1           Background

Since August 2018, the Democratic Republic of the Congo (DRC) has been facing a large-scale epidemic of Ebola Virus Disease (EVD) in the eastern provinces of North Kivu and Ituri, with importation to Goma and South Kivu provinces. Since the start of the outbreak in August 2018, there have been 3,303 EVD cases reported and 2,199 people have died (World health Organisation (WHO), 26 November 2019). Around 28 per cent of cases are children, a larger proportion than reported in previous outbreaks of Ebola. On 17 July 2019, WHO declared the Ebola outbreak in North Eastern DRC a Public Health Emergency of International Concern.

As one of the most densely populated countries in Africa, and with high-quality transport infrastructure, Rwanda is at high-risk of rapid spread of EVD. In 2018, the Government of Rwanda (GoR) developed an Ebola preparedness plan and activated mechanisms to minimise the risk of importation.  In partnership with UNICEF, the World Health Organisation, the Ministry of Health’s Rwanda Biomedical Center conducted a rapid Knowledge, Attitudes and Practices (KAP) assessment to gauge the level of public awareness about Ebola Virus Disease, as well as the prevailing attitudes and practices related to the disease. The interventions under the Risk Communication and Community Engagement (RC&CE) pillar of the National Contingency Plan have been largely informed by the results of this study.

Although Rwanda remains free of Ebola, it is still at risk of cross-border spread as the country borders with DRC, Uganda, Burundi and Tanzania. The protracted emergency preparedness effort requires up-to-date understanding of the prevailing levels of knowledge, perceptions of risk, attitudes and practices among parents, caregivers, health workers, teachers, ECD caregivers, children and key influencers (including community and religious leaders) with regards to EVD.

2.  Rationale and Justification

The proposed KAP study will assess knowledge, attitudes and practices in relation to preventing EVD and allow for better understanding of its barriers and drivers, building on an earlier rapid assessment (2018). The findings of this study will inform/help to evaluate the progress since the rapid KAP and identify where Rwanda needs to adjust the RC&CE interventions of the National Contingency Plan going forward. 

Designing and conducting the KAP study requires a highly qualified institutional consultancy. Therefore, UNICEF plans to contract an experienced and competent research institution to undertake this exercise.

3.  Purpose, objectives and expected results 

The overall goal of this KAP study is to assess knowledge, attitudes and practices in relation to preventing EVD and to better understand corresponding health-related behaviours; and drivers and barriers for risk communication. Important gender dimensions and social norms will be considered during this exercise. 

The specific objectives of the study are to:

·         Establish current levels of knowledge, perceptions of risk, attitudes and practices among parents and caregivers (persons from different backgrounds who might include cross border traders, students, drivers of the public transport, security bodies, immigration and airport staff among others), health workers, teachers, ECD caregivers, adolescents and key influencers (including community and religious leaders) on EVD;

·         Establish whether people know other consequences of Ebola apart from death, such as: the importance of safe burials, separation and isolation of the infected and affected through contact and importance of contact tracing;

·         Identify current myths, beliefs about EVD as well as barriers and drivers of communication;

·         Identify cultural and social norms and traditions, in particular gender-related, influencing or impacting health-seeking behaviours as well as family and community resilience mechanisms to prevent an EVD outbreak;

·         Identify potential discriminatory attitudes towards those with EVD among parents, caregivers, service providers and key influencers;

·         Identify underlying causes for potential discriminatory attitudes;

·         Conduct a communication analysis in the context of disease outbreaks to establish: target audiences, current behaviours, barriers to achieving desired behaviours, behavioural objectives, behaviour change mass, interpersonal, group communication and information preferences (channels, approaches, media, interventions etc.);

·         Identify credible sources of information for participant groups;

·         Identify what is considered as the other significant source of information (second opinion) that facilitates respondents to make decisions;

·         Identify economic and social power dynamics in communities and decision-making processes in families and communities related to disease outbreaks and EVD in particular;

·         Identify possible entry points for communication including ideas for adjusting EVD-related messaging;

·         Identify approaches and authentic/credible sources of information for various participant/respondent groups

·         Assess health workers, including community health workers (CHWs) knowledge and practice in communicating key messages on EVD to families, parents and caregivers;

·         Assess community and religious leaders' knowledge and attitudes about EVD and how to prevent EVD and their engagement and influence in EVD prevention and preparedness behaviours;

·         Identify most effective communication channels that have been used so far;

·       Identify the ways rumours around EVD emerge and get disseminated.

Key elements of the study:

The output of the study is a comprehensive report, including the following elements:

1.       Desk (literature) review (with a gender analysis component) of existing policy and programme documents as well as available research documents and EVD KAP studies conducted in Rwanda and in countries with comparable context.

2.       Data collection and analysis with a gender lens:

a.       Refine the research methodology based on consultations with the Ministry of Health and UNICEF and other relevant stakeholders as advised by UNICEF;

b.       Prepare an inception report including research questions and draft research instruments;

c.       Prepare, translate into Kinyarwanda (and possibly French) and pre-test the research instruments;

d.       Conduct training of enumerators and data collectors;

e.       Conduct field research as per proposed and agreed methodology and timeline;

f.        Data-cleaning and analysis of the collected data;

g.       Prepare draft KAP study report and accompanying presentation in PowerPoint with preliminary findings and share with UNICEF to facilitate the review and feedback by all relevant stakeholders. The report should include recommendations on adjusting the communication approaches/messages based on the findings;

h.       Finalise full KAP study report based on feedback from all relevant stakeholders and share the final version and accompanying presentation in PowerPoint with UNICEF;

i.         Provide data-sets.

Methodology and data sources: 

The study methodology consists of:

1.       Review of the secondary data, which will be derived from the desk review of existing policy and programme documents, as well as existing quantitative and qualitative data (the package of relevant documents will be provided at the inception stage) to both inform the study design and provide additional contextual analysis.

2.       Generation of primary data using a mix of quantitative (household core survey) and qualitative methods. The selected institution is expected to propose a detailed methodology for both components of the study.

Household survey

The caregiver survey is intended to provide quantitative measures of caregiver’s knowledge, risk perception, attitudes and practices and will serve as a basis for analysis of changes over time as well as geographic differences across and within the provinces. The sample size should be maximum 1,000 households. The survey should be concise and take no longer than 15 minutes to administer.

In addition to background characteristics of the main respondent, including disability status, the questionnaire should also include the listing of all members and their characteristics (age, sex, marital status, disability status and educational attainment).

Important is to determine caregivers’ mass-media consumption, preferred sources of information on EVD preparedness, prevention and control. Eligible respondents will include parents of children 0-18 years old (50 per cent mothers and 50 per cent fathers).

Qualitative methods

The qualitative methods should target the following respondents:

a.       Parents/caregivers

b.       Community health workers;

c.       Community and religious leaders;

d.       Teachers;

e.       ECD caregivers; 

f.        Adolescents, preferably both in and out of school (if possible).

The research proposal should include proposed appropriate qualitative methods for each of the above groups, and propose a sample size for each method, taking into consideration gender aspects.

These respondent groups are chosen because of their role and influence on EVD prevention, preparedness and response. Therefore, establishing current levels of their knowledge, attitudes and practices as well as concerns and constraints with regards to EVD will be critical for determining/adjusting communication intervention strategies. 

Geographical locations: The KAP study will be conducted in five locations, namely one selected district in each of the four provinces and Kigali City.

Key areas of inquiry: The institution is encouraged to use a conceptual framework such as the Social Ecological Model and/or any relevant Health Behaviour Theories, in the conceptualization of the study variables.