Environmental and Behavioral Determinants of Lassa Fever: A Qualitative Exploration among Communities and Health Care Workers in Tonkolili and Kenema Districts, Sierra Leone

"The government of Sierra Leone has prioritized activities to both strengthen testing and surveillance activities and decrease, through use of community sensitization approaches, risk behaviors for zoonotic diseases among populations in endemic areas."

Local health authorities have classified Lassa fever as a priority zoonotic disease in many sub-Saharan African countries, including Sierra Leone. In spite of endemicity in many West African countries, detailed knowledge of Lassa fever among community members is surprisingly low. Breakthrough ACTION, in collaboration with the Sierra Leone One Health Risk Communication Technical Working Group (OHRC TWG), conducted qualitative research interviews to identify the sociocultural and behavioural risk drivers of Lassa fever in Sierra Leone. This research aims to provide high quality data to inform evidence-based risk communication and behavioural communication programming for Lassa fever in Sierra Leone through the Breakthrough ACTION Sierra Leone programme.

The study population included adult men and women living in Tonkolili and Kenema districts of Sierra Leone. Healthcare workers (HCWs) at the Lassa fever ward of Kenema Government Hospita (KGH) were also included in the sample. Interviewers conducted a total of 45 in-depth interviews (IDIs) in both districts. Key findings:

• Community context: While rats were reportedly widespread in the study area, Lassa fever was perceived to be an illness among inhabitants of economically poor rural areas and where farming is the predominant occupation. Proximity to farms, lack of appropriate community storage facilities for harvests, and poor food storage practices were mostly associated with an increased presence of rats in communities. Other factors included poor housing structures, inadequate community sanitation amenities, and poor personal and environmental hygiene practices.
• Knowledge: While awareness of Lassa fever was high, community knowledge of the details of transmission and prevention was restricted to a few topics.
• Risk perception and behaviours: Many interviewees voiced complacency regarding actions to prevent exposure to and transmission of Lassa fever. This low risk perception may be related to habituation to the presence of rats in the environment. Farmers reported having daily encounters with rats on their farms and opportunities to catch them for food, and young boys frequently hunted rats for leisure and to sell for money. Perceived risk from eating rat meat was variable; connecting illness to eating rodent meat in general (both rats found in the bush and rats found in towns and homes) might be an effective strategy. Discussing consumption of rat meat appeared to be uncomfortable for some participants from Kenema, but participants from Tonkolili more readily discussed it, often describing the practice as a norm. Strategies that rely on interpersonal or group discussions for promoting behaviour change may need to consider ways to engage participants and facilitate transparency, truth, and social acceptance without causing distress.
• Prevention behaviours: The study results identified a limited number of prevention behaviours among the study participants. Community members may need to identify community solutions for safely storing harvest and ensuring environmental sanitation to manage the increased presence of rats in the community.
• Appropriate care-seeking: Community members often delay care-seeking for Lassa fever due to limited knowledge of signs and symptoms of potential Lassa fever, predispositions toward the belief that any fever is malaria, self-treatment of illness, and failure to link encounters with rats and sick individuals with one's own symptoms.
• Information sharing: The majority of participants reported a preference for community-level information sharing.

Social and behaviour change (SBC) recommendations, based on these results in the context of Sierra Leone, along with studies from other countries, that could lessen the impact of Lassa fever include:

• Increasing early care-seeking behaviours at health facilities: Seeking testing and treatment for any fever should be emphasised in areas where Lassa fever is endemic. Specific interventions might include: (i) linking fever to recent encounters with rats or someone who is sick, which may motivate individuals to seek care for themselves or their dependents; and (ii) leveraging key health-related influencers, including traditional healers, pharmacists, chemical sellers, and advocates, with personal experiences with Lassa fever to develop a reinforcement and referral chain in which community members are consistently encouraged to seek care for fever.
• Increasing knowledge of Lassa fever: Providing information about Lassa fever with a focus on routes of transmission beyond eating rats and contaminated food may be beneficial. Leveraging HCWs and community radio to disseminate information could tap into a large audience. Known and trusted HCWs in rural areas could also draw upon user-friendly communication resources and job aids for health workers aligned with key messages for behaviour change and sensitisation campaigns, such as posters, flipcharts, and pictures. Furthermore, they could leverage community gatherings, such as weekly markets or holidays, to increase their reach. Messaging should aim to not only educate people on Lassa fever but also dispel rumours and misinformation spread in communities, including superstition. Given that some community members ascribed cases of Lassa fever to religious-based causes, religious leaders might serve as strong communication facilitators, especially given their high status in communities.
• Increasing risk perception for Lassa fever: Connecting Lassa fever to negative effects on health (rather than limiting effects to livelihoods) may motivate communities to protect themselves from possible illness. Specific high-risk groups such as farmers, youth and adolescents, and HCWs could benefit the most from interventions. Lassa fever ambassadors could be used to convey the reality and the seriousness of Lassa fever in their communities. Personal case stories about experiences with Lassa fever relayed by survivors, or families of those who succumbed to illness, may be an effective strategy for motivating unconcerned community members to action. Large community events like lumas (weekly markets) or holidays could promote and amplify messaging further.
• Developing community-based risk prevention strategies: Lassa fever can be a highly transmissible disease that puts the whole community, not just an individual, at risk. Those who implement community risk prevention strategies can reduce overall exposure to rats, while sharing costs and labour, by working with community leaders, local community groups, and programmes to develop community-wide solutions for storing harvests. Programmes addressing Lassa fever prevention might spark engagement by sponsoring competitions for the best solutions, including at schools, and leveraging the private sector to develop local solutions. They could organise community cleanliness exercises with community groups and/or get people involved in efforts around appropriate and secure storing of food.
• Motivating individuals for action by framing rats and Lassa fever within community perceptions: Connecting Lassa fever to rats in a manner that is meaningful to the lived experiences of community members may motivate them to take rat prevention measures. Many individuals lamented the destructive force of rats as a priority challenge. Thus, framing the risk rats pose as beyond health could be a helpful element to a behaviour change programme.
• Developing effective community response mechanisms: Effective lines of communication between community leaders and HCWs could limit the spread of misinformation and panic in communities and allow people to get treatment quickly. Supporting the development of community action plans aimed to ensure effective community response to Lassa fever cases and outbreaks may accelerate the identification and treatment of cases while also ensuring community members remain calm and cooperative during these exercises.