Quantifying the Impact of Engaging Religious Leaders to Promote Safe Burial Practices During the 2014-2016 Ebola Outbreak in Sierra Leone

Background: Traditional burials involving physical contact with deceased Ebola Virus Disease (Ebola) victims were linked to disease transmission during the 2014-2016 Ebola outbreak in West Africa. An estimated 2 · 5 new cases of Ebola resulted from each traditional burial. Over 6,000 religious leaders across Sierra Leone were engaged to promote the use of specialised burial teams in order to avoid risky traditional practices. We aimed to quantify the impact of engaging religious leaders in promoting safe burials during the outbreak in Sierra Leone. Methods: We analysed population-based household survey data (N=3,540) collected around the peak of the outbreak in Sierra Leone in December 2014. Multilevel logistic regression modelling was used to examine if exposure to faith-based messages was associated with protective burial intentions and behaviours. Findings: Exposure to faith-based messages was associated with a nearly two-fold increase in the intention to accept safe alternatives to traditional burials and the intention to await burial teams for ≥2 days (adjusted odds ratio [aOR] 1·69, 95% confidence interval [CI] 1·23-2·31 and aOR 1·84; 95% CI 1·38-2·44 respectively). Behaviourally, exposure to faith-based messages was also associated with an increased reported avoidance of traditional burials and an increased reported avoidance of suspected Ebola patients (aOR 1·46, 95%CI 1·14-1·89, aOR 1·65 95% CI, CI 1·27-2·13 respectively). Interpretation: Faith-based messages promoted by religious leaders may have influenced safe burial intentions and protective behaviours during the Ebola outbreak in Sierra Leone. Engagement of religious leaders in risk communication should be prioritised during health emergencies in similar settings. Funding Statement: The survey was funded by the CDC Foundation. Declaration of Interests: The authors declare no competing interests. Ethics Approval Statement: Ethical approval for the survey was granted by Sierra Leone Research and Scientific Review Committee. The Center for Global Health at the U.S. Centers for Disease Control and Prevention determined that the assessment was part of the public health response to the Ebola outbreak in Sierra Leone, and was determined to be non-research. The secondary data analysis protocol was further approved by the Ethical Review Board at Karolinska Institutet in Stockholm, Sweden (dnr 2018/1276-31).