Burial workers’ perceptions of community resistance and support systems during an Ebola outbreak in the Eastern Democratic Republic of the Congo: a qualitative study

BACKGROUND: Community Health Workers (CHWs) provide vital services during disease outbreaks. Appropriate burials of those who died from an infectious disease outbreak is a critical CHW function to prevent infection and disease spread. During the 2018 Ebola Virus Disease (EVD) outbreak in Beni Town, North Kivu, Democratic Republic of the Congo, we sought to understand the levels of understanding, trust, and cooperation of the community in response to the outbreak, the barriers burial workers faced in their health work and its impact on local burial workers and other CHWs. METHODS: 12 EVD burial CHWs in Beni Town completed an hour-long qualitative in-depth interview on their experiences. They were recruited from a local counseling center. Interviews were recorded, transcribed and translated into English. A team of 3 researchers identified structural and emergent themes using applied thematic analysis. RESULTS: Workers reported major misconceptions in the community surrounding the initiation of the outbreak. Community misconceptions were based on widespread governmental mistrust as well as a belief system that intertwines traditional and scientific understandings of the world. EVD burial workers identified violence directed at them and community misinformation as the two largest barriers to effectively carrying out their work. They named several important support systems including family and friends, personal relaxation techniques, and a local counseling center. CONCLUSIONS: As with other disease outbreaks globally, we found that government mistrust and religious beliefs strongly impacted community perceptions of the EVD outbreak. Previous studies have demonstrated clinic-based medical personnel are often the targets of violence. Our research shows that burial workers were also targeted and exposed to extreme levels of violence in their work. Along with their ability to effectively respond to the outbreak, violence has a negative impact on their own mental wellbeing. Burial workers found group counseling sessions to be an effective tool for managing the stress associated with their work. Further developing and testing of group-based interventions for this group is a priority for future research.