{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,10,18]],"date-time":"2025-10-18T19:10:23Z","timestamp":1760814623150,"version":"build-2065373602"},"reference-count":42,"publisher":"BMJ","issue":"6","license":[{"start":{"date-parts":[[2022,6,27]],"date-time":"2022-06-27T00:00:00Z","timestamp":1656288000000},"content-version":"unspecified","delay-in-days":26,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open"],"accepted":{"date-parts":[[2022,6,17]]},"published-print":{"date-parts":[[2022,6]]},"abstract":"<jats:sec>\n                  <jats:title>Objective<\/jats:title>\n                  <jats:p>To investigate the extent of geospatial clustering of reported deaths during the Ebola outbreak in Liberia and the covariates associated with the observed clustering.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Design<\/jats:title>\n                  <jats:p>Cross-sectional study.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Participants<\/jats:title>\n                  <jats:p>Male and female respondents from the 2019\u20132020 Liberia Demographic and Health Survey. The analysis covered 11 928 (women=7854 and men=4074) respondents for whom complete data were available.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Outcome measures<\/jats:title>\n                  <jats:p>The outcome variable was the death of a household member or relative during the Ebola outbreak in Liberia, coded 1 if the respondent reported death and 0 otherwise.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Methods<\/jats:title>\n                  <jats:p>We applied the Bayesian geoadditive semiparametric regression to examine the extent of geospatial clustering of deaths at the district-level and community-level development and socioeconomic factors associated with the observed clustering.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Results<\/jats:title>\n                  <jats:p>Almost a quarter (24.8%) of all respondents reported the death of a household member or relative during the Ebola outbreak. The results show that deaths were clustered within districts in six (Grand Cape Mount, Bomi, Monsterrado, Margibi, Gbarpolu and Lofa) of the 15 counties in Liberia. Districts with high death clustering were all near or shared borders with Sierra Leone and Guinea. The community-level development indicators (global human footprint, gross cell production and population density) had a non-linear associative effect with the observed spatial clustering. Also, respondents\u2019 characteristics (respondent\u2019s age (non-linear effect), educational attainment and urban-rural place of residence) were associated with the observed clustering. The results show that death clustering during outbreaks was constrained to poor settings and impacts areas of moderate and high socioeconomic development.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Conclusion<\/jats:title>\n                  <jats:p>Reported deaths during the Ebola outbreak in Liberia were not randomly distributed at the district level but clustered. The findings highlight the need to identify at-risk populations during epidemics and respond with the needed interventions to save lives.<\/jats:p>\n               <\/jats:sec>","DOI":"10.1136\/bmjopen-2021-054095","type":"journal-article","created":{"date-parts":[[2022,6,27]],"date-time":"2022-06-27T13:35:18Z","timestamp":1656336918000},"page":"e054095","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":1,"title":["Geospatial clustering and correlates of deaths during the Ebola outbreak in Liberia: a Bayesian geoadditive semiparametric analysis of nationally representative cross-sectional survey data"],"prefix":"10.1136","volume":"12","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-0896-937X","authenticated-orcid":false,"given":"Fiifi","family":"Amoako Johnson","sequence":"first","affiliation":[{"name":"Department of Population and Health, Faculty of Social Sciences, College of Humanities and Legal Studies, University of Cape Coast, Cape Coast, Ghana"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Barbara","family":"Sakyi","sequence":"additional","affiliation":[{"name":"Department of Population and Health, Faculty of Social Sciences, College of Humanities and Legal Studies, University of Cape Coast, Cape Coast, Ghana"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"239","published-online":{"date-parts":[[2022,6,27]]},"reference":[{"key":"2025101811571727000_12.6.e054095.1","doi-asserted-by":"crossref","first-page":"893","DOI":"10.1097\/INF.0000000000000707","article-title":"Ebola virus disease: focus on children","volume":"34","author":"Kourtis","year":"2015","journal-title":"Pediatr Infect Dis J"},{"key":"2025101811571727000_12.6.e054095.2","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(18)33132-5"},{"key":"2025101811571727000_12.6.e054095.3","doi-asserted-by":"publisher","DOI":"10.1056\/NEJMp1409858"},{"key":"2025101811571727000_12.6.e054095.4","doi-asserted-by":"crossref","first-page":"359","DOI":"10.1146\/annurev-med-052915-015604","article-title":"Ebola: anatomy of an epidemic","volume":"68","author":"Lo","year":"2017","journal-title":"Annu Rev Med"},{"key":"2025101811571727000_12.6.e054095.5","doi-asserted-by":"crossref","DOI":"10.1186\/s12992-016-0194-4","article-title":"Understanding Ebola: the 2014 epidemic","volume":"12","author":"Kaner","year":"2016","journal-title":"Global Health"},{"key":"2025101811571727000_12.6.e054095.6","doi-asserted-by":"crossref","first-page":"20160308","DOI":"10.1098\/rstb.2016.0308","article-title":"Heterogeneities in the case fatality ratio in the West African Ebola outbreak 2013-2016","volume":"372","author":"Garske","year":"2017","journal-title":"Philos Trans R Soc Lond B Biol Sci"},{"key":"2025101811571727000_12.6.e054095.7","doi-asserted-by":"publisher","DOI":"10.1371\/currents.outbreaks.406ae55e83ec0b5193e30856b9235ed2"},{"key":"2025101811571727000_12.6.e054095.8","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pntd.0006161"},{"key":"2025101811571727000_12.6.e054095.9","article-title":"Temporal variations in the effective reproduction number of the 2014 West Africa Ebola outbreak","volume":"6","author":"Towers","year":"2014","journal-title":"PLoS Curr"},{"key":"2025101811571727000_12.6.e054095.10","doi-asserted-by":"publisher","DOI":"10.3201\/eid2202.151456"},{"key":"2025101811571727000_12.6.e054095.11","unstructured":"WHO . Health worker Ebola infections in guinea, Liberia and Sierra Leone: a preliminary report 21 May 2015. Geneva: Switzerland, 2015."},{"key":"2025101811571727000_12.6.e054095.12","article-title":"The Ebola outbreak, 2013-2016: old lessons for new epidemics","volume":"372","author":"Coltart","year":"20171721","journal-title":"Philos Trans R Soc Lond B Biol Sci"},{"key":"2025101811571727000_12.6.e054095.13","doi-asserted-by":"crossref","DOI":"10.11604\/pamj.supp.2019.33.2.19074","article-title":"Ebola virus disease outbreak in Liberia: application of lessons learnt to disease surveillance and control","volume":"33","author":"Fall","year":"2019","journal-title":"Pan Afr Med J"},{"key":"2025101811571727000_12.6.e054095.14","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pmed.1002508","article-title":"The 2014-2015 Ebola virus disease outbreak and primary healthcare delivery in Liberia: time-series analyses for 2010-2016","volume":"15","author":"Wagenaar","year":"2018","journal-title":"PLoS Med"},{"key":"2025101811571727000_12.6.e054095.15","first-page":"1","article-title":"The largest Ebola outbreak\u2013 what have we learned so far","volume":"16","author":"Das","year":"2015","journal-title":"J Med"},{"key":"2025101811571727000_12.6.e054095.16","doi-asserted-by":"crossref","first-page":"e439","DOI":"10.1016\/S2214-109X(15)00065-0","article-title":"Health-care worker mortality and the legacy of the Ebola epidemic","volume":"3","author":"Evans","year":"2015","journal-title":"Lancet Glob Health"},{"key":"2025101811571727000_12.6.e054095.17","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pntd.0004260"},{"key":"2025101811571727000_12.6.e054095.18","unstructured":"Mayala B FT , Eitelberg D , Dontamsetti T . The DHS program geospatial covariate datasets manual. 2nd edn, 2018."},{"key":"2025101811571727000_12.6.e054095.19","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pone.0031743"},{"key":"2025101811571727000_12.6.e054095.20","doi-asserted-by":"crossref","first-page":"33","DOI":"10.1007\/s40609-018-0123-y","article-title":"The politics of disease epidemics: a comparative analysis of the SARS, Zika, and Ebola outbreaks","volume":"7","author":"Kapiriri","year":"2020","journal-title":"Glob Soc Welf"},{"key":"2025101811571727000_12.6.e054095.21","doi-asserted-by":"publisher","DOI":"10.1089\/bsp.2014.0032"},{"key":"2025101811571727000_12.6.e054095.22","doi-asserted-by":"crossref","first-page":"47","DOI":"10.2222\/jsv.65.47","article-title":"Epidemiological situation of Ebola virus disease in West Africa","volume":"65","author":"Arima","year":"2015","journal-title":"Uirusu"},{"key":"2025101811571727000_12.6.e054095.23","doi-asserted-by":"crossref","first-page":"38","DOI":"10.1017\/dmp.2014.117","article-title":"Triage management, survival, and the law in the age of Ebola","volume":"9","author":"Burkle","year":"2015","journal-title":"Disaster Med Public Health Prep"},{"key":"2025101811571727000_12.6.e054095.24","doi-asserted-by":"publisher","DOI":"10.15585\/mmwr.su6503a6"},{"key":"2025101811571727000_12.6.e054095.25","doi-asserted-by":"publisher","DOI":"10.3201\/eid2207.151990"},{"key":"2025101811571727000_12.6.e054095.26","doi-asserted-by":"publisher","DOI":"10.1590\/1414-431X20165420"},{"key":"2025101811571727000_12.6.e054095.27","unstructured":"Liu H . Comparing W comparing Welch\u2019s ANOVA, a Kruskal-W A, a Kruskal-Wallis test and tr allis test and traditional aditional ANOVA in case of Heterogeneity of Variance. Virginia Commonwealth University, Graduate School at VCU Scholars Compass 2015."},{"key":"2025101811571727000_12.6.e054095.28","doi-asserted-by":"crossref","unstructured":"Kneib T , Tutz G . Statistical modelling and regression structures. Springer, 2010.","DOI":"10.1007\/978-3-7908-2413-1"},{"key":"2025101811571727000_12.6.e054095.29","doi-asserted-by":"publisher","DOI":"10.18637\/jss.v063.i18"},{"key":"2025101811571727000_12.6.e054095.30","doi-asserted-by":"crossref","first-page":"222","DOI":"10.4103\/2229-3485.167092","article-title":"Common pitfalls in statistical analysis: odds versus risk","volume":"6","author":"Ranganathan","year":"2015","journal-title":"Perspect Clin Res"},{"key":"2025101811571727000_12.6.e054095.31","doi-asserted-by":"publisher","DOI":"10.1111\/j.2007.0906-7590.05171.x"},{"key":"2025101811571727000_12.6.e054095.32","doi-asserted-by":"publisher","DOI":"10.1016\/j.chom.2015.11.008"},{"key":"2025101811571727000_12.6.e054095.33","unstructured":"UNICEF . UNICEF-Liberia Ebola virus outbreak SitReps 2014. Monrovia, 2014."},{"key":"2025101811571727000_12.6.e054095.34","doi-asserted-by":"publisher","DOI":"10.3201\/eid2104.141940"},{"key":"2025101811571727000_12.6.e054095.35","doi-asserted-by":"publisher","DOI":"10.3390\/v6114760"},{"key":"2025101811571727000_12.6.e054095.36","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0137208","article-title":"Social vulnerability and Ebola virus disease in rural Liberia","volume":"10","author":"Stanturf","year":"2015","journal-title":"PLoS One"},{"key":"2025101811571727000_12.6.e054095.37","unstructured":"LISGIS . Household income and expenditure survey 2016. Monrovia: Liberia Institute of Statistics & Geo-Information Services, 2016."},{"key":"2025101811571727000_12.6.e054095.38","unstructured":"LISGIS, MoH, and ICF . Liberia demographic and health survey 2019-20. Monrovia, Liberia and Rockville, Maryland, USA: Liberia Institute of Statistics and Geo-Information Services (LISGIS), Ministry of Health (Liberia), and ICF, 2021."},{"key":"2025101811571727000_12.6.e054095.39","first-page":"1","article-title":"Measuring and understanding global human settlements patterns and processes: innovation, progress and application","volume":"13","author":"Ehrlich","year":"2020","journal-title":"Int J Digi Earth"},{"key":"2025101811571727000_12.6.e054095.40","doi-asserted-by":"publisher","DOI":"10.1038\/ncomms12558"},{"key":"2025101811571727000_12.6.e054095.41","first-page":"22","article-title":"Measuring geographic distribution of economic activity in Nigeria using gross domestic product","volume":"10","author":"Lawal","year":"2018","journal-title":"Ghana Journal of Geography"},{"key":"2025101811571727000_12.6.e054095.42","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0174610","article-title":"Night-time lights: a global, long term look at links to socio-economic trends","volume":"12","author":"Proville","year":"2017","journal-title":"PLoS One"}],"container-title":["BMJ Open"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/bmjopen-2021-054095","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,18]],"date-time":"2025-10-18T18:57:25Z","timestamp":1760813845000},"score":1,"resource":{"primary":{"URL":"https:\/\/bmjopen.bmj.com\/lookup\/doi\/10.1136\/bmjopen-2021-054095"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2022,6]]},"references-count":42,"journal-issue":{"issue":"6","published-online":{"date-parts":[[2022,6,27]]},"published-print":{"date-parts":[[2022,6]]}},"alternative-id":["10.1136\/bmjopen-2021-054095"],"URL":"https:\/\/doi.org\/10.1136\/bmjopen-2021-054095","relation":{},"ISSN":["2044-6055","2044-6055"],"issn-type":[{"type":"print","value":"2044-6055"},{"type":"electronic","value":"2044-6055"}],"subject":[],"published":{"date-parts":[[2022,6]]}}}