Diminished Quality of Life among Women affected by Ebola

Journal of Social, Behavioral, and Health Sciences

2016, Volume 10, Issue 1, Pages 112–133

©Walden University, LLC, Minneapolis, MN

DOI: 10.5590/JSBHS.2016.10.1.11

Please address queries to: Jessi E. Hanson, Graduate School of Public and International Affairs, University of

Pittsburgh. Email: jessi.hanson@ymail.com

We wish to acknowledge Ernest Garnark Smith Jr. and Prisie Badu from Renewed Energy Serving Humanity for

leading data collection and data sharing, Meekie Glayweon and Victoria Zaway for research consultation, and Divya

Nawale for research support editing.

Diminished Quality of Life Among Women Affected by Ebola

Jessi E. Hanson

University of Pittsburgh

Alexis C. Decosimo

East Tennessee State University

Megan A. Quinn

East Tennessee State University

This article analyzes data collected from Liberian women afflicted by the Ebola virus disease,

survivors of the virus and noninfected persons living in Ebola-affected homes. This research

is one of the first statistical analyses examining factors diminishing quality of life: negative

experiences, stigma, and psychosocial symptoms among females affected by the virus after

the outbreak. The research presents a thorough literature review, including research related

to other infectious diseases like HIV/AIDS, to inform the gap in studies on Ebola’s effects on

quality of life. Women who are Ebola virus disease survivors demonstrate significant

differences in stigma and psychosocial stress when compared to their female peers. This

article attempts to broaden understanding of the conditions and mental health of women

affected by Ebola.

Keywords: Ebola, psychosocial stress, stigma, negative events, programming, female adults, quality

of life, living with disease, survivors

Introduction

In 2014, the hemorrhagic contagion of Ebola broke out in West Africa, affecting thousands of people.

A study by the Liberian nonprofit organization, Renewed Energy Serving Humanity (RESH, 2015),

provided initial findings of the quality of life of persons in households affected by the Ebola virus

disease (EVD), including factors of negative events, stigma, and developed psychosocial symptoms

because of the disease. This study particularly revealed the implications of EVD for female adults,

whose lives can be drastically altered after the virus enters their household. In the present article,

the data from the RESH study is examined in relation to mental health/trauma, stigma, and

negative experiences. Additionally, quality of life factors identified by the health community as

afflicting individuals living with infectious diseases, specifically with HIV/AIDS will be

comparatively explored.

During the 2014/2015 Ebola outbreak, tens of thousands of households in West Africa were reported

with confirmed or suspected cases of the virus. EVD cases are listed as suspect (demonstrating

potential symptoms of EVD but have not yet tested positive) and confirmed/positive (have more than

Hanson, Decosimo, & Quinn, 2016

Journal of Social, Behavioral, and Health Sciences 113

three to five symptoms of EVD and their blood test is positive for the virus in their system). The

Zaire strain of Ebola was responsible for at least 28,600 cases (Chughtai, Barnes, & Macintyre,

2016). The average survival rate ranged from 30 to 60%, depending on a variety of factors including

an individual’s age, health status, and access to medical treatment. The exact number of EVD

survivors in affected countries is unknown, as not all potential cases received treatment or were

tested for confirmation of infection during the crisis. In Liberia, over 5,000 Liberians are officially

registered as survivors of the disease, more than half of which are female; additionally, there are

thousands of people living in households that had one or more confirmed or suspected EVD cases

(Glayweon & Hanson, 2015).

This article presents data collected by RESH from Liberian women affected by EVD: survivors of the

virus and women living in EVD-affected homes. The analysis demonstrates the common negative

experiences, stigma, and psychosocial symptoms reported and observed amongst the women. This

study presents the factors affecting women with Ebola related to their diminished quality of life. It

draws from literature related to HIV/AIDS as a reference point as to Ebola’s effects on the quality of

life for those affected by the disease. This report aims to contribute to the study of data collected on

persons affected by EVD, focusing particularly on negative experiences, stigma, and psychosocial

wellbeing. It is an initial assessment that aims to further the understanding of key factors afflicting

affected populations, primarily women. This study also strives to draw potential connections to

previous literature on infectious diseases to better inform health and support services for victims of

Ebola.

Method

This article provides a statistical analysis of the RESH dataset from a June–July 2015 study, as well

as a thorough literature review of the effects of disease on peoples’ lives. After data collection

conducted 3 months after the country was first declared Ebola free, RESH later shared a modified

dataset of the study with the authors, presenting only nonidentifiable information of individual

participants, for an external statistical analysis.

The data assessed are from 40 communities that were randomly selected from a government list of

communities identified as EVD affected (or former hot zones), in three Liberian counties:

Montserrado, Bomi, and Margbi. Data collection was conducted by nonclinician social workers and

psychosocial workers of the Playing to Live program. Data collection occurred during the baseline for

this program, and enumerators were trained and monitored by RESH clinical supervisors, in

collaboration with the Government of Liberia (GoL) and support by UNICEF. A total of 144 female

heads of households were purposely selected within each of the 40 evaluation sites. Priority selection

of participants was first given to households with EVD survivors, secondly to households with

confirmed EVD cases, and lastly to households residing within the hot zone, as recommended by the

Liberian Ministry of Health (MoH) and the Ebola Survivors’ Network. All participants were

interviewed individually by enumerators using a list of survey questions. Captured personal

information included age, education, household indicators, socioeconomic and marital status such as

employment/income generation. Additional individual disease information included disease status,

stigma by family or community members, at-risk behaviors, and psychosocial symptoms that they

have experienced as a direct result of EVD. The interviews were conducted orally as many

participants were illiterate. Enumerators were trained to first ask each survey question formally,

and if the participant had difficulty understanding, to then restate the question colloquially in

Liberian English. Enumerators worked in pairs with clinicians supervising interviews.

Hanson, Decosimo, & Quinn, 2016

Journal of Social, Behavioral, and Health Sciences 114

Data collection for main quality of life factors, including negative events, stigma by family or

community members, at-risk behaviors, and psychosocial symptoms (PSS), was verified through

triangulating using methods of observation and interviews with other household adults. For

instance, if a participant listed a PSS symptom like poor eating habits, the enumerator verified this

by observing mealtime to see if the person ate normal amounts of food, or asked another household

adult to verify the development of this symptom after Ebola entered the home/community. If a

participant reported experiencing a form of stigma, the enumerator would observe for interaction

with other family or adult members, or speak with another adult member to list a specific time or

incident that they witnessed this stigma. If the symptom or stigma could not be confirmed through

triangulation, it was deleted from the survey.

Many households affected by EVD are headed by women who are single, widowed, divorced, or

abandoned by partners due to their EVD status. Of the 144 women sampled from EVD-affected

communities, nine were confirmed EVD survivors (T1) making up the total population in the survey

areas, 67 were noninfected persons whose household had one or more EVD case that often resulted

in death (T2), and 77 were noninfected persons who had no EVD cases in their household but lived in

proximity of outbreaks (T3).

The present study uses the literature review in tandem with the presentation of the 2015 EVD study

findings. An overview of the literature review on the negative events, stigma, and psychosocial

trauma experienced by persons affected by HIV/AIDS is presented as a guide for the discussion of

Ebola’s effects on individuals. The analysis further examines the common negative experiences

reported by female EVD survivors before, during, and after the outbreak. The total population of

EVD survivors in the EVD-affected communities was included in this study (N = 9) and is not a

random sample of survivors. All participants were purposefully selected based on priority listing.

The negative experiences of the survivors are compared to those of their peers, assessing for

statistically significant mean differences and presenting ordinary least squares regression analysis,

including factors such as income and childrearing. The next section presents the data on stigma

experienced by both survivors and women living in EVD-affected homes who are noninfected

persons. The final section reviews of the data on the psychosocial stress symptoms both self-reported

and observed in participants.

Results and Discussion

HIV/AIDS Literature

Health literature shows that persons living with an infectious, life-threatening disease frequently

are affected beyond the physical effects of their condition (Fife & Wright, 2000; Goffman, 1963).

There is limited published research asserting the effects of EVD on affected populations; however,

the literature on other infectious viruses is more advanced and provides a foundation for assessing

the relationships between disease and an individual’s quality of life. Specifically, persons living with

HIV/AIDS are affected by prevalent factors including traumatic events, mental illness, and

stigmatization, which are associated with negative health outcomes. These studies linking mental

health and negative experience with HIV/AIDS further provide insight to improving medical

treatment protocols and support services for persons living with a chronic disease (Alonzo &

Reynolds, 1995; Stoskopf, Kim, & Glover, 2001; Whetten, Reif, Whetten, & Murphy-McMillan, 2008).

Individuals diagnosed with HIV/AIDS, their family, and their friends frequently confront high rates

Hanson, Decosimo, & Quinn, 2016

Journal of Social, Behavioral, and Health Sciences 115

of stigmatization by people with whom they interact such as their own family, neighbors, and

coworkers (Alonzo & Reynolds, 1995; Valdiserri, 2002).

There is an assumption that the aggressive and querulous nature of EVD may separate this

hemorrhagic disease from other deadly infectious diseases such as HIV/AIDS. While there are

distinctions in the nature of these disease types, they share notable similarities, including human-to-

human transmission through bodily fluid, no known cure, and incubation periods during which there

are few to no symptoms and testing is difficult. A 2014 literature review, presented by Davtyan,

Brown, and Folayan (2014), confirmed these similarities, and further concluded that HIV/AIDS and

Ebola are present-day epidemics connected to social stigma, causing affected communities to face

violence, isolation, and a reduced quality of life. Moreover, the findings from the present Liberia

study show similar trends between disease diagnosis and the negative experiences with which

victims and their families present. In parts of Africa, HIV/AIDS and EVD also frequently include

misconceptions among impoverished populations, who tend to have limited education and may have

less access to readily available awareness information and medical services. Scientific concepts of

disease transmission and infection can further conflict with traditional spiritual beliefs that assert

illness because of curses and divine fate. Additionally, preventative health protocols often clash with

important traditional practices (Glayweon & Hanson, 2015).

Negative Experiences Before Ebola

Liberian women often experienced trauma before the 2014/2015 Ebola outbreak. During the civil

war, most Liberian women and girls were victims of horrific events. Sixty to seventy percent of

females were either raped, lost family members, or fled violence as refugees. Most women lived in

extreme poverty in the years after the war (OECD Development Centre, 2015; Toral, 2012). The

women in the present study likely suffered from psychosocial stress and trauma that they

experienced from the war and the recovery. No data was collected by the study before the outbreak,

which would have captured trauma levels in women before EVD. When Ebola struck their

communities, EVD survivors and their family members reported that they experienced emotions

such as anxiety, fear, and flashbacks that they associated with wartime (Glayweon & Hanson, 2015).

This analysis acknowledges that most participants experienced trauma before EVD entered the

country.

There is a cultural trend of not sharing war trauma stories. Only a few of the study participants

made direct reference to negative experiences or traumatic events that they underwent during the

war and recovery period. Further evaluation of trauma levels experienced by people before and after

EVD particularly in post-war settings may better reveal these relationships and the impact on the

individual, and inform supportive services.

Negative Experiences During Ebola

Numerous documentaries and studies captured the traumatic stories of individuals who were

diagnosed positive for Ebola and were admitted into Ebola treatment units (ETUs). These pieces

have helped identify the core issues affecting survivors, often qualitatively. A 2015 qualitative study

identifies the mental distress amongst survivors discharged from an ETU (Rabelo et al., 2016). The

study presents common experiences evidenced in quotes from focal groups of survivors facing trauma

within the care units while sick. Further, it shows that their suffering continued even after

discharged from treatment. Research such as in the present study and the work by UNICEF to

Hanson, Decosimo, & Quinn, 2016

Journal of Social, Behavioral, and Health Sciences 116

capture survivors’ stories help to communicate the need. Yet the quantitative narrative of the crisis

is less known. There are few statistical analyses on EVD, and much less quantitative analysis of

Ebola’s impacts on people’s mental health, stigma, and negative experience.

The MoH and the Ministry of Gender, Children, and Social Protection (MoGCSP) in Liberia

identified women and older girls as particularly at risk to EVD due to the nature of its transmission.

Liberian women may be more susceptible to infection due to traditional gender roles, such as tending

sick people, leading ceremonial funeral preparations including body washing, and washing and

cleaning of household items like clothing and dishes, which may be contaminated by the virus. More

women suffered from EVD than men and were placed in ETUs.

At the outbreak climax, there were not enough ETU beds to meet the capacity of the sick people

lying in wait to be saved. Inside the ETU, patients underwent severe physical, mental, and

psychological trauma (Chertow et al., 2014; Rabelo et al., 2016). They recounted undergoing extreme

physical pain from the virus, watching other persons suffering, with blood and other human fluids a

common visual, and body bags a daily experience. One woman recounted that her physical pain felt

as excruciating as being in labor for days (Glayweon & Hanson, 2015).

Females are also at risk of sexual infection of EVD if their male partner is infected with the virus, or

is a survivor and does not use proper protection, as scientific studies show that male semen can carry

the virus for months after recovery (Christie et al., 2015; Deen et al., 2015). The present study

primarily focused on interviewing participants about their experiences after EVD and less about

their experiences before and during the crisis. We focus on literature to further inform the narrative

based on the findings of the study.

Nearly 50% of the 144 participants’ households from the 2015 study reported an EVD case, in which

half the women spoke about the hardship of watching family members and neighbors suffering from

the horrific symptoms of the disease. Throughout the crisis, misunderstanding and lack of awareness

of the disease caused much of the population to believe Ebola did not exist or was propaganda by the

government, and fear of stigma in contact cases (Nyenswah et al., 2015). Misconceptions about how

this new disease functioned heightened fear and confusion amongst the general population, similar

to when HIV/AIDS infected new areas. This was compounded by the fact that these two viruses

spread by contact with bodily fluids, have no cure and are deadly (Davtyan et al., 2014).

In the early stage of the outbreak, many within the populace believed EVD was not real. Most

symptoms were easily mistakable for those of other diseases (Goeijenbier, Van Kampen, Reusken,

Koopmans, & Van Gorp, 2014; Green, 2014). Many households avoided going to an ETU as they

heard of inconsistent health services, such as nurses refusing to administer medicines. Cremation of

the dead was also a traumatic experience (burning of dead bodies in ETUs). This new practice,

originally implemented as a public health precaution to minimize contagion, defied traditional

ceremonial burials and caused distress amongst families who could not properly mourn and bury

their dead (Agusto, Teboh-Ewungkem, & Gumel, 2015; Nyenswah et al., 2014).

As infected persons’ symptoms progressed, female heads of household reported watching their loved

ones struggle against death. Ebola incubation periods ranged from 2 to 21 days. Persons with

probable or suspect Ebola often could not be touched for threat of infecting others. Women who could

not help alleviate the pain of their beloved underwent emotional strain. Many died at home, while

others were taken to ETUs in ambulances. Interviewed participants repeatedly made reference to

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Journal of Social, Behavioral, and Health Sciences 117

the anxiety they felt at the sound of ambulances; in Liberia, there were few ambulances before the

outbreak.

Another common negative experience among households with EVD cases (T1–T2) was the loss of

their home and possessions immediately as a result of the disease. County Health Teams and MOH

burial teams routinely sprayed disinfectant in and around contaminated homes, which destroyed

many household items. Community members also often burned or disposed of possessions that

patients with suspect or positive cases owned, such as clothing, bedding, and dishware, as means of

preventing disease spread through touching infected items. Lost items were rarely replaced by those

who destroyed them, and left survivors, many of whom were poor, unable to buy new ones. Some

families were left with few to no mattresses, dishes or clothing after discharge, living in dire poverty.

They also tracked all persons who had been in contact with probable and infected persons, which was

also an integral part of preventing further spread (Nyenswah et al., 2015); however, those people

whom had come into contact with sick persons often hid from the tracking teams in fear of being

labeled as a possible case and being placed in quarantine. Patients discharged from ETUs were

regularly given one-time stipends, and a supply of basic need items. This support was often

reportedly not enough to cover the loss of victims. Some survivors were forced to relocate or were

legally evicted from their homes (Glayweon & Hanson, 2015).

In ETUs, survivors' individual stories were wrought with hardship. Often admitted for 3 weeks in

quarantine, infected patients had minimal contact with the outside. They were stripped of their

personal possessions, and then assigned to beds next to other patients in similar stages of the

disease. Qualitative research captured the difficult environment in the ETU (Rabelo et al., 2016),

often described as chaotic and frightening. Healthcare workers wore protective gear and masks.

There were frequently not enough workers for the number of patients. Survivors reported waiting in

agony for hours for help. They lay next to dead bodies waiting for later removal. Patients fought

extreme symptoms including high fevers and symptoms (Goeijenbier et al., 2014), similar to cholera.

Some survivors reported feeling strengthened by healthcare workers and volunteer psychologists,

who counseled them, prayed with them, and encouraged them to fight on. Upon discharge, survivors

often were given used clothing. There was a celebration with ETU staff of their discharge. Family

and friends greeted survivors to take them home. However, upon departure, they all learned who of

their beloved were dead. Health workers avoided informing interned patients undergoing treatment

of family who had passed away; patients who found out their relations had died often suffered

depression which lowered their own chances at recovery. For some discharged persons, no one was

left (Glayweon & Hanson, 2015).

Negative Experiences After Discharge

Upon returning to their communities, survivors (T1) faced additional negative experiences. Survivor

participants reported finding their homes looted or their possessions destroyed. A church member

wearing the survivor's dress ironically greeted one survivor, returning to her community; the church

member claimed the county burial team burned all the survivor's things. Discharged patients also

tended to face the sudden experience of being isolated from family and friends. People often avoided

those who were discharged from ETUs and their families out of fear and misconception either that

they likely still carried the disease or related to local spiritual and cultural beliefs prevalent in West

Africa that these persons had the misfortune to be cursed. Spiritual beliefs are often associated with

traditional tribal religious and cultural practices. Health issues like illness often are attributed to

spiritual causes colloquially labeled as dark magic or ill fortune.

Hanson, Decosimo, & Quinn, 2016

Journal of Social, Behavioral, and Health Sciences 118

Survivors (T1) and women from EVD-affected homes (T2) reported feeling stigma in public, including

acts of public shaming. Survivors were instructed by health workers to avoid sexual contact for

several months after discharged as EVD remained in the body such as in semen (Christie et al, 2015;

Deen et al., 2015). There was confusion as to how they could be labeled "EVD free" yet still carried

the disease, causing emotional confusion and likely loss of self-esteem. Some women worried that

they may be infertile due to suffering Ebola.

Income

In Liberia, females historically face high levels of gender inequality and socio-economic disparities,

including lower rates of education, employment, and income generation than men, according to the

United Nations Development Programme’s (2015) Human Development Report. The 16-month crisis

halted much of the economy; 90% of the female participants reported being unemployed. Some EVD

survivors (T1) felt their disease status negatively affected their ability to make money. Following the

end of the crisis, the MoH/MoGCSP worked with key agencies to ensure priority was given to hire

survivors as voluntary program workers such as in ETUs. Participants who were survivors had a

higher frequency of working compared to their peers, although this difference was not statistically

significant. Survivors’ income was often unstable. This is likely due to issues of timely pay during the

emergency. Additionally, their jobs were typically temporary and ended with the crisis.

Excluding two outlier incomes of over US $50/day, the average daily household income of the 144

participants was US$2.61. However, nearly 70% of all the women reported their last daily income as

US$0. Table 1 shows that survivors made US$1.09 per day less than their peers despite their

temporary employment. The difference between incomes was not significant between survivors and

noninfected persons, yet this may be due to the small number of survivors in the sample as

demonstrated in the effect size. Further demonstrated in Table 2, the effect of being an EVD survivor

and/or living in an EVD-affected household yielded no significant effect on the outcome variables of

daily income.

Table 1: Negative Experience Factors on Income and Raising Children Among Female Adults

Ebola Virus Disease (EVD) Survivors (T1) Compared to Peers, in Liberian EVD-Affected

Communities

Note. CI = confidence interval.

* p < .1. ** p < .05. *** p < .01.

Factor

Survivors (T1)

M, SE, SD

[CI], N

Peers

M, SE, SD

[CI], N

Difference

M, SE, [CI],

t Value, Cohen’s d

Daily income

(US$)

1.59, 0.70, 2.12

2.68, 0.66, 7.66

1.09, 2.57, [–3.98, 6.17],

0.43, 0.15

[–0.46, 3.22], 9

[1.37, 4.0], 134

Adult–child ratio (# of

children per 1 adult)

1.9, 0.52, 1.4

[0.7, 3.1], 8

1.5, 0.09, 0.95

[1.4, 1.7], 126

–0.39, 0.36, [–1.10, 0.32], –

–1.09, –0.40

Hanson, Decosimo, & Quinn, 2016

Journal of Social, Behavioral, and Health Sciences 119

Childcare

The HIV/AIDS epidemic in Africa and other parts of the world led to the development of a new

categorical status for orphaned and vulnerable child affected by the disease. Numerous countries like

Kenya and Tanzania have a heavy burden on surviving adults affected by HIV/AIDS to raise

orphaned or abandoned children (Cluver, Gardner, & Operario, 2007; Evans, 2005; Nyambedha,

Wandibba, & Aagaard-Hansen, 2003). Similarly, a major concern from the Ebola crisis was that the

same burden befell victims of EVD. During the crisis, survivors and families affected by EVD

reported to GoL the added responsibility of taking on adopted children of family and neighbors who

had died of virus when no other direct family was available. GoL policy enforced that children be

placed with blood relatives over persons who were not direct kin. Some household groups were

broken up multiple times, creating distress for some women who had formed bonds with adopted

children who were returned to family (Fowler et al., 2014; Glayweon & Hanson, 2015).

Table 2: Ordinary Least Squares Regression Analysis of Income and Childrearing Among Liberian

Females Affected by Ebola Virus Disease (EVD)

Variables

Daily Income

Adult–Child Ratio

Model 1

Model 2

Model 3

Model 4

Model 5

Model 6

EVD survivor

–2.03

–2.01

0.25

0.20

(1.87)

(1.71)

(0.51)

Living in EVD HH

–0.07

0.04

0.21

0.20

(1.48)

(1.43)

(0.18)

(0.17)

Age

–0.04

0.00

(0.03)

(0.04)

(0.03)

(0.01)

Education

–0.21

–0.20

–0.19

–0.10*

–0.11*

–0.10*

(0.32)

(0.33)

(0.32)

(0.06)

Working

7.89***

7.81***

0.04

0.03

0.05

(2.68)

(2.65)

(2.69)

(0.28)

(0.27)

Adult–child ratio

–0.47

–0.49

(0.36)

(0.35)

(0.34)

Fixed effects

3.14

3.08

–0.08

–0.07

–0.08

(Interlocation:

(2.71)

(2.61)

(2.68)

(0.18)

(0.17)

County)

–1.45**

–1.46**

–1.37**

–0.10

–0.05

–0.11

(0.66)

(0.62)

(0.65)

(0.28)

(0.29)

(0.28)

Constant

4.31**

4.25*

4.04**

1.53***

1.74***

1.57***

(2.11)

(2.30)

(2.02)

(0.44)

(0.46)

(0.44)

Observations

124

125

0.12

0.11

0.06

0.05

Adjusted R

0.056

0.064

0.060

–0.000

–0.003

0.005

Note. HH = household.

* p < .1. ** p < .05. *** p < .01.

Hanson, Decosimo, & Quinn, 2016

Journal of Social, Behavioral, and Health Sciences 120

There was the common perception by emergency responders that in EVD-affected households,

surviving adults had more children to care for than households where no one died of Ebola. Yet this

assumption may be faulty. The study finds that after the crisis, women affected by EVD tended to

have the same average adult–child ratio as their community peers whose homes did not have EVD.

Survivor households had an average ratio of one adult per nearly two children, while nonsurvivor

households had 1:1.5. As shown in Table 2, we further regress the effect of being an EVD survivor

and/or living in an EVD-affected household on the dependent variable of adult–child ratio, for which

both independent variables’ effects show to be not significant; however, this yields a problematic

interpretation due the small sample size of survivors. A larger sampling in future research may

provide more conclusive results.

HIV/AIDS literature on households living with the disease demonstrate psychological and behavioral

distress that adults raising affected children face and the need for them to have supplemental

support to cope (Cluver et al., 2007; Evans, 2005; Nyambedha et al., 2003). The need for

programmatic support for orphans and vulnerable children, and their caregivers has been identified

as vital for recovery, particularly in Liberia after the outbreak (Abramowitz et al., 2015). In several

EVD-affected homes, there were extreme instances of one adult per five children. There remain

outlying cases of female survivors and female heads of households affected by EVD who care for a

large number of children.

Stigmatization

Various illnesses have been historically connected to stigma, or the inclusion of stigma within a

social category with the outcome of a "spoiled identity" that distances the person from others (Fife &

Wright, 2000; Goffman, 1963). Stigmatization is a social construct, and may be defined as the

undesirable or discrediting attribute that an individual possesses that reduces the individual’s

status within the perspective of his/her society (Brown, Trujillo, & Mcintyre, 2001; Davtyan et al.,

2014; Goffman, 1963; Preston, D'augelli, Kassab, & Starks, 2007; Whetten et al., 2008). Fife and

Wright (2000) stated that stigma may include being socially rejected, ostracized, isolated, shamed, or

treated poorly. More recently, HIV/AIDS research identified stigma as the individual’s anxiety or

worry of experiencing negative attitudes or discrimination as a result of disclosure of their HIV

status by others. Whetten et al. (2008) reviewed the effects of HIV/AIDS and referenced nine studies

identifying the harmful effects of experienced and perceived stigma among people due to their

disease-status.

There is growing health research that recognizes the similarities between the stigma directed

towards persons affected by HIV/AIDS and persons affected by EVD. Linkages include the life-

threatening nature of both diseases, as well as the misinformation and misconceptions around the

virus, which cause particularly are frequent amongst affected groups. The differences between the

viruses including the mortality rates, modes of transmission, timespan of infection are noted,

however stigma against affected persons remains similar and disturb the quality of life (Davtyan et

al., 2014). At the initial phase of the EVD outbreak in West Africa, stigma was quickly recognized as

a public health and social issue. Instances of violence against suspected cases and persons who

survived EVD were reported. Safety issues and negative community response often were issues due

to a poor understanding of how the disease spread (Abramowitz et al., 2015). Public messaging

campaigns at the local and national level attempted to present accurate information to the general

population, however it was slow and limited. The research by Daytyan et al. (2014) further concluded

that while the spread of HIV/AIDS has a longer history, there are key lessons learnt from this

Hanson, Decosimo, & Quinn, 2016

Journal of Social, Behavioral, and Health Sciences 121

pandemic, which may be applied to EVD, especially to reduce and prevent stigma against those who

become infected, their families, and friends. Yet first, the development and response community

must better understand the nature of the stigma that can erupt in an outbreak.

The 2015 Liberia study by RESH captured the stigma that female EVD survivors (T1), heads of

household of EVD-affected homes (T2), and heads of households with no EVD cases (T3) reported

experiencing as a direct result of EVD. The present external analysis examined the frequency of

experiencing stigma by family and community, first for EVD survivors (T1) compared to their peers

(presented in Table 3), and secondly of heads of households affected by EVD who did not have the

disease (T2), presented in Table 4. Lastly, the authors regressed the effects of both variables on

stigma (Table 5).

Table 3: Stigma Amongst Female Adults Who Are Ebola Virus Disease (EVD) Survivors (T1)

Compared to Peers, in Liberian EVD-Affected Communities

Negative

Factor

Peers (N = 135)

Survivors (T1; N = 9)

Pearson’s



Fisher’s

Exact (One-

Sided)

Frequency

Expected

Frequency

Expected

Frequency

No community

stigma

66%

64%

33%

64%

Experienced

community

stigma

34%

36%

67%

37%

Difference

3.89**

0.07 (0.06)

No family

stigma

89%

86%

44%

Experienced

family

stigma

11%

14%

56%

14%

Difference

13.94***

0.003 (0.003)

Note. For 

: ** p < .05. *** p < .01.

The interview differentiated between the stigmas that individuals felt from their family and from

members of their community to assess for levels of significance. Enumerators verified the self-

reported stigmatization by later observing for demonstrated acts against the individuals that could

confirm their feeling of stigma, as well as for asking for instances in which they experienced acts of

stigma and confirming these events through asking other adult family members or friends.

Community Stigma

Conducting a stratified statistical analysis, all three tiers included large percentages of women who

reported experiencing EVD-instigated stigma by community members. This includes T3 women who

come from former outbreak communities, which may be attributed to feeling a sense of stigma likely

by the outer community. Table 3 demonstrates that 67% of EVD survivors reportedly experienced

community stigma compared to their peers’ average frequency rate of 34%. While this difference is

significant, due to the low sample size of survivors, these results should be interpreted with caution.

Comparatively, as shown in Table 4, 45% of women living in Ebola-affected households who never

Hanson, Decosimo, & Quinn, 2016

Journal of Social, Behavioral, and Health Sciences 122

had the virus (T2) experienced stigma, which was also significantly more than their peers

particularly women in T3 who lived in homes with no EVD case history. Women living in EVD

affected homes including survivors often reported to the MoH incidences where community members

tried to illegally evict them or pressured them to move out of the community (Glayweon & Hanson,

2015). After discharge from ETU, several of the study participant survivors in fact were forced to

relocate their families to new areas where their disease status was unknown by their neighbors.

Table 4: Stigma Among Female Adults Living in Ebola Virus Disease (EVD)-Affected Homes Who

Are Noninfected Persons (T2) Compared to Peers, in Liberian EVD-Affected Communities

Negative

Factor

Peers (N = 77)

T2 Females (N = 67)

Pearson’s



Fisher’s

Exact (One-

Sided)

Frequency

Expected

Frequency

Expected

Frequency

Not

experienced

community

stigma

71%

64%

55%

64%

Experienced

community

stigma

29%

36%

45%

36%

Difference

4.07**

0.06 (0.03)

Not

experienced

family

stigma

87%

86%

85%

86%

Experienced

family

stigma

13%

14%

15%

14%

Difference

0.11

0.81 (0.46)

Note. For 

: ** p < .05.

Using the logistic regression model presented in Table 5 that includes fixed effects on interlocation

(county) and controlling for all other variables, we assessed the effects of the independent variables

of being an EVD survivor and/or living in an EVD-affected home on the outcome of community

stigmatization. Models 1–3 correspond to the y variable of community stigma, while Models 4–6

instead regress on the outcome of family stigmatization.

Interpreting Table 5, Model 1, if a person is an Ebola survivor, the odds of experiencing community

stigma (versus no community stigma) increase by a factor of 3.23. Specifically, the marginal effect of

being an Ebola survivor is 64%, indicating the odds of experiencing community stigma holds truer

for survivors than their peers.

Hanson, Decosimo, & Quinn, 2016

Journal of Social, Behavioral, and Health Sciences 123

Table 5: Logistic Regression Analysis of Stigma Experienced by Females Affected by Ebola Virus

Disease (EVD)

Variable

Community Stigma

Family Stigma

Model 1

Model 2

Model 3

Model 4

Model 5

Model 6

EVD survivor

3.23

2.61*

4.17***

3.88***

(2.20)

(1.50)

(1.54)

(1.48)

Living in EVD HH

1.50***

1.31***

0.76

0.36

(0.50)

(0.48)

(0.64)

(0.57)

Age

0.03

0.02

0.03

0.02

0.01

(0.02)

(0.03)

Education

–0.20

–0.19

–0.40*

–0.42**

–0.36*

(0.13)

(0.22)

(0.21)

(0.19)

Working

0.79

0.91

0.25

0.41

(0.83)

(0.66)

(0.81)

(0.93)

(1.00)

(0.90)

Adult–child ratio

–0.42

–0.29

–0.34*

–0.46*

–0.40*

–0.26

(0.26)

(0.23)

(0.20)

(0.25)

(0.23)

(0.28)

Fixed effects

–3.62***

–3.44***

–3.27***

–2.53**

–2.54**

–1.67

(Interlocation:

(0.90)

(0.82)

(1.17)

(1.06)

(1.10)

(1.11)

County)

–0.89

–0.54

–0.96

(0.90)

(0.92)

(0.87)

Constant

–1.26

–0.10

–1.03

–1.62

–1.05

–1.13

(1.08)

(0.92)

(1.04)

(1.63)

(1.44)

(1.36)

Observations

125

116

Pseudo R

0.194

0.211

0.258

0.119

Note. HH = household.

* p < .1. ** p < .05. *** p < .01.

Model 1 further predicts the odds of experiencing community stigma multiples by a factor of 1.5

when a woman living in a household with EVD case history rather than a home with no Ebola. The

marginal effect of this relationship corresponds to a 30% increase in the odds that dependent

variable of community stigma is true. Models 2 and 3 present different odds ratio modeling to better

assess this relationship. Community stigma appears to correspond to higher odds with the

independent variable of living in an EVD-affected household than with being a virus survivor.

Family Stigma

The difference in reported family stigma among women of EVD-affected homes (T2) and their peers

was not significant, as referenced in Table 4. Yet reported frequency of stigmatization by family

members was significantly higher amongst EVD survivors (T1) than non-EVD survivors (presented

in Table 3). One in two female survivors in the study experienced family stigma. It should be

mentioned that the sample size of survivors was low. The Ebola Survivors’ Network–Liberia reports,

however, often survivors were feared as possibly still being infectious even after discharge from an

ETU and are blamed for being the root cause of the spread of the disease among the family, or being

viewed as cursed which could spread through association (Glayweon & Hanson, 2015).

Models 4–6 in Table 5 further explores logit modeling including fixed effects on interlocation (county)

and holding all other variables constant to examine the effect of the independent variables of being

Hanson, Decosimo, & Quinn, 2016

Journal of Social, Behavioral, and Health Sciences 124

an EVD survivor and/or living in an EVD-affected household (T2) on family stigma. If a person is an

Ebola survivor, the odds of experiencing community stigma (versus no community stigma) increase

by a factor of 3.23. However, the variable of being a survivor (T1) is statistically significant. Model 4

demonstrates that if a person is an Ebola survivor, the odds of experiencing family stigma (versus no

family stigma) increase by a factor of 4.14. In other words, this model predicts that being a survivor

versus never testing positive for Ebola corresponds to a 76% increase in the odds that the dependent

variable of experiencing family stigma is true. Models 5 and 6 further test the potential

relationships. Although they vary in their coefficients for the effect of being a survivor and living in

an Ebola-affected household, the different models demonstrate similar pattern in odds-ratios.

Psychosocial Stress Symptoms

HIV/AIDS literature identifies the relationship between HIV-related stigma, increased depression,

posttraumatic stress disorder, and risky behaviors in male and female populations, in the United

States and Africa (Mahajan et al., 2008; Preston et al., 2007; Simbayi et al., 2007; Whetten et al.,

2008). This fear of stigma comes at risk of affecting proper reporting based on individuals’ attempts

to minimize judgment from medical providers of how they or their family were infected as well as

neighbors and family discovering their status (Valdiserri, 2002). Similarly, during the 2014 EVD

crisis a common issue was reports of persons with possible symptoms not openly disclosing their

health issues and incidents of EVD exposure to medical staff, not seeking treatment, or not

cooperating with health policies, primarily out of fear of being labeled EVD-positive (Weyer,

Blumberg, & Paweska, 2014). One evaluation by Bellan, Pulliam, Dushoff, and Meyers (2014)

recognized that survivors of symptomatic Ebola likely experienced psychosocial trauma or

stigmatization, which may negatively affect their ability to perform if recruited for work positions.

Additionally, qualitative research shows that ETU-discharged survivors also demonstrated distress

during care (Rabelo et al., 2016). Yet limited research exists that demonstrates quantitative trauma

rates in EVD-affected persons.

As most of the enumerators in the 2015 RESH study were social workers or trained PSS workers

who were not monitored by clinician supervisors in field, they were not fully authorized to diagnose

depression, posttraumatic stress disorder or other clinical symptoms. However, they were trained to

identify symptoms listed on a MoH-authorized PSS scale for nonclinicians (Glayweon & Hanson,

2015). There is similar research with tools that have been developed and commonly utilized to

diagnosing post-traumatic stress for clinicians (Davidson et al., 1997; Foa, Cashman, Jaycox, &

Perry, 1997; Foa, Riggs, Dancu, & Rothbaum, 1993). Common symptoms on the 2015 Liberian PSS

scale included frequent sadness/crying, anger, withdrawal, worry/anxiety, nightmares, flashbacks,

lack of energy, extensive violence, bad eating habits (lack of eating or overeating), lack of sleep, poor

self-care (bathing, attention to health, etc.), and substance abuse (alcohol/drugs/smoking).

Enumerators asked each female adult if she had experienced each symptom after EVD entered her

community and/or home.

Hanson, Decosimo, & Quinn, 2016

Journal of Social, Behavioral, and Health Sciences 125

Table 6: Psychosocial Stress Symptoms (PSS) Among Female Adults Who Are Ebola Virus Disease

(EVD) Survivors (T1) Compared to Female Peers in EVD-Affected Communities

Note. CI = confidence interval.

* p < .1. ** p < .05. *** p < .01.

As shown in Table 6, the study participants who were EVD survivors (T1) suffered an average of 36%

of the 12 potential PSS symptoms; this is a significant difference of 13% more symptoms compared to

their peers. Females from EVD-affected homes who never tested positive for Ebola (T2) also

demonstrated high rates of PSS compared to their peers, yet this difference was not significant. EVD

survivors had higher reported and demonstrated rates for nearly all individual PSS symptoms, some

more than others. Symptoms that were most associated with surviving the disease include: poor

eating habits, withdrawal, substance abuse and flashbacks.

The 67 noninfected heads of households affected by EVD (T2) did not demonstrate statistically

significant differences in levels of psychosocial stress, including most individual PSS symptoms,

compared to their study peers. The average noninfected female living in an EVD-affected home

demonstrated 25% of all possible 12 symptoms, only 3% higher compared to their peers (t = –0.97, p

< .40, Cohen’s d = –0.16). Sorrow, poor self-care, and low energy were moderately correlated with

living in EVD-affected homes.

A 2015 statistical analysis in Guinea identified anorexia as common diagnosed symptom among EVD

survivors as effects of the virus, not due to a lack of food but an indication of trauma (Qureshi et al.,

2015). Yet poor eating habits (eating disorder) was also significant among survivors reported as a

psychosocial stress indicator, including lack of eating/loss of appetite and overeating, which the

evaluation clinicians attributed to stress eating. Further, Haddad and Gillespie (2001) state that

eating disorders like anorexia are also identified as possible symptoms, which need to be additionally

treated in persons with HIV/AIDS.

Like EVD, withdrawal is associated with positive HIV/AIDS status, yet it is often related to stigma

affecting the individual, per Fife and Wright (2000). Additionally, there are prevalent rates of

patients with HIV/AIDS who are also diagnosed with substance abuse and depression, yet this

relationship is complex (Berger-Greenstein et al., 2007; Breitbart et al., 1997). It is culturally

atypical for women to use substances such as alcohol in Liberia. The female survivors in the study

who reported using alcohol and other substances admitted doing so after returning to their

communities from ETU, and demonstrated a desire to indulge in at-risk behaviors like partying that

they had not previously done before Ebola.

Factor

Survivors (T1)

M, SE, SD

[CI], N

Peers

M, SE, SD

[CI], N

Difference

M, SE, [CI],

t Value, Cohen’s d

Total PSS symptoms

(average % of all

possible 12

symptoms)

36%, 0.07, 0.21

[0.20, 0.52], 9

23%, 0.01, 0.17

[0.20, 0.26], 135

–13%**, 0.06, [–0.24, –0.01],

–2.22, –0.77

Hanson, Decosimo, & Quinn, 2016

Journal of Social, Behavioral, and Health Sciences 126

Table 7: Ordinary Least Squares Regression Analysis of Average % of Psychosocial Symptoms

(PSS) Among Liberian Females Affected by Ebola Virus Disease (EVD)

Note. HH = household.

* p < .1. ** p < .05. *** p < .01.

Examining OLS modeling using fixed effects on inter-location including adult-child ratio, we regress

the effect of being an EVD survivor and/or living in an EVD-affected home on the outcome of average

percentage of listed/demonstrated PSS symptoms (presented in Table 7). Models 1–5 present various

interpretations of the key independent variables on the outcome. For this analysis, we specifically

examine Model 5 presenting the joint effect of two key dependent variables on the outcome of total

percentage of psychosocial stress, holding adult-child ratio constant. Being a survivor of EVD is

associated with a 16% increase in psychosocial stress, while living in an EVD-affected household

increases stress by 7%, for which both variables’ differences are significant (p < .05; Adjusted R

0.18).

However, the relationship between EVD disease status and living in a home that had members with

positive EVD is complex in discerning between stress suffered because of surviving the status

compared to caring for and losing family members to the disease, or the negative factors that these

women face as a result of the outbreak.

Variable

Average % of Total PSS

Model 1

Model 2

Model 3

Model 4

Model 5

EVD survivor

0.13*

0.13

0.14*

0.16**

(0.07)

(0.08)

Living in EVD HH

0.03

0.06*

0.07**

(0.03)

Age

–0.00

(0.00)

Education

–0.01

(0.01)

Working

–0.00

(0.05)

Adult–child ratio

–0.04***

–0.03*

–0.03**

(0.01)

Interlocation

–0.09***

–0.10***

(County)

(0.03)

–0.17***

–0.15***

–0.17***

(0.04)

(0.03)

(0.04)

Constant

0.23***

0.22***

0.40***

0.31***

0.28***

(0.01)

(0.02)

(0.08)

(0.03)

Observations

144

125

133

0.03

0.01

0.18

0.14

0.18

Adjusted R

0.0267

0.000

0.120

0.112

0.143

Hanson, Decosimo, & Quinn, 2016

Journal of Social, Behavioral, and Health Sciences 127

Conclusions

Female adults affected by EVD, both survivors of the virus and those living with others with the

disease, face difficult experiences that can negatively impede their recovery. Health literature

demonstrates that adults living with a disease such as HIV/AIDS often are at higher risks of caring

for additional children than they normally would raise and have difficulty in earning a stable income

sufficient to support their household (Cluver et al., 2007; Evans, 2005; Nyambedha et al., 2003).

During the Ebola outbreak, government agencies and international development organizations

worried that a person’s disease status affected her ability to work. Yet the findings of this study

demonstrate that while survivors and women in EVD-affected homes made less money and worked

less on average, this difference was not statistically significant. The crisis made finding stable work

and income difficult for most women regardless of their disease status. Many female heads of

households shared the common concern of adequately providing for their families, such as feeding,

clothing, and paying school fees.

Similarly, the concern that EVD affected persons were placed in the position to foster and raise more

children due to their parents dying in the crisis is shown by the research findings to be not

significant compared to normal households in former hot zones. There are some affected households

where the number of adults to children was highly unbalanced. Living in homes where one or only a

handful of adults are raising five or more children can have grave consequences in terms of stress on

the adults, financial burdens, and the quality of care for their children. These households require

special government support and tracking. Furthermore, women in affected households are much

more likely to experience family and community stigma. EVD survivors experienced the greatest

risks of being socially ostracized and blamed even after Ebola had left the community. The reality

remains that female EVD survivors are often shunned and discriminated against after their physical

recovery from the disease; indicating the need for individual special support services, as well as more

community awareness and intervention programming in locations with reported survivors.

Research by Amuri, Mitchell, Cockcroft, and Andersson (2011) showed that with HIV/AIDS, stigma

manifests itself on an individual, family, and community level. Ebola is comparable to this finding.

Additional research has found that psychological trauma is disproportionately higher among men

and women living with HIV when compared to the general population (Fellows, Spahr, Byrd, Mindt,

& Morgello, 2014). Psychological trauma responses due to trauma are likely to be expected after

experiencing Ebola personally, within the home, or in the community (Shultz, Baingana, & Neria,

2014). Trauma and stigma can cause both psychological and social harm to an individual. This harm

can result in an increased risk for depression, anxiety, reduced self-esteem, decreased individual

economic opportunities, and isolation (Amuri et al., 2011; Tsai & Venkataramani, 2015).

If an individual receives limited to no mental health support after a significant traumatic event, they

are at a high risk for life long deficiencies. Trauma memories and reactions do not simply go away

with time. A diagnosis of HIV/AIDS has been associated with long-term depression disorders,

anxiety disorders, and mood disorders (Feldman, Betts, & Blausey, 2014). With the similarities of

social stigma and psychological impact of HIV and Ebola, one could assume that an Ebola survivor

has a higher chance of psychological disorders due to their exposure. Long-term care for Ebola

survivors should emphasize mental health care as a priority. Due to limited clinicians and access to

care, mental health support may be provided through building community awareness and education

about trauma and Ebola, survivor support groups, and individual care with trained and local

psychosocial support workers (Shultz et al., 2014).

Hanson, Decosimo, & Quinn, 2016

Journal of Social, Behavioral, and Health Sciences 128

The literature review demonstrates that with infectious diseases such as HIV/AIDS, adults living

with disease need supportive services to address the negative impacts that the disease inflicts in

their households. This includes ongoing financial and program support, including mental health

services. The importance of providing ongoing program support for heads of households affected by

EVD and those in their keep, including children who lost one or more parents or caregivers will be

critical cannot be forgotten after the recovery phase of the outbreak. The effects of the outbreak

continue to play on in the lives of the survivors even as Ebola is eliminated from the region.

Persons affected by EVD often are discharged with high levels of trauma. This trauma brings about

newly developed psychosocial stress symptoms, such as poor eating habits and withdrawal. Instead

of being offered circumstances to recover, in many possible cases their trauma increased as they

faced the bleak reality of piecing back together what remained of their former life, or forced to start

their lives completely anew.

This study attempted to broaden understanding of the conditions and mental health of women

affected by EVD, including their negative experiences, stigma, and psychosocial wellbeing.

Monitoring and evaluation, and coordination of advocacy and support for survivors and affected

households since the start of the outbreak has primarily been led through the continuous leadership

of the Liberian MoH, MoGCSP, and the Ebola Survivors’ Network. Yet more effort is clearly needed.

Women in Liberia are often in vulnerable socio-economic states, which are compounded by

emergencies like Ebola. The present study demonstrated numerous parallels between HIV/AIDS and

Ebola. This research is one of the first of its kind, including a statistical analysis of an initial study of

an EVD-affected population. More thorough future research will help improve understanding and

causal generalizations of what EVD-affected persons face and how to best help them through

advocacy and program services: before, during and after an outbreak. This study further

demonstrated the need to draw upon literature on infectious diseases in order to better inform health

and support services for victims of Ebola. While these results may prepare the health and response

community for future EVD outbreaks, the present study also serves as a reminder of those victims

who already exist and need ongoing support by key national agencies and the international

development community.

Limitations

Because of previous trauma and negative experiences, it is a challenge to distinguish between PSS

existing before and after the outbreak. To minimize reporting error, enumerators were trained and

given procedures to better distinguish between experiences and feelings that occurred before and

after Ebola. They asked participants for symptoms that developed (listed on the PSS scale)

specifically after Ebola first entered their community/home. Any symptoms that existed before the

community and home were a hot zone were recorded as likely not attributable to Ebola. As a second

measure, enumerators triangulated for self-reported PSS symptoms through later randomly

selecting listed symptoms and observed for those symptoms given observation criteria (e.g., for poor

self-care, was there a picture of the person in better appearance than now, or did the person

demonstrate poor hygiene such as strong body odor or unkempt hair). They also spoke with older

household members who could verify whether these symptoms developed within the specified

timeframe. If the symptoms could not be verified, then they were dropped from the individual scale

assessment and not included in data entry.

Hanson, Decosimo, & Quinn, 2016

Journal of Social, Behavioral, and Health Sciences 129

The present study examined adult-to-child ratios of participants’ households to examine how the

crisis may have burdened households with orphaned or vulnerable children due to EVD. Yet the

study was unable to determine accurately the number of adopted children or children taken in

because of the virus. There was a perception that survivors and households affected by virus had

more nonbiological children than same-community households without Ebola. However, the study

data only captured the total number of children verses adults in the house, and how many biological

children that the participant had. It may not have adequately captured additional rates such as total

adopted children or children who passed away from the virus.

When assessing daily income, the differences in incomes between groups appeared nonsignificant,

yet there are indications that there is a potential validity error in how the survey captured income,

as it is unclear whether respondents misunderstood what to report as net income. There was also a

wide range in reported incomes across socio-economic status, which may misconstrue averages with

outlier cases. Further investigation into income and working differences may be useful to better

assess the assumption that positive EVD status lowers an individual’s ability to work and their

income.

The current study conducted an analysis at three tiers. The significance of the findings is weakened

by the low number of survivor participants in the study compared to their peers; however, these data

included the entire population of adult survivors in the EVD-affected communities included in this

study and is not a random sample of survivors. Survivors in study sites were purposefully selected by

the GoL for study. As suggested by Shadish, Cook, and Campbell (2002), the study also presented

effect sizes and conservative statistical test results to account for the potential lack of statistical

power to represent more transparently generalizations and irrelevancies issues. This emphasizes the

need for further similar research on survivors using multiple methods to better inform causal

generalizations.

Most persons infected by EVD died. Numerous EVD survivors hid their identity when admitted to

ETUs or were never formally blood tested. The present study excluded any survivors whose status

could not be confirmed by the government registry. Although the sample size of survivors is small,

all known survivors in the study area were included in the study, and therefore assumptions of the

statistical analyses were met. These findings should be interpreted with caution; however,

establishing relationships between survivorship and quality of life in this population is pertinent for

future research related to EVD survivors. Further, this study provides a foundation to

understanding the differences in experiences for survivors versus noninfected people and to better

understand quality of life for EVD survivors, which are extremely important in the aftermath of the

Ebola outbreak and can help inform future research. Currently, other scientific research is being

conducted primarily on EVD survivors with larger sample sizes, which will likely provide more

informative findings on the status of survivors.

Hanson, Decosimo, & Quinn, 2016

Journal of Social, Behavioral, and Health Sciences 130

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