communication concepts, have not yet beenapplied sufficiently and internalized.
Regarding limitations of the present study, it is important tonote that alongside recruiting participants through a universityInternet Web site, we used a nonprobability sampling method.Although the choice of nonprobability sampling techniques couldthreaten the external validity of the results, our choice was moti-vated by an attempt to reach a relatively large sample quicklybecause data had to be collected quickly in light of the increasedspread of Ebola in different countries in the world.
AsMowat41 noted, citizen science has never beenmore relevant.This concepthelps identify the failure to break thebarrier separatingexperts and citizens and build a relationship between them. Thechallenge that organizations face is not only to convey knowledge,but also to find ways to convey information that reflect uncertaintyand empower the public to make fact-based health decisions.
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