1. Introduction

Among the neglected tropical diseases, Ebola hemorrhagic fever (EHF) is the most dreadful recent viral outbreak [1]. Ebola Virus Disease (EVD) is an acute, viral and fatal illness among humans. It can be transmitted from wild animals to humans and could spread from to human [2]. EVD was first discovered in 1976 in Ebola River in the Democratic Republic of Congo [Centre of Disease Control and Prevention, 2014]. This spellbound virologists, epidemiologists and clinicians because of its high fatality rate 25%-90% and transmissibility; it requires level 4 bio-safety approaches [3]. Its geographical limitation was advantage since the disease was contained and its spread was controlled accordingly. Few outbreaks were reported later but were silenced by the quick action of the medics who were able to manage it. The need for a vaccine was also established but the target population for the researchers was limited [4]. Ebola is a public health problem and a great concern to many countries especially the countries that were not affected during the recent outbreak which the Gambia is not an exception. In West Africa (Guinea, Sierra Leone and Liberia), it was reported that the fatality rate of EVD was 90% in 2013 outbreak. This was an international public health emergency since there were 5,740 cases in Guinea, 9,890 in Liberia and 5,000 in Sierra Leone as of November 2nd, 2014 [2]. There has been a big change in the epidemiology of EVD in the countries affected during the most recent outbreak. Data collected in West Africa between March 2014 and May 2015 revealed that there were 14,913 confirmed, 2,081 probable and 9,099 suspected cases with 11,005 deaths [2]. 

The findings of the study will help nurses and other health service providers in developing health prevention and promotion programmes that will seek better ways in improving the knowledge and attitude of women on Ebola prevention. The study will also contribute to new knowledge on the topic and it will as well close the gap on lack of studies on the topic especially in the Gambia. The main aim of this research is to assess the knowledge and attitude of women attending Polyclinic RCH on Ebola prevention. The research objectives are to explore the knowledge of women attending Polyclinic RCH on Ebola Prevention and to determine the attitude of women attending Polyclinic RCH on Ebola prevention. Questions of; what is the knowledge of women attending Polyclinic RCH on Ebola prevention? What is the attitude of women attending Polyclinic on Ebola Prevention?. 

2.Literature Review

The name of Ebola virus was known to be driven from the Ebola River, which passes near the Yambuku village where the outbreak first was noticed. Despite this region being the origin of Ebola, the case of the current Ebola Virus Diseases (EVD) was reported in Guinea Bissau in March 2014 and it travels beyond the borders to the neighbouring countries like Liberia and Sierra Leone [5-7]. The first outbreak of Ebola virus diseases (EVD) is still debatable, while some studies has confirmed that the first outbreak occurred simultaneously in Nzara, Sudan and Yakumbuku, Zaire the now Democratic Republic of Congo. The statistics shows that while the former was 281 patients and out of which 151 died, the later registered even more number of 280 out of 318 deaths [5, 7].This high number of mortality is due to the severity of EVD; it has an average case fatality rate of 50%. The statistics stood at 22,500 confirmed cases as of 4th February 2015 and almost 9,000 deaths have been reported [8]. In 2016, a combined 28,639 suspected, probable and confirmed cases and 11,316 deaths from Ebola during the 2014, West African Ebola epidemic [9]. The latest outbreak was announced to be occurred in North Kivu Province and as of now, the numbers are as follows: Total cases: 181, Confirmed cases: 146, Probable cases: 35, Deaths: 115, Confirmed: 80 and Probable: 35 [2].

Beyond this date, there are new cases that includes both confirmed and suspected of which the statistics lacks credibility never the less, this outbreaks have affected the economic resources of these countries and moved the people to the state of panic. Majority is panic since the preventive and control measures are not evenly comprehended by the inhabitants. The recent outbreak distribution; while considering the economic, infant mortality rate, life expectancy and the number of health care givers per patients, has answered questions as to the link between Ebola and poverty. Since all of these parameters have been used to measure the degree of poverty to EVD in these regions, it can be clearly felt that due to the economic unrealities, the rate at which the virus spread was high. The prevention and control of Ebola outbreaks for those working directing (nurses, cleaners and housekeepers) and indirectly (visitors, family members and volunteers) in the hospitals require high discipline of personal protection. Ebola patients in health-care facilities need thorough assessments and the personnel as well are deemed to be well trained [7]. WHO [8] has reviewed that Ebola prevention and control are but not limited to; General patient care in any health-care facility, Direct patient care for suspected or confirmed patients with hemorrhagic fever, Environmental sanitation and its management, waste disposal and management, non-patients care activities including; movement and burial of human remains, management exposure to virus through body fluids, post-mortem examinations etc. [7]. In the opts for the prevention and control for Ebola virus transmission that spontaneously leads to infection, WHO declared it a “Public Health Emergency of International Concern” on August 7, 2014 [9]. In fact Ebola outbreak has affected the decisions on vaccine trial and viral research [4]. There is a hope that when the vaccine and immunization interventions, this dreadful diseases will be checked. 

3. Methodology

The study adopted a qualitative design to explore the knowledge and attitude of women attending Polyclinic on Ebola prevention. The study was conducted at Polyclinic in Banjul after seeking permission from the Chief Medical Director. The clinic offers Reproductive and Child Health Services including family planning, Outpatient department which sees a lot of patients especially during the raining season ENT, Dental, Eye, Laboratory, Psychiatry, STI and Public Health Services. The target population is the population from which the sample is chosen and to which study findings are generalized. The target population was 200 however, 132 women attending Polyclinic RCH were recruited. A sample has been defined as a group of respondents as a subset of population in which data or information is collected. The exclusion criteria for a participant to be part of the study; she must be a woman attending Polyclinic RCH and she should agree to participate in the study. In the other hand, women attending other units of the clinic and those who did not agree to participate were excluded. 

The data collection was based on interview guides that were designed and developed and a tape recorder was also used for voice recording of the respondents who cannot write. A focus group discussion was held in the clinic at a convenient place. The interviews were open ended and guides were not strictly followed because sometimes answers provided by respondents require probing to further explain emerging issues. Interviews were digitally recorded with the participant’s consent. The data analysis was based on data are sequenced and coded based on the recorded responses. It was later recorded into themes and the results were finally analyzed under each theme using tables and charts. Ethical clearance was sought from the Chief Medical Director of Edward Francis Small Teaching Hospital before the commencement of the study. The researcher complied with the principle of voluntary participation and of informed consent to ensure that the respondents knowingly and willingly agreed to participate in the research. Those willing to withdraw from the study at any particular time were at liberty to do so. The anonymity and confidentiality of the respondents were guaranteed by not writing names on the questionnaires instead of their names to conceal their identity for their safety, dignity and privacy. 

4. Results

From the survey on the knowledge and awareness by 132 women attending polyclinic on Ebola Prevention, the results are as follows; 48% of the respondents are fully aware of Ebola. 64% were able to absolutely identify the signs and symptoms of Ebola. Almost all the respondents first heard Ebola outbreak on the national TV. At least 75% were sure of the existences of Ebola and are very aware of its means of transmission however, almost half are not aware of the preventive measures and even fewer number are not well equip with the most effective means of avoiding with Ebola transmission. Due to the highly emotional sociobiology nature of Gambia, 76% are willing to keep and render assistance to family who might be infected and recovered from Ebola. Figure 1 represents the socio-demographic data of respondents.

Figure 1: Socio-Demographic data of respondents. 

Key: AE-About Ebola; FH-First heard; SS-Signs and Symptoms; T-Transmission; EP-Ebola Prevention; EE-Ebola Existence; CA- Coming across Ebola Patient or Suspected case; I and R-Infected and Recovered Case of Ebola.

Out of the respondents, only 48% of the respondents are fully aware of Ebola. The remaining percentage either saw it as an infection that came as a result of punishment by God or western stereotype. Some respondents claimed although they heard it from people, they have little or no knowledge of Ebola. While 64% were able to absolutely identify the signs and symptoms of Ebola, the other respondent have fairly any idea as to the clinical manifestation of Ebola infection. Apart from the few who for the first time came across Ebola outbreak news from health posts, friends and neighbors, all the other respondents first heard Ebola outbreak on the national TV. Despite the higher percentage (75%) that were sure of the existences of Ebola and are very aware of its means of transmission, there were some whose awareness of Ebola virus transmission is only through eating bush meat and fewer number are not well equip with the most effective means of avoiding coming in contact with Ebola. Up to 40% of the respondents instead understood that, with the implementation of only basic sanitation approaches, Ebola transmission can be controlled. Yet at least 4 respondents do not believe that Ebola is anything real and does not exist. The outbreak is a mere propaganda they believed. 

A good number of respondent are aware of avoiding body contact that might establish body fluid transmission and calling on Emergency Ebola Team. In contrary to this, another good number are not aware of emergency number instead will initiate personal protection while isolating the patients or suspected case. At least 2 responded that they would not care much and one believed that hand washing and seeking prayers from God is the only method of approaches. What to do with Ebola contaminate food is still not understood by the respondents; at least 2 would burn down the food to control the spread of the infection. Of more than 80% would have thrown away the contaminated food and this might encourage the spread of the virus and 3 respondents would not just eat the food and have no idea what to do with it. Due to the highly emotional sociobiology nature of Gambia, 76% are willing to keep and render assistance to family member who might be infected and recovered from Ebola or suspected Ebola case. 20%, despite the family love would isolate the patient and few would seek treatment as they have no idea as to a cure to Ebola. At least one respondent claimed to be scared of and would not know what to do due to fear of contracting the pathogen. 

5. Limitations

Due to the fear surrounding Ebola, it was a bit challenge to recruit participants and probably due to the fear and shock that always come to the minds of many might have affected the responses gathered from this research. 

6. Discussion

The outbreak of Ebola virus in some of the West African countries in 2014 has brought the inhabitants to the world of panic and this fear has gone across the globe. However, despite this world dreadful diseases outbreak, the level of awareness and preventive measures in case of any emergency is not fully comprehended by some. The 52% of the respondents do not know exactly what Ebola is and until this 21th century, a whole lot of people do believe in the theory of spontaneous generation. Ebola is not contagious instead it is a punishment by God to the people who might have caused a very sinful act. There is a gap between the scientists and the lay people regarding the concept of disease and its occurrence. While the former are well grounded scientifically but couldn’t establish forums to create awareness, the latter are reluctant to the pre-medical concepts and would instead see the elites or medical practitioners as the last generation who are not fortunate to understand the diseases occurring phenomena. Some respondents although heard the outbreak, they fairly know what is it all about and since it is not in Gambia, the interest of digging out the facts about could not be established. 

The awareness created by the National Television (TV) and Public Health Officers in The Gambia and the early Ebola symptoms resemblance with Malaria that is very common in Gambia, enable a greater number of the respondents to be well informed about both the early and late symptoms of Ebola case. Some were able to first hear the outbreak through friends and neighbors. This indicates the social cohesion among the inhabitances sharing the same neighborhood. The spectacular rate of the belief that Ebola is real and existed as per outbreak in the neighboring countries speaks a lot as to the level of awareness and an increasing number of elites in the communities of The Gambia. In this recent years, people listen to those they believed are educated, some are still reluctant to western form of education and even see some pressing issues as politically affiliated or western propaganda. The modes of transmission of Ebola virus are still not thoroughly understood among the women attending policlinics across The Gambia. While few are aware of the virus transmission through bodily fluids, majority are confusing it with the modes of transmission of Human Immune Deficiency Virus (HIV). Avoiding eating bush meat is the universal code of conduct for almost everyone while a good number still would have share domestics items with an infected or suspected individual and would only avoid having sexual activities as reference to acquired Immune Deficiency Syndrome (AIDS). In response to this ill information, there is a need for another mass sensitization despite the incidence is calmed. 

The level of preparedness among the women attending polyclinic has some worrying factors. In an event wherein Ebola case is suspected, many respondents have little knowledge as to what emergency approaches to be taken. While a larger percentage would protect themselves and avoid body contact, few among the respondents are well informed about the Ebola Emergency Team that the nation has put in place. Yet there are some who, based their fate on Ebola as not existing would dare not considering any preventive measure. In The Gambia, due to the tradition and strong social relationship among families, friends and even neighbors, people would still not neglect their members even if Ebola suspected case. Many respondents, almost everyone would render care and support to the family member who might have been infected and recovered. In response to this, a fresh presentation on the emergency approaches on outbreaks management is required. The love for family at some extent is embedded in the personal protective assessment scheme. Due to its fear and dreadfulness, few respondents could not give a clear approach to be taken and one instead would do anything to avoid contracting the pathogen. 

7. Conclusion

From the results, although there are recommendable interventions by the Ministry of Health in training individuals for Ebola Emergency, there is still insufficient information to the lay people who must be visiting hospital and clinics and are prone to nosocomial (health posts acquired) infections and Ebola would not be an exception. A similar study by Abramowitz et al. [10] on Community-centered responses to Ebola in urban Liberia reveals the inadequate awareness and knowledge by the people in the community.

Recommendation

In line with Abramowitz et al. [10]’s concept of improving coordinated, multidisciplinary approaches to health emergencies, Ebola outbreaks requires variety of approaches to ensure an effective management of any case or suspected case. From this study, the need to organize a fresh mass sensitization among the populace is of paramount importance. In science, what is not written is not done so as to prevention of diseases, what is not known cannot be applied. The weak surveillance and the unprecedented rural urban migration that encourages overcrowding may increase the risk of quick transmission. In fact this was the reason while Ebola got its way through Liberia and Sierra Leone from Guinea in 2014 [3]. The Government of The Gambia should check the settlement strategies as part of the preparation for any similar outbreaks. 

Acknowledgement

Thanks and praises to the Almighty Allah for everything, family for standing by us and believing in us, colleagues for the admiration and influencing my efforts, friends. We would specially acknowledge Mr. Lamin. A. Jabang for his exceptional assistances in proofreading and the supporting staff at Edward Francis Small Teaching Hospital and Polyclinic for the conducive environment and high show of commitment. 

Finally, my esteemed acknowledgment goes to the staff of Polyclinic for their patience and understanding and all those who participated in the questionnaires. We shall remember you all. 

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