Social resistance drives persistent transmission of Ebola virus disease in Eastern Democratic Republic of Congo: A mixed-methods study

Autoři: Kasereka Masumbuko Claude aff001;  Jack Underschultz aff002;  Michael T. Hawkes aff002
Působiště autorů: Department of Medicine, Université Catholique de Graben, Butembo, Democratic Republic of Congo aff001;  Department of Pediatrics, University of Alberta, Edmonton, Canada aff002;  Department of Medical Microbiology and Immunology, University of Alberta, Edmonton, Canada aff003;  Department of Global Health, School of Public Health, University of Alberta, Edmonton, Canada aff004
Vyšlo v časopise: PLoS ONE 14(9)
Kategorie: Research Article
doi: 10.1371/journal.pone.0223104



The second largest Ebola virus disease (EVD) epidemic in history is currently raging in Eastern Democratic Republic of Congo (DRC). Stubbornly persistent EVD transmission has been associated with social resistance, ranging from passive non-compliance to overt acts of aggression toward EVD reponse teams.


We explored community resistance using focus group discussions and assessed the prevalence of resistant views using standardized questionnaires.


Despite being generally cooperative and appreciative of the EVD response (led by the government of DRC with support from the international community), focus group participants provided eyewitness accounts of aggressive resistance to control efforts, consistent with recent media reports. Mistrust of EVD response teams was fueled by perceived inadequacies of the response effort (“herd medicine”), suspicion of mercenary motives, and violation of cultural burial mores (“makeshift plastic morgue”). Survey questionnaires found that the majority of respondents had compliant attitudes with respect to EVD control. Nonetheless, 78/630 (12%) respondents believed that EVD was fabricated and did not exist in the area, 482/630 (72%) were dissatisfied with or mistrustful of the EVD response, and 60/630 (9%) sympathized with perpetrators of overt hostility. Furthermore, 102/630 (15%) expressed non-compliant intentions in the case of EVD illness or death in a family member, including hiding from the health authorities, touching the body, or refusing to welcome an official burial team. Denial of the biomedical discourse and dissatisfaction/mistrust of the EVD response were statistically significantly associated with indicators of social resistance.


We concluded that social resistance to EVD control efforts was prevalent among focus group and survey participants. Mistrust, with deep political and historical roots in this area besieged by chronic violence and neglected by the outside world, may fuel social resistance. Resistant attitudes may be refractory to short-lived community engagement efforts targeting the epidemic but not the broader humanitarian crisis in Eastern DRC.

Klíčová slova:

Ebola hemorrhagic fever – Medical doctors – Nurses – Public and occupational health – Questionnaires – Surveys – Vaccination and immunization – Vaccines


1. WHO Ebola virus disease fact sheet. 2016. (accessed Aug 13, 2018).

2. Centers for Disease Control and Prevention. 2014 Ebola Outbreak in West Africa. In: Ebola (Ebola Virus Disease). Centers for Disease Control and Prevention. 2016. (accessed Aug 13, 2018).

3. WHO Ebola situation reports: Democratic Republic of the Congo. (accessed July 20, 2019).

4. Jalloh MF, Bunnell R, Robinson S, Jalloh MB, Barry AM, Corker J, et al. Assessments of Ebola knowledge, attitudes and practices in Forecariah, Guinea and Kambia, Sierra Leone, July-August 2015. Philos Trans R Soc Lond B Biol Sci. 2017;372(1721). doi: 10.1098/rstb.2016.0304 28396475; PubMed Central PMCID: PMC5394642.

5. Jalloh MF, Robinson SJ, Corker J, Li W, Irwin K, Barry AM, et al. Knowledge, Attitudes, and Practices Related to Ebola Virus Disease at the End of a National Epidemic—Guinea, August 2015. MMWR Morb Mortal Wkly Rep. 2017;66(41):1109–15. doi: 10.15585/mmwr.mm6641a4 29049279; PubMed Central PMCID: PMC5689093.

6. Jiang H, Shi GQ, Tu WX, Zheng CJ, Lai XH, Li XX, et al. Rapid assessment of knowledge, attitudes, practices, and risk perception related to the prevention and control of Ebola virus disease in three communities of Sierra Leone. Infect Dis Poverty. 2016;5(1):53. doi: 10.1186/s40249-016-0142-9 27264269; PubMed Central PMCID: PMC4893841.

7. Blair RA, Morse BS, Tsai LL. Public health and public trust: Survey evidence from the Ebola Virus Disease epidemic in Liberia. Soc Sci Med. 2017;172:89–97. doi: 10.1016/j.socscimed.2016.11.016 27914936.

8. Wilkinson A, Fairhead J. Comparison of social resistance to Ebola response in Sierra Leone and Guinea suggests explanations lie in political configurations not culture. Crit Public Health. 2017;27(1):14–27. doi: 10.1080/09581596.2016.1252034 28366999; PubMed Central PMCID: PMC5351787.

9. Blackley DJ, Lindblade KA, Kateh F, Broyles LN, Westercamp M, Neatherlin JC, et al. Rapid intervention to reduce Ebola transmission in a remote village—Gbarpolu County, Liberia, 2014. MMWR Morb Mortal Wkly Rep. 2015;64(7):175–8. 25719678; PubMed Central PMCID: PMC5779598.

10. Loignon C, Nouvet E, Couturier F, Benhadj L, Adhikari NKJ, Murthy S, et al. Barriers to supportive care during the Ebola virus disease outbreak in West Africa: Results of a qualitative study. PLoS One. 2018;13(9):e0201091. doi: 10.1371/journal.pone.0201091 30183718; PubMed Central PMCID: PMC6124726.

11. Wilkinson A, Parker M, Martineau F, Leach M. Engaging 'communities': anthropological insights from the West African Ebola epidemic. Philos Trans R Soc Lond B Biol Sci. 2017;372(1721). doi: 10.1098/rstb.2016.0305 28396476; PubMed Central PMCID: PMC5394643.

12. Johnson RB, Onwuegbuzie AJ. Mixed Methods Research: A Research Paradigm Whose Time Has Come. Educational Researcher. 2004;33(7):14–26.

13. Tariq S, Woodman J. Using mixed methods in health research. JRSM Short Rep. 2013;4(6):2042533313479197. doi: 10.1177/2042533313479197 23885291; PubMed Central PMCID: PMC3697857.

14. Ostlund U, Kidd L, Wengstrom Y, Rowa-Dewar N. Combining qualitative and quantitative research within mixed method research designs: a methodological review. Int J Nurs Stud. 2011;48(3):369–83. doi: 10.1016/j.ijnurstu.2010.10.005 21084086.

15. Coghlan B, Brennan RJ, Ngoy P, Dofara D, Otto B, Clements M, et al. Mortality in the Democratic Republic of Congo: a nationwide survey. Lancet. 2006;367(9504):44–51. Epub 2006/01/10. S0140-6736(06)67923-3 [pii] doi: 10.1016/S0140-6736(06)67923-3 16399152.

16. Moran B. Fighting Ebola in conflict in the DR Congo. Lancet. 2018;392(10155):1295–6. doi: 10.1016/S0140-6736(18)32512-1 30322568.

17. Kitzinger J. Qualitative research. Introducing focus groups. BMJ. 1995;311(7000):299–302. doi: 10.1136/bmj.311.7000.299 7633241; PubMed Central PMCID: PMC2550365.

18. Carlsen B, Glenton C. What about N? A methodological study of sample-size reporting in focus group studies. BMC Med Res Methodol. 2011;11:26. doi: 10.1186/1471-2288-11-26 21396104; PubMed Central PMCID: PMC3061958.

19. Sandelowski M. What's in a name? Qualitative description revisited. Res Nurs Health. 2010;33(1):77–84. doi: 10.1002/nur.20362 20014004.

20. Claude KM, Underschultz J, Hawkes MT. Ebola virus epidemic in war-torn eastern DR Congo. Lancet. 2018;392(10156):1399–401. doi: 10.1016/S0140-6736(18)32419-X 30297137.

21. Obenauer J, Rubsamen N, Garsevanidze E, Karch A, Mikolajczyk RT. Changes in risk perceptions during the 2014 Ebola virus disease epidemic: results of two consecutive surveys among the general population in Lower Saxony, Germany. BMC Public Health. 2018;18(1):628. doi: 10.1186/s12889-018-5543-1 29764410; PubMed Central PMCID: PMC5952518.

22. Graham JE, Lees S, Le Marcis F, Faye SL, Lorway RR, Ronse M, et al. Prepared for the 'unexpected'? Lessons from the 2014–2016 Ebola epidemic in West Africa on integrating emergent theory designs into outbreak response. BMJ Glob Health. 2018;3(4):e000990. doi: 10.1136/bmjgh-2018-000990 30116598; PubMed Central PMCID: PMC6089294.

23. AWF E. The measure of association in a 2 x 2 Table. Journal of the Royal Statistical Society. 1963;126(1):109–14.

24. Social Science in Humanitarian Action. Social Science and Behavioural Data Compilation (No. 3), Ebola Outbreak Eastern DRC February-May 2019. Available at: Accessed 14 July, 2019.

25. Larson HJ, Heymann DL. Public health response to influenza A(H1N1) as an opportunity to build public trust. JAMA. 2010;303(3):271–2. doi: 10.1001/jama.2009.2023 20085957.

26. Salmon DA, Dudley MZ, Glanz JM, Omer SB. Vaccine hesitancy: Causes, consequences, and a call to action. Vaccine. 2015;33 Suppl 4:D66–71. doi: 10.1016/j.vaccine.2015.09.035 26615171.

27. Whetten K, Leserman J, Whetten R, Ostermann J, Thielman N, Swartz M, et al. Exploring lack of trust in care providers and the government as a barrier to health service use. Am J Public Health. 2006;96(4):716–21. doi: 10.2105/AJPH.2005.063255 16507725; PubMed Central PMCID: PMC1470533.

28. Jegede AS. What led to the Nigerian boycott of the polio vaccination campaign? PLoS Med. 2007;4(3):e73. doi: 10.1371/journal.pmed.0040073 17388657; PubMed Central PMCID: PMC1831725.

29. Kasereka MC, Sawatzky J, Hawkes MT. Ebola epidemic in war-torn Democratic Republic of Congo, 2018: Acceptability and patient satisfaction of the recombinant Vesicular Stomatitis Virus—Zaire Ebolavirus Vaccine. Vaccine. 2019;37(16):2174–8. doi: 10.1016/j.vaccine.2019.03.004 30878249.

30. Kamara S. (2014, July 31). Out of the bag: Ebola is at crisis point, we need a national day of reflection. Sierra Leone News. Avaliable at: Accessed 5 November 2018.

31. Adams V, VANH T, English D. Chronic disaster syndrome: Displacement, disaster capitalism, and the eviction of the poor from New Orleans. Am Ethnol. 2009;36(4):615–36. doi: 10.1111/j.1548-1425.2009.01199.x 20161644; PubMed Central PMCID: PMC2818205.

32. Miller NP, Milsom P, Johnson G, Bedford J, Kapeu AS, Diallo AO, et al. Community health workers during the Ebola outbreak in Guinea, Liberia, and Sierra Leone. J Glob Health. 2018;8(2):020601. doi: 10.7189/jogh-08-020601 30023054; PubMed Central PMCID: PMC6030670 form at (available on request from the corresponding author) and declare no competing interests.

33. Southall HG, DeYoung SE, Harris CA. Lack of Cultural Competency in International Aid Responses: The Ebola Outbreak in Liberia. Front Public Health. 2017;5:5. doi: 10.3389/fpubh.2017.00005 28197401; PubMed Central PMCID: PMC5281539.

34. Lisa Schnirring. CIDRAP News. Sep 05, 2018. DRC Ebola outbreak expands to large city as Beni cases rise. Available at: Accessed 3 November 2018.

35. Washington Post. Health workers in Congo’s Ebola outbreak attacked weekly. Available at: Accessed 3 Nov 2018.

36. Lisa Schnirring. CIDRAP News. Sep 24, 2018. Violence suspends response in DRC Ebola hot spot as cases rise. Available at: Accessed 3 Nov 2018.

37. AP News. Battles over safe Ebola burials complicate work in Congo. Available at: Accessed 3 Nov 2018.

38. David Mackenzie. CNN News. Deadly violence in DRC hampers Ebola control. Available at: Accessed 3 November 2018.

39. Peter Salama, WHO Deputy Director-General for Emergency Preparedness and Response. Twitter feed. Available at: Accessed 3 November 2018.

40. Lisa Schnirring, CIDRAP News. Oct 01, 2018. DRC reports 4 more Ebola cases over the weekend. Available at: Accessed 3 November 2018.

41. Abramowitz SA, Hipgrave DB, Witchard A, Heymann DL. Lessons From the West Africa Ebola Epidemic: A Systematic Review of Epidemiological and Social and Behavioral Science Research Priorities. J Infect Dis. 2018;218(11):1730–8. doi: 10.1093/infdis/jiy387 29939284.

42. Nuriddin A, Jalloh MF, Meyer E, Bunnell R, Bio FA, Jalloh MB, et al. Trust, fear, stigma and disruptions: community perceptions and experiences during periods of low but ongoing transmission of Ebola virus disease in Sierra Leone, 2015. BMJ Glob Health. 2018;3(2):e000410. doi: 10.1136/bmjgh-2017-000410 29629189; PubMed Central PMCID: PMC5884263.

43. Chandler C, Fairhead J, Kelly A, Leach M, Martineau F, Mokuwa E, et al. Ebola: limitations of correcting misinformation. Lancet. 2015;385(9975):1275–7. doi: 10.1016/S0140-6736(14)62382-5 25534188.

44. Richards P, Amara J, Ferme MC, Kamara P, Mokuwa E, Sheriff AI, et al. Social pathways for Ebola virus disease in rural Sierra Leone, and some implications for containment. PLoS Negl Trop Dis. 2015;9(4):e0003567. doi: 10.1371/journal.pntd.0003567 25886400; PubMed Central PMCID: PMC4401769.

45. Edward McCallister. The Independent. 'I don't know how to live anymore': Horror and fear grip survivors of Congo's hidden war. Available at:

Článek vyšel v časopise


2019 Číslo 9