American Journal of Infection Control xxx (2015) 1-7
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of
Infection Control
journal homepage: www.ajicjournal.org
Major article
What does the public know about Ebola? The public’s risk
perceptions regarding the current Ebola outbreak in an as-yet
unaffected country
Anat Gesser-Edelsburg PhD a, *, Yaffa Shir-Raz PhD a, Samah Hayek MPH, DrPH a,
Oshrat Sassoni-Bar Lev MA b
a
b
Health Promotion Department, School of Public Health, University of Haifa, Haifa, Israel
Department of Communication, University of Haifa, Haifa, Israel
Key Words:
Ebola epidemic
Knowledge and risk perceptions
Health care and nonhealth care workers
Uncertainty trust and irrationality
Citizen science and mental models
Background: The unexpected developments surrounding the Ebola virus in the United States provide yet
another warning that we need to establish communication preparedness. This study examines what the
Israeli public knew about Ebola after the initial stages of the outbreak in a country to which Ebola has not
spread and assesses the association between knowledge versus worries and concerns about contracting
Ebola.
Methods: Online survey using Google Docs (Google, Mountain View, CA) of Israeli health care professionals 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 the
disease has not spread to Israel. No statistically significant difference was found between health care
workers versus nonhealth care workers in the knowledge score. Additionally, no statistically significant
association was found between knowledge and worry levels. The survey indicated that Israelis expect
information about Ebola from the health ministry, including topics of uncertainty. More than half of the
participants thought the information provided by the health ministry on Ebola and Ebola prevention was
insufficient (50.5% and 56.4%, respectively), and almost half (45.2% and 41.1%, respectively) were unsure if
the information was sufficient.
Conclusion: The greatest challenges that the organizations face is not only to convey knowledge, but also
to find ways to convey comprehensive information that reflects uncertainty and empowers the public to
make fact-based decisions about health.
Copyright Ó 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 in
the United States provide yet another warning that we need to
establish communication preparedness, according to an editorial in
the Journal of Health Communication.1 Ratzan and Moritsugu discussed communication chaos regarding the Ebola crisis, including
lack of understandable, reliable, and actionable information from
network news, newspapers, and social media. The current Ebola
crisis demonstrates that communication, which should be a central
weapon against diseases,2 is still not central enough in the authorities’ arsenal.
Trust, empowerment, rationality, and uncertainty
* Address correspondence to Anat Gesser-Edelsburg, PhD, Head of Health
Promotion Department, School of Public Health, University of Haifa, 199 Aba
Khoushy Ave, Mount Carmel, Haifa 3498838, Israel.
E-mail address: ageser@univ.haifa.ac.il (A. Gesser-Edelsburg).
Funding support: The research leading to these results has received funding
from the European Union Seventh Framework Programme (FP7/2007-2013) under
grant agreement no 612236.
Conflicts of interest: None to report.
Risk communication literature defines 4 components of an
effective 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 the
situation, trust in government organizations becomes key in the
public’s reception of the risk management approach.3
0196-6553/$36.00 - Copyright Ó 2015 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ajic.2015.03.005
2
A. Gesser-Edelsburg et al. / American Journal of Infection Control xxx (2015) 1-7
Media and scholars have criticized the Centers for Disease
Control and Prevention (CDC) for projecting overconfidence with
regard 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, critics
cited the CDC’s assurance that “U.S. hospitals can safely manage
patients with Ebola disease.” According to Rosenbaum,5 the CDC
said the nurses probably contracted the disease because of a protocol breach. However, it turned out there was no protocol, which
made things even worse.
Regarding empowerment, the literature refers to the authorities’
exercise of power. Optimally, they should empower the public to
make decisions about risks for themselves.6 According to Ratzan
and Moritsugu,1 in the Ebola crisis, the public remained afraid and
confused, mainly because of multiple spokespeople, incoherent
information, and an overly general message that did not address
subpopulations.
Regarding rationality, governments and organizations have
often explained the public’s failure to follow certain recommendations as irrational. Current studies show that individuals make
decisions not because they are irrational but because they evaluate
risk according to its relevance to their lives.7,8 The public’s behavior
in a crisis is driven by sometimes contradictory motives: rationality
versus emotionality9 and seeking official sources of security versus
thinking independently.
Regarding uncertainty, unpredictability and lack of control
characterize uncertain situations of communicating risk to the
public during crises. Uncertainty is characterized by unpredictability and lack of control regarding uncertain situations of
communicating risk to the public during crises. Maxim et al10 noted
that laypeople raise more and different uncertainties than those
communicated by researchers.
Sandman and Lanard emphasize the need to proclaim uncertainty: “When imperfect, tentative information is all you have, then
imperfect, tentative information is what you must give people so
they can decide how best to cope.”11 In a health crisis, the major
communication challenge is providing timely information that
explains how the public should protect itself.
In the current crisis, uncertainty concerns fundamental questions, such as how the Ebola virus is transmitted. This question is
central when communicating about Ebola and is connected to the
issue of precautionary measures. Leading health authorities (World
Health Organization and CDC) and local health authorities convey
the message that the virus spreads through direct contact with
blood or other body fluids or with contaminated objects and materials, but is not airborne, and that infected people are not contagious until they develop symptoms.12-14 Alongside this official
line, the media has highlighted Ebola researchers who claim that
airborne transmission cannot be ruled out.15,16 Others warned that
even if the virus is not presently airborne, it could become so.17
The Pentagon issued a requirement for a 21-day quarantine for
all service members who had contact with Ebola patients.18 Despite
criticism, for example a New England Journal of Medicine editorial
claimed 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 and
technology or hostility to a lack of understanding. It is associated
with a division between experts who have the information and
nonexperts who do not.
The second approach stems from the concept of citizen science
and is more optimistic about the public’s knowledge. The term was
used to describe expertise among those traditionally seen as
ignorant laypeople.21
Citizen science does not view the public and experts in dichotomous termsdas those lacking knowledge versus those possessing
it. As such, “.‘laypeople’ are not viewed as tabulae rasae, as
disinterested or ‘innocent’ of the issues.but as the very embodiment of knowledge about the practical world.”22
Media’s role: relevance and severity
Today, various bodies of work pay critical attention to the media’s
role in risk communication. The spread of Ebola from West Africa to
Western countries has led to an increase in the health organizations’
alertness and media coverage throughout the world. The public’s
ability to absorb information from the media and conduct a dialog
depends on how the organizations address the public’s states of
relevance and severity. The health belief model suggests that if the
purpose is to prepare the public for a threat, people must believe
that it is relevant to their world and that it is severe.23
OBJECTIVE
Therefore, the purpose of this study is to examine what the Israeli public knew about Ebola after the initial stages of the outbreak
(mid-September to November 2, 2014) in a country to which Ebola
has not spread. Our overall goal is to assess the association between
knowledge about Ebola (spread, vaccine, treatment, and prevention) versus worries and concerns about contracting Ebola. In
addition, we analyzed differences between health care workers and
nonhealth care workers in their knowledge about Ebola versus
worries and concerns about contracting Ebola. We also examined
uncertainty in this context.
Theoretical framework
We examined the public’s knowledge in light of the 2 opposing
approaches: the deficit model, which assumes that the public has
less knowledge than health care workers, and citizen science,
which does not view the public and the experts in dichotomous
terms. The study uses the 2 approaches as a conceptual basis to
examine the public’s knowledge. We examined whether the public’s and health care workers’ knowledge levels influence their
worries and concerns.
Hypothesis
The current study has 2 hypotheses. The first is that no difference
will be found between the health care workers and public with regard to knowledge levels about Ebola. The second hypothesis is that
there is an association between knowledge level about Ebola and
level of worries and concerns regarding contracting Ebola in Israel.
METHOD
Data collection
An online survey (N ¼ 327) within a cross-sectional study was
conducted to examine degree of knowledge about Ebola among the
Israeli public. The data had to be collected quickly. Ongoing news
about the disease could affect people’s attitudes and beliefs
regarding Ebola; therefore, the survey was created and distributed
via Google Doc online software (Google, Mountain View, CA) from
mid-September to November 2, 2014. This platform enables
creating interactive online questionnaires and distributes them via
e-mails or social media outlets.
A. Gesser-Edelsburg et al. / American Journal of Infection Control xxx (2015) 1-7
The survey was distributed in 3 central ways. First, it was
distributed through snowball sampling,24 where the first wave of
respondents distributed the questionnaire link to others, via
e-mail and social media outlets, mainly Facebook. This enabled us
to reach mostly laypeople, without medical or public health education. Second, it was distributed through the official Web site of
an Israeli university, which also enabled us to reach students and
people, most of whom are laypeople, to compare them to health
care workers. By using both of these techniques, we were able to
achieve a relatively large sample quickly. Finally, the questionnaire
was distributed to health care professionals by sending the link
through the University of Haifa School of Public Health mailing list
to ensure that a sampling of health care professionals would take
this survey along with a sampling of the general public.
Table 1
Demographic characteristics (N ¼ 327)
Questionnaire
NOTE. Values are mean SD (range), n (%), or n.
The questionnaire was based on a literature review dealing with
the recent studies on Ebola. As we wrote in the questionnaire, no
audience studies were conducted yet; therefore, our study was a
pioneer in the field.
The main purpose of the questionnaire was to measure the
knowledge of the general public and health care workers regarding
Ebola. The questions were developed around these issues. The
questionnaire related to the levels of knowledge and concern as
main components in the literature regarding risk perception.25
Regarding the level of knowledge, we included questions
dealing with the definition of Ebola, its transmission routes, who
can contract Ebola, is there any specific treatment or vaccine for
Ebola, and the severity of Ebola. Regarding the level of concern, we
included questions dealing with the risk of an Ebola outbreak in
Israel and worry about contracting Ebola.
Another component we included was expectation from the
Ministry of Health. We chose to examine to what extent do the
public want to receive more information from the Ministry of
Health on Ebola and to what extent do people feel that the Ministry
of Health provided comprehensive information on the subject.
The questionnaire opened with an explanation about the survey
and assured the confidentiality and anonymity of the respondents.
The questionnaire examines knowledge about Ebola, extent of
concerns or worries regarding Ebola, and what Israelis expect from
the Israeli Ministry of Health regarding Ebola.
Level of concern
The study includes the 2 following dependent variables that
measure the level of concerns/worries:
1. To what extent are you afraid of contracting Ebola?: a categorical variable with 3 levels (low, medium, and high).
2. To what extent are you afraid that Ebola will spread to Israel?: a
categorical variable with 3 levels (low, where the risk is <50%;
medium, where the risk is 50%; and high, where the risk is
>50%).
Characteristic
Age, y
Sex
Male
Female
Missing
Health care worker
Yes
No
Missing
Education
High school
>High school
Academic degree
Missing
3
Value
39.7 14.02 (19-89)
114 (35.6)
206 (64.4)
7
70 (21.8)
250 (78.1)
7
29 (9.0)
43 (13.4)
250 (77.7)
5
Expectations from the Israeli Ministry of Health
This variable includes 5 questions that assess Israelis’ expectations from the Ministry of Health. These questions included information on interest in receiving information from the Ministry of
Health, and if so, what kind; and if the Ministry of Health has
provided sufficient information about Ebola, treatment, and
prevention.
Demographic characteristics
Demographic characteristics included age, sex, profession
(health care worker or nonhealth care worker), and education.
Analysis
First, participants’ characteristics were summarized using frequencies, means, and SDs. Second, we compared the differences of
series of bivariate analyses (ie, c2 test for categorical variables, t test
for continuous variables) to determine the difference between
health care workers versus nonhealth care workers in knowledge
level about Ebola.
Finally, we used ordinal logistic regression to assess the association between knowledge level about Ebola and our dependent
variables while considering differences in demographic characteristics. We presented the adjusted odds ratio (AOR), with 95% confidence interval (CI). All the statistical analyses were conducted
using SAS version 9.3 software (SAS Institute, Cary, NC). Two-sided
P values < .05 were considered statistically significant.
Ethics committee approval
This research has been approved by the University of Haifa
Faculty of Social Welfare and Health Sciences Ethics Committee for
Human Research (approval no. 259/14).
RESULTS
Independent variables consisted on different measures
Knowledge score
The knowledge score was the sum of the score of 5 questions
that includes information about the individual’s general knowledge
about Ebola; if the respondent answered correctly, then the answer
was counted in the score. The questions that assessed the knowledge level are the definition of Ebola, transmission route, who can
be infected, if there is any treatment for the disease or prevention,
and to what extent Ebola is a serious disease.
The study garnered 327 responses. The average age of participants was 39.7 years; the youngest participant was 19 years, and
the oldest was 89 years. More than half of the respondents were
women (64.4%), and most had academic degrees (77.7%) and were
nonhealth care workers (78.1%) (Table 1).
The mean of the knowledge score SD was 4.18 0.83. The
range of the score was 2-5. This indicates that every respondent had
at least 2 out of 5 correct answers. The study shows that Israelis
were knowledgeable about Ebola during the period in question.
4
A. Gesser-Edelsburg et al. / American Journal of Infection Control xxx (2015) 1-7
Table 2
Distribution of knowledge, worry, and expectation from the Ministry of Health in
Israel (N ¼ 327)
Measure/Question
Knowledge
Definition of Ebola
An infection transmitted from person to person
It is not a contagious infection
Do not know
Missing
Transmission route
Fluid (eg, blood, saliva, feces, etc)
Air droplets
Do not know because scientists are uncertain
Do not know
Missing
Who can contract Ebola
Immigrants or international workers from Africa
Everyone
Pregnant women and children
Health care workers (doctors, nurses, etc)
Missing
Treatment for Ebola or vaccine
There is a specific treatment for Ebola
As of today, there is neither a vaccine nor any
specific treatment for Ebola
As of today, there is no specific treatment for
Ebola, but there is a vaccine
Do not know
Missing
Severity of Ebola
Fatal disease
It is a dangerous disease that can be fatal,
only for people at risk
Ebola is dangerous, but it is possible to recover
Ebola is not dangerous at all
Do not know
Missing
Knowledge score
Knowledge score for correct answers
Worry
Risk of an Ebola outbreak in Israel
High (>50%)
Medium (50%)
Low (<50%)
Missing
Worry about contracting Ebola
High
Medium
Low
Missing
Expectation from the Ministry of Health
Receiving more information from the
Ministry of Health
Yes, just in case we have reported cases in Israel
Yes, now
Not interested to get any kind of information
Missing
If you answered yes to the previous question,
what kind of information would you like?
What to do to prevent the transmission
Everything related to Ebola, treatment,and
prevention (also subjects that include
scientific uncertainty)
Everything related to Ebola, but just for topics
that have scientific certainty
Missing
Extent of agreement that the Ministry of
Health provided comprehensive information
on Ebola
Strongly agree
Agree
Not sure
Disagree
Strongly disagree
Missing
Value
306 (94.4)
2 (0.6)
16 (4.9)
3
170
82
33
38
4
(52.6)
(25.4)
(10.2)
(11.8)
26
294
1
1
5
(8.1)
(91.3)
(0.3)
(0.3)
34 (10.6)
224 (70)
29 (9.1)
33 (10.3)
7
244 (76.3)
37 (11.6)
25 (7.8)
0
14 (4.4)
7
4.18 0.83 (2-5)
24 (7.4)
98 (30.3)
201 (62.2)
4
73 (22.6)
108 (33.4)
142 (43.9)
4
109 (33.6)
190 (58.6)
25 (7.7)
3
43 (14.7)
157 (54)
91 (31.3)
36
8
25
145
99
44
6
(2.5)
(7.8)
(45.2)
(30.8)
(13.7)
(continued)
Table 2
Continued
Measure/Question
Extent of agreement that the Ministry
of Health provided
comprehensive information on
Ebola prevention
Strongly agree
Agree
Not sure
Disagree
Strongly disagree
Missing
Value
3
24
132
117
45
6
(0.9)
(7.5)
(41.1)
(36.4)
(14)
NOTE. Values are n (%), n, or mean SD.
Almost all of the participants knew that Ebola is an infection
transmitted from person to person (94%), more than half of the
participants (52.4%) reported that it is transmitted through body
fluids, and 25.4% incorrectly reported that it is transmitted via air.
Of the participants, 10.2% reported that there is uncertainty
regarding transmission route. Of the participants, 90% reported that
anyone could contract Ebola, and 70% reported that there is no
treatment or vaccine. Most (76.3%) of the participants answered
that Ebola is fatal (Table 2). Most of the participants reported a low
level 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 from
the Ministry of Health. They expect updates on Ebola (58.6%) and
updates on topics of uncertainty (54%) related to Ebola. Almost half
of the participants thought the information provided by the Ministry 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 association in the knowledge score between levels of worry about contracting Ebola or having an outbreak in Israel, we found that there
is no statistical difference between knowledge score and worry
levels of the 2 dependent variables (P > .05) (data not shown).
Additionally, bivariate analysis shows that there are no statistical
differences between health care workers versus nonhealth care
workers in the overall knowledge score (P > .05). When we
assessed each item related to knowledge, we found that there is a
significant statistical difference between health care workers
versus nonhealth care workers regarding knowledge of who could
contract Ebola and whether there is any Ebola treatment or vaccine (Table 3).
The results showed that there is an association between age, sex,
and medium level of worry of contracting Ebola. Older people are
less likely to worry about contracting Ebola. For a 1 year increase in
the age of the participants, the odds of a medium level of worry are
0.97 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 worry
than men. Women are twice more likely than men to worry at a
medium level (AOR ¼ 2.19; 95% CI, 1.3-4.27). However, the study did
not find any association between age and high level of worry or
between sex and high level of worry. The knowledge and knowledge score for health care workers and education were not significantly associated with any level of worry (Table 4).
Furthermore, when we assessed the association between
knowledge score and worry level of contracting Ebola in Israel,
we could not find any significant association between knowledge
and worry level regarding an Ebola outbreak in Israel. Additionally, age, sex, being a health care worker, and education were not
significantly associated with knowledge and worry level
(Table 4).
A. Gesser-Edelsburg et al. / American Journal of Infection Control xxx (2015) 1-7
5
Table 3
Differences 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
4.15 0.82
4.28 0.83
1.13
9.19
.259
.027y
1 (1.4)
68 (97.1)
0
1 (1.4)
25 (10.1)
221 (89.5)
1 (0.4)
0
8.63
.035y
3 (4.3)
6 (8.7)
31 (12.6)
22 (8.9)
57 (82.6)
3 (4.3)
163 (66.3)
30 (12.2)
Overall knowledge level (score), mean SD
Infected with Ebola
Immigrants or international workers from Africa
Everyone
Pregnant women and children
Health care workers (doctors, nurses, etc)
Treatment for Ebola or vaccine
There is a treatment for Ebola
As of today, there is no treatment for Ebola, but there is a vaccine
for Ebola
As of today, there is neither a treatment for Ebola nor a vaccine
Do not know
NOTE. Values are n (%), n, or as otherwise indicated.
*P value is statistically significant at P < .05.
y
For categorical variables the c2 test is used, and for continuous variables the t test is used.
Table 4
Ordinal logistic regression for the association between knowledge level and worry level for Israelis to contract Ebola and for Ebola to break out in Israel
Worried to find Ebola cases in Israel
Worried to be infected
Demographic characteristics
Age
P value
Sex
Male
Female
P value
Education
High school
>High school
P value
Academic degree
P value
Health care worker
Health care worker
Nonhealth care worker
P value
Knowledge score
P value
High
Medium
Low
High
Medium
Low
0.98 (0.94-1.02)
.273
0.97 (0.95-0.99)*
.009
Ref
1.00 (0.97-1.02)
.923
0.99 (0.97-1.01)
.542
Ref
Ref
2.39 (0.75-3.59)
.139
Ref
2.19 (1.3-4.27)*
.020
Ref
Ref
0.94 (0.46-1.96)
.883
Ref
1.38 (0.72-2.65)
.331
Ref
Ref
NS
Ref
1.04 (0.29-3.78)
.538
0.59 (0.20-1.75)
.157
Ref
Ref
0.88 (0.19-4.11)
.220
0.43 (0.11-1.63)
.085
Ref
0.80 (0.19-3.36)
.693
0.46 (0.14-1.57)
.110
Ref
Ref
1.75 (0.70-4.43)
.228
0.88 (0.58-1.34)
.555
Ref
1.84 (0.72-3.07)
.290
1.04 (0.71-1.51)
.848
NS
Ref
1.99 (0.51-7.85)
.324
1.05 (0.56-1.97)
.875
Ref
1.56 (0.75-3.27)
.235
1.18 (0.82-1.72)
.377
Ref
Ref
Ref
Ref
Ref
Ref
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.
DISCUSSION
The study indicates that Israelis were knowledgeable about
Ebola during the questionnaire time frame. This finding emphasizes
the concept of citizen science21 that states that the public is
knowledgeable regarding environmental and health topics. According to this approach, the public does not lack knowledge as is
stated in the deficit model.20 Rather, the analysis-acceptability
distinction fails to recognize the potential multiple sources of
knowledge regarding risk issues.
This finding stands out because there have been no instances of
the disease in Israel and in light of the finding that most participants thought the information provided by the Israeli Ministry of
Health on Ebola and Ebola prevention was insufficient. The public’s
knowledge can be explained by the flood of news media, especially
social media.26 Studies of the impact of public warnings about
emerging diseases in uncertain situations have shown that they can
receive much news coverage.27 The mass media are a leading
source of health information for the public and can influence
health-related beliefs, attitudes and behaviors.28,29
Furthermore, this study underscores that scientific information
cannot be limited messages because we assume that the public is
constantly exposed to information through the media.
Another interesting finding is that not only is the public
knowledgeable, but differences were found between health care
professionals and the public regarding Ebola. A bivariate analysis
shows that there is no difference between health care workers and
nonhealth care workers in their knowledge score. When we
assessed each item regarding knowledge level, we found that there
was no statistically significant difference in most of the knowledge
items (ie, transmission route, severity of the disease).
These findings undermine the deficit model’s assumption that
public health professionals have greater access to scientific information and are more likely to understand it. We can interpret it in
light of the fact that health care workers, similar to the public, are
exposed to information mainly via the media. Because Ebola has
not reached Israel, it is possible that health care workers, doctors,
and nurses have been exposed to few, if any, professional discussions to which the general public had not been exposed.
In addition, this study reveals that we must take into account
that health care professionals do not have the comprehensive
knowledge of virologists. This group is often viewed as expert,
whereas it is actually a subgroup of the general public. The difference between health care professionals and the public was reflected in only 3 findings: in 3 out of 7 items, the study found a
statistically significant difference between health care and
6
A. Gesser-Edelsburg et al. / American Journal of Infection Control xxx (2015) 1-7
nonhealth care workers (ie, who can be infected and whether
treatment exists). Health care workers might know more about the
nonexistence of a vaccine because if a vaccine was developed they
would be informed by the health authorities.
Also of interest is the breakdown of the findings as to ways of
contracting Ebola. When respondents were asked how Ebola is
contracted 52.4% answered body fluids and 25.4% incorrectly reported airborne. About a quarter of respondents chose airborne
contagion, including health care workers, despite health organizations’ official position.12-14 This indicates that the public is still
exposed to alternative voices in the media about uncertainty concerning the possibility of airborne Ebola transmission.15,16 (Our goal
was to indicate that the public is aware of a certain debate around
the issue of transmission. This debate surfaced in the media and
gained wide exposure both in traditional and new media. For this
reason, we deliberately presented media articles because these
articles are the sources accessible to the public.) Some studies and
articles suggest that the issue of transmission comprises uncertainty and deserves further research.30-35 Nevertheless, this uncertainty is not reflected in the health authorities’ messages.
Furthermore, ambiguous messages from authorities reflected in
the media may have influenced the range of answers given in the
survey, including the 10.2% who replied “I do not know because
there is uncertainty among scientists” and the 11.8% who responded “I do not know.” These ambiguous messages include the positions 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 contracting
Ebola are significant because they indicate the importance of
providing the public with practical information about preventing
the disease. The survey indicates that the respondents will not know
how to protect themselves in the event of an outbreak in Israel.
Furthermore, when asked if they wanted to receive information that
expresses scientific uncertainty, 54% of respondents said yes. This
finding is consistent with risk communication studies about uncertainty, which indicate that the public wants full transparency of
information, including updates about uncertainty and disagreements 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 respondents’ level of knowledge and their concerns regarding an
Ebola outbreak in Israel. As a result of the bivariate analyses to
assess the difference in knowledge levels across the different levels
of concern about contracting the disease and concerns about contracting the disease in Israel, we found that there is no statistical
difference between knowledge and worry levels for the 2 dependent variables. This finding is not surprising because according to a
statistical approach, one can assume that the chances of outbreak
or infection are small. The fact that Ebola did break out in Western
countries challenges this view. In the context of the survey findings,
the Israeli public might still view Ebola as a distant and irrelevant
third-world disease and may believe it has low relevance. This is
consistent with studies of public apathy and in accordance with the
health belief model23 when the threat is not immediate.39,40 In
addition, this finding emphasizes other studies that contend that
public risk perception is rational and embodies attitudes, relevance,
contextuality, and emotions regarding the risk.7,8 The public’s
behavior in a crisis is to seek official sources of security while
tending 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 is
still defined as a third-world disease but threatens to spread?
When respondents were asked: To what extent do you agree that
the health ministry provided comprehensive information about
Ebola prevention?, 56% answered they did not feel they received
comprehensive information, and 41% were unsure. This finding
might indicate that concepts of transparency, inclusion, and trust
building,3 basic risk communication concepts, have not yet been
applied sufficiently and internalized.
Regarding limitations of the present study, it is important to
note that alongside recruiting participants through a university
Internet Web site, we used a nonprobability sampling method.
Although the choice of nonprobability sampling techniques could
threaten the external validity of the results, our choice was motivated by an attempt to reach a relatively large sample quickly
because data had to be collected quickly in light of the increased
spread of Ebola in different countries in the world.
As Mowat41 noted, citizen science has never been more relevant.
This concept helps identify the failure to break the barrier separating
experts and citizens and build a relationship between them. The
challenge that organizations face is not only to convey knowledge,
but also to find ways to convey information that reflect uncertainty
and empower the public to make fact-based health decisions.
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