We identified multiple beliefs and practices that contributed to the spread of Sudan virus in Uganda during 2022. These included engaging traditional healers for treatment, communalism, touching ill persons during prayers, attribution of illness to supernatural forces, and conduct during traditional burials. Such practices should be recognized for their potential contribution to spread of infection during ebolavirus outbreaks in Uganda and similar settings. A follow up study to identify the acceptable alternatives to these approaches together with the community could help reduce spread of infection in future outbreaks.

Traditional healers are regarded as custodians of daily traditional and cultural values in many communities in Africa, and using them as the first line of care during an illness is common [18, 19]. Media reports from 2021 suggested that traditional healers outnumbered medical doctors by a ratio of 35:1 in Uganda [20]. Traditional healers are often more highly regarded than persons who promote conventional medicine or other forms of health care [18]. Many practices of traditional healers in Uganda put them – and subsequently their future patients – potentially at risk of ebolavirus infections during an outbreak. A 2003 study from Northern Uganda reported traditional healers making incisions into people’s bodies and rubbing in herbal medicine, which led to the spread of ebolavirus [21]. Reports for at least 15 patients in our study documented their visits to traditional healers while they were ill; participants in our qualitative study suggested that such visits led to at least some subsequent SUDV infections.

Indeed, at least two patients in the outbreak were themselves traditional healers. Because of the preference in some communities for traditional healers as the first line of treatment, some have advocated for the engagement of traditional healers in controlling the spread of ebolaviruses [4, 16, 18]. In a study in West Africa, traditional healers were trained about ebolaviruses, how to recognize symptoms early, where suspected patients should be referred, and how to protect themselves; they were subsequently involved in risk communication for their communities. The communities trusted their communication, ultimately supporting disease control in the outbreak [18]. Another study in northwestern Uganda that described the training of traditional healers to identify plague symptoms and refer patients noted the importance of not stigmatizing or treating traditional healers as ‘less than’ conventional health providers. The study emphasized the importance of respecting differences in belief and practice to facilitate collaborative relationships for epidemic control [2].

Some people believed that the illness caused by SDV infection was caused by supernatural beings, witchcraft from neighbors or vengeance from an offended god as a result of transgressions committed in the past by an individual or parents. This is commonly observed during ebolavirus outbreaks, which frequently occur in communities with a strong belief in witchcraft as a cause of illness [1, 2,9]. A study in Nigeria also found that community members, especially those living in rural areas, believed that most health problems were spiritually related and could be resolved without allopathic medicine, resulting in their seeking treatment from a traditional healer to remove the witchcraft rather than a hospital [22]. In Sierra Leone, both traditional healers and community members initially attributed outbreak-related deaths to witchcraft or poisoning [23].

Religious and spiritual healing practices (touching ill persons during prayers) may also have contributed to the spread of the 2022 SDV outbreak in Uganda. Multiple patients had documented experiences during their illness of visiting religious leaders and those healers themselves also represented some of the outbreak patients. Community members reported that they sought spiritual healing to dispel the ‘witchcraft’. Similar findings were reported in a study in West Africa, in which religious leaders both contracted the illness from sick persons and passed it to others in prayer sessions [18, 24]. A subsequent intervention engaging religious leaders enabled them to educate their institutional members about the importance of seeking healthcare first in health facilities, isolating if ill, and using protective equipment in case of unexplained bleeding [25].

The normal cultural practices around funerals in many African settings, which involve washing and touching the body by family and mourners, can contribute to Ebola viruse(or SDV) spread during an outbreak [26]. Such practices, according to community members, are highly valued because they are regarded as critical steps in the transition from the world of the living to the spiritual world, which must be facilitated by surviving relatives through specific rituals [2, 4, 13, 18]. Similar to other studies, we heard from participants that funeral practices contributed to the spread of SUDV in Uganda [14, 21, 27]. Other practices reported by study participants, such as exhumation, are related to the lack of acceptance of safe and dignified burials, and contributed to the spread of SUDV. The rapid burial of the deceased without allowing relatives to view the dead bodies gave rise to the suspicion that medical professionals were keeping the corpses in order to sell their relatives’ body parts [14]. During a SUDV outbreak in Northern Uganda in 2003, such mistrust was exacerbated by rumors that some Westerners were purchasing human body parts [8, 28]. Without mutual trust between community members and health workers, adherence to preventive measures during an Ebola outbreak is likely to be compromised. In some communities, health officials attempting to conduct safe and dignified burials were attacked and prevented from executing their duties [28]. Initiating community engagement studies to identify appropriate and acceptable ways to allow them to participate in safe and dignified burials could reduce illness spread in a future SVD outbreak.