Social, Cultural and Behavioural Contexts of 2014 Ebola Virus Disease (EVD) Outbreak in Nigeria: Community Perspectives and Nurses' Preparedness

Saturday, 7 November 2015: 3:15 PM

Mildred E. John, PhD, BSc, RN, RM, RNE, FWACN1
Margaret I. Ekanem, BSc, RN, RM, RPHN2
Ibitoru Peterside, BSc, RN, RM, RPHN3
P. E. Samson-Akpan, PhD, MPH, BSc, RN/RM, RNE, FWACN1
Idongesit I. Akpabio, PhD, MSc, MPA, BSc, RN/RM, FWACN1
Ijeoma Okoronkwo, PhD, MSc, BSc, RN, RM, RNT, FWACN4
(1)Department of Nursing Science, University of Calabar, Calabar, Nigeria
(2)Infectious Diseases Control Unit, Department of Public Health, Ministry of Health, Uyo, Uyo, Nigeria
(3)Maternal and Child health Unit, Braithwaite Memorial Hospital, Port Harcourt, Port Harcourt, Nigeria
(4)Department of Nursing Science, University of Nigeria, Enugu Campus, Enugu, Nigeria


The current Ebola outbreak in West Africa has been described as the largest, most deadly since Ebola was first discovered in 1976 (WHO, 2014). The affected nations have suffered tremendous social problems while survivors and families of victims have suffered stigmatization and severe psychological distress. As at February 4, 2015 there have been nearly 22,500 Ebola cases in eight countries, with over 9,000 deaths including health workers (WHO, 2015). This international health emergency has led to the recruitment and training of hundreds of health workers from other countries (including Nigeria) to help with Ebola control in hardest hit nations. The outbreak of Ebola Virus Disease (EVD) in Nigeria between 15/07/2014 and 15/09/2014 had twenty cases with eight deaths in two states. During the period, the health response faced significant challenges because Ebola is not just a medical problem, but also a people problem with community responses being driven by cultural beliefs and practices. Some socio-cultural beliefs and practices are deep rooted and have the tendency to influence Ebola control. Few studies exist in this area. Guidelines for Ebola control suggest that understanding and consideration of local views and responses to the outbreak is very important. This study sheds new light on the rarely considered issue of socio-cultural influences on Ebola control.

The two aims of the study were: to identify the socio-cultural beliefs and practices and behavioural responses that may influence the control of Ebola in the community; and to determine nurses' knowledge of the socio-cultural perspectives of Ebola and their preparedness to provide relevant socio-cultural care.

Materials and methods

Qualitative and quantitative methods were used. For the qualitative part, Kleinman's mini-ethnographic explanatory model (1978) was used to explore the socio-cultural and behavioural perspectives of Ebola Virus Disease in different communities. Data were collected through focus-group discussion (FGD) and semi-structured interview from 178 conveniently selected adults living in four communities in two South-South states of Nigeria. Questionnaire was used to collect quantitative data from 85 nurses randomly selected from 6 community health centres. The choice of the two states (Rivers and Akwa Ibom) hinged on two factors. Firstly, because there was Ebola outbreak in Rivers State (with 4 cases and 2 deaths) and to avoid quarantine and EVD-related stigma, many contacts migrated to nearby states including Akwa Ibom State. Secondly, these 2 states are located in the tropical rain forest where "bush meat" is a prized delicacy and hunters and sellers of "bush meat" get into close contact with infected wild animals.

Ethical approval was obtained from the Health Ethical Committees of Rivers state and Akwa Ibom state.

Qualitative data were transcribed for content analysis using NVivo 7.0 and socio-cultural beliefs and practices were coded into categories. Only factors mentioned by at least five persons were retained. Quantitative data were analyzed using descriptive statistics on SPSS 20.0.


Qualitative data revealed the following:

Notions of the disease were in 2 domains - socio-cultural and spiritual (outbreak believed to be caused by angry gods, evil spirits and witchcraft affliction. These notions initially affected receptivity to health promotion messages and treatment but within 3 weeks many said they realised "this is no ordinary disease that sacrifice to the gods can control"

Naming the disease: Ebola is called 'touch and die' disease or 'virus of quick death'

Beliefs that may impede Ebola control: "Not performing traditional burial rites is dishonouring the dead and may bring repercussions". Because of this some said they would rather hide and bury their dead in the "evil forest"  than hand them over to health workers. "Not touching or caring for sick relatives means abandonment and is culturally wrong", so they touch and care for the sick, even if they have Ebola. "Family members should be in close contact with one another"

Social and cultural practices that may impede control measures: culture that is heavily reliant on close physical contact, especially during illness; traditional greeting which includes hugging, touching and shaking hands; funeral/burial rites where family members touch, kiss, wash and dress the corpse; family members sleeping on same bed or mat; hunting and eating of "bush meat".

Behavioural  responses that enhance control: taking personal responsibility for self protection; suspension of traditional way of greeting and following the "no touching" rule; suspension of public funerals and traditional funeral rites; use of strategically placed public hand washing kits & hand sanitizers; carrying hand sanitizers in handbags and pockets to enhance accessibility.

Issues of Concerns: stigmatization of infected people and their families; burial of the dead in "culturally unacceptable manner"; isolation/quarantining of contacts ("they just take you away to an unknown place and your family cannot visit"; so people generally run away to avoid being quarantined)

Quantitative data: results showed that nurses of varying levels of education and years of experience and 92.9% were female. Only 41.2% nurses (especially younger nurses and those qualified within the past five years), were able to identify the Ebola- related socio-cultural factors; 55.3% did not see socio-cultural factors as playing any important role in Ebola care. Only 22.4% agreed that they needed training in socio-cultural care of Ebola patients. These results reveal low level of preparedness of nurses to deal with the socio-cultural issues of the Ebola epidemic and provide relevant socio-cultural care.


Effective control of EVD does not only involve screening, isolating and treating cases but also requires an understanding and consideration of the psychological, socio-cultural and behavioural responses to the disease in the general population. Lack of knowledge of these factors hinders the ability of nurses to give effective health promotion and provide culturally-relevant care to Ebola patients and psychosocial counselling to family members. In the face of socially and culturally complex impacts of Ebola disease, the explanatory model is valuable in describing people’s views of the course of illness and developing a framework for culturally capable care by the nurse (Hewlett & Amola, 2003).


Certain socio-cultural beliefs and practices may influence Ebola control in Nigeria but nurses working in the community do not have adequate knowledge of these and this affects their preparedness for  culturally capable Ebola care.