Background: Since the discovery of Ebola in 1967, many localized outbreaks have occurred but the recent cross-border epidemic was fueled by the high level of illiteracy and some bad cultural practices. Aim: To assess the awareness, knowledge, and misconceptions of Ebola among residents of a rural community in Sokoto State, Nigeria. Materials and Methods: A cross-sectional study design was used. The study was conducted in a rural community and the participants were selected using the systematic sampling method. The data were analyzed with Statistical Package for the Social Sciences (SPSS) version 20.0. Skewed quantitative variables were summarized using median and categorical variables using frequencies and percentages. Chi-square test was performed to assess the relationship between outcome variables (knowledge of Ebola) and respondents’ sociodemographic characteristics. Binary logistic regression analysis was also performed to identify the predictors of outcome variable. Results: Respondents’ median age was 30 years and nearly half of the respondents (49%) had no formal education. A large proportion (88%) of the respondents was aware of Ebola and radio was their major source of information. Residents’ knowledge of Ebola was low and only 13% had good knowledge. Eating bitter kola, bathing with salt water, and drinking salt water were mentioned as methods of preventing the spread of the disease. Of their socio-demographic characteristics, only the educational level attained did predict their knowledge of Ebola. Respondents without formal education [odds ratio (OR) = 0.198, P < 0.02] and secondary education (OR = 0.292, P < 0.01) were more likely to have poor knowledge. Conclusion: Although the majority was aware of Ebola, their knowledge about it was very low and misconceptions and misinformation were still not uncommon. There is a need for continuous public education and enlightenment about Ebola.
Keywords: Ebola virus disease (EVD), knowledge, misconceptions, rural community, Sokoto
|How to cite this article:
Kaoje AU, Yahaya M, Sabir AA, Raji MO, Abdulmumin S, Mohammed AU. Awareness, knowledge, and misconceptions of Ebola virus disease among residents of a rural community in Sokoto, Northwest Nigeria. Ann Trop Med Public Health 2016;9:105-11
|How to cite this URL:
Kaoje AU, Yahaya M, Sabir AA, Raji MO, Abdulmumin S, Mohammed AU. Awareness, knowledge, and misconceptions of Ebola virus disease among residents of a rural community in Sokoto, Northwest Nigeria. Ann Trop Med Public Health [serial online] 2016 [cited 2020 Aug 10];9:105-11. Available from: https://www.atmph.org/text.asp?2016/9/2/105/177378
Ebola virus disease (EVD) is a viral hemorrhagic disease caused by Ebola virus, which is filamentous in morphology resembling a “shepherds rod.” , Ebola is characterized by elevated body temperature, fatigue, vomiting, diarrhea, abdominal pain, or unexplained hemorrhage.  Forest-dwelling fruit-eating bats are suspected to be the reservoir of the virus and five virus species have been identified (Zaire, Sudan, Tai Forest, and Bundibugyo) that cause disease in humans while the Reston ebolavirus causes disease in nonhuman primates. 
Human transmission and spread occurs through direct physical contact with infected bodily fluids from gorillas, antelopes, and from either symptomatic patients or dead EVD patients. 
Since the discovery of Ebola, many localized outbreaks occurred in sub-Saharan Africa prior to the 2014 cross-border epidemic, which was more severe in terms of the morbidity, mortality, and spread. , The first known case in Nigeria was recorded on July 20, 2014 in a traveler from Liberia and led to an outbreak involving two states of the federation. ,
In Guinea and other affected countries, despite government efforts to inform people about the disease, public mistrust and widespread myths, rumors, and conspiracy theories predominate. ,,
|Materials and Methods|
The study was conducted in a rural community of Sokoto State and the study population comprised all the residents of the community. The community was 15 km away from the state capital and also formed part of the metropolis. A cross-sectional study design was used and a total of 443 residents participated in the community survey. They were selected using systematic sampling technique. Houses in the community were numbered and the list was used as a sampling frame. For some houses that were selected where no one was around or where the persons declined from participating, the next household was used. A questionnaire from the national training of state rapid response teams on Ebola emergency management, preparedness, and response by Nigeria Centre for Disease Control (NCDC) was modified and adapted for the data collection. The data were analyzed with Statistical Package for the Social Sciences (SPSS) version 20.0. (IBM Corporation). Skewed quantitative variables were summarized using median and interquartile range (IQR) while categorical variables were summarized using frequencies and percentages. Chi-square test of association was performed to assess the relationship between outcome variables, knowledge of EVD, and respondents’ sociodemographic characteristics. Binary logistic regression analysis was also performed to identify predictors of knowledge of EVD among residents of the rural community. The level of significance was set at 5%.
[Table 1] showed that respondents’ median age was 30 years (IQR 25-40 years). The age group of 25-39 years was more represented (45.6%) followed by 40-64 years who accounted for 27.4%. Adolescent and young adults (18-24 years) constituted 24.9% of the study population. There were more males than females (68.3% vs 31.7%) and almost half of the respondents (49%) had no formal education. A large proportion of the population was self-employed (61%) while 16% were civil servants and 23.4% were not gainfully employed.
|Table 1: Sociodemographic characteristics of the respondents
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[Table 2] showed that the majority (88.3%) of the residents had heard of EVD and radio was the major source of their information. Although a large proportion (65.3%) was aware of the episode of EVD in Nigeria, only 10.4% correctly mentioned Lagos and Port Harcourt as the affected cities. Eighty-two percent were not aware of the existence of a special number that can be called when a suspected case of Ebola occurs in their community; among the few (18.1%) that were aware of the hotline, none knew the number.
|Table 2: Awareness of Ebola virus disease
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[Table 3] showed that only very few respondents (13.0%) had good knowledge of Ebola, with an overall mean percentage knowledge score of 16%. A majority of the respondents had poor knowledge of its cause, signs of Ebola disease, how the disease is spread, and measures of preventing the spread of the disease.
|Table 3: Knowledge of Ebola virus disease among respondents
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[Table 4] shows that 53.7% of the respondents did not know the cause of Ebola. While 30.2% reported infection as the cause, 2.6% and 2.1% mentioned spiritual attack and a curse as cause of EVD, respectively. Twenty-three percent did not know how the disease spreads, 27.3% reported its spread through air, and 1.4% mentioned drinking contaminated water and sexual intercourse as the modes of Ebola spread. Abnormal bleeding from any part of the body was the most reported sign (85%) followed by fever (35%). Seventeen percent did not know how to prevent themselves from contracting Ebola while 18.2%, 17.6%, and 5.4% of the respondents mentioned bathing with salt water, drinking salt water, and eating bitter kola, respectively, as the methods of preventing its spread.
|Table 4: Knowledge of different aspects of EVD
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In [Table 5], results of the chi-square test of association shows a statistically significant association between knowledge and gender [X 2 (1) = 6.45, P = 0.01], knowledge and educational level attained (Fisher’s exact test = 20.06, P = 0.0001), knowledge and occupation [X 2 (2) = 16.34, P = 0.001], and knowledge and awareness of Ebola disease [X 2 (1) = 7.46, P = 0.006].
|Table 5: Association between respondents’ knowledge of Ebola virus disease and their sociodemographic characteristics
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[Table 6] shows that only respondents’ educational level attained predicted their knowledge of EVD. Those who have no formal education [odds ratio (OR) = 0.198, P < 0.01] and secondary education (OR = 0.292, P < 0.02) are more likely to have poor rather than good knowledge.
|Table 6: Predictors of Ebola virus disease knowledge
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Since its discovery in 1976, although sporadic or small clusters of cases have been documented, the recent epidemic was the largest outbreak to date that involved Guinea, Liberia, and Sierra Leone, and spread to Nigeria from an imported case from Liberia. Nigeria recorded fewer cases compared to the aforementioned countries (a total of 21 cases and 12 deaths).
The findings from this study showed that a large proportion of the study participants was aware of EVD and its presence in Nigeria but very few were aware of the hotline phone number to call when a suspected case of Ebola occurred in the community. Mass media was the predominant source of their information about EVD; for the majority, it was the radio followed by television. During the outbreak in the country, there was hype among the public in awareness in almost all the media platforms. Being a rural community and coupled with poor electricity supply, the radio is the only viable way to obtain information at any time as it only requires replaceable batteries, which is accessible in the community. Awareness of large community members is a reflection of effective public enlightenment campaigns embarked upon by the Nigerian Government following the first reported case to reach the target audience. In Lagos, Nigeria, everyone was aware of Ebola but only a few (28%) were aware that there were hotlines (help lines) for the disease and the main source of information was the television followed by the radio and the newspaper.  A similar study in Sierra Leone revealed that everyone was aware of EVD and nearly everyone believed that it was present in the country, with radio as the preferred means of obtaining information.  The difference in the awareness levels may be due to the fact that the disease did not spread to the study area, whereas in the other study settings many cases were recorded and deaths also occurred.
Even though a good number of community members were aware of EVD, knowledge about the disease was generally low and only very small proportions had good knowledge of the different aspects of EVDs as it related to the cause, signs, and symptoms, how the disease was spread, and measures of preventing the spread of the disease. Half of the respondents did not know the cause of Ebola. While one-third reported infection as the cause, very few respondents mentioned spiritual attack and curse as the causes of EVD. One in every five did not know how the disease spreads, about one-third of the respondents reported its spread through air, and very few mentioned drinking contaminated water and sexual intercourse as the modes of Ebola spread. Abnormal bleeding from any part of body was the sign most reported by respondents, one-third mentioned fever and less than one-third of the respondents mentioned each of the other signs. With respect to prevention of the spread of Ebola, in spite of public campaigns, one in six did not know how to prevent himself/herself from contracting the disease while a good number of the respondents still mentioned bathing with salt water, drinking salt water, and eating bitter kola as the methods of preventing the spread. Although this may sound worrisome, it is not unexpected in this typical study setting in a rural community where Western education is poorly accepted and where schools are poorly attended; the quality of education is so poor that it may not make a significant difference. Secondly, nearly half of the respondents had no formal education, which may be a reflection of the educational status of the community. Belief in superstition, rumors, and hearsay was still common among the respondents. Rumors and misinformation including the belief that Ebola does not exist and that it was political were common in Nigeria.
In Lagos, a study revealed that nearly all the respondents had good awareness and knowledge on how to protect themselves from contracting Ebola disease; yet more than one-third associated the disease with sins and spiritual attack, and that it could be spread by air and mosquito bite. Nearly one-third believed it could be cured with local or traditional remedies such as herbs and concoctions and one in five believed that certain churches had the spiritual power to cure the disease. 
Similarly, in Sierra Leone, knowledge on EVD prevention was generally low and about half still have misconception about the disease. Almost one-third of the population thought that Ebola was airborne and could be spread by mosquitoes. Respondents also believed it could be treated successfully by spiritual healers and that bathing with salt water and hot water could prevent Ebola.  Some other beliefs, rumors, and misconceptions regarding EVD include mixture of ginger, honey, garlic, onion, and vinegar as a cure for Ebola, the drinking of alcohol that prevents Ebola virus transmission, Ebola as a curse, organs are taken from Ebola patients to be sent to Europe, people are injected and killed at the health center, White people eat corpses, the Whites are here just for money, at the hospital they take two liters of blood from the heart and sell it in Europe, patients are put straight into body-bags, and some people starve to death in the hospital because they do not get fed.  One rumor holds that Western governments have planted the virus, another that spraying of disinfectants is actually a means of infecting others, and even that Ebola treatment centers are used for the extraction and trafficking of human organs.  The similarity in many of the findings among the studies reflects the many similarities in the sociocultural characteristics of Africans ranging from the health-seeking behaviors to funeral and burial practices, and eating habits. Poor educational level in many settings in Africa coupled with the fact that many of African populaces are in rural communities where Western education is not a priority and schools are lacking provide a conducive environment for such misconceptions to grow and strive. It is worth noting that although good knowledge alone may not be adequate to promote preventive care and behavioral change, it is critical. Knowledge is a powerful weapon in fighting not only the prevention and spread of the diseases but also the stigmatization of those it has affected. It was widely reported in Nigeria that survivors and their families were seriously stigmatized, some lost their jobs, some were sent out from their rented apartments while some were ostracized from the community. The 2014 Ebola outbreak was adjudged to be fueled by a combination of poor health system, high level of illiteracy, poor road networks, and some bad cultural practices that were more worrisome in the rural areas of the West African subregion. 
Ebola is not a new disease in medical literature; it is however, a strange disease to nonmedics. And in spite of efforts by different government and organizations to create awareness about the disease including method of prevention through mass media campaigns and community meetings, myths and misconception still thrive and were more widely accepted among the general population. There may be a need for further study to explore more on this issue to better prepare and plan for the control of future outbreaks of EVD and other similar diseases.
In conclusion, this study found that there is generally low knowledge of EVD and only few individuals had good knowledge in spite of all the government efforts on public education and health promotion through mass media, seminars, and community meetings. Radio was the main source of their information followed by television, even though nearly all the respondents were not aware of the Ebola helpline and all did not know the helpline phone numbers. Rumors and myths still persist as some respondents believed the Ebola was a curse and that bathing and drinking salt water and eating bitter kola would help prevent transmission of the disease. Therefore, it is of paramount importance that more efforts are geared toward demystifying the myths and misconceptions through specific community engagement activities such as community dialogues, strong involvement of community and religious leaders in mass media campaigns, and developing messages based on the sociocultural context of target audience. It is also important to put in place a surveillance system that monitors not only the occurrence of diseases but myths and misconceptions as well. This will play a major role in developing messages that addresses common misconceptions that will hinder preventive measures.
We wish to acknowledge the kind support of the 2014/2015 set of medical students (400A Level) who helped to administer the questionnaire while doing their rural posting rotation with the community medicine department.
Financial support and sponsorship
There was no source of support (it was self-supported).
Conflicts of interest
There are no conflicts of interest.
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Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]