Barriers and Facilitators to Adopting Safe Burial Practices During an Ebola Virus Disease Outbreak in Liberia: A Mixed Methods Study

Background Traditional funeral practices were a significant factor in the transmission of Ebola virus disease (EVD) during the West Africa outbreak from 2014–2016. In Liberia, these practices often conflict with public health directives, resulting in noncompliance and secret burials. Understanding the barriers to and facilitators of adopting safe burial practices is critical for informing future epidemic responses. Methods This mixed-methods study was conducted in Vai and Clara Towns, Monrovia, Liberia. Data collection included surveys (n = 200), in-depth interviews (n = 40), and four focus groups (n = 40) with family members and community leaders. The quantitative data were analyzed via descriptive statistics. Thematic analysis was applied to the qualitative data to identify major themes. Results The quantitative findings revealed high knowledge of EVD transmission and generally positive attitudes toward safe burial practices, with more than 90% of the participants answering the knowledge questions correctly. Most participants recognized funerals as high-risk settings. Qualitative analysis revealed seven major themes: cultural and traditional resistance, mistrust and stigma, misinformation, emotional and psychological distress, communication and logistical challenges, socioeconomic constraints, and facilitators of safe practices. Conclusions Although knowledge and risk perceptions were high, compliance with safe burials was undermined by cultural norms, mistrust, and systemic barriers. Future responses should prioritize early community engagement, the involvement of traditional and religious leaders, culturally sensitive adaptations of protocols, and adequate psychosocial and logistical support.