Knowledge, attitudes and practices on schistosomiasis and soil-transmitted helminths among caregivers in Ingwavuma area in uMkhanyakude district, South Africa

The Ingwavuma area is in the North-Western part of uMkhanyakude District in KwaZulu-Natal, South Africa. It is arid and sub-tropical marked by erratic rainy and dry seasons. It also characterised by a hot and humid summer from November to February and a cooler, drier winter from June to August [21]. The hydrological network is formed by the Pongola and Ingwavuma rivers. Most communities in the Ingwavuma have limited access to piped water and as such depend on rivers, dams and ponds to sustain their domestic water needs [22].

Quantitative data was collected using KoBo Collect software [28] and subsequently imported into SPSS. Statistical analysis was done after data validation. Qualitative data from interviews was transcribed per verbatim and typed into an excel spreadsheet. A code sheet was developed for the focus group discussions after which, the data was coded into selected themes and was analyzed. Researchers checked for consistency of the transcripts against the audio files to ensure the accuracy of the transcribed files.

Table 1 presents the overall sample characteristics. A total of 442 caregivers comprising of 28 (6.3%) males and 414 (93.7%) females participated in the study. The participants were caregivers to 442 PSAC that had been screened for schistosomiasis and STH. The majority (63.1%) of the caregivers were in the 15–34 year age group while 364 (82.4%) of the caregivers were unmarried.

We conducted 3 FGDs among CCGs and 8 FGDs among caregivers on KAP in relation to schistosomiasis and STH. A total of 62 CCGs, preschool teachers and traditional authorities responded to schistosomiasis and STH KAP interviews. There was a single male respondent among CCGs and a single female respondent among traditional authorities. All preschool teachers were females and the youngest respondent in in-depth interviews was 35 years old. More than two-thirds of CCGs were born in the study area.

Most study participants (87.1%) acknowledged having previously heard of schistosomiasis (Fig. 2). Out of these, almost two-thirds knew signs and symptoms (69.1%) and prevention measures (61.6%) of schistosomiasis while half (48.3%) and only 5% knew about treatment and control and life cycle respectively. These notable knowledge gaps arose from study participants who declared not having any information on schistosomiasis ranging from 30.9% on signs and symptoms and 95.1% on the life cycle. Consequently, only about half of the sub-sample that had heard of schistosomiasis could accurately name a specific symptom (53%), knew about prevention (48.1%) while 33% had knowledge on treatment and control and 1% knew could describe the life cycle. Overall, the proportion of sampled participants with knowledge of schistosomiasis ranged from 0.23% on the life cycle to 42.15% on signs and symptoms.

Figure 3 presents overall findings on knowledge of soil-transmitted helminths in the Ingwavuma area of uMkhanyakude. Although 79.6% of participants had heard about STH, a large proportion did not have detailed knowledge. Almost two thirds (62.2%) of participants knew some signs and symptoms of STH. However, only 2.3% of participants confirmed knowledge of STH life cycle. Effective knowledge was poor, lower proportions of the sample correctly listed at least a single STH sign/symptom (50.6%), cause (32.4%), life cycle (1.4%) or prevention measure (42.9%).

Results show significant misconceptions on signs and symptoms, transmission, life cycle and prevention of schistosomiasis (Table 2). Participants related sexual practices and symptoms of sexually transmitted diseases with schistosomiasis citing genital sores as being symptomatic of schistosomiasis, unprotected intercourse as a transmission mode and protected intercourse as a preventive measure. Other notable misconceptions included transmission of schistosomiasis through feeding practices and including the soil as part of the schistosomiasis life cycle. Misconceptions were also widespread on signs and symptoms, causes, life cycle and prevention of STH. The misconceptions included teeth grinding, dietary habits and treatment as signs, transmission ways and preventive methods respectively.

Out of 385 caregivers who acknowledged to have heard about schistosomiasis and STH, friends/relatives 121(31.4%) and community meetings 91(23.6%) were the most reported as major sources of information while clinics/hospitals were the least reported 46(11.9) source (see Fig. 3).

Caregivers’ knowledge of schistosomiasis and STH and their main source of information Table 3 shows that caregiver’s knowledge on the transmission was associated with the source of information (p-value: 0.001) and most participants with correct responses received the information in community meetings. The caregivers’ knowledge of schistosomiasis prevention, signs and symptoms were also associated with the main source of information (p-value: 0.001). Those knowledgeable received the information from community meetings and relatives-friends. For STH, only the knowledge on prevention was associated with the source of information and most of the caregivers were also informed through community meetings.

Five themes emerged from the data: (i) preferred sources of information, (ii) knowledge and misconception, (iii) attitudes (iv) water and sanitary practices (v) control and (vi) health-seeking behaviour (see Table 4). Most of the study participants reported to have inadequate knowledge, attitudes on modes of transmission, life cycle, prevention and control “As for me, I don’t have good information about these diseases, but I remember growing up, our elders used to warn us against jumping over fire and even eating cold food” ; Male respondent – FGD. Noted misconceptions were related to the schistosomiasis and STH transmission, signs and symptoms, and prevention. FGD participants mentioned that schistosomiasis may be caused by sexual intercourse, jumping over fire, and drinking dirty water.

Additional file 1: Table S1 shows the association between caregiver’s knowledge and attitudes towards schistosomiasis and STH; Respondents who regarded schistosomiasis and STH as minor infections that could heal without any intervention (p-value: 0.001) and assumed that schistosomiasis treatment was costly (p-value: 0.001) were more likely to have a negative attitude towards schistosomiasis control and prevention. The same trend was also observed with STH.

Results from the bivariate analysis showed a significant association between age group and source of family income and practices on both STH and schistosomiasis (see Additional file 2: Table S2 and Additional file 3: Table S3). Formal education attainment and source of information was significantly associated with knowledge of STH while the source of health information was the only significant variable for schistosomiasis knowledge.

From the multivariate analysis, caregivers who got information through community meetings (COR 2.425, 95% CI: 1.363–4.316) and health institutions (COR 2.630, 95% CI: 1.349–5.130) were more likely to report good STH practices than those reporting not receiving any information (see Table 4). Caregivers with at least secondary education were 66% (COR 0.335, 95% CI: 0.146–0.766) less likely to have high knowledge of STH relative to their counterparts without any formal education. On the other hand, caregivers who accessed health information through the media had higher odds (COR 3.813, 95% CI: 1.561–9.314) of attaining high knowledge levels on STH when compared with caregivers not receiving any information. However, there was no noticeable change in the likelihood of attaining higher knowledge levels on STH for caregivers at least secondary education (AOR 3.744, 95% CI: 1.518–9.232) those accessing information through the media (AOR 0.344, 95% CI: 0.148–0.798) after controlling for other variables. Being aged at least 35 years increased the odds of reporting good practices on schistosomiasis by 65% (COR 1.652, 95% CI: 1.073–2.543) while receiving health information through community meetings (COR 0.072, 95% CI: 0.010–0.548) significantly reduced the odds of having good knowledge on schistosomiasis (Additional file 2: Table S2).

This study shows a significant relationship between caregiver’s major source of information and the ability to give at least one correct answer. Our study revealed that most people relied on family friends and community meetings for health information. Caregivers that could not give accurate responses on schistosomiasis and STH were those that relied on family and friends for schistosomiasis and STH related information. Our findings are in line with previous studies that found that peers and family members tend to give inaccurate health messages [29, 30] due to limited health-related knowledge [31]. This suggests therefore that, if community members are empowered with accurate information, schistosomiasis and STH control programs can leverage on them as existing dissemination channels, in order to halt the spread of infection through behaviour change strategies.

This study aimed to understand knowledge, attitudes and practices on schistosomiasis and STH among caregivers in rural KwaZulu-Natal, South Africa. Our study provides invaluable insights into KAP in rural South Africa. There was education intervention among participants prior to the study. The establishment of the level of knowledge and misconception prior to an intervention program was important to design context-specific educational programs on schistosomiasis and STH. Most respondents claimed to be aware of schistosomiasis and STH. however, knowledge levels declined drastically with follow-up questions assessing the accuracy of the self-reported knowledge. Knowledge was highest on signs and symptoms and the least on life cycle for both schistosomiasis and STH. The low knowledge was prevalent across categories of key caregivers’ socio-demographic characteristics. The low level of knowledge despite high awareness levels have been reported widely by KAP studies conducted in Bangladesh [32], Kenya [33], South Africa [34] and Ethiopia [35]. A recent systematic review on KAP of schistosomiasis in SSA reported low levels of comprehensive knowledge despite high levels of self-reported disease awareness ranging from between 75 and 98% [15]. This strongly suggests communities may overestimate their health-related knowledge which may, in turn, hinder the effectiveness of treatment and control programs and has implications for health promotion intervention. For this reason, contextual realities ought to be considered when designing health awareness campaigns particularly in rural areas with low levels of formal education. Risky water and sanitary related practices were observed among most of the participants who reported relying on open water sources due to water scarcity and whose children practice open defecation due to the unavailability of appropriate toilets for PSAC. Previous studies have overemphasized the importance of water, sanitation and hygiene (WASH) in the control of schistosomiasis and STH [36]. Disadvantaged communities, however, are still grappling with the provision of such services due to financial constraints and expertise required for their implementation.

Our findings revealed widespread misconceptions on schistosomiasis and STH among all participants and respondents i.e. community caregivers, traditional leaders, preschool teachers, caregivers in the Ingwavuma community. Most fallacies related to schistosomiasis signs and symptoms, transmission and prevention. For instance, participants in FGDs and in-depth interviews confused schistosomiasis with sexually transmitted infections due to the blood in urine. Our findings are consistent with previous findings from other settings including Tanzania [37], Mozambique [38], and Kenya [39, 40]. On the other hand, the few misconceptions on STH were seemingly mythical. Rural communities are often marked by dominant cultural influences characterized by widespread close-knit structures of influence thus wrong messages may easily lead to widespread misconceptions and risky practices that cascade across generations [41]. The distortion of health seeking behaviour resulting from misconceptions and myths on illness may hinder control efforts in the case of schistosomiasis and STH.

Most male participants in our study underestimated the seriousness of schistosomiasis and STH, rating them as infections that not cause death easily. Earlier studies from Uganda [42], Tanzania [37], Kenya [43] and Nigeria [20] had similar findings where respondents believed schistosomiasis was a natural disease that did not require medical attention. In our study, FGDs with men also revealed that they believed it was the responsibility of women to acquire health information because their cultural and ordained role is to take care of their children and the entire family. Contrary to this belief, earlier systematic review findings reported that women had lower levels of health-related knowledge compared to men [15], however, men tend to have poor health-seeking behaviour compared to women [44]. Such variations in beliefs and practices, however, are not surprising considering that in most rural areas in African societies, human behaviour is mainly governed by strong sociocultural influences and expectations [45]. Such beliefs, however, may become bottlenecks for control interventions. Ultimately, they hinder programs from timely controlling and eliminating Schistosomiasis and STH in such settings.