Introduction
The 2014–2016 Ebola virus disease (Ebola) outbreak in West Africa was the largest,
longest, deadliest and most geographically expansive Ebola outbreak since the virus
was first discovered in the Democratic Republic of Congo in 1976.1–5 Given the unprecedented
escalation of the outbreak, the WHO declared it a Public Health Emergency of International
Concern in August 2014,6 a designation that lasted for 20 months until March 2016.7
By the time the epidemic was controlled, it affected 10 countries through locally
acquired or imported Ebola cases, resulting in 28 652 Ebola cases and 11 325 deaths
from the disease reported to WHO.8 When comparing the 2014–2016 epidemic with the
combined 24 previous Ebola outbreaks, there were 12 times more cases, 7 times more
deaths and 21 times more patients with Ebola who recovered from and survived the disease.
While Nigeria was more prompt in containing its Ebola outbreak, compared with Sierra
Leone, Liberia and Guinea, fear-driven behaviours aggregated adverse consequences
on its economy and healthcare utilisation—described as fearonomic effect.9 10 Misinformation
caused people to ingest large amounts of salt water (a rumoured curative), breaking
quarantine to obtain ‘holy water’ in Lagos, also rumoured to cure the disease, and
casual transmission beliefs caused people to avoid crowded areas—causing many businesses
to fail—and health facilities. Ebola survivors and health workers were particularly
affected by fear-driven stigmatisation. In Sierra Leone, Ebola survivors reported
acute fear and depression when they initially suspected Ebola, as well as experiencing
stigmatisation in the community after release from Ebola treatment centres.11 In Guinea,
some Ebola survivors avoided disclosing their Ebola survivorship status to sexual
partners, possibly due to the fear of stigmatisation and rejection.12
Few studies have attempted to assess the mental health impact of Ebola on directly
affected populations such as Ebola survivors,11–15 healthcare workers16–19 and other
Ebola response staff.20–22 In Sierra Leone, one study assessed the nationwide impact
of the protracted epidemic. Nearly one-fifth of participants in the Sierra Leone sample
reported symptomology that met the definition for probable post-traumatic stress disorder
(PTSD) diagnosis if screened in a clinical setting.23 In this editorial, we examine
recent published research10–12 23 24 to provide contexts for better understanding
of the mental health impact of Ebola. We discuss the unique role of fear-driven behaviours
and the influence of culture on mental health outcomes, possible implications for
future outbreak responses, and whether current measurement tools are sufficiently
reliable and valid to assess mental health impact during large-scale epidemics.
Effects attributed to fear and stigma
Fear-related behaviours shaped the recent Ebola epidemic in West Africa.9 Defined
as ‘individual or collective behaviors and actions initiated in response to fear reactions
that are triggered by a perceived threat or actual exposure to a potentially traumatizing
event’, they were implicated in accelerating Ebola transmission, when people avoided
seeking healthcare for fear of exposure within the health setting. Describing a different
domain of fear-related behaviours, researchers reported damages to the Nigerian economy
due to misinformation and fear-induced avoidance, driven by fear of exposure to Ebola,
for example on aeroplanes believed to harbour infected individuals, within health
centres, inside populated hotels and so on.10
Fear-driven stigmatisation adversely affected Ebola survivors. In an August 2014 national
survey in Sierra Leone, the majority (95%) of all respondents expressed at least one
discriminatory attitude towards Ebola survivors.24 For instance, 78% of respondents
in that survey said they would not welcome an Ebola survivor back into the community
after recovering from the disease. In a national sample of Guineans in August 2014,
17% incorrectly stated that Ebola survivors may continue to spread the disease through
casual contact such as shaking hands or hugging.25 Qualitative assessments with Ebola
survivors in Sierra Leone and Liberia documented both their own fear of the disease’s
consequences as well as being feared and stigmatised by some members of their communities.11
13 Ebola survivors’ experience became even more complicated due to the emergence of
sexual transmission of the Ebola virus linked to viral persistence in the semen of
male survivors.26–29 The possibility of sexual transmission by Ebola survivors created
a new dimension of fear. In a survey in Guinea, female sexual partners of Ebola survivors
who said they were not informed of their partners’ Ebola survivorship status had 20
times greater odds to be unaware of Ebola sexual transmission risks when compared
with those who were informed.12 Ebola survivors may have feared stigmatisation, and
therefore hid their status from sexual partners. A flare-up of Ebola cases in Guinea,
following containment of the original outbreak, was linked to sexual transmission
by an Ebola survivor.30
Similar to Ebola survivors, health workers who took care of patients with Ebola were
reportedly stigmatised. Indepth interviews with healthcare workers who survived Ebola
revealed repeated discrimination when reintegrating into their communities and health
facilities.31 In addition, generalised fear and xenophobic attitudes have been documented
outside of the Ebola-affected countries.32 For example, a non-representative sample
survey of adult Italians found that African immigrants were perceived to be at increased
risk for transmitting Ebola.33 Taken together, fear-driven stigmatisation may have
had adverse mental health impact on Ebola survivors, health workers and their families.
Ebola-related stigma may have produced unwanted consequences on containment of the
epidemic by discouraging suspected patients from seeking care in order to avoid the
label of Ebola. Interventions addressing social stigma during epidemics should be
prioritised to address negative mental health impact, and other unwanted consequences
on economies and healthcare utilisation.
Cultural influences and effects on traditional practices
The 2014–2016 Ebola epidemic vastly disrupted cultural practices and health-seeking
behaviours in affected countries in West Africa. Traditional burial rituals involving
physical contact when washing corpses were halted in order to reduce transmission
risk.34 Traditional burials were replaced with medical burials by trained Ebola response
teams. However, dissatisfaction with medical burials were documented. Alternatives
to traditional burials eventually included allowing families to observe the burial
from a safe distance and having a religious leader offer a final prayer on the corpse.35
Such alternatives may have helped improve social acceptance of safe medical burials.
Traditional healing practices, usually involving direct physical contact between the
healer and the patient, were routinely banned across Sierra Leone in the latter part
of the epidemic to mitigate Ebola transmission risks. Traditional healers were encouraged
to report all patients to the nearest health facility or to the 1-1-7 national alert
line.36 It is unclear if the restriction of traditional healing practices had any
effects on the population’s mental health, especially given that traditional healing
is customarily sought for suspected mental health problems.
It is possible that other unrestricted aspects of Sierra Leonean culture may have
served as protective factors against mental and psychological distress brought on
by the epidemic. A key cultural aspect worth investigating is the population’s willingness
to openly discuss their experiences during the epidemic. Following the end of the
civil conflict in 2002, Sierra Leoneans also used dialogue and story-telling—often
in community or group settings—to recount traumatic experiences, which may have been
a protective coping mechanism.37 Prolonged disruptions in sacred cultural and traditional
practices, especially for loved ones who died, may have had severe mental health impact
on affected families during the Ebola crisis. However, other pre-existing cultural
dynamics may have fostered resilience against expected, adverse mental health outcomes.
Compared with participants in other population-based, mental health studies, those
in Sierra Leone showed similar or less severe levels of post-traumatic stress (PTS)
symptomatology.23 38 Assuming that Ebola touched the lives of most respondents in
some way,39 prevalence of PTSD seemed lower than expected from the assumed psychological
trauma exposure40 given the high case fatality of Ebola.34 However, consistent with
studies conducted in Western societies,41 42 Sierra Leoneans who had a direct exposure
to the epidemic—such as knowing someone who died from Ebola—were more likely to report
PTSD symptoms compared with those who did not.23 Another study found that PTSD symptoms
were significantly associated with lower self-reporting of Ebola prevention behaviours
in a regionally representative sample of Sierra Leoneans.43 Not only was the likelihood
of death extremely high with Ebola, witnessing patients haemorrhage from various parts
of their body added another psychological traumatic experience.40 Although it has
never been assessed, the inability for some families to care for their sick relatives
coupled with the inability of some family members to perform traditional and religious
burial rituals for their loved ones may have caused psychological distress.
Following Sierra Leone’s horrific civil war (1991–2002), the mental health effects
of the conflict on former child soldiers have been systematically documented.44–46
Such experiences often involved witnessing brutal killings, rapes and other extreme
violence. In one study, levels of depression and anxiety were increased among former
child soldiers who returned to communities characterised by social disorder and improved
among those who perceived their communities to be accepting of them.44 A study of
adjustment of these former child soldiers showed reductions in PTSD from 32% to 16%
in 4 years even with limited access to care.46 Community social support is hypothesised
to have contributed to the reduced level of PTSD among former child soldiers.
Prior research has illustrated the potential therapeutic benefit of putting traumatic
experiences into words. In one study, college students were randomised to write for
15–20 min a day, for several days, either about past traumatic events about which
they had seldom spoken, or about trivial topics.47 Those who wrote about traumatic
events made half as many visits to the student health centre as those who did not.
Organising inchoate emotions and fragmented thoughts resulting from traumatic experiences
may have created an organising narrative, which ‘cools’ the emotional turmoil.48
It is possible that Sierra Leoneans may have benefited from cultural dynamics that
provided innate social support through their near-constant conversations, which during
the Ebola crisis almost certainly included conversations about people’s experiences
related to the epidemic. Additional research is needed to better understand the effects
of cultural attributes on mental health outcomes during large-scale outbreaks. Nonetheless,
individuals with Ebola-related experiences—such as knowing someone who died from Ebola
or were quarantined—may require additional psychosocial support.23 Directly affected
populations in affected countries including Ebola survivors, healthcare workers in
Ebola treatment centres, ambulance teams and burial workers may also need professional
attention including psychosocial support to address the prolonged trauma they witnessed.13
14 16 19 49
Measuring and preventing mental health impact
Aiming to capture the impact of Ebola experiences and risk perceptions on mental health
in Sierra Leone, researchers conducted a population-based study of the epidemic.23
In the study, 76% of all respondents reported one or more PTS symptoms, while 16%
met the clinical cut-off according to screening guidelines for PTSD in the Impact
of Events Scale-6 (IES-6).23 Interpretation of such findings, however, is made difficult
by the limited literature on mental health in Sierra Leone, and lack of other comparable
national-level data related to Ebola outbreaks in Africa.
Measuring and responding to the mental health impact of a large-scale epidemic is
challenging.40 Doing so, in settings where measurement tools have not been validated
or used before, is even more challenging. For instance, various screeners used to
measure anxiety-depression (Patient Health Questionnaire-4)50 51 and PTSD (IES-6)38
52 in Sierra Leone had not been validated before for use in that setting. Careful
efforts were taken by the researchers to ensure accurate translations from English
to local languages, especially given that Krio and other local languages are predominantly
oral languages. Although PHQ-4 and IES-6 demonstrated acceptable internal reliability
and factorial validity in measuring mental outcomes following the Ebola outbreak in
Sierra Leone,23 there is a larger need for reliable validated measurement tools to
assess mental health outcomes in West African settings.
Conclusion
Taken together, findings from research projects conducted in the aftermath of the
Ebola epidemic have been pointing to a number of challenges that need to be addressed
in future large-scale epidemics in low-income/middle-income countries. First, fear-related
behaviours and stigmatisation are common, and negatively affect access to care, quality
of care and spread of the epidemic. This phenomenon should be addressed from the outset
by public and mental health professionals aiming to educate the public via social
and digital media, attempting to directly contain fear and panic, and improve access
to modern care. Second, local cultures often play a key role in medical response,
burial rituals and treatment-seeking for trauma-related disorders such as PTSD, anxiety
and depression. Sensitive adaptation of modern psychiatric care to local practices
should be an ongoing effort regardless of epidemic breaks, facilitated via partnerships
with community and spiritual players. Third, despite early concerns, epidemiological
research discussed above highlights impressive levels of emotional resilience throughout
Ebola-affected communities. These findings should alleviate early concerns about the
scope of the impact of the outbreak and should be accounted in future public health
policies.
Nevertheless, the studies also highlight important unmet needs of large populations
who suffer from Ebola-related mental health problems, such as PTSD, among people directly
affected by the virus, their families, and medical and burial teams. For them culturally
sensitive, trauma-focused interventions should be developed and tested before future
outbreaks occur, to ensure appropriate and accessible mental health response. Such
intervention should integrate gold standard treatments (eg, prolonged exposure treatment),
traditional cultural norms, habits, spiritual support and community healing practices.
Such integrative efforts may include also assessment methods, training efforts and
transmission of public health information via modern communication platforms such
as social media.