Proceedings of the 5th National Conference of the Society for Occupational Safety and Environmental Health (SOSEH). November 11-14, 2009. Main Auditorium, Nnamdi Azikiwe University, Awka, Anambra State, Nigeria
KNOWLEDGE, ATTITUDE AND PRACTICES (KAP) OF PERSONS AFFECTED BY ONCHOCERCIASIS IN THREE ENDEMIC AREAS OF ENUGU STATE, NIGERIA Obiukwu, M. O., Onwuzulike, I. F. V., *Ikpeze, O. O and Egbuche, C. M Department of Parasitology and Entomology, Nnamdi Azikiwe University, Awka *Corresponding author:
[email protected] ABSTRACT Data on quantitative and qualitative studies that investigated Onchocerciasis-related perceptions, attitudes and practices (KAP) of affected subjects from three endemic Local Government Areas of Enugu State, Nigeria was carried out in 2009, using structured questionnaire, key format interviews and matrix ranking exercises. Gender variations observed on their KAP were not significant (P>0.05). Loss of self-esteem, hindrance to marriage prospects, loss of income, and absence from social gathering, and gender stigmatization of affected persons ranked high among perceived socio-economic and psychological impacts of Onchocerciasis in the area. Ignorance of role of the black fly in the transmission of river blindness persisted in the study area, where intense sunshine, distant trekking, witchcraft, charms, heredity, intimate contact with affected persons, and food poisoning were thought to be responsible for the infection. Due to public enlightenment, however, about 86% of the people now agreed that avoiding the black fly could prevent the disease but thought it would be impossible since they cannot abandon their black fly-infested fertile farmlands and streams. Nodulectomy is practiced by traditional healers in the area, but most villagers were willing to accept the Mectizan® which is being freely offered to them by government through the Community Directed Treatment with Ivermectin (CDTI). Keywords: Onchocerciasis, KAP, Stigmatization, CDTI, Enugu State INTRODUCTION Endemic areas for Onchocerciasis in Africa have been defined in terms of the savannah and forest vegetation zones, but there are areas sometimes called forest savannah mosaic (Okonkwo et al., 1991) where the savannah and forest zones merge. Uzo-Uwani, Ezeagu and Oji-River Local Government Areas (LGAs) in Enugu State of Nigeria are typical examples of such areas. Nwoke, et al., (1998) reported that the disease thrives in fertile, arable lands around rapidly flowing rivers that provide breeding sites for the insect vector. The disease is caused by the parasitic filarial worm, Onchocerca volvulus, and transmitted by Simulium damnosum complex. In endemic areas, the disease may cause disfiguration of the skin and blindness. It is also responsible for poor academic performance and a higher rate in school drop-out among infected children. It also causes low productivity, low income, high health related costs in endemic communities, and gender differences in the stigma associated with Onchocercal Skin Diseases (OSD) in infected adults (Obiukwu et al., 2006; Okolo et al., 2004; Vlassoff et al., 2000; Nwoke, 1990). The aims of this study were to determine the level of knowledge and attitude of the people, patients’ health-seeking behavior, management practices in Uzo-Uwani and Oji-River LGAs, as well as their perception of the psychological and socio-economic impacts of Onchocerciasis. The result will help to fill the gap that exists in the knowledge, attitude and practices (KAP) of Onchocerciasis amongst the residents of the study areas. MATERIALS AND METHODS Study Area: The study was done in Uzo-Uwani, Ezeagu and Oji-River Local Government Areas (LGA) of Enugu State, located in the forest savanna mosaic vegetation zone of south-eastern Nigeria. Water bodies that traverse the Udi-Hills escarpment flow into the Oji-River, which forms rapids and waterfalls as it flows through the study area, thus creating suitable breeding sites for the Simulium damnosum sensu stricto that vectors the microfilaria responsible for river blindness in the area (Ozumba et al., 2009 a, b). Statistics obtained from Onchocerciasis Unit of the Enugu State Ministry of Health show that the estimated population of people living in each of these areas were 71925 for Uzo-Uwani, 79184 (Ezeagu), and 47869 (Oji-River) LGAs. Three communities of Adani, 130
Proceedings of the 5th National Conference of the Society for Occupational Safety and Environmental Health (SOSEH). November 11-14, 2009. Main Auditorium, Nnamdi Azikiwe University, Awka, Anambra State, Nigeria
Aguobuowa and Achiagu, taken from each of the LGAs, respectively, constituted the target areas of the study. Rural dwellers in these communities engage in Agriculture activities, especially rice cultivation in Adani. Graphed Map of Enugu State (Figure 1) shows the relative locations of the study LGAs and communities under study. Data Collection: Data were collected by rapid assessment method (RAM), focus group discussions (FGDS), oral-interviews with infected and susceptible individuals (Figure 2a and b), healthcare workers (Figure 2c), and government officials were the main methods of data collection. Structured questionnaire to investigate participants’ knowledge, attitude and perception on Onchocerciasis (Gypong et al., 2000) was adopted and modified to address identified needs and additionally required information. Six hundred questionnaires were administered randomly among participants in the three communities. Ranking exercises were also conducted during discussions to ascertain reasons for choices and decisions. RAM involves palpation of nodules over bony prominences on the trunk, ribcage, and in the groin region to estimate the size, consistency and texture of the nodules. Clinical skin manifestations like ‘lizard and leopard’ skins were observed visually.
a
b
c Figure 1: Map of Enugu State showing the study areas (Graphed by of Aniagu, E. of Ministry of Health Enugu)
Figure 2: Interview with infected individuals (a & b) and health workers (c)
RESULTS AND DISCUSSION Tables 1-6 show the responses to questions posed to Onchocerciasis affected individuals in the areas of study. More than 70% of the respondents were more worried about itching, swelling and physical appearance (Table 1), which they claimed had caused them public embarrassment more than the wrinkles and rashes. Men (82.1%) appeared to be worried about physical appearance more than women (65.7%). Loss of self esteem (80.1%), hindrance to marriage prospects (79.3%), loss of income (77.9%), and absence from of social gathering ranked high among socio-economic and psychological impacts of Onchocerciasis (Table 2). Loss of self esteem perceived by affected women (86.1%) more than men (76.2%) and this may have resulted in their absence from social events (89.8%). More men (81.1%) perceived that the condition affected their capability to earn income and had affected their marital relationships, which sometimes ended in divorce or desertion. About 94.4% of the women were of the view that the condition adversely affected marriage prospects in the 131
Obiukwu, M. O. et al.,: Knowledge, Attitude and Practices (KAP) of persons affected by Onchocerciasis ……………………………………
community. Gender differences in the stigma associated with Onchocercal Skin Diseases (OSD) in infected adults have been observed in other endemic areas (Obiukwu et al., 2006; Okolo et al., 2004; Vlassoff et al., 2000; Nwoke, 1990). About 22.1% of the respondents perceived that children who conduct the blind, due to river blindness, invariably dropped out of school. These children and the affected would eventually become dependent on others for their upkeep, contributing to the vicious cycle of poverty, joblessness and loss of income. Table 1: Worrisome aspects of Onchocerciasis as perceived by affected respondents Response from Onchocerciasis affected subjects Source of worry Itching Rashes Swelling Wrinkles Physical appearance
Total (n = 276) No. % 260 94.2 171 61.9 225 81.5 17 6.2 209 75.7
Male (n = 168) No. % 159 94.6 107 63.7 142 84.5 12 7.1 138 82.1
Female (n = 108) No. % 101 93.5 64 59.3 83 76.8 5 4.6 71 65.7
Table 2: Socio-economic impact of Onchocerciasis as perceived by affected respondents Response from Onchocerciasis affected subjects Consequences of Onchocerciasis Hinder daily income Loss of income Absenteeism from school Loss of self esteem Increased spending on healthcare Dependent on others Absence from social gathering Divorce or desertion Hinder marriage prospects
Total (n = 276) No. % 171 61.9 215 77.9 61 22.1 221 80.1 138 50.0 113 40.7 207 75.0 137 49.6 219 79.3
Male (n = 168) No. % 108 64.3 137 81.5 30 50.0% 128 76.2 98 58.3 53 31.5 110 65.5 83 49.4 117 69.6
Female (n = 108) No. % 63 58.3 78 72.2 31 50.0% 93 86.1 40 37.0 60 55.5 97 89.8 54 50.0 102 94.4
Table 3: Cause and mode of transmission of Onchocerciasis as perceived by affected respondents Response from Onchocerciasis affected subjects Cause and mode of transmission Working under the sun Walking long distances Sexual intercourse with infected person Witchcraft Visit to the stream Stepping on charms Food poisoning Lack of personal hygiene Black fly bite Inherited
Total (n = 276) No. % 89 32.2 167 60.5 65 23.5 68 24.6 179 64.8 121 43.8 90 32.6 79 28.6 235 85.1 42 15.2
Male (n = 168) No. % 53 31.5 97 57.7 48 28.5 40 23.8 107 63.7 89 53.0 73 43.4 42 25.0 137 81.5 30 17.8
Female (n = 108) No. % 36 33.3 70 64.8 17 15.7 28 25.9 72 66.6 32 29.6 17 15.7 37 34.2 98 90.7 12 11.1
River Blindness Control Programme, Enugu State, has sent Key Health Education Messages through an Information Brochure for Community Directed Distributors (CDDS) of Mectizan ® (Ivermectin) in the study areas. One such information is that River Blindness is a disease caused by a worm, which gets into a person’s body as a result of black fly bite. Despite of this, many people were not very knowledgeable about the actual cause and mode of transmission of river blindness in the area 132
Proceedings of the 5th National Conference of the Society for Occupational Safety and Environmental Health (SOSEH). November 11-14, 2009. Main Auditorium, Nnamdi Azikiwe University, Awka, Anambra State, Nigeria
of study (Table 3). About 32% thought that working under intense sunshine caused the disease. Another 60% attributed it to walking long distances, perhaps to their distant farmlands, which also exposed them to intense sunshine. It is interesting to hear that some still believe that witchcraft (24.6%), charms (43.8%), food poisoning (32.6%), lack of personal hygiene (28.6%) were sometimes held responsible for the infection. That river blindness was inherited (15.2%) may have led some respondents (23.5%) to claim that sexual intercourse could actually transmit the disease from infected to susceptible persons. However, about 65% and 80% of the respondents associated river blindness with ‘visit to the stream’ and ‘bite by the black fly’, respectively. The black fly is known in local parlance as Kpu-kpu, a descriptive name for the humped backed Simuliun fly (Obiukwu et al., 2006). Because of local beliefs on the cause and transmission of river blindness, some of the people thought that avoidance of sexual intercourse (28.3%) or body contact (20.3%), and eating with affected persons (15.2%) could prevent them from contracting the infection (Table 4). These actions may be responsible to stigmatization associated with Onchocerciasis in the study areas, and in other endemic areas (Wijesinghe et al., 2007; Vlassoff et al., 2000). In the light of the afore-mentioned key health message on the cause of the infection, about 86% of the people agreed that avoiding black fly would be the best prevention method, but emphasized that it was very difficult for them to do so because they must frequent their farmlands and streams where the black fly would have ample opportunity to bite them. Table 4: Methods of prevention of Onchocerciasis as perceived by affected respondents Response from Onchocerciasis affected subjects Prevention methods Total (n = 276) No. % 78 28.3 56 20.3 141 51.1 79 28.6 239 86.6 42 15.2
Avoid sexual intercourse with affected person Avoid body contact with infected person Sacrifice to appease gods Good personal hygiene Avoid black fly Avoid eating with affected person
Male (n = 168) No. % 57 33.9 38 22.6 87 51.8 42 25.0 141 83.9 30 30.8
Female (n = 108) No. % 21 19.4 18 16.6 54 50.0 37 34.3 98 90.7 12 11.1
Table 5: Preferred health- providers’ patronage as perceived by affected respondents Response from Onchocerciasis affected subjects Health-care provider
Patent medicine store Primary health care Traditional healer Community member (CDDS) Home medication
Total (n = 276) No. % 208 75.3 160 57.9 175 63.4 235 85.1 40 14.5
Male (n = 168) No. % 128 76.2 97 57.7 103 61.3 137 81.5 23 13.7
Female (n = 108) No. % 80 74.1 63 58.3 72 66.6 98 90.7 17 15.7
Table 6: Matrix ranking for health providers’ patronage as perceived by affected respondents Ranking factor Convenience Affordability Family choice Reputation Confidentiality Proximity Efficacy
Patent medicine store +++ ++++ +++ + +++ +++ +
Primary health care +++++ ++++ ++ ++ + ++++ ++
Traditional healer ++++ +++++ +++ ++ +++++ +++ ++++
Community member (CDTI) ++++ +++++ +++++ ++++ +++++ ++++ ++++
Home medication +++++ +++++ + ++ + +++++ +
However, the affected persons have reasons for patronizing different health-care providers (Tables 5 and 6). Incision marks earlier observed on the body of some Onchocerciasis victims in 133
Obiukwu, M. O. et al.,: Knowledge, Attitude and Practices (KAP) of persons affected by Onchocerciasis ……………………………………
Ufuma (Obiukwu et al., 2006) were present on some of the people in the area, which shows that nodulectomy is practiced in the area of study. Most of the villagers were willing to accept Mectizan ® treatment for the disease since they had in the past patronized medicine vendors for Banocide ®. About 63.4% of the respondents visit traditional healers for remedy, which they claimed were affordable, efficacious, convenient and for confidentiality. In the study area, traditional healers practice nodulectomy, as has been reported from another endemic area in Abia State (Abanobi et al., 1999). Those who patronize CDDS (85.1%) and primary health care centers (57.9%) do so because of family choice, reputation, and for the free Mectizan®. Patent medicine stores are mostly patronized (75.3%) for the Banocide®. This drug, which caused the death of onchocercal microfilariae (mf), prevented them from migrating to the eye balls where they would have eventually died to produce sclerotising keratitis – a hardening inflammation of the cornea – the cause of blindness (Pearlman, 1996). REFERENCES Abanobi, O. C., Edungbola, L. D., Obiri, G and Nwoke, B. Akogun, O. B and Onwuliri, C. O. E. (1991). Hyperendemic Onchocerciasis in the Taraba River valley of Gongola State (old Adamawa Province), Nigeria. Annals of Parasitology, 66: 22-26. Gypong, M., Gypong, J., Weiss, M and Tanner, M. (2000). The burden of hydrocoele on men in northern Ghana. Acta Tropica, 77(30): 287-294. Nwoke, B. E. B. (1990). The socio-economic aspects of human Onchocerciasis in Africa: The present appraisal. Journal of Hygiene, Epidemiology, Microbiology and Immunology, 34(1): 37-44. Nwoke, B. E. B., Dozie, I. N. S., Gemade, E. I. I and Jiya, J. Y. (1998). The present status of human Onchocerciasis in southern Nigeria using Rapid Epidemiological Mapping of Onchocerciasis (REMO). Nigerian Journal of Parasitology, 19: 11-18. Obiukwu, M., Ikpeze, O and Igbodika, M. (2006). Human Onchocerciasis: Current Epidemiological and Dermatological Assessment of the Disease in Ufuma, Nigeria. Animal Research International, 3(3): 521-526. Okolo, C. G., Dallah, C. N and Okonkwo, P. O. (2004). Clinical manifestations of Onchocerciasis and some aspects of its control in Achi, Oji-river Local government Area. Enugu State, Nigeria. Nigerian Journal of Parasitology, 25: 101-106. Okonkwo, P., Akpa, A., Ihekwaba, A., Nwagbo, D., Umeh, R., Adibua, S., Ezike, V and Ogbuokiri, I. (1991). Studies on Onchocerciasis in forest-savannah mosaic areas of Nigeria, I: investigations in Gbaraga, Oji-River. Annals of Tropical Medicine and Parasitology, 85: 617623. Ozumba, N. A., Onyido, A. E., Ezike, V, I., Ikpeze, O. O., Nwankwo, E. C., Ekwunife, C. A and Nwosu, E. O. (2009 a). Biting density of Simulium damnosum (Diptera: Simulidae) at three distances from the Oji-River breeding foci, south-eastern Nigeria. The Nigerian Journal of Development Studies, 7(1): 91-98. Ozumba, N. A., Onyido, A. E., Ezike, V, I., Ikpeze, O. O., Nwankwo, E. C., Ekwunife, C. A and Nwosu, E. O. (2009 b). Onchocerciasis infection rates of communities away from Oji-River breeding focus of Simulium damnosum (Diptera: Simulidae) in south eastern Nigeria. The Nigerian Journal of Development Studies, 7(1): 99-110. Pearlman, E. (1996). Experimental Onchocercal Keratitis. Parasitology Today, 12: 261-267. Vlassof, C., Weiss, M., Ovuga, E. D. L., Eneanya, C. I., Nwel, P. T., Babalola, S. S., Awedoba, A. K., Theophilus, B., Cofie, P and Shetab, P. (2000). Gender differences in the stigma associated with onchocercal skin disease (OSD) in five African sites. Social Science and Medicine, 50: 1353-1368. Wijesinghe, R. S., Wickremasinghe, A. R., Sriyani, E and Perera, M. S. A (2007). Physical disability and psychological impact due to chronic filarial lymphoedema in Sri-Lanka. Filarial Journal, 6(4): 117-121.
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