Psychosocial Effects of Ebola Virus Disease on Children and Caregivers in Sierra Leone

Background and Purpose. The psychological consequences of infectious disease outbreaks can be devastating for child development. The 2013-2016 Ebola Virus Disease (EVD) epidemic in West Africa resulted in more than 28,000 cases 11,000 deaths. Children accounted for more than one-fifth of EVD cases and more than 16,000 children lost caregivers. Existing studies demonstrate a clear link between exposure to EVD and mental health problems, and between caregiver and child mental health more generally. Yet, no studies have examined child and caregiver mental health in relation to EVD. The purpose of this study is to examine the effects of EVD exposure on children’s mental health over time, and whether this relationship is mediated by caregivers’ mental health.

Methods. This NIH-funded R01 study was implemented across six geographically diverse districts in Sierra Leone across two time points (2020-2021, and 2022). Using existing lists of EVD survivors, we recruited n=222 child EVD infected survivors, n=208 children affected by EVD but not infected (defined as living in the same household as someone who was infected), and n=233 control children (defined as neither being infected nor affected, recruited using community-based sampling, and matched by age, gender, and district to the survivor group). We also surveyed children’s primary caregivers (n=663). Independent variables included child’s EVD infected or affected status (vs. control group). Control variables included child’s age, gender, district, urban vs. rural, and household wealth. Parallel mediating variables included caregiver anxiety and depression at Time 1 using the Hopkins Symptom Checklist (Anxiety (α =.86) and Depression (α=.88)). Dependent variables included the caregiver reported Strengths & Difficulties Questionnaire (SDQ) Prosocial Subscale (α =.72) and Total Difficulties Score (α =.75) for children at Time 2. An SEM model was employed to test the hypothesis that parent mental health mediates the relationship between child EVD status and child behavioral outcomes, with bootstrapped standard errors to account for clustering across districts.

Results. There was a direct effect on child total problems by infected EVD status (b=1.16, se_bs=0.36, p=.001) and affected status (b=0.86, se_bs=0.39, p=.028). Parent anxiety and depression mediated the relationships between EVD affected status on child total problems (b=0.26, se_bs=0.13, p=.037) and child prosocial behavior (b=.23, se_bs=0.07, p=.001). Finally, both infected and affected EVD statuses showed significant total effects on child total problems (infected: b=1.20, se_bs=0.36, p=.001; affected: b=1.13, se_bs=0.39, p=.004).

Discussion and Implications. Both EVD exposure and caregiver mental health proved to be significant predictors of child mental health. Compared to controls, EVD-infected and -affected children were more likely to demonstrate behavioral difficulties nearly a decade after the EVD outbreak. The influence of caregiver mental health was more pronounced for affected children, suggesting that household stress plays a role in children’s mental health, but that being infected is a more important predictor. We worked closely with the local EVD survivors’ association to disseminate these findings in each community where we collected data. Community members’ feedback was instrumental in determining next steps for our research, which will focus on the impact of EVD stigma on child and caregiver wellbeing.