Associations between Mental Health and Ebola-Related Health Behaviors: A Regionally Representative Cross-sectional Survey in Post-conflict Sierra Leone

BackgroundLittle attention has been paid to potential relationships between mental health, trauma, and personal exposures to Ebola virus disease (EVD) and health behaviors in post-conflict West Africa. We tested a conceptual model linking mental health and trauma to EVD risk behaviors and EVD prevention behaviors.Methods and FindingsUsing survey data from a representative sample in the Western Urban and Western Rural districts of Sierra Leone, this study examines associations between war exposures, post-traumatic stress disorder (PTSD) symptoms, depression, anxiety, and personal EVD exposure (e.g., having family members or friends diagnosed with EVD) and EVD-related health behaviors among 1,008 adults (98% response rate) from 63 census enumeration areas of the Western Rural and Western Urban districts randomly sampled at the height of the EVD epidemic (January–April 2015). Primary outcomes were EVD risk behaviors (14 items, Cronbach’s α = 0.84) and EVD prevention behaviors (16 items, Cronbach’s α = 0.88). Main predictors comprised war exposures (8 items, Cronbach’s α = 0.85), anxiety (10 items, Cronbach’s α = 0.93), depression (15 items, Cronbach’s α = 0.91), and PTSD symptoms (16 items, Cronbach’s α = 0.93). Data were analyzed using two-level, population-weighted hierarchical linear models with 20 multiply imputed datasets. EVD risk behaviors were associated with intensity of depression symptoms (b = 0.05; 95% CI 0.00, 0.10; p = 0.037), PTSD symptoms (b = 0.10; 95% CI 0.03, 0.17; p = 0.008), having a friend diagnosed with EVD (b = −0.04; 95% CI −0.08, −0.00; p = 0.036), and war exposures (b = −0.09; 95% CI −0.17, −0.02; p = 0.013). EVD prevention behaviors were associated with higher anxiety (b = 0.23; 95% CI 0.06, 0.40; p = 0.008), having a friend diagnosed with EVD (b = 0.15; 95% CI 0.04, 0.27; p = 0.011), and higher levels of war exposure (b = 0.45; 95% CI 0.16, 0.74; p = 0.003), independent of mental health. PTSD symptoms were associated with lower levels of EVD prevention behavior (b = −0.24; 95% CI −0.43, −0.06; p = 0.009).ConclusionsIn post-conflict settings, past war trauma and mental health problems are associated with health behaviors related to combatting EVD. The associations between war trauma and both EVD risk behaviors and EVD prevention behaviors may be mediated through two key mental health variables: depression and PTSD symptoms. Considering the role of mental health in the prevention of disease transmission may help fight continuing and future Ebola outbreaks in post-conflict Sierra Leone. This sample is specific to Freetown and the Western Area and may not be representative of all of Sierra Leone. In addition, our main outcomes as well as personal EVD exposure, war exposures, and mental health predictors rely on self-report, and therefore raise the possibility of common methods bias. However, the findings of this study may be relevant for understanding dynamics related to EVD and mental health in other major capital cities in the EVD-affected countries of West Africa.

研究背景：在后冲突时期的西非地区，心理健康、创伤经历、个体埃博拉病毒病（Ebola virus disease, EVD）暴露情况与健康行为之间的潜在关联尚未得到足够关注。本研究构建并验证了一则将心理健康、创伤经历与埃博拉病毒病风险行为、预防行为相关联的概念模型。
研究方法与结果：本研究基于塞拉利昂西部城区与西部郊区的代表性样本调查数据，针对2015年1-4月埃博拉病毒病疫情高峰期内，从西部郊区、西部城区的63个普查枚举区中随机抽取的1008名成年受访者（应答率98%），分析了战争暴露经历、创伤后应激障碍（Post-traumatic stress disorder, PTSD）症状、抑郁、焦虑、个体埃博拉病毒病暴露情况（例如，有家人或朋友被诊断为埃博拉病毒病患者）与埃博拉病毒病相关健康行为之间的关联。
本研究的主要结局指标包括埃博拉病毒病风险行为（共14个条目，克朗巴哈α系数=0.84）与埃博拉病毒病预防行为（共16个条目，克朗巴哈α系数=0.88）。核心预测变量涵盖战争暴露经历（共8个条目，克朗巴哈α系数=0.85）、焦虑症状（共10个条目，克朗巴哈α系数=0.93）、抑郁症状（共15个条目，克朗巴哈α系数=0.91）以及创伤后应激障碍症状（共16个条目，克朗巴哈α系数=0.93）。
研究采用20个多重插补数据集，通过两水平、人群加权的分层线性模型对数据进行分析。分析结果显示，埃博拉病毒病风险行为与抑郁症状严重程度（回归系数b=0.05；95%置信区间[0.00, 0.10]；p=0.037）、创伤后应激障碍症状（回归系数b=0.10；95%置信区间[0.03, 0.17]；p=0.008）、有朋友被诊断为埃博拉病毒病患者（回归系数b=-0.04；95%置信区间[-0.08, -0.00]；p=0.036）以及战争暴露经历（回归系数b=-0.09；95%置信区间[-0.17, -0.02]；p=0.013）存在显著关联。
在控制心理健康因素的前提下，埃博拉病毒病预防行为与更高水平的焦虑症状（回归系数b=0.23；95%置信区间[0.06, 0.40]；p=0.008）、有朋友被诊断为埃博拉病毒病患者（回归系数b=0.15；95%置信区间[0.04, 0.27]；p=0.011）以及更严重的战争暴露经历（回归系数b=0.45；95%置信区间[0.16, 0.74]；p=0.003）显著相关。此外，创伤后应激障碍症状与更低水平的埃博拉病毒病预防行为相关（回归系数b=-0.24；95%置信区间[-0.43, -0.06]；p=0.009）。
研究结论：在后冲突环境中，既往战争创伤与心理健康问题均与埃博拉病毒病防控相关的健康行为存在关联。战争创伤与埃博拉病毒病风险行为、预防行为之间的关联，可能通过抑郁症状与创伤后应激障碍症状这两个核心心理健康变量介导。关注心理健康在疾病传播预防中的作用，将有助于应对塞拉利昂后冲突时期持续存在以及未来可能出现的埃博拉病毒病暴发疫情。
本研究的样本仅针对弗里敦及西部区域，无法代表塞拉利昂全国人群。此外，本研究的主要结局指标、个体埃博拉病毒病暴露情况、战争暴露经历以及心理健康预测变量均基于自我报告，因此存在共同方法偏差的潜在可能。不过，本研究结果或可为理解西非埃博拉病毒病受累国家其他主要首都城市中埃博拉病毒病与心理健康的相关动态提供参考。