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Lassa fever (LF) is an emerging viral haemorrhagic disease endemic to West Africa that can potentially cause a global pandemic. Nigeria has experienced yearly LF outbreaks since 2012 and the 2018 outbreak recorded an unprecedented number of cases and deaths. A critical gap in controlling neglected tropical diseases such as LF is our limited understanding of how people access care and how structural and cultural factors constitute barriers to care. This study examines concepts of illness and healthcare-seeking behaviours to investigate these barriers. From October to December 2019, we conducted a mixed-methods community-based study consisting of 51 interviews, 21 focus groups, and direct observations, in 5 villages of a 2018 LF hotspot in Ebonyi state, Nigeria. Participants' perceived severity and frequency of diseases aligned with the current biomedical understanding. In contrast, some diseases were associated with witchcraft or bad behaviours. Most participants knew LF disease but denied its yearly recurrence. In addition, LF victims and caregivers suffered from a strong stigmatisation. We identified a mismatch between preferred and actual healthcare-seeking behaviours. Most participants preferred hospital care but defaulted to traditional healers and patent medicine vendors (chemists). Reasons reported were high care fees, life-sustaining jobs conflicting with commuting time to hospitals, and a low English literacy. Age and education correlated with healthcare-seeking behaviours: elder and less formally educated people preferred traditional healers. LF-related stigma reportedly impacted timeliness and adequacy of care during the 2018 outbreak. Participants had a good knowledge of the diseases and true barriers to care came from structural factors and LF-related stigma. This led to mismatches between disease knowledge and healthcare-seeking behaviours. Awareness campaigns may have a limited impact if they focus on disease knowledge without addressing barriers to care. Key messages To enhance LF detection and control, LF policies in rural Nigeria should focus on barriers to care through public health messaging addressing stigma and through bringing care closer to remote areas. This community-based study illustrates the importance of understanding the socio-cultural ecology of the diseases to inform evidence-based and locally adapted strategies for disease control.