Background
In 2001 a resolution was passed during the 54th World Health Assembly
(WHA) with the target (for member states) to regularly administer anthelmintic drugs
to at least 75 % and up to 100 % of all school-aged children at risk of morbidity
due to schistosomiasis by 2010 [1]. In
the same year, the World Health Organization (WHO) assembled an expert committee to
refine the global strategy for the prevention and control of schistosomiasis. Since
then, millions of school-aged children have received praziquantel against
schistosomiasis [2]. Even though it has
limitations because older population segments are insufficiently addressed, and
hence new knowledge on prevention and control of schistosomiasis infections is
minimal [2].
In Kenya, more than 6 million people, or approximately 23 % of the
total population, are infected with urinary or intestinal schistosomiasis
[1]. In 2005, Kenyan Ministries of
Health and Education initiated a parasite control programme with the aid of Japan
International Co-operation Agency (JICA) and Kenya Medical Research Institute
(KEMRI). The programme was targeting S. mansoni and Soil transmitted helminthes
(STHs) in school age children. After sensitizing and educating the community health
officers and education officers in the district, 43,928 school age children from 86
schools were de-wormed with praziquantel and albendazole by trained school teachers
[3]. Prior to the de-worming, baseline
prevalence and intensity of parasitic infections were determined through examination
of stool samples of class three children (age range 9–14 years). A follow up study
of five cohort primary schools was carried out to monitor the effectiveness of the
control programme for four consecutive years. The prevalence of the parasitic
infections in the five cohort schools was 38 % for S. mansoni before treatment
[4]. However, there was an overall
parasitic re-infection rate of 16 % for S. mansoni, 6 months after treatment. The
trend of re-infection continued after treatment to 22 % in the second year, 31 % in
the third year and 17 % in the fourth year [4]. Although the program achieved significant results, there is a
continuous challenge of disease re-establishment after completion of program
[5]. Mwea irrigation scheme in
Kirinyaga County, where transmissions of schistosomiasis, is relatively high has a
prevalence of 47.4 % [3].
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Knowledge, Attitudes and Practices in relation to the disease are
critical in establishing effective control measures. However, data on the knowledge,
attitude, and practices (KAP) of populations in endemic areas in Kenya with regard
to schistosomiasis are not available. Community awareness and involvement are
considered as one of the cardinal tools for the success and sustainability of any
disease control programme [3]. Within
this context, the present study aims to evaluate the KAP towards schistosomiasis in
the Mwea Population. It is hoped that the findings will provide new information
about the schistosomiasis-related KAP of the targeted population, and will add new
insights about the prevention and control of this devastating disease in
Kenya.
Methods
Study area
The study was conducted in Mwea irrigation scheme located in
Kirinyaga County, central Kenya. Administratively, the new upgraded Kirinyaga
County has two districts (Mwea East and Mwea West). The county is located about
100 km north east of Nairobi, Kenya. It covers an area of 513 km2 and it is
estimated to have 51,444 households and a total population of 176,261 persons. The
mean annual rainfall in this area is in the range of 1200–1600 mm per year and
varies by the time of year. Mwea West district, where the study was conducted has
two locations (Kangai and Thiba) and seven villages. The main socio-economic
activity in this area is rice farming, which is done by gravity flow irrigation
using water from river Thiba and Nyamindi. Mwea west district is endemic for both
S. mansoni and Soil transmitted helminths (STH).
Study design
The study employed descriptive cross-sectional design adopting both
qualitative and quantitative data approaches for assessing Knowledge, Attitude and
Practices on schistosomiasis prevention and control in Mwea division of Kirinyaga
Sub County.
Study population
The division was selected based on schistosomiasis endemicity in
the area after doing a consultation with the District Public Health Officer and
previous studies conducted in the area in the control program [3]. The study population will be selected on the
basis of availability during the time of study.
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Sample size determination
The minimum sample size will be computed using the formula by
Fischer et al. [6].
The current prevalence is unavailable, thus an assumed prevalence
of 50 % will be used in the computation of the minimum sample size required for
this study.
\( \mathrm{n}=\frac{{\mathrm{z}}^2\upalpha \mathrm{p}\mathrm{q}}{{\mathrm{d}}^2} \) Where
Zα
= standard normal deviate = 1.96
p
= estimated prevalence. = 0.5 (50 %)
q
= (1 − p) = 0.5
d
= (Precision) = 0.05
\( \mathrm{n}=\frac{(1.96)^2(0.50)(0.50)}{0.05^2} \) n = 384.16 approximately 385 participants
385 × 1.2 (design effect) = 461 participants is the minimum sample
size required for the study.
Sampling procedure
Three villages were purposively sampled based on high
schistosomiasis prevalence for the study [3]. The number of households to participate, in each of the three
villages were selected with a probability proportionate to their sizes and Mianya
which has 1200 households was represented by 301 households, Murubara has 500 and
was represented by 126 and Mbui Njeru which has a total of 135 households was
represented by 34 households.
Selection of households
In the quantitative component, simple random sampling technique was
applied to select the households from each village. The number of households per
sub-location depended on the household sizes. The household heads were interviewed
in each household, in the absence of the household head an adult representative
was interviewed using the structured questionnaire.
Questionnaire
An interviewer based questionnaire was used for the household
heads. Issues pertaining to socio-demographic characteristics, water usage and
sanitation, knowledge, attitudes and practices related to schistosomiasis
infection, housing factors (such as type of construction of the house, type of
floor inside house, sanitary conditions, waste disposal, acceptability and
willingness to use the current preventive and control measure was used.
Questionnaires were administered with both closed ended and open ended questions
to capture elements of quantitative and qualitative data respectively. The
questionnaire was administered using the local language and translated to English
and Kiswahili.
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Qualitative data
Key informant interviews
Stratified purposive sampling technique was used to select key
personalities i.e. local administration, head teachers, opinion leaders,
religious and group leaders and health officers. In each village, schools were
selected for each division and the headmasters for the selected schools were
interviewed in any one school. Purposive selection was done in the village. The
village elders, an area member of parliament or councilors, health officers in
the local health facilities and church or mosque leaders were also interviewed.
At least 10 key informant interviews were conducted in the three administrative
locations, totaling up to 30 interviews. The key informant guide that was
developed was pre-tested and amended accordingly and used to interview the above
selected participants in various aspects. The guide was used to explore the
individual knowledge, attitude and practices on schitosomiasis infection. The
KII guide helped in exploring the insights of the real issues in regard to
factors influencing the prevention and control of schistosomiasis infection from
the informants.
A total of 18 in-depth interviews were conducted with opinion
leaders from three administrative locations. Fourteen of the participants were
male and four female.
The respondents mean age was 50, the youngest was 26 years old
and the oldest was 75 years old. Majority (6) of respondents were farmers and
teachers were three while three were village elders and three social group
leaders with three business people. All (18) respondents were Christians, 17
were married and one was single.
Focus group discussions
Focus group discussions were conducted and led by trained
moderators and note-takers fluent in the local languages on the above selected
participants. The researcher developed themes and sub-themes on the subject of
discussion. The themes and sub-themes developed were used to probe the members,
while the note takers were recording gestures, assent, expressions, and other
non-verbal information that maybe coming out. An evaluation was done at the end of
the meeting by the researcher to validate the information collected. Discussions
were gathered on two digital voice recorders and transcription were done by voice
recognition software called Dragon voice recognition then typed into Ms Word and
analyzed using the NUDI.ST NUIRO.6 software.
A total of 12 FGDs were done in all the three administrative
locations, with each of the administrative locations having four FGDs each. The
participants were asked to attend a specially arranged session of 30 to 45 min for
a focus group discussion. The FGDs participants included single sex adult
(36 years and above) and youth (18 to 35 years) male and female participants of
homogenous characteristics. The FGDs were further categorized into gender (male
youth and female youth and female adult and male adult). The adults had to be
between 36 years of age and above. There was no exclusion in terms of language for
this category Study participants were randomly selected from pools of individuals
that met the inclusion criteria. The youth, whether male or female had to be
between 18 and 35 years of age and able to speak either English or Swahili. Each
FGD contained a minimum of 8 and a maximum of 12 participants. Community health
workers, familiar with the villages, helped to mobilize participants for the
study. Further screening was done on site to make sure that participants met the
inclusion criteria before obtaining consent, and that they were fully
representative of the different villages.
Quality assurance
Quality assurance measures included training enumerators and data
entry clerks on the survey instruments, field testing with a special focus on a
‘real-life’ situation, as much as possible so as to improve the process and to
enhance the understanding of the study team. Field supervisors were also engaged
to immediately review questionnaires on a daily basis and to rectify any
inconsistencies that may arise. Data Cleaning was a multi-stage process. The data
was cleaned immediately after data entry in MS Access, data was continually
exported to excel and fed into SPSS during analysis until the final report was
completed.
Data management and analysis
Quantitative data collected was entered into the Ms Excel and
Access software. Statistical analysis was done after data validation. Descriptive
statistics including mean, or median, frequencies and proportions were
appropriately generated. Chi square test was used to test associations between
variables. Bivariate analysis was performed to identify the factors significantly
associated with the KAP variables among the studied population. A P value of <0.05 was considered to be statistically
significant.
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Data collected from qualitative interviews was transcribed verbatim
into Microsoft Word. The research team then checked the consistency of the
transcripts against the audio files to ensure accuracy of the transcribed files.
The cleaned transcripts were then imported into qualitative text analysis software
NUID.IST NUIRO.6 This software allowed the data to be coded systematically.
Qualitative data was analysed using content and thematic analysis to identify
emerging themes. The process of analysis involved familiarization with the data,
development of initial codes based on the research questions and issues emerging
from data, refinement of codes and their allocation to broad themes. Data was then
stored in electronic storage devices like DVDs, USB, files containing the data
were encrypted and access was only authorized PI to ensure quality control.
Results
Socio-demographic characteristics of the respondents
The results indicating socio-demographic characteristics of the
respondents are presented in Table 1. Out
of the 400 and 65 respondents, there was a higher number of females (63.9 %) while
males were 36.1 % in the three divisions, with a significant difference between
the genders. There were also significant differences in the categories of age,
marital status, religion, occupation and education level. The majority (70.0 %) of
the participants were married compared with 30.0 % who had never married. In the
selected communities, the majority of the residents were farmers 79.1 % while less
that 1.0 % were unemployed. Primary-educated residents accounted for 67.0 %, while
the rest had either, no formal education, secondary education or postsecondary.
Notably, the majority of residents (99.6 %) were predominantly Christians with
Muslims and others constituting only 0.2 %.
Table 1
Socio-demographic characteristic of respondents
Variable | Response | No. of respondents (N = 465) Percentage (%) |
|---|---|---|
Gender | Male | 168 (36.1 %) |
Female | 297 (63.9 %) | |
Marital status | Married | 371 (70.0 %) |
Single | 45 (13.8 %) | |
Divorced | 23 (7.9 %) | |
Widow | 20 (6.3 %) | |
Widower | 6 (2.0 %) | |
Religion | Christian | 463 (99.6 %) |
Muslim | 1 (0.2 %) | |
Other | 1 (0.2 %) | |
Level of education | No Formal Education | 34 (7.3 %) |
Primary Education | 311 (66.9 %) | |
Secondary Education | 107 (23.0 %) | |
Post Secondary | 11 (2.4 %) | |
Occupation | Public Servant | 4 (0.9 %) |
Farmer | 368 (79.1 %) | |
Business | 32 (6.9 %) | |
Informal Employment | 59 (12.7 %) | |
Not Employed | 2 (0.4 %) | |
Age group (years) | 17–30 years | 166 (35.8 %) |
31–40 years | 126 (27.1 %) | |
41–50 years | 60 (12.8 %) | |
51–60 years | 49 (10.6 %) | |
61–70 years | 40 (8.4 %) | |
71–80 years | 18 (3.8 %) | |
81–90 years | 6 (1.3 %) |
Knowledge about schistosomiasis, symptoms, transmission, prevention and control among Mwea population
From the analysis, over half of the participants (58.71 %)
indicated that the most common disease in the area was schistosomiasis. Majority
of the respondents (92.9 %) stated that they were aware of schistosomiasis. A
third of the participants (39.87 %) indicated health workers as the main source of
information. Another third of the participants (30.51 %) mentioned stomach ache as
the most common sign and symptom of schistosomiasis. Approximately 41 % of the
respondents stated that the disease was transmitted through contact with infected
water while about 14.04 % did not know the medium of transmission. Study results
reveal that majority of the respondents or a member of their household (70.97 %)
had suffered from schistosomiasis. Slightly above a third of the participants
(34.49 %) indicated the use of toilet facility as a way of preventing
schistosomiasis, and for those already infected over half of the respondents
(51.79 %) indicated that prescribing to schistosomiasis medication would avoid the
risk of re infection. With regard to intervention strategies for schistosomiasis,
slightly below half of the respondents (49.25 %) indicated that community
intervention programmes existed, with a third of the participants (31.6 %) stating
that the intervention programmes were government initiatives as indicated on
Table 2.
Table 2
Knowledge about schistosomiasis, symptoms, transmission,
prevention and control among Mwea population
Questions | Response | n (%) |
|---|---|---|
Have you heard of schistosomiasis | Yes | 432 (92.90) |
No | 32 (6.88) | |
No Answer | 1 (0.22) | |
Have you or any member of your household suffered from
schistosomiasis? | Yes | 330 (70.97) |
No | 135 (29.03) | |
In your Knowledge, have there been any community
intervention programmes on schistosomiasis prevention and control in
this area? | Yes | 229 (49.25) |
No | 236 (50.75) | |
If yes, which programmmes are these? | Government Programmes | 147 (31.6) |
NGO Programmes | 59 (12.7) | |
FBO Programmes | 0 (0) | |
Community Initiated | 19 (4.1) | |
Individual Initiated | 2 (0.4) | |
Don’t Know | 8 (1.7) | |
NA | 230 (49.5) | |
What is the Common Disease in this area? | ||
Frequency | Percent | |
Bilharzia | 273 | 58.71 |
Malaria | 163 | 35.05 |
Diarrhoea | 8 | 1.72 |
Don’t know | 5 | 1.08 |
N/A | 2 | 0.43 |
Other | 14 | 3.01 |
Total | 465 | 100.0 |
How can a person prevent him/herself from getting
Schistosomiasis? | ||
Not working in rice fields | 77 | 15.71 |
Not using other person’s belongings | 13 | 2.65 |
Stepping or walking on dirty water | 94 | 19.18 |
Washing hands | 80 | 16.33 |
Using the toilet facility | 169 | 34.49 |
Wearing of shoes | 57 | 11.63 |
Total | 490 | 100 |
Which of the following signs and symptoms did you or members
of your family experience? | ||
Stomach ache | 285 | 29.5 |
Vomiting | 115 | 11.9 |
Diarrhea | 221 | 22.88 |
Bloody Stool | 212 | 21.95 |
Swollen Stomach | 27 | 2.8 |
Abdominal Pain | 106 | 10.97 |
Total | 966 | 100 |
How can a person who is already infected with
Schistosomiasis reduce their risk of re infection? | ||
Prayer | 4 | 1.02 |
Practice good sanitation | 169 | 43.11 |
Putting on of gumboots while in the pad | 16 | 4.08 |
Those already infected to take medicine | 203 | 51.79 |
Total | 392 | 100 |
When are you likely to get Schistosomiasis? | ||
Wading, bathing or swimming in infected | 212 | 35.1 |
Working/rice planting in rice paddies | 309 | 51.16 |
Interaction with infected persons | 18 | 2.98 |
Not using the toilet facility | 64 | 10.6 |
Use of other persons’ personal belonging | 1 | 0.17 |
Total | 604 | 100 |
Source of Information on Disease | ||
Media | 37 | 5.9 % |
Health Workers | 250 | 39.87 % |
Family | 118 | 18.82 % |
Friends, Peers | 111 | 17.7 % |
Religious Leader | 9 | 1.44 % |
Teacher | 61 | 9.73 % |
Community Baraza | 32 | 5.1 % |
Campaigns | 9 | 1.44 % |
Total | 627 | 100 % |
Association of awareness of the participants on schistosomiasis with some demographic factors
The study results on the association between demographic
characteristics and awareness on schistosomiasis are as presented in
Table 3. The results revealed that
awareness on schistosomiasis was significantly associated with age (p = 0.011) and education level (p = 0.046). However the results revealed that awareness on
schistosomiasis was not significantly associated with gender (p = 0.060) and marital status (p = 0.71).
Table 3
Association of awareness of schistosomiasis with some
demographic factors
Factors | Awareness | Total | Statistical Significance | |
|---|---|---|---|---|
Yes n (%) | No n (%) | |||
Gender | ||||
Male | 158 (94.0) | 7 (6.0) | 168 (100) | p = 0.060 |
Female | 268 (90.2) | 29 (9.8) | 297 (100) | |
Age | ||||
17–30 | 144 (86.7) | 22 (13.3) | 166 (100) | p = 0.011 |
31–40 | 123 (97.6) | 3 (2.4) | 126 (100) | |
41–50 | 53 (88.3) | 7 (11.7) | 60 (100) | |
51–60 | 46 (94) | 3 (6) | 49 (100) | |
61–70 | 37 (93.9) | 2 (6.1) | 40 (100) | |
71–80 | 18 (100.0) | 0 (0.0) | 18 (100) | |
81–90 | 4 (66.7) | 2 (33.3) | 6 (100) | |
Education | ||||
Not Educated | 30 (88.2) | 4 (11.8) | 34 (100) | p = 0.046 |
Primary | 304 (97.7) | 7 (2.3) | 311 (100) | |
Secondary | 107 (100.0) | 0 (0.0) | 107 (100) | |
Post Secondary | 8 (72.7) | 3 (27.3) | 11 (100) | |
Marital Status | ||||
Married | 344 (92.7) | 27 (7.3) | 371 (100) | p = 0.071 |
Single | 39 (86.7) | 5 (13.3) | 45 (100) | |
Divorced | 19 (82.6) | 4 (17.4) | 23 (100) | |
Widow | 20 (100.0) | 0 (0.0) | 20 (100) | |
Widower | 5 (83.3) | 1 (16.7) | 6 (100) | |
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Qualitative data presentation
Assessment of knowledge and awareness
Avenues of information
The FGDs with community members revealed that the majority of
the participants had heard about schistosomiasis before. The sources of
information included schools, posters, radio and community gatherings
(baraza), with the health workers the
most mentioned. A 37-year-old male casual labourer (informal employment) from
Mianya said, “I heard about it through the community
health workers, they normally visit us a lot especially when there are
barazas at the chief’s camp for health talks especially on
schistosomiasis.”
Preferred sources of information
With regard to spreading information about schistosomiasis,
participants mentioned a few sensitization methods that they felt would work best
in their community: a 40-year-old female farmer from Murubara said: “Door to door is best because the village elders know each and
every one of their village and they can do it easily….” A 37-year-old male farmer in Mianya said: “I wish they can use billboards up to those rural areas it is the
best one because you see as you walk.”
Knowledge about schistosomiasis
Adult male FGDs indicated that some of the common diseases in the
area were (as mentioned by participants); Schistosomiasis,
Malaria, and high blood pressure and the main symptoms (as mentioned
by participants); Urinating blood, blood in stool, stomach ache, head ache,
dizziness and joint aches. Our study revealed that the majority of the
participants felt they did not have adequate information about schistosomiasis. A
30-year-old female business owner from Mbuinjeru said: “Some are informed while others are not, depending on the literacy level. If
you didn’t go to school then you can’t be informed about it.” A
26-year-old male youth in Mianya said: “Me personally, I
don’t think that am well informed about it, because I only know that it is being
caused by snails in the infested areas but what about the symptoms and the
medications? I don’t know.”
Some of the participants had some information on how the disease
can be prevented. For example, a 27-year-old adult female from Mbuinjeru said:
“I think by washing hands before eating, entering the
rice paddies with gum boots can help in prevention.” A male youth
from Murubara: “For example, if I apply jelly oil before
entering the rice paddies then I won’t be infected.”
But lack of knowledge also turned out to be expensive for the
community economically. This was echoed by one of the male respondents from the
key interviews who reported that ‘due to lack of knowledge
the community do face problems when they are infected with Schistosomiasis for
it often causes death and also a lot of energy is lost in terms of finances,
much time is consumed hindering one from participating in economic growth and it
impairs growth in children’ 43 years old village elder from Mbuinjeru
division.
At risk groups
It was the general view of participants that there is no particular
gender or age that is more at risk compared with others. They attributed this to
modernization where both women and men do more or less the same tasks and have the
same levels of exposure as explained by a 55-year-old female farmer in Murubara
“I think both male and female. Because nowadays, people
believe that it is gender equality. What men can do, ladies also
try.” This was echoed by a 37-year-old farmer from Mbuinjeru,
“As for me, I think anybody can get infected by this
disease (schistosomiasis), whether it’s a child or an adult and especially those
people whose main work constantly involves water.” A few however,
bearing in mind gender roles, felt that a particular gender was more at risk
“For me, if I may reflect back on how we grew up,
men…, male children were the people who were
really affected by schistosomiasis; I didn’t know any girl suffering from
schistosomiasis; I can’t tell whether they were infected since I did not observe
it—perhaps they hid it as girls. So it is us men who would realize that we were
passing out blood or victims of bilharzia. The reason why we are mostly affected
is that we expose ourselves in areas having water when we go to graze animals or
when we are playing while girls are always at home.” said a
44-year-old farmer from Mbuinjeru. FGD youth female indicated rice farmers, and
children as the group that tends to get the disease more with challenges faced
from the disease (as mentioned by participants); Weakness, unable to eat, going to
the toilet many times, some people become bed ridden. Though adult male FGDs
showed that everybody was at risk of getting the disease.
Assessment of attitudes
One of the factors that the participants mentioned and that could
pose as a barrier in schistosomiasis control is the attitude of community members
toward those infected with the disease. A 42-year-old male farmer in Murubara
said: “They can judge you and mistake it for other
diseases like HIV.” A 47-year-old female in Mbuinjeru put it
succinctly: “when you suffer from those symptoms like
diarrhea and swollen stomach, they think that you are HIV positive.”
A female youth in Mianya said: “I think when you become
sick, there are things you can’t share with your spouse like
blankets.”
The youth female FGDs thought that toilets should be build, they
should come together and build toilets in the paddies as a community and that the
government needs to be more involved by building more latrines, taking care of
existing latrines and educating the community on health education more often. A
42 years old farmer in Mianya said “our people don’t like
using latrines in the paddies, majority would rush home to use latrines and some
do not mind they just diarrhea in the paddies.”
Seeking treatment
The majority of the participants thought that treating
schistosomiasis is very expensive. The youth female discussions indicated that
seeking treatment is costly and its time consuming. Participants indicated
visiting the health facility for treatment and drugs but some opted to use herbal
treatment which they found cheap. Community members opted to optimize the door to
door campaign by the health worker as reported by a 40-year-old administrator from
Mianya, ‘the community have advanced a step forward in the
recent days out of the tireless activities of our community health workers who
go door to door to campaign and teach our community on general health issues and
even give our children dewormers’.
Susceptibility and severity
More than half of the participants were of the opinion that
schistosomiasis is a serious disease, and that their activities exposed them to
infection. These sentiments were reflected by a 25-year-old female youth in Mianya
division “Where I come from it is a problem because, next
to our home we have a river. People swim there ….” A 35-year-old female from Mbuinjeru went on to
elaborate “Shistosomiasis is not a joke, reason being that
it also brings with it headache, diarrhea of bloody stool, and as you urinate
blood you end up losing a lot of blood. So it comes along with many infections
to your body. You are always weak even standing up to walk becomes a
problem.” Similar thoughts were echoed by a 40-year-old male
administrator from Murubara. “It’s very serious because
any disease can kill if not treated in time, so according to me schistosomiasis
can kill and therefore it’s a very serious disease.”
Assessment of practice
Use of sanitation facilities and hand washing (p = 0.014, p = 0.001)
Most of the community members thought that they are the main
cause of spreading the disease. For example, one of the respondent who is a
farmer aged 60 years from Murubara Division reported that ‘the community in large numbers do not use pit latrine and they
usually dig shallow holes which after filling they take a long time to prepare
another one’. A village elder who is 43 years old from Mianya also
lamented that ‘the community around me do use toilet but
in most cases they forget to wash their hands after visiting the toilet which
is a link to one of the diseases like diarrhea’.
This was further echoed by one of the respondent from the key
informant interviews who reported that’ there is need
for the community to be sensitized on how to use the toilet facilities for not
many do wash hands after visiting the toilet.’72 year old retired
teacher from Murubara.
Seventy five year old chairman in one of the organizations
reported that’ most of the community members working in
paddies have no toilets, hence they go to the canals or in the rice fields to
relieve themselves’. A local administrator to the area also
lamented that ‘I would say that the community within my
area of jurisdiction are conversant with using toilet for about 60 %
residential do each have a toilet facility only that some sense of hygiene
need be conveyed to many because about 40 % of these people do not remember to
wash their hands after visiting the toilet before eating.
Wearing protective gear (p = 0.142)
On wearing of protective gear, a 51-years-old administrator from
Mbuinjeru division reported that ‘in actual fact,
practices of wearing protective gears while in the rice paddies is inevitable
unless maybe they may be introduced to farmers in future for there has never
been such commodities ever since rice farming was invented in Mwea
scheme’.
A 56-year-old Director at a local factory reported that’ they are not needed most people do not know the importance of using
protective wears they say they are too heavy e.g. gum boots and hand gloves will
make them work slowly in paddies and they are so expensive’.
One of the respondents aged 26 also reported this on wearing
protective gear ‘the community at large do not wear any
protective gear because the paddies are very deep’.
Household compound affected by floods (p = 0.005) and water for use in the household
A common practice by the community members included, fetching water
for household use from canals, drainage, paddies this was from the youth male
FGDs. On households being affected by floods, one of the key informants reported
that ‘most of the area is flooded with water in rainy
season. Many people do not use toilet facilities’ a 50 year old
female farmer from Mianya division. Another respondent who is 40 years of age from
also added that ‘many toilets within the region are 3 ft
or 4 ft they stay for 3 months in dry spells but during rainy season they are
over flown with water all over the village’.
A 33 years old male instructor from Murubara reported that
‘the area is swampy and you dig 3 ft deep and after the
rainy season water floods all over the community making it dirty. Therefore the
water available becomes contaminated hence wasted for there is no piped
water.
Association between practices and having suffered from schistosomiasis infection
Table 4 indicates the
relationship between practices and having suffered from schistosomiasis infection.
There was an association (p = 0.037) between
frequency of visits to the paddies and having suffered from schistosomiasis
infection. There was a significant association between washing of hands after
visiting the toilet and having suffered from schistosomiasis infection (p = 0.001). Further, the results show that having
suffered from schistosomiasis infection had a significant association with having
a toilet facility at home, (p = 0.014); raring
animals at home (p = 0.031) and household being
affected by floods (p = 0.005). Study indicate
no significant association between working in the paddies (p = 0.144), not wearing protective footwear (p = 0.142) and having suffered from schistosomiasis infection.
Table 4
Distribution of respondents’ practice and having suffered from
schistosomiasis infection
Factors | Having suffered from Schistosomiasis infection | Total n (%) | Statistical Significance | |
|---|---|---|---|---|
Yes n (%) | No n (%) | |||
Working in the paddies | ||||
Yes | 325 (74) | 113 (26) | 438 (100) | p = 0.144 |
No | 17 (65) | 10 (35) | 27 (100) | |
Frequency of visiting paddies | ||||
Frequently | 284 (76) | 91 (24) | 375 (100) | p = 0.037 |
Rarely | 38 (61) | 25 (39) | 63 (100) | |
Wearing protective footwear while in the
paddies | ||||
Yes | 5 (56) | 4 (44) | 9 (100) | p = 0.142 |
No | 320 (74) | 111 (26) | 431 (100) | |
Handwashing after toilet visiting | ||||
Yes | 176 (64) | 99 (36) | 275 (100) | p = 0.001 |
No | 160 (84) | 30 (16) | 190 (100) | |
Sanitation facility available at home | ||||
Yes | 323 (73) | 119 (27) | 442 (100) | p = 0.014 |
No | 20 (87) | 3 (13) | 23 (100) | |
Raring Animal at home | ||||
Yes | 178 (80) | 46 (20) | 224 (100) | p = 0.031 |
No | 168 (70) | 73 (30) | 241 (100) | |
H/Hold compound affected by floods | ||||
Yes | 258 (78) | 75 (22) | 333 (100) | p = 0.005 |
No | 84 (64) | 48 (36) | 132 (100) | |
Discussion
Study findings showed that 39.87 % of the respondents indicated that
they had heard about the disease from the healthcare personnel. However, a study in
Senegal [7] showed low awareness of
intestinal schistosomiasis among the population. Despite 7 years of health education
interventions using a diversity of communication outlets including radio, television
and posters, a previous study in Senegal revealed that although 86 % of the
respondents stated that they had heard about schistosomiasis, only 30 % had adequate
knowledge about the symptoms and modes of transmission of the disease [7]. The present study revealed poor knowledge about
the modes of transmission and preventive measures of schistosomiasis; with 34.49 %
of the respondents indicating that use of toilet facility would prevent one from
getting schistosomiasis infection. In western Kenya, a previous study found that
some of the participants knew snails and poor sanitation contributed to the spread
of the disease, but lacked understanding of the transmission cycle [7]. Hence, it is clear that the lack of this
knowledge among the targeted population may create an additional burden and cost for
controlling the disease and may cause the failure of the schistosomiasis eradication
programme.
Although the majority of the respondents had heard about
schistosomiasis, the results showed that awareness about the symptoms, ways of
transmission and preventive and control measures among the participants was
generally poor. The present study was carried out in endemic areas that underwent
the active control and prevention surveillance by Japan International Cooperation
Agency (JICA together with GoK line ministries (MoH, MoE) which may explain why
92.90 % of the respondents had heard about the disease. This is also consistent with
the finding that 70.97 % of the respondents had declared history or a member of
their household having suffered from shistosomiasis which supports the endemicity of
infection in these communities. Study findings revealed that 28.50 % of the
respondents mentioned stomachache as the main signs and symptoms. Conversely,
previous studies from Brazil and Ethiopia reported diverging information where the
majority of the subjects were able to associate these symptoms with the infection
[8, 9]. Similarly, it is also worth noting that knowledge about the
symptoms of schistosomiasis among the respondents was negligible, as only 22.88 % of
them mentioned diarrhea and 21.95 % blood in stools. This could be attributed to the
disease being frequently confused with other intestinal infections exhibiting
similar symptoms, such as amoebic dysentery, which is common among the targeted
populations [10, 11]. The theoretical foundation in the Health
Belief Model (HBM), integrates people’s knowledge, perceptions, attitude and
practices to a disease in establishing trends of infection [12].
The study further revealed a significant association (p ≤ 0.05) between washing of hands after visiting the
toilet with having suffered from schistosomiasis infection. The current study was
consistent with studies conducted in Gondar and Babile [12, 13], where there was significant association between intestinal
parasitic infections and hand washing practice. A study conducted in Brazil reported
that daily contact of open water source results in higher rate of infection by S.
mansoni [14].
The current study indicates that, availability of toilet facility at
home was significantly associated with having suffered from schistosomiasis
infection. This does not concur with a study from Yemen which reported that the
absence of a functioning toilet in the house was significantly associated with the
prevalence of schistosomiasis and this was in accordance with other previous studies
[15].
The findings of the present study showed that raring animals at home
was significantly associated with having suffered from schistosomiasis infection.
Results of a survey in Xinzhuang, indicated grazing cattle, digging vegetables,
cutting grass in the field, and raising cattle by free grazing are some of the risk
factors for schistosomiasis hence greater infection rates [16].
The study results further indicated that households being affected by
floods was significantly associated with having suffered from schistosomiasis
infection. While it is clear that sanitation breaks the transmission cycle of many
diseases, the season can have impacts on the sanitation facilities themselves with
heavy rains causing pit latrines and sewerage systems to flood and become inoperable
and possibly contaminate the environment. A study by Wu XH et al. [17] indicated that the number of acute cases with
schistosomiasis japonica was markedly higher in years characterized by floods; on
average, 2.8 times more cases were observed when compared to years that the Yangtze
River had normal water levels [17].
The present study reveal that gender, marital status, wearing
protective gear and working in the rice paddies were not significantly associated
with having suffered from schistosomiasis. This concurs with a study by Hany Sady et
al. [18] which found no significant
difference in the prevalence of schistosomiasis between male and female participants
and marital status. The study indicated female as more prone to schistosomiaisis
infection than men, these could be attributed to females being responsible for
fetching water and washing clothes and utensils at these water sources, and
therefore, have similar exposure to infective stages. Other studies elsewhere have
also reported significantly higher infection rates among females compared to their
males counterparts [19, 20].
Self-protection during agricultural work plays an important role of
reducing the risk of infection, at least in principal. However, this present study
indicated no significance between wearing protective gear and having suffered from
schistosomiaisis infection. This concurs with a study by which revealed that PPE
wearing behaviours were not improved by the intervention that the project put in
place. It still scored lowly. When asked about the reason for not using any
protection, most people responded that “however useful in interrupting transmission,
it was uncomfortable and inconvenient to wear rubber gloves or boots while working
in the fields”. While this illustrates the difference between understanding the
benefit and modifying behaviour, as suggested in other studies of
occupationally-related behaviour change [21], it also raises the issue of the practicalities of sustained
personal protection in an inherently risky environment. Spear et al. [22] argues that a focus on environmental
improvements and monitoring systems to signal early risks of infection are better
long-term solutions than personal protection in rural China as they are in
occupational settings worldwide [22].
The study results reveal that working in the rice paddies was not
significantly associated with having suffered from schistosomiasis. This does not
concur with a study by Bukenya et al. [23] which indicated that schistosomiasis mansoni in the study area
is closely linked to working in the rice paddies.
Conclusions/significance
This study reveals inadequate knowledge, attitude and practices
concerning schistosomiasis among the Mwea population, which could be a challenging
obstacle to the endevour towards the elimination of schistosomiasis from Kenya.
Schistosomiasis infection is still a major problem with regard to prevention and
control in Mwea. Thus, there is a great need for a proper health education
intervention and community mobilization in order to enhance prevention and instill
better knowledge concerning the transmission and prevention of schistosomiasis.
Providing efficient health education to people residing in schistosomiasis endemic
areas is imperative for an effective and sustainable control programme in order to
save the lives and future of the most vulnerable population in Kenya.
These findings support an urgent need to start an integrated,
targeted and effective schistosomiasis control programme with a mission to move
towards the elimination phase. Besides periodic drug distribution, health
education i.e. handwashing and community mobilisation, provision of clean and safe
drinking water, introduction of proper sanitation are imperative among these
communities in order to curtail the transmission and morbidity caused by
schistosomiasis. Emergence response during floods should also be used as a
mitigation strategy in curbing new infections. Screening and treating other
infected family members should also be adopted by the public health authorities in
combating this infection in these communities. This study recommends a focus on
change in practices in the community to complement existing efforts aimed at
creating knowledge and awareness on schistosomiasis.
Study limitations
Since it was a Cross-Sectional study, it was therefore difficult to
infer causality.
Acknowledgements
The authors would like to acknowledge Director KEMRI for providing the
Internal Research Grant that facilitated the project. Vote of thanks goes to the
study participants and the study team as a whole. We wish to express our sincere
thanks to the District administrators in Kirinyaga County, staff of the Ministries
of health and the community members for facilitating the smooth running of the
project in Mwea. We are also grateful to Danvers Omolo of DNDI for his statistical
inputs. This paper is published with the permission of the Director
KEMRI.
Funding
This study received financial support from Kenya Medical Research
Institute (KEMRI), Eastern and Southern Africa Centre of International Parasite
Control (ESACIPAC). The Kemri Internal Research Grant No. IRG/072/3.
Availability of data and materials
That all data used in the manuscript is available for
sharing.
Authors’ contributions
JM-conceived of the study, participated in its design coordination,
and helped to draft the manuscript. MB-participated in the design of the study and
helped to draft the manuscript. SN-participated in the design, coordination and
helped to draft the manuscript. All authors read and approved the final
manuscript.
Authors’ information
JM-is a Research Scientist at ESACIPAC/KEMRI.
SN-is a Chief Research officer at ESACIPAC/KEMRI.
MB-is a Research officer at ESACIPAC/KEMRI.
Competing interests
The authors declare that they have no competing interests.
Consent for publication
Not applicable.
Ethics approval and consent to participate
This study was approved by the KEMRI Ethical Review Committee
(SSC/ERC protocol No. (2061). The study used questionnaires uniquely coded with
results of each questionnaire being kept in strict confidence. Participating in
the study was voluntary and one could withdraw at any point. The purpose of the
study and its objectives were explained to local authorities, opinion leaders,
village elders, and community members. Informed consent was obtained from the
participating respondents. Subjects were assured about confidentiality of
information obtained from them and personal identifiers were removed from the data
set before analysis.
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