Background
Schistosomiasis (also known as bilharzias) is a neglected tropical disease (NTD) of public health importance in many tropical and sub-tropical developing countries [
1]. The disease occurs in 74 countries worldwide, with an annual estimate of 207 million people being infected globally and an additional 779 million people at risk of infection. Sub-Saharan Africa (SSA) accounts for more than 90% of the cases [
2,
3]. In Tanzania schistosomiasis is highly prevalent and the country ranks second, after Nigeria, in terms of disease burden on the African continent [
2,
4,
5]. Intestinal schistosomiasis caused by
Schistosoma mansoni (
S. mansoni) is highly endemic in areas surrounding Lake Victoria in Tanzania [
4,
6], and is implicated in significant morbidity [
4,
7]. School-aged children, adolescents, and young adults are groups that bear the highest burden of disease resulting into significant impairment of their physical, nutritional, and cognitive potentials [
3,
4,
8‐
10].
Three key approaches are currently used to control schistosomiasis, including: improved sanitation, health education, and mass treatment with Praziquantel [
11]. However, in many endemic areas including Tanzania, schistosomiasis control has largely relied on periodic mass treatment of school-age children with Praziquantel in accordance with World Health Organization (WHO) recommendations [
8,
12]. Lack of awareness about the modes of transmission of parasitic infections increases the risk of infection and therefore re-infection following treatment [
13]. Moreover, in high transmission settings, if there has been no change in the sanitary practices and exposure patterns, re-infection tends to occur within one year following treatment, with such trends being higher among young children and adolescents as their adult counterparts demonstrate an acquired partial resistance to re-infections following treatment [
14,
15].
When trying to develop specific interventions aiming at improving communities’ KAPs, pre-existing capacities must be taken into account [
16]. This baseline KAPs level will inform bridging of identified gaps to enhance successful disease control [
11]. Health promotion interventions are likely to fail if they are designed without understanding the typical health behaviours of the target population [
16]. Furthermore, for interventions focusing on community awareness and involving low socioeconomic communities, it is recommended to create supportive environment for the success and sustainability of other strategies [
17,
18].
Although schistosomiasis is prevalent in areas surrounding the Victoria Lake Basin in Tanzania, information on the KAPs on the disease of the most at-risk groups is scarce in the public domain. Therefore, this study was designed to determine schoolchildren’s KAPs on schistosomiasis in the study area.
Discussion
The success of schistosomiasis control interventions in endemic areas can be realized if children, who are the targets of the currently used control interventions, have adequate knowledge, positive attitudes, and correct preventive and control practices. This study aimed at exploring the level of KAPs of schoolchildren on schistosomiasis to inform the development of a targeted control strategy against schistosomiasis.
Our findings showed that majority of the respondents understood that there was schistosomiasis in their village of residence and considered schistosomiasis as a dangerous disease. A similar finding was also reported in other studies elsewhere [
11,
13]. The majority also admitted that the disease could be treated, as it was also reported by Mazigo et al. [
23].
In this study, it was found that majority of respondents had heard about intestinal schistosomiasis, which is similar to previous study findings [
11,
13,
23,
24]. However, just having heard about the disease is insufficient, with a proper understanding of the disease and its causes and mode of transmission required [
16]. About three quarters of respondents reported the school to be one of the major sources of information about schistosomiasis, again reflected in previous studies and making schools a potential strategic channel for communicating health information to this most susceptible age group [
23,
25,
26]. In contrast, other studies reported the most common source of information about schistosomiasis to be family or neighbours, which may dilute the knowledge leading to various misconceptions [
13].
Although the majority of the study participants mentioned swimming in the lake to be one way by which intestinal schistosomiasis could be transmitted, visiting the lake was common in this community. This high rate of visiting the lake was also reported in another study where 84% of the children reported going to the lake [
23]. Children also mentioned fishing as an activity through which schistosomiasis might be transmitted. This high level of knowledge on schistosomiasis transmission could be due to the endemic rate in this community. Of greater concern is how this high rate of knowledge has not concomitantly translated into preventive practices [
20]. Surprisingly, only a few (11.25%) of the participants knew that the cause of schistosomiasis were worms, which seems to be a common issue reported in other studies [
23,
24,
26]. Misconceptions about the true cause of schistosomiasis were also present amongst interviewed schoolchildren who believed witchcraft and mosquitoes were causes of intestinal schistosomiasis. Such misconceptions may be a hindrance to implementation of a successful control program; therefore they need to be clarified before launching an integrated control program in the area. Similar to previous studies [
11,
27], misconceptions about the true mode of transmission were held by many children in these communities, with beliefs that schistosomiasis could be transmitted by drinking unboiled water; walking barefoot, and shaking hands. As many inhabitants of these areas use lake water for domestic purpose including drinking and they do suffer recurrent acute water-borne infections, which may have prompted them to believe that intestinal schistosomiasis could be transmitted by drinking unboiled lake water [
27].
Despite high rates of having heard about schistosomiasis, only 39.9% of the respondents reported knowing the symptoms of schistosomiasis. Low level of awareness on the signs and symptoms for intestinal schistosomiasis were reported in Siphofaneni area in the Lowvelds of Swaziland [
24]. In this current study, the majority mentioned stomach ache to be a symptom for intestinal schistosomiasis contrary to blood in stool which was the most commonly reported symptom associated with intestinal schistosomiasis in western Côte d’Ivoire [
26].
Despite the majority of the respondents knowing that avoiding swimming in lake water may be preventive for schistosomiasis, visiting the lake was a common practice amongst study participants due to dependency on the water for domestic and economic use including fishing, swimming, washing utensils, drinking, cooking, and watering animals. Similar results were also reported in western Kenya [
11]. Misconceptions on proper preventive practices against intestinal schistosomiasis were common among study participants, including avoiding drinking unboiled lake water and washing fruits before eating. This was a misconception likely rooted in such preventive measures applying to other water-borne infections which are also endemic in the area. The observed knowledge gap on the signs, symptoms, and preventive measures against intestinal schistosomiasis among study respondents indicates lack of appropriate health education targeting this at-risk group which should be provided in combination with mass treatment campaigns. Such campaigns should enhance children’s knowledge and therefore influence positive practices which will lower re-infection rates following mass drug administration campaigns.
Respondents in this study consider fishermen and schoolchildren to be the most at risk groups for schistosomiasis. These two groups were also perceived to be the most at risk groups in a different study [
11]. Despite high knowledge on the mode of transmission of intestinal schistosomiasis and the reported high rate of toilet ownership, indiscriminate defecation practices were common among study participants. This practice implies that the knowledge on the mode of transmission for intestinal schistosomiasis has not influenced children’s sanitation (toileting) practices. This finding may signify that behavioural changes, which are often more difficult to achieve, are not guaranteed by awareness alone, and that long intervals are required to ensure uptake and compliance of healthier practices [
13,
28]. Similar findings have been reported elsewhere, children felt comfortable defecating close to lake water when at the lake, as it appeared inconvenient to go back home just to answer a call of nature while there was water around to clean themselves thereafter [
11,
13,
23]. In another study participants reported that, in some cases where the toilets were present, people still preferred defecating in the bush where they found to be more comfortable as compared to pit latrines that were feared to house snakes and were often full [
11]. These findings suggests that provision of toilets alone is not enough to eliminate the indiscriminate defecation practices, providing public education on the importance of properly using toilets in the control of schistosomiasis and other parasitic infections needs to be emphasized in a manner which reaches the targeted populations [
13].
The study further revealed that toilet ownership was lower in Busanga than Kibuyi village and more respondents reported to have indiscriminate defecation practice in Busanga than was reported in Kibuyi village. This observation is likely related to the proximity of Kibuyi village to Musoma municipality which is the headquarters for Mara region potentially leading to people having better access to health information than people at Busanga village which is more distal from the larger centre. Location of the household has been found to be a significant factor in the access and utilization of toilets [
29].
Acknowledgements
The authors thank the District Executive Director, District Medical Officer, and District Education Officer for Rorya District for granting permission to undertake this study. They also thank the head teachers, teachers, and pupils in each of the schools that participated in this study and all the research team members for their assistance in the field work.