Associations between Mental Health and Ebola-Related Health Behaviors: A Regionally Representative Cross-sectional Survey in Post-conflict Sierra Leone

Abstract

BackgroundLittle attention has been paid to potential relationships between mental health, trauma, and personal exposures to Ebola virus disease (EVD) and health behaviors in post-conflict West Africa. We tested a conceptual model linking mental health and trauma to EVD risk behaviors and EVD prevention behaviors.Methods and FindingsUsing survey data from a representative sample in the Western Urban and Western Rural districts of Sierra Leone, this study examines associations between war exposures, post-traumatic stress disorder (PTSD) symptoms, depression, anxiety, and personal EVD exposure (e.g., having family members or friends diagnosed with EVD) and EVD-related health behaviors among 1,008 adults (98% response rate) from 63 census enumeration areas of the Western Rural and Western Urban districts randomly sampled at the height of the EVD epidemic (January–April 2015). Primary outcomes were EVD risk behaviors (14 items, Cronbach’s α = 0.84) and EVD prevention behaviors (16 items, Cronbach’s α = 0.88). Main predictors comprised war exposures (8 items, Cronbach’s α = 0.85), anxiety (10 items, Cronbach’s α = 0.93), depression (15 items, Cronbach’s α = 0.91), and PTSD symptoms (16 items, Cronbach’s α = 0.93). Data were analyzed using two-level, population-weighted hierarchical linear models with 20 multiply imputed datasets. EVD risk behaviors were associated with intensity of depression symptoms (b = 0.05; 95% CI 0.00, 0.10; p = 0.037), PTSD symptoms (b = 0.10; 95% CI 0.03, 0.17; p = 0.008), having a friend diagnosed with EVD (b = −0.04; 95% CI −0.08, −0.00; p = 0.036), and war exposures (b = −0.09; 95% CI −0.17, −0.02; p = 0.013). EVD prevention behaviors were associated with higher anxiety (b = 0.23; 95% CI 0.06, 0.40; p = 0.008), having a friend diagnosed with EVD (b = 0.15; 95% CI 0.04, 0.27; p = 0.011), and higher levels of war exposure (b = 0.45; 95% CI 0.16, 0.74; p = 0.003), independent of mental health. PTSD symptoms were associated with lower levels of EVD prevention behavior (b = −0.24; 95% CI −0.43, −0.06; p = 0.009).ConclusionsIn post-conflict settings, past war trauma and mental health problems are associated with health behaviors related to combatting EVD. The associations between war trauma and both EVD risk behaviors and EVD prevention behaviors may be mediated through two key mental health variables: depression and PTSD symptoms. Considering the role of mental health in the prevention of disease transmission may help fight continuing and future Ebola outbreaks in post-conflict Sierra Leone. This sample is specific to Freetown and the Western Area and may not be representative of all of Sierra Leone. In addition, our main outcomes as well as personal EVD exposure, war exposures, and mental health predictors rely on self-report, and therefore raise the possibility of common methods bias. However, the findings of this study may be relevant for understanding dynamics related to EVD and mental health in other major capital cities in the EVD-affected countries of West Africa.

The Role of Fear-Related Behaviors in the 2013–2016 West Africa Ebola Virus Disease Outbreak

“…After years of primarily anecdotal accounts that described widespread fear responses, research on psychosocial and mental health consequences of the 2013–2016 outbreak is beginning to emerge, with authors emphasizing that Ebola was a “traumatic illness” [24•, 75••]. A just-published landmark study of 1008 respondents from rural and urban districts of Sierra Leone, surveyed during the peak of the outbreak, found that “individuals reporting greater intensity of depression symptoms and higher rates of PTSD symptoms also reported higher rates of behaviors that increase the risk of spreading EVD” [75••].…”

“…A just-published landmark study of 1008 respondents from rural and urban districts of Sierra Leone, surveyed during the peak of the outbreak, found that “individuals reporting greater intensity of depression symptoms and higher rates of PTSD symptoms also reported higher rates of behaviors that increase the risk of spreading EVD” [75••]. Among the primary risk behaviors included in the analyses were actions that qualify as FRBs (FRB1: Keep them (family members with EVD) at home and provide care, Get help from my family at home; FRB4: Move them to another location that is not an Ebola treatment center where I know that family or friends who I know would take care of them) [75••]. …”

“…The obverse is equally important to consider; the “survival rate” was 60.5 %; more than 17,000 EVD patients recovered from illness [5•]. All survivors dealt with a life-threatening illness that carried a powerful psychological overlay and qualified as direct trauma exposure for possible development of posttraumatic stress disorder (PTSD) [24•, 75••]. Survivors remained physically weakened long into the recovery period and many continued to experience symptoms of ”post-Ebola syndrome” [76].…”

“…Heaped upon the trauma of experiencing EVD illness and the loss of family members to the disease, Rabelo and team [29••] described a harsh homecoming marked by ostracism, rejection, isolation, humiliation, and exclusion. Unable to regain their lives and livelihoods, survivors were very likely to experience symptoms of depression and posttraumatic stress disorder [29••, 75••, 79]. Recognition of the extreme difficulties faced by persons attempting to return to their home communities following discharge from the ETUs, CDC and other humanitarian actors developed “reintegration” and support programs to assist survivors [80, 81].…”

“…Sierra Leone and Liberia are also considered postconflict nations slowly recovering from decades of war, extreme violence, and deep oppression. Recent research has documented how war trauma interplayed with EVD trauma to increase risks for depression and PTSD [75••]. For these nations, the abrupt and devastating intrusion of the 2013–2016 EVD outbreak severely counteracted progress along the trajectory of recovery and nation-building.…”