Social Dynamics of Ebola Virus Disease: A Case of Bundibugyo District, Uganda

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DOI: 10.4236/health.2019.111011
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Health, 2019, 11, 108-128
ISSN Online: 1949-5005
ISSN Print: 1949-4998
10.4236/health.2019.111011 Jan. 30, 2019 108 Health
Social Dynamics of Ebola Virus Disease: A Case
of Bundibugyo District, Uganda
Clovice Kankya1,2*#, Daisy Nabadda1,2#, Consolata Kabonesa2, Luke Nyakarahuka1,
James Muleme1, Samuel Okware3, Richard Asaba2
1Department of Biosecurity, Ecosystems and Veterinary Public Health, College of Veterinary Medicine,
Animal Resources and Biosecurity (COVAB), Makerere University, Kampala, Uganda
2Department of Gender, School of Women and Gender Studies, College of Humanities and Social Sciences (CHUSS),
Makerere University, Kampala, Uganda
3Uganda National Health Research Organization, Entebbe, Uganda
Ebola Virus Disease (EVD) presents with a high global mortal-
ity and is known to be a highly infectious disease with devastating and gen-
dered effects on the social fabric, yet most of the science has focused on the
disease’s biology. However, little has be
en documented with regard to the
gender and social aspects of Ebola Virus Disease (EVD) in two
sub counties
(Kikyo and Bundibugyo Town Council) in Bundibugyo District
in Western
Uganda. The study was set to examine the gender differences in the level of
knowledge, attitudes and perceptions about EVD.
The study em-
ployed a cross-
sectional design using both quantitative and qualitative data
collection methods. A structured questionnaire was administered to 254 re-
spondents, 50% of whom were women. Simp
le random sampling was used to
select the participants. Questionnaire data were analysed using SPSS at uni-
variate and bivariate levels. Qualitative methods such as key informant inter-
views (with 6 participants) and Focus Group Discussions (three, one with
men alone, another with women alone and the last one with both men and
women) were also used to collect additional information from participants.
The findings indicated that socio-demographically, the majority
of the respondents were aged between 20 and 29 years, 53% of whom were
females. More women (about 56%) compared to men (44%) attained secon-
dary education while more men (about 51% versus 49% of the women) re-
ported that they were married. In terms of
religion, the majority of the survey
participants were Catholics (59% females and 49% males). With regard to
communities’ knowledge about EVD, there was no signifi
cant relationship
between men and women in terms of prior knowledge about EVD, risk
#Clovice Kankya and Daisy Nabadda have the same contribution to the paper.
How to cite this paper:
Kankya, C., Na-
badda, D
., Kabonesa, C., Nyakarahuka, L
Muleme, J
., Okware, S. and Asaba, R.
Social Dynamics of Ebola Virus
Disease: A Case of Bundibugyo District,
, 108-128.
December 23, 2018
January 27, 2019
January 30, 2019
Copyright © 201
9 by author(s) and
Research Publishing Inc.
This work
is licensed under the Creative
Commons Attribution International
License (CC BY
Open Access
C. Kankya et al.
10.4236/health.2019.111011 109 Health
factors and control measures. However, slightly more males (about 51%) than
females (49%) had heard about EVD and more males (about 52%) than fe-
males (48%) admitted that they were at risk of contracting the disease. On the
control measures, slightly more females than males (about 53% vs. 47% re-
spectively) proposed avoiding contact with infected persons. The results fur-
ther revealed that more males (about 51%) than females (49%) were will
ing to
relate with EVD survivors, and this was due to the latter’s fear of con
the disease. The major devastating effects of EVD that were reported included
loss of lives, disruption of peoples movements, isolation of people, disruption
of children’s school activities, stigma and discrimination of sur
vivors. More
(about 52%) than males (about 48%) reported that EVD survivors
were discriminated during the EVD outbreak in Bundibugyo District.
This study has shown that whereas both men and women demon-
strate average knowledge about EVD, there is need for m
ore training and
sensitization targeting women who have delusions about the severity of the
disease, its risk factors, stigma and the integration of survi
vors in the affected
communities. Communities also need to be sensitized about the gender roles
that increase both the burden of EVD and the risk of men and women con-
tracting the disease. This will lead to more culturally sensitive responses to
EVD outbreaks in future.
Ebola Viral Disease (EVD), Gender, Bundibugyo District, Uganda
1. Introduction
Ebola Virus Disease (EVD) is one of the highly infectious emerging Viral
Haemorrhagic Fevers (VHFs) caused by infection with one or more of the Ebola
virus species. It was first discovered in 1976 near the Ebola River in what is now
the Democratic Republic of the Congo. A second outbreak occurred shortly af-
terwards in Nzara Town South Sudan in the Western Equatorial State. Since
then, major and minor outbreaks have occurred sporadically in Africa [1]. There
is no known treatment for EVD and case fatality rate is terribly high. Several
other deadly VHFs exist and these include: Marburg, Lassa fever, Crimean-Congo
haemorrhagic fever, and Rift Valley fever, among others. Ebola can cause disease
in humans and nonhuman primates (monkeys, gorillas, and chimpanzees). Ebola
is caused by an infection with a virus of the
family and the
genus. Currently, there are five identified Ebola virus species, four of which have
caused disease in humans and these include: the Ebola virus (
Sudan virus (
), Taï Forest virus (
, formerly
Côte d’Ivoire Ebola virus), and newly discovered [2] Bundibugyo virus (
). The fifth species is the Reston virus (
which has had one mild case of a Zoologist in Ivory Coast but no outbreak in
nonhuman primates [3]. The Zaire and the Sudan subtypes are the most severe
C. Kankya et al.
10.4236/health.2019.111011 110 Health
with case fatality rate between 60% and 90% on average. The Bundibugyo out-
break is less lethal with a lower case fatality rate of 34%. The time period be-
tween contracting the disease and showing symptoms after exposure ranges
from 2 to 21 days [4]. The natural reservoir host of Ebola viruses still remains
Ebola is described by [5] as a “severe, acute viral illness”, with initial symp-
toms including a sudden onset of fever, intense weakness, muscle pain, fatigue,
headache and a sore throat, followed by vomiting, diarrhoea, rash, impaired
kidney and liver function, abdominal pain and in some cases, both internal and
external bleeding [6]. There is currently no cure for Ebola and the disease seri-
ously affects several organs in the body leading to multiple organ failure, shock
and death within days. Vital organs like the liver, kidney and the spleen are se-
verely and irreversibly damaged. EVD outbreaks principally occur in Central
and Equatorial Africa with major outbreaks in the Democratic Republic of
Congo (DRC), Gabon, Congo Brazzaville, Uganda, Gabon and South Sudan. The
worst recent outbreak occurred in West Africa between 2014 and 2015 during
which nearly 28,000 cases and nearly 11,000 deaths were reported in Sierra
Leone, Liberia and Guinea. Sporadic cases have been reported in USA, Philip-
pine, Italy (Reston) and some imported cases also reported in Europe. In 2015,
many African countries in West and central Africa were severely affected in-
cluding Liberia, Sierra Leone, Guinea, and Nigeria [7]. A total of 28,256 sus-
pected cases and 11,306 deaths in West Africa alone were recorded by the end of
the outbreak in September 2015 [8].
On the basis of evidence and the nature of similar viruses, researchers believe
that the virus is animal-borne and that bats are the most likely reservoir [9]. In
Uganda for example, a young girl who suddenly died after 3 hours of showing
the signs of EVD in Luwero District was believed to have acquired the virus
around her home since she had not left the home for the past 3 months [10]. Di-
rect contact with body fluids of Ebola patients is a major mode of transmission.
It is also believed that the virus enters the population through contact with body
fluids of non-human primates such as bats and chimpanzees through hunting of
game for food. It is also believed that bats may be the major reservoir carrying
the infection as 5% of bats without symptoms were found to be positive [2]. The
ebola virus has also been isolated in semen up to 61 days post recovery, thereby
increasing the potential through for sexual transmission. Ebola survivors often
suffer from ongoing frustrations like joint and muscle pains, chest pain and vi-
sion problems [3].
Despite its significance as a highly infectious disease, most of the science has
focused on the biology of EVD. The public health, management and care aspects
of Ebola have received relatively little attention. Yet Ebola is closely associated
and fuelled by poor socio economic weakness in society. In Africa gender dif-
ferences emerge as women often are care providers for relatives in low income
settings and in very poor sanitary conditions. On the other hand men often hunt
C. Kankya et al.
10.4236/health.2019.111011 111 Health
game for food thereby exposing themselves and interfacing very closely with
The sociological and gender aspects of the disease such as community knowl-
edge, experience and impacts are only beginning to gain attention in Africa [11].
In Gulu, Uganda the majority (64%) of the 424 cases were women [11]. In Sierra
Leone for example, it has been reported that women are more affected by EVD
than men. The sex differential incidence status in this case was of 56.7% for fe-
males and 43.3% for males respectively [12]. Available evidence from West Af-
rica and Gulu Uganda further shows that Ebola disproportionately affects
women due to their care giving role that increases transmission and resultant
death. Women also bear the social burden of the disease as they play a leading
role in caring for orphans and school-going children. In addition, most of the
healthcare providers such as nurses are often women [13] [14]. This dispropor-
tionate sex differential scenario relates to the social risk factors that women face
which increase their vulnerability to EVD, largely due to their care giving roles
at household and community levels. The differentiated impact is traced to so-
cially prescribed gender norms, behaviour and the gendered division of labour
between men and women that perpetuate gender inequality [12]. In Uganda,
there is limited evidence of sociological and anthropological studies on EVD.
Thus, this study was undertaken in order to understand communities’ response
to EVD and its associated gender and social aspects in one of the areas where an
outbreak has previously occurred in 2007 and that is Bundibugyo District in
western Uganda.
Uganda has documented a total of six Ebola outbreaks since the year 2000, in-
cluding the outbreak in Bundibugyo District in 2007 [11] [15]. The Ugandan
government through the Ministry of Health mounted a national response, which
contained these outbreaks with varying degrees of success. Most of the time
EVD outbreaks were managed by the National Ebola Task Force and district
rapid response committees. They were supported international agencies led by
the WHO. The activities of the various agencies and partners were integrated
into a jointly agreed national strategy and plan [11]. The major response was ac-
tive case search and surveillance, public education and social mobilisation, isola-
tion and care. The care of post Ebola survivors and orphans was an additional
desirable activity. A laboratory centre was established at the Uganda Virus Re-
search Institute (UVRI) at Entebbe [16] for early detection and diagnosis. Early
detection and action provided the best outcome in the Luwero outbreak of 2011
[10]. This outbreak was limited to a single case fatality.
Despite the above initiatives the threat of EVD still remains due to inadequate
health systems for early detection and surveillance. Focusing on care and pre-
vention of EVD is important but it is not enough. Understanding community
perceptions of EVD, its causes and people’s knowledge, attitudes, beliefs and
myths and the gender issues there-in are key in preventing the reoccurrence of
the disease and management of the disease in Uganda and worldwide. Ethno-
graphic parameters for the local population too are critically important in order
C. Kankya et al.
10.4236/health.2019.111011 112 Health
that local cultural practices, misperceptions and beliefs which posed challenges
to disease control and need to be addressed because they normally hinder efforts
to stop the spread of EVD [13]. In addition, understanding men and women’s
knowledge and perceptions about EVD is key aspect. The practices, myths and
beliefs could be another key in influencing health related behaviours and the
success of any public health interventions because Ebola outbreaks cannot be
predicted [17].
Thus, understanding community’s knowledge and perceptions of the disease,
fear, stigma, beliefs and practices of EVD from a gender perspective improves
prevention measures and reduces risks of the disease. Transmission and preven-
tion of Ebola is dependent on complex factors including the socio-cultural, peo-
ple’s knowledge, attitudes and individual perception of the disease. To date, few
studies have documented the gender and ethnographic differences in the af-
fected communities. Few studies on knowledge, attitudes, perception, beliefs,
and practices about EVD are available locally.
2. Materials and Methods
2.1. Study Design
The study took on a cross-sectional design. Both qualitative and quantitative
data collection methods were used to gather data from July to November 2015.
The cross-sectional research design was adopted in order to elicit information
on the situation from a sample of the population at one point in time and to
document EVD experiences from various groups in Bundibugyo District. This
design was also adopted because it enables the examination of functional rela-
tionships in this case through describing beliefs, practices, experiences and ef-
fects of Ebola Virus Disease from a gender perspective. The quantitative design
was vital in eliciting the generalised gendered knowledge, attitudes, perceptions,
beliefs, management, treatment and effects of EVD in Bundibugyo District. The
qualitative approaches allowed the collection of data on various opinions and at-
tributes of the population (men and women) under study in more detail.
2.2. Area of the Study and Rationale
The study was conducted in Bundibugyo District. The district is located in the
Western region of Uganda bordering the Democratic Republic of the Congo
alongside several bordering districts: Ntoroko District to the northeast, Kibaale
District to the east, Kabarole District to the south, and the DRC to the west and
north. The district headquarters at Bundibugyo are located approximately 32
kilometres by road, west of Fort Portal, the nearest large town. This is about 72
kilometres by road, north of Kasese, the largest town in the sub-region. The
geographic boundaries of the district are the Semliki River to the west, the
Rwenzori mountains to the east, and Lake Albert to the north. In 2014, the na-
tional population census put the town’s population at 18,823 (UBOS, 2014). Be-
ing a rugged mountainous area, physical access to the region is often difficult
and is only many by foot. Bundibugyo District was selected because of its char-
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