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R E S E A R C H A R T I C L E Open Access
Knowledge, perceptions and media use of
the Dutch general public and healthcare
workers regarding Ebola, 2014
Lianne G. C. Schol
1
,MadeliefMollers
1*
,CorienM.Swaan
1
, Desirée J. M. A. Beaujean
1
,AlbertWong
2
and Aura Timen
1
Abstract
Background: The Ebola outbreak in West-Africa triggered risk communication activities to promote adequate preventive
behaviour in the Netherlands. Our study investigated the level of knowledge, perceptions, and media use
regarding Ebola.
Methods: In December 2014, an online questionnaire was administered to the Dutch population (n=526)
and Health Care Workers (HCW) (n= 760).
Results: The mean knowledge score (range 0–15) of HCW (m = 13.3;SD = 1.4) was significantly higher than the
general public (m = 10.8;SD = 2.0). No significant difference was found in perceived severity and susceptibility.
Perceived fear of the general public (m = 2.5; SD = 0.8) was significantly higher than among HCW (m = 2.4; SD = 0.7).
Respondents primarily used television to obtain information.
Conclusions: While Ebola was perceived severe, it did not lead to excessive fear or perceived susceptibility for
developing the disease. Nonetheless, our research showed that knowledge with respect to human-to-human
transmission is low, while this is crucial to complying with preventive measures. Our study reveals priorities for
improving risk communication.
Keywords: Ebola, Risk perception, Perceived severity, Perceived fear, Perceived susceptibility
Background
Ebola is characterized by a severe clinical picture and a
case-fatality rate of 50–90% in outbreaks in Africa [1].
Ebola virus can be introduced in the human population
by direct contact with infected wild animals and is further
spread through direct contact with tissues and bodily
fluids of infected people [2]. Ebola patients are infectious
when symptomatic [3].
Since the onset of the Ebola outbreak in December
2013, WHO has reported 28.610 cases of Ebola, with
11.308 deaths [4]. Guinea, Liberia and Sierra Leone were
the three countries with the most widespread and
intense transmission of Ebola. Countries that have
reported imported cases or secondary transmission of
Ebola are Mali, Nigeria, Senegal, the USA, the United
Kingdom, Spain and Italy [5]. In August 2014, faced
with the likelihood of further international spread and
the need for international collaboration to control the out-
break, the WHO declared a Public Health Emergency of
International Concern. [6, 7]. WHO has currently declared
all countries Ebola-free since April 2016.
The risk of an imported case with Ebola and conse-
quently, the risk of secondary transmission in the
Netherlands was considered to be low to very low [5],
mainly due to limited travel to the affected regions,
but could not be ruled out [5, 8, 9]. Therefore, public
health authorities and health care workers (HCW)
undertook preparations to detect, investigate and man-
age suspected Ebola patients through the development
and implementation of guidelines and triage protocols
[10]. An emphasis was put on personal protective equip-
ment and infection control measures, to increase compli-
ance with safe hospital practices and diminish fear among
HCW of becoming infected.
* Correspondence: Aura.timen@rivm.nl
1
Centre for Infectious Disease Control, National Institute for Public Health
and the Environment (RIVM), PO Box 1 (interne 13), 3720, BA, Bilthoven, The
Netherlands
Full list of author information is available at the end of the article
© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Schol et al. BMC Infectious Diseases (2018) 18:18
DOI 10.1186/s12879-017-2906-7
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
In December 2014, one patient who had acquired Ebola
in Liberia was medically evacuated to the Major Incident
Hospital in the Netherlands, upon UN request. The med-
ical evacuation of this patient and the Ebola outbreak in
general triggered comprehensive coverage by traditional
and social media, echoing perceptions and fear of the gen-
eral public with regard to the possibility of further spread
of Ebola to Western countries. To reduce anxiety and to
educate the public on the risks associated with Ebola and
on the (ir)relevance of certain preventive and control
measures, information (e.g. factsheets about Ebola virus
and Q&A’s) was provided on the official websites of the
National Public Health Institute and public health ser-
vices, an Ebola-hotline was established and specific
messages were issued to HCW to share new ‘facts’and
communicate advised control measures.
The effectiveness of preventive and control measures
depend on the behaviour of people and their trust and
willingness to adhere to advised measures [11]. Studies
on public perception and preventive behaviour during
outbreaks of infectious diseases have shown that percep-
tions influence the attitude and reaction towards advised
control measures and related outbreak response [12–16].
Providing accurate and up-to-date information is important
to ensure that the public has a realistic sense of vulnerabil-
ity regarding the risk of infection. In order to promote
adequate preventive behaviour, it is therefore important
that public health authorities are aware of how Ebola is per-
ceived, whether the provided information is understood
and whether the general public and HCW intend to comply
with these measures [11, 17]. Evaluating the penetration of
public health messages is of value for future communica-
tion during public health emergencies.
The aim of the current study was to assess and com-
pare the level of knowledge, perceptions, use of infor-
mation sources and information needs of the general
public and HCW in the Netherlands with regard to
Ebola. We hypothesize that the knowledge level about
Ebola will be higher among HCW in comparison to the
Dutch general public. Additionally, we hypothesize that
higher knowledge levels about Ebola will result in lower
levels of perceived fear and susceptibility among both
respondent groups. The results of the current study will
be used to improve risk communication during future
public health emergencies.
Methods
Study design and population
A cross sectional survey using an online questionnaire
was performed among the general public and HCW
between 12 and 24 December 2014. Formal ethical
approval from a medical ethical committee was not re-
quired for this research in the Netherlands [18, 19], since it
does not entail subjecting participants to medical treatment
or imposing specific rules of conduct on participants.
Members of the general public (aged ≥18) were recruited
via a commercial research panel (http://www.flycatcher.eu)
that consists of 16,000 members aged ≥12 years. The mem-
bers are incentivised to participate. The panel has a repre-
sentative distribution of demographics with regard to the
Dutch general public.
HCW involved in the care for (suspected) Ebola patients,
i.e. physicians (infectious disease specialists and emergency
physicians), nurses and ambulance staff were recruited via
their professional associations. On behalf of the researcher,
these associations either sent out an e-mail or posted a call
in their newsletters, in which the link to the online survey
(Formdesk, Innovero Software Solutions B.V) was provided.
The obtained information was processed anonymously.
The questionnaire responses were received in de-identified
form.
Questionnaire
The questionnaire was based on the constructs of per-
ceived severity and susceptibility from The Health Belief
Model and the Protection Motivation Theory [20] and
on questionnaires used during previous outbreaks of
infectious diseases (e.g. Salmonella, Influenza (H1N1), Q
fever and SARS) [12–16].
The questionnaire consisted of 35 questions, divided
into three domains: knowledge, perceptions, and informa-
tion use and needs. Knowledge was assessed by fifteen
true/false statements regarding symptoms, modes of trans-
mission, preventive measures, and treatment. Perceptions
(i.e. perceived severity, −fear and -susceptibility) were
assessed by multiple items with a five-point Likert scale
ranked from 1 to 5 (completely disagree, disagree, neutral,
agree, and strongly agree) (see Additional file 1: Table S1).
In order to compare Ebola-related risk perceptions to
other diseases, respondents were asked to indicate their
perceived fear and susceptibility with regard to six other
diseases. Exposure to information was assessed by asking
questions about how often the respondents talked about
Ebola with other people and about their passive and active
search for information. Information need was assessed by
asking the respondents if they would like to receive add-
itional information. If this was the case, follow-up ques-
tions were asked about the preferred type of information,
sources, and methods of information distribution. The
questionnaire was piloted prior to commencement of the
study by a convenience sample of 6 persons. To reach 4%
precision and a sample which is representative of the
Dutch population at least 500 persons had to be included.
Data analysis
Data from both surveys were analysed separately and com-
bined using SPSS v. 22.0 (SPSS Inc., Chicago, IL, USA) and
Schol et al. BMC Infectious Diseases (2018) 18:18 Page 2 of 9
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R v. 3.1.0. Significance was determined at the 5% level
(p-value ≤0.05).
Coding and validating the constructs
Mean scores were computed for the constructs and they
were recoded into a new variable with three options: low
(score < 2), average (score 2–3) and high (score > 3). The
knowledge construct consisted of fifteen statements, for
which each correctly answered statement received a
score of 1. A sum score was computed for assessing the
knowledge level (ranging from 0 to 15, where 0 is no
knowledge and 15 is full knowledge), which was then
subsequently categorized into three categories: low (score
0–6), average (score 7–10) and high (score 11–15). The
variables assessing how often and where the respondents
saw, heard or read about the outbreak of Ebola in West
Africa were dichotomized and computed into a new vari-
able indicating the use of the various sources (where 0
indicated an use of less than once a week, and 1 indicated
an use of once a week or more frequently). In order to
assess internal consistency of three intended constructs
related to perceptions (i.e. perceived severity, −fear, and
-susceptibility), Cronbachs’s alpha was calculated and the
cut-off value was set at 0.6. See also [21]. All constructs
met this cut-off (see Additional file 1: Table S2).
Assessing differences between two respondent groups
Descriptive statistics were performed for the demograph-
ics, knowledge, and use of information sources, for each
respondent group separately. The Chi-squared test was
used to test the statistical significance of group differences
in terms of the distribution regarding knowledge, per-
ceived severity, perceived fear, perceived susceptibility,
and need for information, and the t-test was used to de-
scribe groups differences in terms of the mean.
Testing for associations between constructs and its
potential predictors
For each combination of construct and respondent groups
(general public and HCW) a regression analysis was per-
formed to identify factors significantly associated with the
respective construct. The construct perceived severity was
not analyzed as a dependent variable due to the fact that
the vast majority of both respondent groups perceived
Ebola as severe. In total, eight regression models were
fitted, of which most concern a construct with three
categories (low, medium, high) that was analyzed with
ordered logistic regression [22]. Exceptions to this are the
model concerning knowledge for the HCW group, which
was dichotomized to ‘very high’and ‘high’because few
had scored low, and the two models concerning need for
information (no/yes). These models were analyzed with
binary logistic regression.
The following independent variables were included in
each model for the general public: sex, age (categorized
as 0–25, 26–35, 36–45, 46–55, 56–65, and 65+), nation-
ality (categorized as Dutch, or non-Dutch), children in
household (categorized as: children not present, at least
one child present), education level (categorized as low,
intermediate and high), and working in the healthcare
sector (no/yes). The models for HCW included the
following independent variables sex, age, nationality,
children in household, profession (physician, nurse, ambu-
lance staff), years of working experience (0–1, 2–6, 6–10,
and > = 11 years), and weekly worktime spend on topics
related to Ebola (no/yes).
Results
Demographics
Of the 1286 respondents who returned the questionnaire,
526 (41%) were members of the general public and 760
(59%) were HCW. Except for age ≤25, the sample of the
general public (response rate of 57%) is representative for
the Dutch population. Thirteen percent of the general
public worked in the healthcare sector.
The group of HCW consisted of nurses (59%, n= 446),
physicians (18%, n= 136), and ambulance staff (12%, n=
92) (see Table 1). The majority of HCW had ≥11 years
of working experience (52%, n= 397). 47% (n=356) of
HCW spend no time, 49% (n= 372) spend less than 25%
and 4% (n= 32) spend more than 25% of their weekly
working time on topics related to Ebola.
Compared to the general public, HCW were younger
(p< 0.001), were significantly more often Dutch (99%;
n= 750 vs. 90%;n=475; p< 0.001), lived together with
a partner more often (84%;n= 640 vs. 72%;n=377; p<
0.001) and there were more often children in the house-
hold (63%;n= 480 vs. 29%;n=155;p<0.001)(Table1).
Knowledge
The mean knowledge sum score (range 0–15) of HCW
(m = 13.25;SD = 1.44) was significantly higher (p< 0.001)
than the general public’score (m = 10.84;SD = 21.97) (see
Table 2). 62.4% (n= 328) of the general public had high
levels (sum score of 11 or higher)) of knowledge, which
was significantly lower (p< 0.001) than for the HCW
(95% of 760 individuals) (see Table 2). Ten percent (n=51)
of the general public and 32% (n= 243) of HCW knew that
Ebola cannot be transmitted through coughing. The fact
that only symptomatic patients with Ebola are infectious
was known by 18% (n= 96) of the general public and 66%
(n= 505) of HCW. HCW scored higher on all statements.
This difference was significant for eleven of the fifteen pre-
sented statements (see Additional file 1: Table S1).
In the regression analysis, predictors of higher levels
of knowledge among the general public were age (46–55
and 56–65 years) and educational level (intermediate
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Table 1 Respondent demographics of the Dutch general public and HCW, and p-values resulting from a series of Chi-square tests
that test for a difference in demographic distribution between general public and HCW for each demographic
a
Demographic General public
N= 526
Healthcare workers
N= 760
p-value
n%n %
Sex
Male 277 52.7 376 49.5
Female 249 47.3 384 50.5
Age <0.001
≤25 36 6.8 3 0.4
26 to 35 73 13.9 135 17.8
36 to 45 90 17.1 233 30.7
46 to 55 92 17.5 276 36.3
56 to 65 115 21.9 110 14.5
> 65 120 22.8 3 0.4
Parental status <0.001
Single 107 20.3 87 11.4
Living together or married; with children 143 27.2 452 59.5
Living together or married; no children 234 44.5 188 24.7
One-parent family 12 2.3 28 3.7
Other 30 5.7 5 0.7
Children in home <0.001
Yes 155 29.5 480 63.2
No 371 70.5 280 36.8
Nationality <0.001
Dutch 475 90.3 750 98.7
Other 51 9.7 10 1.3
Level of education N/T
Low 176 33.5
Intermediate 221 42.0
High 129 24.5
Works in healthcare sector N/T
Yes 69 13.1
No 457 86.9
Profession N/T
Nurse 446 58.7
Physician 136 17.9
Ambulance staff 92 12.1
Other 86 11.3
Years of working experience N/T
≤1 29 3.8
2to5 165 21.7
6to10 169 22.2
≥11 397 52.2
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and high). Having a household with children was signifi-
cantly related to lower levels of knowledge (see Table 3).
HCW who reported spending more worktime on topics
related to Ebola had significantly higher levels of know-
ledge. Nurses and ambulance staff had significantly lower
levels of knowledge compared to physicians (see Table 3).
Perceptions
Perceived severity
No significant difference was found between the perceived
severity of the general public and HCW (see Table 2). The
majority of the general public (98%; n= 516) and HCW
(98%; n= 746) perceived Ebola as a severe disease. The
respondents considered Ebola to be as severe a threat for
their health as HIV/AIDS or a heart attack (see Additional
file 1: Table S3).
Perceived fear
The perceived fear for Ebola was significantly higher
among the general public than HCW (see Table 2). A
minority of the general public (22%;n= 116) and HCW
(16%;n= 121) had high levels (mean score of 4 or 5) of
perceived fear.
In the regression analysis, predictors of higher levels of
perceived fear among the general public were sex (female),
knowledge level (intermediate and high), and perceived
susceptibility (intermediate and high). Age between 26
and 35 years was significantly related to lower levels of
perceived fear compared to other age groups. Perceived
Table 1 Respondent demographics of the Dutch general public and HCW, and p-values resulting from a series of Chi-square tests
that test for a difference in demographic distribution between general public and HCW for each demographic
a
(Continued)
Demographic General public
N= 526
Healthcare workers
N= 760
p-value
n%n %
Amount of worktime spent on topics related to Ebola N/T
No time spent 356 46.8
≤25% 372 48.9
26 to 50% 18 2.4
51 to 75% 7 0.9
> 75% 7 0.9
a
If left blank, the demographics only apply to either the general public or HCW; no Chi-square tests were performed for these demographics (as denoted by “N/T”)
Table 2 Descriptives and statistical significance of knowledge, perceived severity, perceived fear, perceived susceptibility, and need
for information of the general public and HCW
General public
N= 526
Healthcare workers
N= 760
p-value
c
mean or n SD or % mean or n SD or %
Knowledge
Mean sum score (SD) 10.84 (1.97) 13.25 (1.44) <0.001
High level of knowledge
a
328 62.4 560 95.1 <0.001
Perceived severity
Mean score (SD) 4.72 (0.46) 4.74 (0.45)
High level of perceived severity
b
516 98.1 746 98.2
Perceived fear
Mean score (SD) 2.94 (0.79) 2.83 (0.73) <0.05
High level of perceived fear
b
116 22.1 121 15.9 <0.01
Perceived susceptibility
Mean score (SD) 3.29 (0.65) 3.25 (0.60)
High level of perceived susceptibility
b
173 32.9 244 32.1
Need for additional information
Category Yes 361 68.6 564 74.2 <0.05
a
High level of knowledge is mean sum score is 11 or higher
b
High level perceived severity, perceived feelings of concern and perceived susceptibility if scored 4 or 5
c
Chi-squared test was used to test statistical significance of group differences for levels/categories, t-test was used to test for group differences for scores
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susceptibility is of greatest influence on the level of fear
(see Table 3).
Predictors of higher levels of perceived fear among
HCW were having children at home, profession (nurse
and ambulance staff) and perceived susceptibility
(intermediate and high). High level of knowledge was
significantly related to lower levels of fear. Perceived
susceptibility is of greatest influence on the level of fear
(see Table 3).
Perceived susceptibility
No significant difference was found between the perceived
susceptibility to Ebola of the general public and HCW
(see Table 2). 33% (n= 173) of the general public and 32%
(n= 244) of HCW had high levels (mean score of 4 or 5)
of perceived susceptibility. Of all statements, both re-
spondent groups considered it most likely that an
infected healthcare worker might be coming to the
Netherlands from abroad, rather than being diagnosed
with Ebola themselves or the onset of an Ebola outbreak
in the Netherlands (see Additional file 1: Table S2).
Both respondent groups indicated to be most suscep-
tible to Influenza and least susceptible to HIV/AIDS (see
Additional file 1: Table S4). The perceived susceptibility
of the general public with regard to all diseases (except
Salmonella, which was similar) was significantly higher
than the perceived susceptibility of HCW.
In the regression analysis, there were no significant
predictors of the level of perceived susceptibility among
the general public (see Table 3).
The predictor of higher levels of perceived susceptibility
among HCW was profession (nurses and ambulance
staff). High level of knowledge was significantly related to
lower levels of perceived susceptibility. Being ambulance
staff is of greatest influence on the level of perceived sus-
ceptibility (see Table 3).
Table 3 Predictors of knowledge, perceived fear, perceived susceptibility and need for information
Knowledge Perceived fear Perceived susceptibility Need for information
GP HCW GP HCW GP HCW GP HCW
OR OR OR OR OR OR OR OR
1 Sex: female 0.95 0.91 1.63* 1.08 1.34 1.17 1.2 0.72
2 Age: 26–35 years 1.72 2.59 0.41* 0.39 0.8 0.78 0.56 <0.01
Age: 36–45 years 1.84 3.22 0.45 0.33 0.88 0.58 1.08 <0.01
Age: 46–55 years 2.92* 4.22 0.46 0.41 1.31 0.51 0.58 <0.01
Age: 56–65 years 2.25* 3.67 0.54 0.31 1.49 0.68 0.58 <0.01
Age: > 65 years 1.8 >1000 1.17 2.97 0.9 0.68 0.97 <0.01
3 Children in home 0.54** 1.19 0.86 1.39* 1.28 0.97 0.76 0.73
4 Nationality: Dutch 1.62 0.6 0.84 1.46 1.13 3.03 0.76 0.29
5 Level of education: intermediate 1.7* –0.86 –1.2 –0.7 –
Level of education: high 4.01*** –0.58 –0.7 –0.97 –
6 Works in healthcare sector 1.17 –0.94 –0.7 –0.76 –
7 Profession: nurse –0.22*** –1.7* –2.46*** –1.34
Profession: ambulance staff –0.12*** –2.69** –2.48** –1.31
8 Years of working experience: 2–5–0.53 –1.86 –1.06 –0.96
Years of working experience: 6–10 –0.63 –1.43 –1.46 –0.63
Years of working experience: > = 11 –0.55 –1.52 –1.48 –0.65
9 Worktime spend on topics related to Ebola –1.92*** –1.03 –0.82 –0.79
10 Knowledge level: intermediate ––5.31** –1.34 –2.53 –
Knowledge level: high ––4.14* 0.64** 1.02 0.46*** 3.25* 0.82
11 Perceived fear: intermediate ––– – – – 1.88** 1.84**
Perceived fear: high ––– – – – 4.39*** 4.31***
12 Perceived susceptibility: intermediate ––13.87*** 2.94*** –– 0.99 0.81
Perceived susceptibility: high ––181.27*** 21.76*** –– 2.46* 1.38
Reference categories are 1) sex: male, 2) age: ≤25 years, 3) no children in household, 4) other nationality, 5) level of education: low, 6) not working in healthcare
sector, 7) profession: physician, 8) years of working experience: ≤1, 9) no worktime spend on topics related to Ebola, 10) knowledge level: low, 11) perceived fear:
low, and 12) perceived susceptibility: low
*p< 0.05, ** p< 0.01, ***p< 0.001
- variable not included in regression analysis
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Exposure to- and need for information
The additional need for information of HCW (m =
0.74;SD = 0.44) was significantly higher than the general
publics’additional need for information (m = 0.69;SD =
0.46) (see Table 2). Both groups acknowledged to have
been primarily exposed to information through television
(general public 90%;n= 474 vs HCW 91%;n=694) (see
Additional file 1: Table S5).
The general public wished to receive more factual
disease-related information (e.g. about symptoms (30%),
mode of transmission (23%), and infection prevention
(21%). HCW were interested in preventive measures and
behavioural information (e.g. about what to do when in
contact with Ebola patient (34%), what the Dutch author-
ities are doing to diminish the risk of importation and
spread of Ebola (30%), and how to treat Ebola (22%)). The
preferred source of information for the general public was
the government (73%). The preferred sources of informa-
tion for HCW were their employer (45%) or the National
Institute of Public Health 38%).
In the regression analysis, predictors of the need for
information among the general public were the level of
knowledge (high), perceived fear (intermediate and high),
and susceptibility (high). A high level of perceived fear is of
greatest influence on the need for information (see Table 3).
The predictor of the need for information among HCW
was perceived fear (intermediate and high). A high level of
perceived fear is of greatest influence on the need for
information (see Table 3).
Discussion
This study evaluates and compares the knowledge, per-
ceptions, use of information sources and information
needs of the general public and HCW regarding Ebola in
the Netherlands. In brief, the majority of the general
public and HCW have some overall knowledge of Ebola,
but the knowledge with respect to person-to-person trans-
mission is not optimal. Despite the broad media coverage
and the fact that Ebola is perceived as a severe disease, the
Dutch general public and HCW appear to have low levels
of perceived fear and perceived susceptibility. The respon-
dents report to have been exposed to information primarily
from television. The majority of the respondents expressed
an additional need for information.
Knowledge
Despite the fact that Dutch HCW appear to be significantly
more knowledgeable than the Dutch general public, this
study indicates that both respondent groups have high
knowledge levels. Physicians have significantly higher level
of knowledge in comparison to nurses and ambulance staff.
Nonetheless, knowledge regarding human-to-human trans-
mission of Ebola is low, while this is crucial to the under-
standing of and compliance with preventive measures. The
results of the current study are in line with studies con-
ducted in the same time period in Australia, Germany and
Sudan [23–25], also showing that knowledge about modes
of transmission is often poor. A common misperception is
that Ebola virus spreads through air, Lacking knowledge re-
garding the transmission route of Ebola (and other dis-
eases with similar severity and propensity to spread) is
pivotal, as adequate knowledge provides the basis for
the general public, risk groups and HCW to understand
the rationale for the measures national authorities take.
Insufficient knowledge may cause misunderstandings
and anxiety, especially with respect to travellers and
HCW, who return from affected areas and need to be
able to have access to public facilities in daily life [26].
This is the reason why the control measures and their
communication strategies are comprehensively described
in disease specific guidelines and national preparedness
plans [27].
The Dutch authorities have adopted the policy to ac-
tively monitor temperature in high risk contacts instead
of applying home quarantine, which restricts the individ-
ual freedom of movement. Healthy people (i.e. people
without any symptoms related to Ebola) returning from
affected areas do not pose a threat to public health and
quarantine measures are therefore irrelevant. To under-
stand and endorse the measures, appropriate knowledge
about Ebola transmission is needed.
We observed a discrepancy with regard to knowledge
among the two study groups. As we expected, a higher level
of knowledge among HCW is significantly associated with
lower levels of perceived fear and lower levels of perceived
susceptibility. On the contrary however, having intermedi-
ate or high levels of knowledge was significantly related to
higher levels of perceived fear and a need for additional
information of the general public. These results thus sug-
gest two important aspects: 1) while authorities believe it is
importantthatthegeneralpublichas(somelevelof)know-
ledge with regard to Ebola in order to promote adequate
preventive behaviour, this may unintentionally lead to
higher levels of perceived fear and an additional need for
information, and 2) HCW appear to benefit from higher
levels of knowledge. These findings highlight the relevance
of specifically tailoring the information to pre-defined target
groups and enhancing the relevance of the information pre-
sented [26, 28]. They also show that authorities and com-
munication specialists need to focus their efforts in
maintaining the delicate balance between too much and
just enough information. Studies of knowledge and percep-
tions during ongoing outbreaks or threats allow for timely
readjustment of the information.
Perceptions
The Dutch general public and HCW perceived Ebola as
a severe disease, comparable with HIV/AIDS or a heart
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attack, perceptions similar to results obtained from stud-
ies conducted in other countries [24, 25, 29]. Although
perceived severity was high, the perceived susceptibility
to Ebola and perceived fear of Ebola among both groups
was low. However, when specifically looking at the differ-
ent HCW, our results show that nurses and ambulance
staff have a significantly higher level of perceived fear and
perceived susceptibility in comparison to physicians. One
possible explanation for this difference may be related to
the fact that nurses and ambulance staff are likely to be
the first ones to get in contact with a (suspected) Ebola
patient and generally have more physical contact with the
patient. The results are in line with a study conducted in
Germany, in the same time period that revealed similar
levels of perceived susceptibility and fear among their par-
ticipations; 29% of the participants were worried [24].
However, on the contrary, a similar study in the U.S
conducted in the same time period, contradicts the trad-
itional notions of health behaviour, as they show that
while the perceived susceptibility is low, the behavioural
intention (i.e. avoiding public transportation, avoiding those
who travelled to affected areas, or changing hygiene prac-
tices) is high [29].
Our findings, and the results of similar studies, underline
the need to sufficiently educate the public and HCW and
to tailor education, training and communication efforts to
these specific groups.
Need for information
The general public and HCW were well aware of the
Ebola outbreak in West Africa. The respondents obtained
their information primarily from television and newspa-
pers, a finding in accordance with previous outbreaks
[12, 15, 30–32] and similar studies [23–25]. The offi-
cial websites of the National Public Health Institute
and public health services, and the dedicated Ebola-hotline
were less often consulted than traditional media to gather
information. However, these results may be subject to recall
bias. When it comes to preferred and trusted information
channels, the government, the National Public Health
Institute, and the employer were mentioned.
Strengths and limitations
A strength of this study is the comparison, at the same
point in time, of two respondent groups; the general
public and three groups of HCW. Especially since we
show that the level of knowledge, perceptions, exposure
to information sources and information needs of the
general public and HCW varies. Another strength of this
study is that a large proportion of the included HCW
were nurses. Nurses are closely involved in the care for
infectious patients and are at higher risk for acquiring
an infection (for secondary transmission), highlighting
the relevance of assessing their level of risk perception.
Our study has several limitations. This is a cross-
sectional survey and thus trends over time could not be
identified due to the design of this study. Our study
was restricted to the Dutch general public and a selection
of Dutch HCW. We cannot state with certainty that our
results are also applicable to other (Western) countries.
Conclusions
We have shown that the Ebola outbreak in West Africa
has not led to excessive fear or perceived susceptibility
for developing the disease among the Dutch population
and HCW, despite the fact that the disease Ebola was
perceived as (very) severe and the study was undertaken
immediately after the medical evacuation of a patient
with confirmed Ebola to the Netherlands. The results of
the current study indicated that the Dutch population
and HCW were well aware of the Ebola outbreak in
West Africa and were exposed to information primarily
via traditional media (i.e. television and newspapers).
The majority of the Dutch general public and HCW had
an additional need for information. The general public
more often expressed a need for factual disease-related
information; HCW more often expressed a need for in-
formation on personal protection and preventive mea-
sures. Despite the lack of specific knowledge with regard
to the transmission of Ebola, the overall level of know-
ledge among the respondents was high.
The results of the study can be used to improve risk
communication during future outbreaks and threats.
The importance of specifically tailoring information and
education to the different groups of HCW is under-
pinned by our results. Since this study has been carried
out rather early during the course of the Ebola outbreak
in West Africa, the results have been directly communi-
cated to the by the communication experts allowing
them to specifically address the information needs about
Ebola transmission. This has been the most valuable lesson
learned following the execution of the study, with clear pol-
icy implications related to the content and preferred chan-
nels for information provision to HCW and public. Future
research should focus on assessing the level of knowledge,
risk perception and information needs of the general public
and HCW at different points in time as the epidemic un-
folds, to allow for re-adjustments of the communication of
risks and preventive measures.
Additional file
Additional file 1: Table S1. Knowledge about Ebola among Dutch
general public and healthcare workers. Table S2. Mean scores and
Cronbach’s alpha of items in three constructs (perceived severity,
perceived susceptibility, and perceived fear). Table S3. Populations’
estimation of severity of various diseases. Table S4. Populations’
estimation of susceptibility to various (infectious) diseases. Table S5.
Respondents’information intake per source (n= 1286). (DOCX 26 kb)
Schol et al. BMC Infectious Diseases (2018) 18:18 Page 8 of 9
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Acknowledgements
- Evelien Belfroid.
- Gerda Doornbos.
Funding
Ministry of Health, Welfare and Sport, the Netherlands.
Availability of data and materials
All data generated or analysed during this study are included in this published
article [and its additional files].
Authors’contributions
LS, MM, AT were involved in the data collection, made substantial intellectual
contributions to the conceptualization of this study and contributed to the
content and preparation of this manuscript. LS, MM, AT, CS, DB, AW made
substantial intellectual contributions to the conceptualization of this study, the
critical reading of the manuscript and final approval of the version to be
published. All authors read and approved the final manuscript.
Ethics approval and consent to participate
Formal ethical approval from a medical ethical committee was not required
for this research in the Netherlands [18, 19], since it does not entail subjecting
participants to medical treatment or imposing specific rules of conduct on
participants.
Consent for publication
Not applicable
Competing interests
The authors declare that they have no competing interests.
Publisher’sNote
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Author details
1
Centre for Infectious Disease Control, National Institute for Public Health
and the Environment (RIVM), PO Box 1 (interne 13), 3720, BA, Bilthoven, The
Netherlands.
2
Department of Statistics, Informatics and Mathematical
Modelling, National Institute for Public Health and the Environment (RIVM),
Bilthoven, The Netherlands.
Received: 26 June 2017 Accepted: 11 December 2017
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