Protective Behaviors Associated With Gender During the 2018-2020 Ebola Outbreak in Eastern Democratic Republic of the Congo

IMPORTANCE In 2018 to 2020, the Democratic Republic of the Congo experienced the world's second largest Ebola virus disease (EVD) outbreak, killing 2290 individuals; women were disproportionately infected (57% of all cases) despite no evidence of differential biological EVD risk. Understanding how gender norms may influence exposure to EVD, intensity, and prognosis as well as personal protective behaviors against the virus is important to disease risk reduction and control interventions. OBJECTIVE To assess whether men and women differ in personal protective behaviors (vaccine acceptance, health-seeking behaviors, physical distancing) and the mediating role of EVD information and knowledge, perceived disease risk, and social relations. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional, multistage cluster survey study of 1395 randomly selected adults was conducted in the Ebola-affected regions of North Kivu from April 20, 2019, to May 10, 2019. Path analyses were conducted using structural equation modeling to examine associations among study variables. Statistical analysis was conducted from August 2019 to May 2020. MAIN OUTCOMES AND MEASURES The main behavioral outcomes of interest were (1) vaccine acceptance, (2) formal health care seeking, and (3) self-protective behaviors. The primary factor of interest was self-reported gender identity. We also assessed sociodemographic factors. RESULTS Among the study's 1395 participants, 1286 (93%) had Nande ethnicity and 698 (50%) were women; the mean (SD) age was 34.5 (13.1) years. Compared with female participants, male participants reported significantly higher levels of education, wealth, and mobile phone access. There were associations found between gender and all EVD preventive behavioral outcomes, with evidence for mediation through EVD knowledge and belief in rumors. Men reported greater EVD knowledge accuracy compared with women (mean [SE] score for men: 12.06 [0.13] vs women: 11.08 [0.16]; P < .001), and greater knowledge accuracy was associated with increases in vaccine acceptance (beta = 0.37; P < .001), formal care seeking (beta = 0.39; P < .001), and self-protective behaviors (beta = 0.35; P < .001). Lower belief in rumors was associated with greater vaccine acceptance (beta = -0.30; P < .001), and greater EVD information awareness was associated with increased adoption of self-protective behaviors (beta = 0.23; P < .001). CONCLUSIONS AND RELEVANCE This survey study found gender differences in adopting preventive protective behaviors against EVD. These findings suggest that it is critical to design gender-sensitive communication and vaccination strategies, while engaging women and their community as a whole in any response to infectious disease outbreaks. Research on the potential link between gender and sociodemographics factors associated with disease risk and outcomes is needed.