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Homecare for sick family members while waiting for medical help during the 2014-2015 Ebola outbreak in Sierra Leone: a mixed methods study
  1. Kirsten Schmidt-Hellerau1,
  2. Maike Winters1,
  3. Padraig Lyons1,
  4. Bailah Leigh2,
  5. Mohammad B Jalloh3,
  6. Paul Sengeh4,
  7. Alhaji Babah Sawaneh4,
  8. Zangin Zeebari5,
  9. Mariano Salazar1,
  10. Mohamed F Jalloh1,6,
  11. Helena Nordenstedt1
  1. 1Department of Global Public Health, Karolinska Institute, Stockholm, Sweden
  2. 2Department of Community Medicine, University of Sierra Leone College of Medicine and Allied Health Sciences, Freetown, Western Area, Sierra Leone
  3. 3Office of the Chief Executive Officer, FOCUS 1000, Freetown, Sierra Leone
  4. 4Research and Evaluation, FOCUS 1000, Freetown, Sierra Leone
  5. 5Jönköping International Business School, Jönköping University, Jonkoping, Sweden
  6. 6Division of Global Health Protection, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
  1. Correspondence to Ms Kirsten Schmidt-Hellerau;{at}


Introduction Caring for an Ebola patient is a known risk factor for disease transmission. In Sierra Leone during the outbreak in 2014/2015, isolation of patients in specialised facilities was not always immediately available and caring for a relative at home was sometimes the only alternative. This study sought to assess population-level protective caregiving intentions, to understand how families cared for their sick and to explore perceived barriers and facilitators influencing caregiving behaviours.

Methods Data from a nationwide household survey conducted in December 2014 were used to assess intended protective behaviours if caring for a family member with suspected Ebola. Their association with socio-demographic variables, Ebola-specific knowledge and risk perception was analysed using multilevel logistic regression. To put the results into context, semi-structured interviews with caregivers were conducted in Freetown.

Results Ebola-specific knowledge was positively associated with the intention to avoid touching a sick person and their bodily fluids (adjusted OR (AOR) 1.29; 95% CI 1.01 to 1.54) and the intention to take multiple protective measures (AOR 1.38; 95% CI 1.16 to 1.63). Compared with residing in the mostly urban Western Area, respondents from the initial epicentre of the outbreak (Eastern Province) had increased odds to avoid touching a sick person or their body fluids (AOR 4.74; 95% CI 2.55 to 8.81) and to take more than one protective measure (AOR 2.94; 95% CI 1.37 to 6.34). However, interviews revealed that caregivers, who were mostly aware of the risk of transmission and general protective measures, felt constrained by different contextual factors. Withholding care was not seen as an option and there was a perceived lack of practical advice.

Conclusions Ebola outbreak responses need to take the sociocultural reality of caregiving and the availability of resources into account, offering adapted and acceptable practical advice. The necessity to care for a loved one when no alternatives exist should not be underestimated.

  • viral haemorrhagic fevers
  • KAP survey
  • qualitative study
  • other study design
  • control strategies

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  • Handling editor Stephanie M Topp

  • Contributors KS-H, MW, MFJ and HN led the overall study design with substantial contributions made by the all other co-authors for one or more of the study components. MFJ, MBJ and BL were involved in organising and coordinating primary quantitative data collection. KS-H led secondary quantitative data analysis with support from MW, MFJ, PL, ZZ and HN. KS-H, MW, MFJ and HN provided critical input to the data interpretation. Qualitative data collection was planned by KS-H with substantial input from MFJ, HN and PS and conducted by ABS and KS-H. KS-H conducted qualitative data analysis, supported by MFJ, MS and HN. KS-H led the writing of the manuscript with substantial contributions made by all co-authors. All the authors reviewed and approved the final version of the manuscript.

  • Funding The KAP survey was mainly funded by the Centers for Disease Control and Prevention Foundation (not affiliated with the US Centers for Disease Control), who had no role in the preparation of the manuscript. Through a sub-partnership agreement, the KAP survey was administered by eHealth Africa, the data collection facilitated by FOCUS 1000. The qualitative part was partly funded by a grant from the Swedish Medical Research council (2017-05581), who did not have an influence on the research process.

  • Disclaimer The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval Ethical permission was granted by the Sierra Leone Ethics and Scientific Review Committee (Quantitative part: 16 December 2014, Qualitative part: 28 February 2019). The committee considers survey participants 15 years or older capable to consent.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon request. Data access requests should be sent to

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