Psychological Distress among Ebola Survivors Discharged from an Ebola Treatment Unit in Monrovia, Liberia – A Qualitative Study

Abstract

IntroductionA consequence of the West Africa Ebola outbreak 2014–2015 was the unprecedented number of Ebola survivors discharged from the Ebola Treatment Units (ETUs). Liberia alone counted over 5,000 survivors. We undertook a qualitative study in Monrovia to better understand the mental distress experienced by survivors during hospitalization and reintegration into their community.MethodsPurposively selected Ebola survivors from ELWA3, the largest ETU in Liberia, were invited to join focus group discussions. Verbal-informed consent was sought. Three focus groups with a total of 17 participants were conducted between February and April 2015. Thematic analysis approach was applied to analyze the data.ResultsThe main stressors inside the ETU were the daily exposure to corpses, which often remained several hours among the living; the patients’ isolation from their families and worries about their well-being; and sometimes, the perception of disrespect by ETU staff. However, most survivors reported how staff motivated patients to drink, eat, bathe, and walk. Additionally, employing survivors as staff fostered hope, calling patients by their name increased confidence and familiarity, and organizing prayer and singing activities brought comfort. When Ebola virus disease survivors returned home, the experience of being alive was both a gift and a burden. Flashbacks were common among survivors. Perceived as contagious, many were excluded from their family, professional, and social life. Some survivors faced divorce, were driven out of their houses, or lost their jobs. The subsequent isolation prevented survivors from picking up daily life, and the multiple losses affected their coping mechanisms. However, when available, the support of family, friends, and prayer enabled survivors to cope with their mental distress. For those excluded from society, psychosocial counseling and the survivor’s network were ways to give a meaning to life post-Ebola.ConclusionExposure to death in the ETU and stigma in the communities induced posttraumatic stress reactions and symptoms of depression among Ebola survivors. Distress in the ETU can be reduced through timely management of corpses. Coping mechanisms can be strengthened through trust relationships, religion, peer/community support, and community-based psychosocial care. Mental health disorders need to be addressed with appropriate specialized care and follow-up.

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

“…The Ebola treatment centers did not provide privacy, so those afflicted with EVD directly witnessed other patients (sometimes their own loved ones and children) in close proximity who were displaying the full spectrum of EVD symptoms, and sometimes “bleeding out” and dying, with the corpse remaining in view for hours [29••]. …”

“…The most identifiable individuals who are likely to experience serious and enduring psychological consequences are the 17,000 survivors who have recovered from EVD [5•]. A qualitative study of Ebola survivors who have received care in an ETU determined that psychological distress was widespread and related to direct exposures to suffering, death, and corpses left visible and unattended on the units while they were in treatment [29••]. …”

The symbolic violence of ‘outbreak’: A mixed-methods, quasi-experimental impact evaluation of social protection on Ebola survivor wellbeing

“…Survivor programs have varied widely within and across the three most affected countries. According to interviews with survivors discharged from Liberia’s largest Ebola treatment unit, for example, many survivors lost jobs and housing, were separated from breadwinning family members, and were excluded from markets in which they could buy and sell products (Rabelo et al, 2016). Similar economic concerns have been documented in Guinea: a study of 121 Ebola survivors in urban parts of that country found most in poorer socioeconomic conditions, work situations, and workplace relationships following their acute illness than before it (Delamou et al, 2017).…”

“…In Liberia, for example, the Firestone Natural Rubber Company established a reintegration program in which the company’s medical personnel held meetings with survivors’ communities to allay concerns regarding the risks of Ebola transmission, organized community-wide celebrations to welcome survivors home, and visited survivors weekly for three months following discharge (Arwady et al, 2014). Counseling and other forms of psychosocial support have also been proposed as interventions to help survivors better cope with feelings of marginalization, isolation, guilt, distress, and shame (Mohammed et al, 2015; Rabelo et al, 2016), as have media engagement and public messaging to more broadly convey survivors’ stories and build acceptance (Karafillakis et al, 2016). Throughout West Africa, Ebola survivors and their supporters have created survivor networks, such as the Sierra Leone Association of Ebola Survivors (SLAES), to promote group healing and peer support, while advocating against stigma and drawing government and public attention to the unmet needs of thousands of survivors (Acland, 2016; SLAES, 2017; World Health Organization, 2015).…”

Care of Ebola Survivors and Factors Associated With Clinical Sequelae—Monrovia, Liberia

“…However, it may be challenging for survivors to access health care services. Survivors may face stigma within their community and in certain instances have lost their jobs and become isolated from the community [14]. …”