Operational definitions
For the purpose of the current study we used the following definitions:
Knowledge: Awareness or familiarity of the participants with schistosomiasis, its control and preventions.
Attitude: The manner in which participants view schistosomiasis and how this view affects the way they might view the need for managing risky behaviors, and an ongoing intervention program (MDA).
Practice: The habitual way of the participants’ response to schistosomiasis, its prevention and an ongoing intervention program (MDA).
Introduction
Despite the global control efforts of schistosomiasis, the prevalence, and worm loads remain high, particularly in Sub-Saharan Africa (SSA), which accounts for about 90% of people living with schistosomiasis [
1]. Of the five known species of
Schistosoma, the most prevalent in SSA are
S. haematobium which causes urogenital schistosomiasis, and
S. mansoni which causes intestinal schistosomiasis [
2].
The distribution and impacts of
Schistosoma in endemic countries in SSA differ significantly, with a greater impact on the poor and marginalized communities [
3]. These populations are living in areas that have a low socioeconomic status with limited access to clean water and adequate sanitation. In most of the schistosomiasis endemic countries, people who have frequent contact with infected natural water bodies, because of the nature of their work are at a greater risk of infection [
4]. The high
Schistosoma infection risk among these groups is mainly due to risky water contact practices, poor sanitation, and lack of knowledge, and misconceptions about schistosomiasis [
5].
Community awareness about parasitic infections and a better understanding of the socio-cultural and behavioral determinants of the targeted community affect the magnitude and prevention of the infections and additionally support in designing effective prevention and control strategies [
6,
7]. The active participation of the targeted communities in the prevention and control efforts is one of the key ways for the success and sustainability of disease prevention and control programs [
8]. Likewise, understanding the perception of the targeted population is of great importance for developing evidence-based, and cost-effective intervention plans [
9].
In communities where poverty and schistosomiasis are a double burden, intervention through public awareness is often recommended as the first line and cost-effective action to create the enabling environment for other strategies to succeed [
10]. The World Health Organization (WHO) inspires endemic countries to adopt policies and programs focusing on an integrated approach of Mass Drug Administration (MDA) programs with primary health care interventions, especially, with health education programs, which help in eliminating schistosomiasis rather than just controlling its morbidity [
11].
The finding of a recent systematic review and meta-analysis in Ethiopia showed that the prevalence of schistosomiasis is high despite continued prevention and control efforts [
12]. Although the knowledge, attitude, and practice (KAP) of the community could have a significant role in the success of any control strategies, such studies towards schistosomiasis are limited in the country. Hence, this study was aimed to investigate the levels of schistosomiasis related to KAP of schistosomiasis endemic community in the remote lowlands of the Abbey and Didessa Valleys in Benishangul Gumuz Region of Western Ethiopia, during an ongoing MDA campaign and 30 years after the first schistosomiasis control was attempted.
Methods
Study area and population
The details of the study area are presented elsewhere [
13]. The area is located in the remote lowlands of western Ethiopia with poor infrastructure. Benishangul Gumuz Region is one of the nine regional states of Ethiopia which shares a border with Sudan from the west, Amhara regional state from the East, and Orommia regional state from the south. The Grand Ethiopian Renaissance Dam (GERD) is being constructed on the Nile River in this regional state. The current study was conducted in three of the same villages of the region, where Gundersen et al. [
14] observed a lasting effect of campaigns and mass deworming 20–30 years previously. The villages were: (a) Chessega village in the Sirba Abbey area of the Abbey Valley and (b) in the other two villages, Metti and Shimala in the adjacent Agallu Metti area, situated eastwards on the hilly slopes south of the junction between the Didessa and Abbey rivers (700-1200 m altitudes). The area is an extensions of the Sudanese savannah with a hot, dry climate and receives seasonal rains from May to October.
The study area is about 600 km west of Addis Ababa and mostly inhabited by a Nilotic ethnic group known as Gumuz, except some Oromos and Amharas who moved to the lowland for farming or public services. The total population of the three study villages is about 8375, of which 2660 are residents of Sirba Abbey (Chessega), 3800 are residents of Metti, and 1915 are residents of Shimala (Agallu Metti). All the inhabitants live under similar poor environmental sanitation and low socio-economic status. They earn their living in small-scale farming using the traditional farming methods. Maize and millet are the most commonly cultivated crops in the area. Schistosoma mansoni is known to be an endemic disease, but the status of this endemic has been unknown for the last 20 years.
Study design
We used the multilevel triangulation-mixed methods design, involving individuals, community groups, and health care providers and program implementers.
Sample size determination
This study was nested within another community-based study that examined the prevalence of schistosomiasis for which sample size was determined [
13] using 63% as the best available estimate for the prevalence of
S.mansoni reported in a previous school-based cross-sectional study in the same area [
14]. The sample size and households that were used for that study [
13] were used to address the objective stipulated in this paper. For the qualitative data, the planned starting number was 12 FGDs, 6 with men and 6 with women, and 25 in-depth interviews. The final numbers of FGDs and in-depth interviews conducted were decided based on information saturation.
Survey sampling procedure
Three villages were purposely selected based on schistosomiasis endemicity after consultation with the District Public Health Officials and previous studies [
14]. The total sample size was distributed to the three villages proportional to their population size. Using the list of households obtained from the Kebele administration in each village, we used a systematic sampling technique to select households for interviews. From each household, an individual whose age was at least 12 years old, who lived in the study area for more than a year and not having any obvious critical medical illness at the time of data collection were eligible for the study provided they give consent/assent to be part of the study. In case the study participant was younger, there should be an adult, parents or guardians, in the household who could give written informed consent on behalf of the child.
Survey questionnaire
The survey questionnaires were prepared in English and translated to Amharic and back to English to check the content change. The questionnaire had three sections: The first part covered demographic data and the second part focused on the knowledge and level of awareness of the respondents regarding schistosomiasis. Questions like a local name for schistosomiasis, sources of information about the disease, signs, and symptoms, methods of transmission, and prevention were included in the 2nd part of the questionnaire. The third part covered the perceived severity of the disease and the attitudes towards interventions. The respondents were asked about their perception of the severity and preventability of the disease and the medical intervention provided by the government as well as any comments regarding the interventions.
Qualitative data
In-depth interviews
Purposive sampling technique was used to select key informants (KIs) for in-depth interviews. The KIs include district administrators, teachers, religious or clan leaders and district health officials, and health care providers. The in-depth interview guide covered topic areas that helped us to explore the insights of the KI’s knowledge, attitude, and practices about schistosomiasis infection, its prevention, and control.
Focus group discussions
Focus Group Discussions (FGDs) were done with men and women community members in each village. The FGDs were led by trained moderators and note-takers fluent in the local languages. The first author developed themes and sub-themes on the subject of discussion which was then used to probe the discussants. An evaluation was done at the end of each FGD to validate the collected data. The whole discussions were audio reordered, transcribed verbatim, translated into English, coded, and then analyzed using thematic analysis.
Observation
We conducted observations to assess schistosomiasis risk behaviors in the community, including the availability and proper use of toilet facilities, water contact activities, and open defecation behaviors. We also observed the availability of diagnostic material for schistosomiasis in local health institutions, the availability of schistosomiasis medications, case registration logs of schistosomiasis cases, and schistosomiasis management guidelines.
Quality assurance
Quality assurance measures included training data collectors, field testing of the survey instruments with a special focus on a ‘real-life’ situation to improve the process and to enhance the understanding of the field data collection team. Field supervisors and the first author were involved in the fieldwork to immediately review questionnaires on a daily basis and to correct any inconsistencies that may arise. Three Ph.D. candidates, two as data collectors and one supervisor were trained for 3 days by an experienced qualitative researcher and by the first author of this paper. The training was included understanding the aim of the study, a common understanding of survey questionnaires and interview guides, ethical issues and consenting procedures, session management and moderating, probing, and data collection procedures. Data cleaning was a multi-stage process. After entering the data in Epidata, the data was cleaned immediately, and it was continuously exported into SPSS for preliminary analysis of quantitative data. Data cleaning was also continued during and after translation, transcription, and coding of qualitative data. Transcripts were reviewed by the first author at each site for translation accuracy and revised when necessary.
Data management and analysis
Quantitative data were entered into the Epidata software. Statistical analysis was done using IBM SPSS version 25 software. Descriptive statistics including frequencies and proportions were used to summarize the data. Chi-square test and Fisher’s exact tests were used to test the significance of associations between variables and a P-value below 5% was considered as an indicator of statistical significance.
The qualitative data were analyzed manually using the thematic method [
15]. All the qualitative data collected were tape-recorded, and verbatim responses to each question were translated and transcribed, and documented in Microsoft Word. We checked the consistency of the transcripts against the audio files to ensure the accuracy of the transcribed files. A code sheet was created following the focus group and the key informant guides after which, the textual data was coded into selected themes and a master sheet analysis was carried out, giving all the responses from the focused group discussions and key informants interview. Thematic analysis was used where responses were categorized into themes and then ideas were formulated by looking at the patterns of responses. Analyzed data were presented in text form. The qualitative data were analyzed by three Ph. D candidates. The analysis team discussed and resolved the differences in coding or themes, revised the codebook or themes accordingly, and re-coded as necessary to ensure consistent application of code.
Discussion
The present study indicates limited knowledge, common negative attitudes, and risky practices related to schistosomiasis in the general population, health staff, and officials. It is obvious that any information by educational campaigns during the first treatment campaign 30 years ago has not been kept up. Moreover, the presently ongoing MDA does not seem to involve the local inhabitants, teachers, health- and other officials to the extent that they have obtained proper schistosomiasis knowledge.
The local health officials did not have specific plans for prevention and control of schistosomiasis except for the MDA campaigns organized by the upper level of the health care system. This finding is similar to a report in Burundi, where knowledge of care providers for intestinal schistosomiasis was very low [
16], and in Ghana, where very low knowledge of genital schistosomiasis by health workers was reported [
17]. However, lower knowledge level than report in Senegal [
18]. This difference may be due to differences in the level of education and having specific training on schistosomiasis. None of the local health care providers in our area were specifically trained on schistosomiasis, unlike that of Senegal’s report. The results of our study showed that material resources for clinical and laboratory diagnosis of schistosomiasis were lacking at the local health facilities and they were not diagnosing and treating schistosomiasis locally. Such shortages were also reported in a study from Burundi [
16].
A few surveyed community participants said that they had heard about schistosomiasis and only a very few of them indicated at least one transmission method, symptom, and prevention method. Although most of the participants involved in in-depth interviews and FGDs had heard about schistosomiasis, only a few had detailed knowledge. Contrary to our observations, previous studies in endemic areas of Ethiopia found a high level of awareness of schistosomiasis [
19‐
21]. Likewise, our present observation of KAP about schistosomiasis is lower than studies from other endemic countries: in Yemen [
22,
23], in Kenya [
24‐
26], in South Africa [
6], in Uganda [
27], in Nigeria [
28], and in Mozambique [
29]. This difference may be due to the geographical periphery of the area and that the large majority of the communities belong to a Nilotic group who were less educated and the rest few were Oromo’s and Amhara’s from highland for farming, who are also poor, less educated farmers and daily laborers.
We had observed that many misconceptions exist, especially, regarding disease transmission and prevention. A majority of participants were believing that schistosomiasis is caused by the Pecka worms biting when people stand on them barefooted. This misconception was also reported in a study in Kenya [
30]. And some believe schistosomiasis is transmitted by drinking dirty water. This misconception was also reported by most studies from different endemic areas: in Ethiopia [
19], in Yemen [
22], and in South Africa [
31]. This misconception promotes risky behaviors unless corrective actions have been taken.
Few of those who indicated that they were aware of schistosomiasis, said they knew the prevention methods, of which some said treatment/MDA and others said not walking barefooted in the water bodies which contain the worm. Whereas the majority said they do not know the prevention methods. Poor knowledge about prevention methods of schistosomiasis is also reported in a study from Mozambique [
29], which may indicate a lack of integrated schistosomiasis control and elimination plans in most developing endemic countries.
The results of this study revealed that males were more aware of schistosomiasis than females. This observation is similar to studies from different endemic areas [
6,
21,
22,
31]. This may be due to in developing endemic countries, females are less educated than males and culturally less participation of females in public meetings and gatherings. Although more participants from Chessega had heard about schistosomiasis, participants from Metti had detailed knowledge on transmission, symptoms, and privation therapy. None of the participants from Shimala were aware of schistosomiasis MDA. This might be due to better advocacy and coverage of MDA in Metti since Metti is a center for the Districts.
The percentage of participants who heard about schistosomiasis increased with the educational level, but there was no difference in detailed knowledge. Primary school students were more aware of MDA, probably due to the ongoing school campaigns. These observations are contrary to a study in Mozambique, which reported better knowledge of risky behaviors, prevention methods, and treatments among higher educated [
29]. We found no schistosomiasis awareness difference among age groups, while a study in Kenya reported an increase in awareness on schistosomiasis transmission with age [
25].
Only a few participants agree that they are at the risk of
Schistosoma infection. Only one participant indicated schistosomiasis as a serious disease. This finding is different from a study in Kenya, where everyone was perceived to be at the risk of schistosomiasis infection and perceived the disease as very serious [
30]. This may be due to poor case identification and poor awareness in our study area. None of the respondents agree that human excreta are a primary source of infection for the disease schistosomiasis. This finding is unlike a Kenyan study where the participants’ perceived open defecation as a cause of schistosomiasis [
30]. This is another indicator of poor awareness of the community, and poor health information communications in the area.
Only a very few participants agree that the MDA is effective in curing or control of the disease schistosomiasis. We observed, there were highly negative attitudes towards the praziquantel drug which is used for mass treatment. The most majority believe that the pill is tasting bad and it had serious side effects. Berhe et al. have described this from Ethiopia already in 2009 [
32]. They found that most abdominal side effects could be prevented by giving the tablet with a small meal, and information that the abdominal cramps would be only transitional. Similar findings are indicated in a study from Uganda [
33]. The side effects were described by a few participants as being more severe than the disease itself. There was also a misconception considering the pill as birth control pills. These perceptions will continuously affect the uptake of MDA [
33] unless corrective information is available to the community.
Even though there were some public hand pumps, the main sources of water for the community were rivers and streams. Our data is indicating that; washing, swimming, and bathing in rivers and streams were common practices, irrespective of age and sex in the community. Open-air defecation was very common, rivers and streamsides are full of human excreta. A study shows that bathing after urination or defecation near rivers and streams facilitates schistosomiasis transmission [
34]. These practices are also, a critical obstacle to schistosomiasis prevention and control efforts.
Conclusion
In the present study areas, the awareness about schistosomiasis was very low, even among the local health personnel. There was also common misconception on transmissions and negative attitudes towards the ongoing mass treatment and common complain about the size and safety of the tablet. There was no local budget and specific local plan for the prevention and control of schistosomiasis. Hence, if the disease prevention and control are ultimate to be achieved, the following strategic plans should be needed nationally and locally: first, strengthening the local health system (having a local budget and trained manpower), advocacy, coordination, and partnerships; secondly, including community stakeholders in developing and delivering awareness programs, which enhance the efficiency of community engagements and information dissemination channels. Thirdly, it required to include developmental interventions such as safe water provision to minimize exposure to the infected water bodies and livelihood activities predisposing the community to infection. Fourthly enhancing neglected tropical diseases monitoring and evaluation, surveillance, and research in such neglected areas. Finally, incorporating strategies that address misconceptions and myths on disease into health awareness activities and control measures. We also, like to recommend international concerned bodies to give due attention to safer Praziquantel pediatrics formulation.
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