INTRODUCTION
Lassa fever is a zoonotic disease, and an emerging public health threat ranked among the top 8 infectious diseases.1 It is included among the World Health Organization’s (WHO) priority pathogens list for diseases with epidemic or pandemic potential that require urgent research and development action.1,2 The incidence of the disease has persisted due to ongoing human-animal interactions, particularly in Western Africa, where Lassa fever is known to be endemic.1 The disease is known to affect at least 58 million people worldwide, annually accounting for 1 -3 million infections and 5000 documented fatalities, with an unknown overall impact in West Africa.1–3 Lassa fever is among agents that pose the greatest risk, being categorised as a category A agent due to its high transmission and fatality rates. Additionally, the possibility of the virus being used as a biological weapon is a grave concern.3,4
Lassa fever is an acute viral haemorrhagic illness caused by the Lassa virus, which is a member of the arenavirus family.1 Transmission of the virus to humans can be either direct through contact with the infected reservoir (multimammate mice) or its fluids, or indirect through contact with infected food, water and fomites, and person-person transmission via direct contact and/or droplets.1,4 Common Lassa fever signs and symptoms include fever, headaches, tiredness, and stomach pain, with severity that can range from mild to fatal haemorrhagic fever.3–5
The West African countries where Lassa fever is endemic are Nigeria, Ghana, Guinea, Liberia, Mali, Sierra Leone, Togo, and Benin.1,3 Scientific and research evidence show that Sierra Lione is among the countries worst affected by Lassa fever, with high transmission and mortality rates.5 The Eastern region of Sierra Lione, comprising of 3 districts, has been worst affected by Lassa fever. In this region, 2 of the 3 districts (Kailahun and Kenema) have been declared Lassa fever hotspots since the 2012 – 2013 outbreaks, with the highest incidence rates and case fatality rate of 38.8%.5–7
In Lassa fever endemic areas, rural populations disproportionately face a higher risk for Lassa fever transmission as well as worst morbidity and mortality outcomes.1,6 This is reportedly due to the more direct human-Lassa fever host interaction, higher levels of health illiteracy and lower-than-actual risk perception leading to limited behavioural adaptability, and the generally more limited healthcare access for early diagnosis and treatment compared to urban populations.7,8 Behavioural insights - evidence from factors affecting human health behaviours and practices - are important for informing policies and practices on behaviour change, risk communication and community engagement.6,8 These efforts can enhance risk perception and behavioural adaptive capability which are important for effectively interrupting Lassa fever transmission. In Sierra Leone, current contextual behavioural insights are scant to inform behavioural change reprograming to end Lassa fever.
METHODS
Study design
This was a descriptive cross-sectional qualitative study.
Study setting
The study was conducted in Kailahun and Kenema districts, which are two of the three districts in Eastern Sierra Lione. These two districts share a border with the Republic of Liberia. They are distinguished by their forested surroundings and highest annual rainfall, providing a favourable habitat for the Lassa fever reservoir, the multimammate rats.9 Lassa fever is endemic in 11 of the 14 Siera Leonian districts, although the highest rates are commonly recorded in Kailahun and Kenema districts, which are the targeted study areas for this study.6,9 Due to the high incidence, the only known specialist isolation wards for Lassa fever in the world are situated in Kenema area. Kailahun and Kenema districts are predominantly inhabited by a black indigenous population of the Mende ethnic group, Muslim being the main religion. Other smaller ethnic groups are the Kissi, Vai, Fula, and the Kroo, whereas Christianity is another common religion in these study areas.
Population and sampling
Sampling of study participants sought to capture diversity in participant characteristics by targeting potentially information-rich groups. These included adult men and women (including household heads), youths, healthcare workers (including government, volunteers and non-governmental workers), community leaders (including traditional and political leaders), and livelihood groups (hunters, farmers and vendors). Potential participants from these identified groups were identified with guidance from local community leaders, healthcare workers, and local research or field workers. Information was collected from representatives of each of these identified groups in the 2 study districts using an appropriate qualitative data collection approach – either focus group discussions (FGDs) or in-depth key informant interviews (KIIs) - guided by the principle of thematic saturation (collecting data until no new themes were emerging). Hence, sample sizes for FGDs and KIIs were guided by the diversity of participant characteristics and thematic saturation. Behavioural observations of community members were also conducted during special cultural and social events to enrich and compliment the data.
Data collection and instruments
Data was respectively collected from the targeted FGD and KII participants using pretested and accordingly revised structured FGD and KII guides. The sample size for FGDs and KIIs were determined by qualitative principles of data saturation, that is, data collection was stopped when the researchers felt that all the relevant ideas and insights have captured and no new information was emerging. FGDs solicited information on knowledge, lived experiences and behaviours concerning contextual Lassa fever transmission and control among the general population, whilst KIIs sought to gather expert insights and contextual understanding of determinants of Lassa fever transmission and control.
Data management and analysis
All KII and FGD data were tape recorded and transcribed verbatim, in original language, onto a word processing program, followed by translation to the English language before thematic data analysis in Atlas.ti.22. This involved analysis of multiple utterances to derive concepts, the classification and interpretation of these concepts to generate themes capturing the essence of knowledge, behaviours and lived experiences on Lassa fever transmission and control. Findings were presented according to themes, using utterances or verbatim quotations from participants to support the themes.
RESULTS
Participants characteristics
A total of 114 participants were included in the study, consisting of 10 FGDs and 14 KIIs as outlined in Table 1.
Emerging themes
Four themes consistently emerged from the qualitative data, which are syndromic overlap between Lassa fever and other diseases; knowledge gap on Lassa fever causation and transmission pathways; Lassa fever-related cultural and traditional health dilemmas and gendered health paradox. The themes are summarised in the saturation Table 2.
Knowledge gap on Lassa fever causation and transmission pathways
There was a general convergence from FGD and KII responses concurring that information about Lassa fever transmission was widely available to communities through various channels. However, although most participants reported familiarity with Lassa fever, it appeared from their responses that they were not as equally knowledgeable and understanding about the disease, including transmission and control. It also emerged that undertaking healthy practices is complemented by availability of the necessary enabling resources, beyond just awareness and knowledge/understanding.
When it comes to Lassa fever, we have been taught about the signs and symptoms, how it is spread and that we must cover our food, trap and kill the rats, always wash our hands with soap and water and avoid touching the sick and dead bodies without gloves, and many other things you know. Now my question is, must I always wash my hands apart from before and after eating or using the toilet? No, I can’t do that! Most of us only wash our hands before and after eating or using the toilet. (Male Hunter, 38 years, FGD #1)
I can as well kill the rat, prepare it for food, and then wash my hands later? Mustn’t that be enough to protect myself?……. But that regular handwashing during other times of the day is not common for us unless there is a specific reason. Again, they just tell us to always wash hands or use gloves, but they do not consider that we don’t have enough gloves, soap and water to do so to protect ourselves. (Male Trader, 24 years old, FGD #7)
It seems like this Lassa fever is transmitted through too many ways, from the infected rats, from contact with infected people, from touching contaminated surfaces and even breathing it… how can we escape all those? Either you must always live in fear, or you must always wash your hands, which to me doesn’t make sense. (Male Adult, 44 years old, FGD #8)
I can say most people in this community have heard about Lassa fever, but not all understand the reason why they must undertake the recommended public health measures. Some people do not participate in health events or pay much attention to key messages; hence they might not understand. I believe with time, they will understand, as we identify the myths, misconceptions and information gaps, and try to address them. (Male Healthcare Worker, 45 years old, KII3)
Syndromic overlap between Lassa fever and other diseases
Utterances and ideas emerging from FGD- and KII-data consistently pointed to participants having challenges distinguishing Lassa fever from other endemic or common diseases with similar signs and symptoms such as common cold and headaches, yellow fever and malaria. Healthcare workers revealed that Lassa fever patients usually first opt for traditional remedies and consequently present to the healthcare facilities later, possibly due to similarities between symptoms for Lassa fever disease and other diseases that are perceived less serious and easily manageable at home.
“We try our best to disseminate key messages on how Lassa fever is transmitted and prevented, even on the signs and symptoms, and encouraging community members to report in time when they suspect Lassa fever infection, including in local languages. However, they always report late to the clinic, and the use of herbs and home remedies is common here, maybe that is one of the reasons why they delay”. (Female Health Worker, 45 years old, KII #8).
"Hmmm…… They tell us about the signs for this Lassa fever through the radio, at clinics, meetings and on posters, but in reality, it is not easy to identify Lassa fever by signs and symptoms, because the signs are very similar to those for other conditions and diseases that we have here…… At first you may just think it is flue or just a headache, then you try home remedies to save money and avoid traveling to the clinic unnecessarily, until it gets worse, but sometimes these herbs work, and one can even get better…… What disease or condition you will not know because they tell us the same signs for malaria, yellow fever and COVID-19. (Female Adult, 52 years old, FGD #6)
Exactly, there is no need for them to give us information about signs and symptoms for Lassa fever, because we end up confused. It’s not easy for me to tell the difference between a normal headache or flue, malaria, yellow fever, COVID-19 and Lassa fever. Only the healthcare worker can do that, so what is the point of teaching me Lassa fever signs and symptoms other than encouraging me to go to the hospital when sick? I have had both COVID-19 and Lassa fever, but I still can’t tell the difference between the two. (Male Youth, 21 years old, FGD #2).
Lassa fever-related cultural and traditional health dilemmas
Dilemmas on cultural diet and practices, food scarcity and health were consistently apparent and predominated FGDs and KIIs. It emerged that for most participants, rats were not only regarded a food source, but also as an indispensable dish at some traditional festivals or ceremonies, hence making them a significant cultural delicacy. Having to refrain from the deeply ingrained practice of rat consumption due to health reasons was not only considered a depiction of cultural non-conformance but to be associated with feelings of deprivation and cultural dietary void.
We have the annual rate control ceremony here. It’s a deeply rooted ritualistic practice that involves hunting, smoking, and collecting rats from each household, symbolizing removal of obstacles and negativity possibly hindering palm tree harvesting, and every household is obligated to participate. This ceremony is accompanied by singing, dancing, and eating dried rats cooked with red palm oil. While it helps to reduce the rat population, you wouldn’t know which rat is infected with this Lassa fever and which one is not, yet it’s not easy to skip the event" (Male Community Leader, 62 years old, KII #1).
I think it is easy to discourage the hunting and eating of rats if one doesn’t understand our culture and tradition. We, including our ancestors, have been eating these rats, and I think to die or live depends on luck. I think not all rats are infected after all. The rats are our traditional delicacy and removing them from the diet is not easy because if I am poor and my husband kills a rat, I will cook and eat it. How can I not cook it when it is the easiest meat that I can find. And to be honest, the meat tastes so good, but maybe people just do not want to confirm it. (Female Farmer, 52 years old, FGD #5)
When you advise people to stop eating rats because of Lassa fever, some of them will listen to you but continue eating them and some can even argue. It’s not that everyone eats rats here, but some still hunt them, touch them and eat them. These are the people who end up spreading the disease to others, and we are trying to reach those people, and encourage them to protect themselves and their loved ones through undertaking healthy behaviours. I think it is not an easy thing to achieve overnight, but I believe with time, it is. The practice of eating rats seems less common now than let’s say 20 years ago when I came here, so I believe there’s hope to end Lassa fever. (Female Healthcare Worker, 55 years old, KII #12).
The practice of caring for loved ones with Lassa fever disease or those who die from it presented another dilemma.
"Our community has a tradition of remaining close to the sick, or even the deceased loved ones during burial ceremonies. However, many don’t realize that this practice — especially washing the bodies, can be extremely risky as certain diseases remain contagious even after death. Culturally, as native people, when our relatives get sick, we are supposed to be very close to them. (Female, Adult 39 years old, FGD #3)
Gendered health paradox
Divergent views emerged as both the male and female genders perceived themselves as more vulnerable for contracting Lassa fever during the execution of their roles than the other. Without making a conclusive judgment on which gender and gender roles bear higher vulnerability to Lassa fever infection; it can be said all genders are faced with the risk of contracting and spreading Lassa fever.
I think us women face more risk of infection because of our roles, such as prioritizing and caring for men and children when they contract Lassa fever, while exposing ourselves in the process. Again, we sell food in the markets where we meet people from all over and risk contracting this and other diseases. On top of that, think of cooking and cleaning in the home, fetching firewood in the bush where these rats are, can’t you see how exposed we are to this virus? (Female adult, 41 years old, FGD #6).
From the way they say the disease is spread, it is clear that males are more exposed than women. Men encounter these rats in the bush as they farm, especially during harvesting. And for those who eat rats, it’s the boys who hunt and prepare them for cooking, you see. I think it’s just that when women get it from the males, they get sick more often and rush to the clinic more than men, hence it appears like women are more exposed (Male youth; 21 years old, FGD #10).
We are all exposed, but maybe in different ways – males, females and children, we are all in one battle. This is not about who is more exposed than the other, because after all, these people live together, and can still transmit the virus to each other, no matter who is more exposed. Everyone can be exposed as they undertake their roles, so it’s more about letting people understand how they can protect themselves and their loved ones. (Female Farmer, 47 years old, KII #11).
DISCUSSION
The study explored behavioural insights into Lassa fever transmission, prevention and control in two Eastern Sierra Leon districts and unveiled the following insights from thematic data analysis:
-
Awareness of Lassa fever, including its transmission, prevention and control methods, does not always translate to equal knowledge and understanding of the same.
-
Awareness, knowledge and understanding of Lassa fever transmission, prevention and control are important but not always sufficient to prompt the adoption of healthy behaviours (health-related knowledge does not always translate into actual healthy behaviours). Other barriers to health behaviour change includes cultural and traditional beliefs, fatigue and resource availability to support the behaviours.
-
All genders are in their own way exposed to Lassa fever virus based on their roles, and infection of one gender is inextricably linked to infection of the other. Response efforts must not focus on which gender or gender roles bear more vulnerability than the other, but rather at identifying all the roles that lead to vulnerability, to target the mitigation of all gender role-related risks.
The study findings show that practices leading to the transmission, prevention and control of Lassa fever virus can be considered a function of several related factors such as individual and community awareness, perception, knowledge, understanding, capacity, and socio-economic advantage, as well as cultural and traditional considerations. This is supported by existing scientific and research evidence that adoption of healthy behaviours is a complex process whose achievement and sustainment depends on shared understanding of community needs and problems.9–14 Health behaviour change is an art and science of understanding people’s way of life, their perceived needs and values, and using the evidence on existing health problems – behavioural insights, to negotiate and co-construct behaviour change initiatives and monitoring and evaluation approaches, with the affected communities.
In this study, a significant number of diverse participants demonstrated and reported positive understanding and practices with regards to Lassa fever transmission, prevention and control. These can be considered a valuable asset in efforts to negotiate, influence, and motivate adoption of protective perception and practices against Lassa fever by community sceptics or late adopters.8,15,16 The utilization of influential members and community leadership has been demonstrated to be effective in promoting and sustaining positive behaviour change required to prevent disease transmission during outbreaks.17,18
Based on study findings, following recommendations are suggested:
-
There is need to invest in contextual behavioural data generation using online and offline sources, and the utilization of this data to segment and target high-risk groups, and to co-construct, reprogram, monitor and evaluate behavioural change initiatives with the affected communities, in keeping up with changing disease outbreak phases.19–21
-
Identification and involvement of influential community members and diverse groups is key to gain important insights on the background and contextual determinants of counterproductive behaviours, such as non-compliance with recommended public health measures. These influential members and diverse groups can also play an instrumental role in suggesting feasible solutions, addressing knowledge gaps and cultural health paradoxes (dispelling misconceptions and debunking myths), negotiating and influencing health behaviour change for interrupting disease transmission.21,22
-
It is worthwhile to study and identify synergies and potential for integrating disease outbreak programs into routine care to enhance efficiency in resource utilization and to reduce the chances for overexposing the public to health programs (leading to health information overload or saturation, exposure to conflicting health information and health program fatigue).
CONCLUSIONS
The study highlights the need for culturally responsive, resource-sensitive, and gender-inclusive health communication. Health behaviour change for Lassa fever prevention and control is a function of several determinants, that are not entirely exclusive to related awareness, knowledge and understanding, but includes other determinants such as availability of behavioural enablers or resources and cultural and traditional considerations. Behaviour change-related policies and programs for Lassa fever control must prioritise context-sensitive behavioural data generation, utilization and evaluation to leverage effective health behaviour change.
Ethics statement
Ethical approval was obtained from the Government of Sierra Leone Office of Ethics and Scientific Review Committee approval 010/062024.
Data availability
The data and materials supporting the results or analyses of this paper will be made available from the corresponding author, Aminata Grace Kobie, Email: minatakobie@gmail.com on reasonable request to bona fide researchers.
Funding
No funding was received for the study.
Authorship contributions
Kobie AG: Conceptualization; Methodology; Investigation; Formal Analysis; Resources; Software; Visualization; Writing – original draft; Writing – review and editing. Okeibunor JC: Conceptualization; Methodology; Supervision; Validation; Writing – Review and Editing. Gonah L: Methodology; Data interpretation; Visualization; Validation; Supervision; Writing – Review and Editing.
Disclosure of interest
The authors completed the ICMJE Disclosure of Interest Form (available upon request from the corresponding author) and disclose no relevant interests.
Correspondence to:
-
Aminata Grace Kobie:
i. Texila American University, Guyana
ii. WHO Regional Office for Africa, Congo Brazzaville. Email: minatakobie@gmail.com
-
Laston Gonah Department of Public Health, Faculty of Medicine and Health Sciences, Walter Sisulu University, Mthatha 5100, Eastern Cape, South Africa lgonah@wsu.ac.za; lggonah@gmail.com