The symptoms of Ebola virus disease EVD are similar to those of common ailments in the Nigeria (such as malaria, cholera and diarrhoea) for which people consult traditional healers. The study investigated level of knowledge about EVD among traditional healers in Ibadan. The research design was descriptive cross-sectional and qualitative data collection approach was adopted to gather information from respondents. The level of awareness about EVD outbreak in Nigeria was high but the healers’ understanding of various aspects of EVD was inadequate. The limited knowledge about EVD revealed need for continuous education of the healers even after outbreak given their popularity in the State and country at large.

•    Nigeria
•    Ebola virus disease
•    Traditional healers
•    Knowledge
•    Outbreak

Aminu K, Jegede AS (2017) Traditional Healers’ Knowledge of Ebola Virus Disease. Ann Public Health Res 4(1): 1054.

EVD: Ebola Virus Disease

Throughout Africa, traditional health practitioners are known to have played important roles in combating multiple and complex health conditions affecting people because traditional medicine was the only available system of health care for centuries before having contact with the Europeans [1]. According to Erinosho [2] the indigenous native healers have been part of Nigerian society since time immemorial although, the faith healers became popular about middle of the 19th century. Traditional healing in the country includes different types of healers or practitioners [3] who are referred to in different terms across cultures, while some call them native doctors; others call them medicine men, indigenous doctors or witch doctors [4]. They are also known as Babalawo, Onisegun, or Adahunse (among the Yoruba), Dibia (among the Igbo) and alfa or boka (among the Hausa) [2,3,5,6].

Despite the criticisms of traditional health care practices in respect of safety, efficacy and standardization of traditional medicines being used [2,7,8] and their perception as primitive and non-therapeutic [5,9]. Traditional healers are still patronised by up to 80% of Africans who employs traditional medicine for their primary health needs. Irrespective of the wide acceptance of Western medicine, traditional healers continue to provide health care services for Nigerians [7,8].

Reasons for this patronage have been documented by authors [2,7,10-12]. In this part of the world people patronise traditional healers for many health problems such as malaria, sore-throat, gonorrhoea, convulsion, diarrhoea, typhoid fever, measles, and other febrile illnesses [13-15]. A recent addition to the list of diseases of great health challenge in Nigeria is Ebola virus disease (EVD). Symptoms of Ebola infection at early stage include: fever, headache, aches, weakness, vomiting, and diarrhoea [16-18]. At the later stages of infection the condition is more severe and damage to blood vessels and extensive internal and external bleeding (haemorrhage) may occur and consequently death [17- 19].

Since symptoms of EVD are similar to common ailments in the country (such as malaria, cholera, diarrhoea and febrile illnesses) for which people consult traditional healers, it is important to investigate the healers’ state of knowledge about EVD especially because there is widespread belief in the supernatural cause of EVD [20] and as mentioned above people have enormous confidence in the competence of these healers and believe they can solve any problem. In fact, experts have recognised the need to incorporate them into efforts geared towards fighting disease outbreak. The neglect of their critical role in combating EVD at early and mid-stages of EVD outbreak in Sierra Leone was too costly for the country and international community as a whole. For instance, Nigeria had her first ever EVD outbreak due to the imported case of EVD from Sierra Leone on 20 July, 2014.

Experiences during recent EVD outbreak in Africa, which lasted for several months and the re-emergence of Lassa fever in Nigeria as well as spread of Zika virus across nations have further revealed the importance of preparedness and need to involve all stakeholders in controlling infections quite early in order to limit the spread, morbidity and rate of mortality from future disease outbreaks. Although, the 2014 EVD outbreak in Nigeria has come and gone but the factors which made the spread of infections easy are still here with us. The outbreak of Lassa fever which claimed more lives than the much dreaded EVD in Nigeria is one case too many hence, the need to continue researching both in laboratory and community.

While many researches have been conducted on EVD since the first case was reported in 1967 [21-26], those that examined knowledge of EVD were carried out in the general population [27- 30] but not many have assessed level of knowledge about EVD in specific groups most at risk of infection. For instance, a study by Alqahtani, and his colleagues [31] in Australia was conducted among the Hajj 2014 pilgrims. Another study in Nigeria was done among health care workers in Lagos [28].

Unfortunately, these researchers have ignored a major group at risk of this deadly disease, the traditional healers, who are so categorised due to the nature of their trade which exposes them to bodily fluids of patients while providing care. Earlier studies on traditional healers’ knowledge were focused on different diseases like HIV/AIDS [32,33], malaria and tuberculosis [33]. Since traditional healers’ knowledge has been found to be disease specific and vary from one healer to another and no research has been conducted on those practicing in Ibadan therefore, this paper raised the question:

1. What is the level of awareness about EVD among traditional healers in Ibadan?

2. How knowledgeable are the traditional healers in Ibadan about EVD?

It is expected that the information provided by this study would be useful to government and other concerned agencies’ control efforts and response on Ebola infection in Nigeria. The study is also in line with World Health Organization’s advocacy on need to fully incorporate and engage the community through major stakeholders who can play significant role in infection control.

Study design

The study design is descriptive, exploratory and crosssectional. We investigated the extent of knowledge about EVD among traditional healers in Ibadan during the outbreak in 2014.

Study location: The study location was Ibadan. It is the capital of Oyo State in South-West Nigeria. The city was purposively selected for its proximity to Lagos State, where the first EVD case was reported in Nigeria. In addition, Ibadan is a nodal and a pre-colonial city where different kinds of traditional healers are found. The city has a history of traditional healing which has been traced to the diverse cultural beliefs and indigenous knowledge and practices brought to Ibadan by the warlords (who established the city) from other parts of the Yoruba land [34], hence, the wide acceptance of traditional medicinal practices by the inhabitants.

Study population: All traditional practitioners in Ibadan constituted the study population, that is, those individuals who engage in healing psychological, social, emotional, spiritual and holistic problems. Unfortunately, official record on the number of traditional practitioners in Ibadan was unavailable during the investigation.

Sample size

Out of thirty-five healers contacted through their association, unfortunately, only twenty-three healers indicated interest to participate in the study as most of them were afraid to speak to the researcher. They felt unsecured to grant the interview despite showing them identity and informing them about purpose of our investigation. This was linked to the unpleasant experience of a popular traditional healer in the country ‘Jeremiah Abalaka’ during early stage of HIV outbreak in Nigeria.

Sampling procedure

Non-probability sampling method was adopted to select traditional healers practicing in the city. The president of the ‘Traditional Healers’ Association of Nigeria’, Ibadan branch was contacted to gain access to members. However, most of them refused to grant the interview as it was during the EVD outbreak in the country. They expressed fear due to the reason cited above. As a result only those who consented were interviewed. The study also utilized a “snowball” sampling strategy because some of the healers did not operate openly. In all, twenty-three healers participated in this study.

Method of data collection

Purely qualitative approach of data collection was utilized; In-depth Interview (IDI) was conducted to understand the participants’ extent of knowledge about Ebola Virus Disease.

Instrument of data collection

An unstructured IDI guide was used to collect information from participants on awareness and extent of knowledge about Ebola virus disease. The interview guide contained questions on important aspects of EVD. We generated the questions from key facts on EVD as contained on the World Health Organization’s website [35]. In addition to socio-demographic information, the guide asked questions about sources of information and understanding of the disease, causes, mode of transmission, diagnosis, incubation period, treatment, prevention strategies, symptoms, duration, and nature of the disease. The interview was also aided by audio recorder which was utilized only after seeking permission from the interviewees, this was supported with field notes used to document hidden bodily expressions difficult to capture.

Method of analysis

The method of analysis used was a combination of thematic and content analysis. Because most of the interviews were conducted in Yoruba language, the analysis started with transcription of the audio data followed by translation into English language and then back-translation into Yoruba language to ensure consistency. This was followed by familiarization with the data and identification of common responses which the researchers used to name and define the themes. These themes were then entered in to a matrix which revealed the frequencies of mention and percentages along with the most appropriate responses capturing the themes. The WHO’s [35] key facts about EVD was used as a standard to measure the healers’ knowledge of the disease.

Ethical consideration

The president of traditional healers’ association in the city was contacted to seek permission before commencing the interview. The researchers also abided by all necessary ethical principles guiding research involving human subjects.

Thirty-five traditional healers who qualified for the study were contacted but only twenty-three granted the interview. Therefore, the result below represents the extent of knowledge about EVD of the twenty-three respondents and may not be generalized.

Demographic characteristics of interviewees

Table (1) below reveal the distribution of participants in respect of age, gender, religion, marital status, education, and source of knowledge of traditional medicine, length of practice and area of specialisation. Women were more represented because herbs-selling in this part of the country is basically a female-centred occupation. With regards to age, only few (4) respondents were over 60 years. The preponderance of youths in healing trade could be attributed to increasing economic problems in Nigeria and high rate of unemployment across the age groups in the country additionally; challenges facing the health care sector are pushing people to traditional healers. Although, not indicated in the table, all the traditional healers interviewed are Yoruba. In terms of religious composition, the two major religions (Christianity and Islam) were well represented while only few respondents claimed to be practicing the Traditional religion (4.3%) and all religions (4.3%). None of the respondents was single and most of them had one form of formal education or the other, this was because the study was conducted in an urban setting. Also, the study area was the former capital of old Western region of Nigeria where the policy of free primary education was introduced by late Chief Obafemi Awolowo in 1955, hence, the legacy is that every child must have formal education. Moreover, the study was not a randomized study. The most reported years of practice by the respondents was between 11 and 20 years (30.4%), while the least mentioned was between 31-40 years, which was reported by 17.4% of the respondents, this could be linked to the age distribution.

Traditional healers’ level of knowledge about ebola virus disease

The healers’ responses to interview questions are presented in Table (1) below. Nigeria is a low EVD incidence country as she experienced EVD outbreak for the first time in 2014. All respondents in this study were aware of EVD outbreak in the country through sources of information ranging from family and friends to the mass media. Using the WHO’s key facts about EVD, only 14 (60.9%) respondents had good understanding of EVD while about (39.1%) had poor understanding. They described it in different ways such as ‘a punishment from God’ and that it has been in the country before 2014 outbreak. Some of the common themes in their understanding of EVD include comparing it to other known/common ailments because it shares similar symptoms with many ailments such as cholera. The name “Ebola” was strange to many and this contributed to poor understanding of EVD.

Responses on signs and symptoms of EVD showed that majority (91.3%) of the healers were familiar with and had good knowledge of EVD signs and symptoms. Some healers in this group also understood the two stages of the symptoms of EVD, that is, the early and the late symptoms. But few (8.7%) had no knowledge of the signs/symptoms.

It was also necessary to examine how well the healers comprehended the ailments which have similar symptoms as EVD because the way people care for symptoms before they receive a diagnosis may contribute to the spread of infectious diseases. When the healers were assessed on their knowledge of similarity of the symptoms of EVD some (13%) of the respondents did not know what the symptoms resemble; majority (87%) likened the symptoms of the disease to common ailments with which they were familiar such as typhoid, cholera, diarrhoea, measles, skin infection, malaria, HIV/AIDS and many others. Some of the healers’ responses indicated that the communication and education on the Ebola virus disease by the concerned authorities are still inadequate Table (2).

When asked about incubation period of EVD, majority (69.6%) of them were found to be knowledgeable while others were not. Their understanding of nature of EVD on the other hand was fair with (52.2%) describing it as a viral/blood infection. Around (34.8%) described the nature of EVD by comparing it with other common illnesses like measles, cholera, malaria and fever, while others (13.0%) had no idea. Their knowledge of EVD causative organisms was similarly good, approximately 15 (65.2%) respondents mentioned virus, bats, primates, bush meat, animals, micro organisms etc as responsible. Some (17.4%) cited hypertension, sexual intercourse with animal, blood infection, and genetic factors. About (8.7%) on the other hand believed it was caused by consumption of contaminated food and evil wind. However, others couldn’t state any causative agent or organism responsible for the disease. Concerning the mode of transmission of EVD, most of the interviewees (87%) exhibited good understanding while 2 (8.7%) interviewees did not know how EVD is contracted; one respondent (4.3%) believed it could not be transmitted from one person to another. Her response is presented next:

In my own opinion, I don’t believe that when someone is infected it can be transmitted to others because it (EVD) is in the blood. When we give them herbs they will excrete the ones in the blood from their system as we know. (Female General Practitioner, Aged 56 years)

Another interesting finding is about diagnosis of EVD. Less than half of the respondents (47.8%) knew the correct means of diagnosing the infection; they explained this could be done in the hospital and laboratory while (52.2%) had poor knowledge about diagnosis. The healers were also divergent in their knowledge of EVD treatment. This is similar to the finding on diagnosis of EVD as not many of them (39.1%) knew that EVD could be treated in hospitals only. Others had poor knowledge of the recommended treatment options for EVD citing use of herbs, hand washing and even prayer (34.8%), the rest of the healers (26.1%) had no knowledge of this as well. The quote below is that of a healer who believed herbs could cure EVD, she mentioned the name of the ailment which she understood EVD to be and the treatment available.

We use herbs. To us, this is just like typhoid and we can use the treatment... for typhoid to treat patient and if we notice signs of infection like blood in the stool and vomiting we know what to add to the herbs. (Male Diviner, Aged 61 years)

Lastly, responses on the prevention strategies for EVD were quite encouraging. Most (74%) of them had good knowledge of preventing EVD citing avoiding contact with infected person’s body fluid, avoiding animals, bats, primates, maintaining personal hygiene and clean environment. A woman who understood preventive strategies is quoted here:

Through cleanliness, before eating one should wash the hands clean. The environment one lives in must be kept clean and good looking at all times... (Female General Practitioner, Aged 56 years)

Table 1: Socio-demographic Characteristics of Traditional healers.

Table 2: Knowledge of EVD among Traditional healers.

Level of knowledge varies from one individual to another and depends on factors like social-demography of an individual (such as age, sex, occupation), past experience, belief, sources of information, stage of epidemic and the disease under consideration [32]. The study found the healers’ level of knowledge about EVD to be average. They were not knowledgeable about some important characteristics of EVD such as recommended treatment. This is consistent with a community study of EVD in Sierra Leone. Similar to this, the Sierra Leone study also found some misconceptions about certain characteristics of EVD, but the misconceptions found in this study were quite different. For instance, respondents in the Sierra Leone study believed mosquito was the cause of EVD while hypertension, sex with animal, blood infection, and gene were mentioned by some healers as causing EVD.

In addition, all respondents were aware of EVD outbreak in Nigeria; this is similar to what the Sierra Leone study discovered. The major source of information mentioned in this study was the mass media (radio and television) followed by family and friends this was due to the high level media reporting of EVD during and after the outbreak unlike the Australian study which noted the Internet, general practitioners and travel agents [31] in addition to sources of information reported by the healers. The study also revealed that almost all interviewees were unaware of EVD before the index case was reported in Lagos, Nigeria.

In general, the healers had average knowledge about the characteristics of EVD and different explanations were given on its various aspects. The characteristics about which they had adequate knowledge are signs and symptoms, incubation period, mode of transmission, and recommended prevention strategies. This may be because this study was carried out in an urban area where sources of information such as the radio and television and hand bills are available, or due to the respondents’ level of education as majority (73.9%) were literate. Alqahtani et al. [31], likewise noted the significance of education to knowledge of EVD.

However, the healers had poor understanding of the nature of EVD and its treatment. Another finding is that majority of respondents did not perceive causes of EVD or any aspect of it as supernatural; rather most aspects of EVD were perceived as natural although, some faith healers believed it to be caused by spiritual forces (sin, wrath of God). The low level of knowledge about all the characteristics of EVD among respondents may be due to many factors (though not part of the objectives), as other studies such as Bashar et al. [36], and King and Homsy [32] have discovered that the socio-demographic factors can influence knowledge about disease.

Similarly, the amount of information the healers were exposed to, as well as beliefs regarding diseases in general and EVD in particular may be responsible for the findings, however, these were not tested for in the study. In addition, the low incidence of EVD in Nigeria may have been another factor. Poor knowledge may be because EVD had never before occurred in this part of the world, even in countries that have been witnessing the outbreak of Ebola virus disease, the particular species of Ebola associated with the last outbreak in West Africa was before now restricted to three countries in Central Africa.

Knowledge of EVD in the studied group was inadequate. The practitioners still hold on to their old knowledge and traditional beliefs about diseases including diagnosis, transmission and treatment irrespective of modernisation and information they are exposed to. This explains the poor health care seeking behaviour among the people such as using home-based treatment and presenting late for treatment at modern medical facilities. By implication, educating the populace in general and stakeholders in particular about emerging zoonotic diseases and rare infections should be continuous. Awareness campaign should not be restricted to disease outbreaks alone in order to prevent future reoccurrence as is the case with Lassa fever.

Due to the non-randomized nature of the sampling technique and small sample size, the findings of this research could not be generalised. Therefore, the need for large scale study on extent of EVD knowledge among traditional healers and other groups at risk is recommended. This has become necessary given the fact that traditional healers share similar worldview with the larger community and often come in contact with the sick more than the orthodox medical professionals who are consulted only when other treatment options have been exhausted.

The authors appreciate all participants in the study who sacrificed time out of their tight schedules to make the research possible.

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