Nigatu Kebede，Alemayehu Worku，Ahmed Ali，Abebe Animut，Yohannes Negash，Wondwossen Abebe Gebreyes，Abhay SatoskarAklilu Lemma Institute of Pathobiology，Addis Ababa University，P.O.Box 76，Addis Ababa，EthiopiaDepartment of Epidemiology and Biostatistics，School of Public Health，College of Health Sciences，Addis Ababa University，P.O.Box 76，Addis Ababa，EthiopiaDepartment of Molecular Epidemiology and Preventive Medicine，College of Veterinary Medicine，The Ohio State University，Columbus，OH 0，USADepartment of Pathology，College of Medicine，The Ohio State University，Wexner Medical Center，Columbus，OH 0，USA

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Community knowledge，attitude and practice towards cutaneous leishmaniasis endemic area Ochello，Gamo Gofa Zone，South Ethiopia

Nigatu Kebede1，2*，Alemayehu Worku2，Ahmed Ali2，Abebe Animut1，Yohannes Negash1，Wondwossen Abebe Gebreyes3，Abhay Satoskar41Aklilu Lemma Institute of Pathobiology，Addis Ababa University，P.O.Box 1176，Addis Ababa，Ethiopia
2Department of Epidemiology and Biostatistics，School of Public Health，College of Health Sciences，Addis Ababa University，P.O.Box 1176，Addis Ababa，Ethiopia
3Department of Molecular Epidemiology and Preventive Medicine，College of Veterinary Medicine，The Ohio State University，Columbus，OH 43210，USA
4Department of Pathology，College of Medicine，The Ohio State University，Wexner Medical Center，Columbus，OH 43210，USA

ARTICLE INFO

Article history: Received 23 Jul 2015 Receivedinrevisedform18Aug，2nd revisedform24Sep，3rdrevisedform 10 Nov，4th revised form 16 Dec，5th revised form 31 Dec 2015 Accepted 10 Jan 2016 Available online 25 May 2016

Community Cutaneous leishmaniasis Knowledge，attitude and practice Ochello Ethiopia

Original articlehttp://dx.doi.org/10.1016/j.apjtb.2016.01.018

ABSTRACT

Objective:To assess the knowledge，attitude and practice of the community related to cutaneousleishmaniasis（CL）inanendemicareaOchello，GamoGofaZone，SouthEthiopia. Methods:We conducted community based cross-sectional survey among residents in OchellofromNovembertoDecember2014.Thestudyareawaspurposelyselectedbasedon previous reports on endemicity of CL.Using simple random sampling technique，a total of 392householdparticipantswereselected inthestudyareaOchello.Structuredquestionnaire was used to collect the data.Regarding the responses given to knowledge，attitude and practice，ascoreof1wasgivenforeachrightresponseand0forunsureresponses.Datawere double entered and analysis was conducted using SPSS version 20 statistical software. Descriptive statistics that includefrequency and percentage wereused to analyze theresults. Results:In total，392 individuals were participated in our study where 225（57.4%）of the participants were males and 167（42.6%）were females.Of all the total participants，265 （67.6%）had heard of the disease，and 127（32.4%）responded that they did not know CL. Based on the scoring results，265（67.6%）participants were knowledgeable about CL.Out of265participantswhoheardaboutCL，mostofthem［215（54.8%）］hadtheattitudethatCL was a problem in their area and had no positive attitude towards the treatment of CL. Approximately，215（54.8%）replied that CL was preventable.Majority of the respondents didnotsleepoutdoorsanddidnotpracticesleepingnearvegetationwithorwithoutbednet. Conclusions:The current finding indicated that the inhabitants of Ochello developed good awareness and encouraging attitude regarding CL.However，their prevention and control practice was very low.Hence，the result of this study calls for organized community awareness creation through various means.

1.Introduction

Leishmaniasis is epidemiologically diverse disease caused by haemoflagellate protozoan parasites of the genus Leishmania （family Trypanosomatidae）transmitted by the bite of the female Phlebotomus sandflies［1，2］.The disease is prevalent in 98 countries［2，3］.It is manifested in different clinical forms including self-curing cutaneous to the deadly visceral form of the disease［4］.

Leishmaniasis，one of the neglected tropical diseases，is among the most important public health problems worldwide.Itcauses disability nearly in 98 endemic countries and 3 territories where 350 million individuals are living at risk of infection［2，5］. According to Alvar et al.［5］，0.7 to 1.2 million new cases of cutaneous leishmaniasis（CL）are estimated per year.With increasing deforestation，human movement，urbanization，and HIV/AIDS，leishmaniasis is a growing public health concern in many countries［6］.Leishmaniasis excessively impinges on the poor，mostly individuals with defenseless homes as well as ecological settings.Low daily earnings together with poor health systems aggravate the productivity of underprivileged communities［4］.

During CL，vector-borne protozoan diseases，cutaneous lesion appears at the site of sandfly bites.The cutaneous lesions vary in clinical manifestations，severity as well as time of healing.In most of the CL patients，lesions might become chronic resulting in disfiguring of the affected part of body or may be leishmaniasis recidvans.CL is not fatal，however，could have considerable social impact due to stigmatization of patients when the lesions/scars appear on the face or visible extremities. According to reports in different parts of the world，CL is associated with sex［7］，age［8］，living with animals［8］and presence of patients in the family and CL in many endemic foci is zoonotic［9］.

In Ethiopia，CL is reported in highland areas in the country ［10-12］.Based on a recent report by Alvar et al.［5］，CL cases of between 20000 and 50000 are reported per year. Health education and facilities，equipment for screening and identification of CL patients in the country are not enough as well as very few trained personnel are available in the field in Ethiopia.Hence，up to date information regarding leishmaniasis is not available on time or not reported at all.CL is deforming and leads to social stigma.

Despite the increased prevalence of CL due to various reasons，there are few studies conducted regarding knowledge，attitude and practice（KAP）of the community in CL endemic areas in Ethiopia.Knowing the impact of leishmaniasis and human behavior surrounding CL is very important to improve its control and treatment.In the present study，we investigated KAP of communities in an endemic area Ochello，Gamo Gofa Zone，South Ethiopia.

2.Materials and methods

2.1.Study area and population

A community-based cross-sectional study was conducted in Ochello between November and December 2014 to investigate the KAP of the community regarding CL.Ochello is located at about 20 km in the north of the town Arba Minch at an elevation of 2016 m above sea level.Arba Minch town is located approximately 500 km in the south of the capital Addis Ababa while 275 km south of Hawassa（capital of the region）. Arba Minch is the main town of the Gamo Gofa Zone in Southern Nations，Nationalities，and Peoples Regional State （Figure 1）.Farming is the main occupation of the residents where cultivation of avocado，mango，banana and rearing livestock is the main activities of the community.This survey was carried out with the support and cooperation from local community leaders，health and agricultural extension workers in Ochello.Based on the 2013 population projection of Ethiopia conducted by the Central Statistical Authority，Arba Minch Zuria woreda had a population of 185302 people of whom 92680 were male and 92622 were female，with Ochello having a population of 32000 people［13］.

2.2.Sampling of the study participants

Considering 50%of the study participants had knowledge，constructive attitude or good practice towards CL［confidence interval（CI）=95%，degree of accuracy 5%］，385 subjects were sampled for the study.In order to increase the precision of the estimates，392 participants at the age of 18 or above were included for this study.Prior to sampling，the chairman of the village was contacted and discussion was made on the objectives of the study.After the discussion，their willingness was requested and permission was obtained from community leaders. The sampling frame which is the list of household heads was obtained in the office of the community leader and selection of study participants were conducted at random.Hence，the selected household heads were communicated to come to the central place for interview.

2.3.Data collection

Questionnaireconsistingofstructuredquestionswere designed in such a way to obtain information on sociodemographic characteristics，knowledge on CL，attitude scale towards CL，and practice related to CL in English language.The following were the questions used in the survey.

Knowledgewasassessedusing6-itemquestionnaire including 1.Have you ever heard of CL？2.Do you believe that CL is a health problem？3.What do you think the cause of CL？4.What are the symptoms of CL？5.Location of lesions/scars，and 6.Where often you/family go to get treatment for CL？Attitude was assessed based on 6-point questionnaire including 1.Is CL a problem in your area？2.Is CL treatable？3.What do you think the outcome of CL if not treated？4.How is CL transmitted？5.Where do sandflies breed？6.Have you ever participated in CL control activities？Practice had 5 items including 1.Is CL a preventable disease？2.What methods do you know to prevent CL？3.Sleeping outdoors，4.Sleeping condition，and 5.Work time preference.

The questionnaire was then translated into Amharic language authorized and pre-tested on 20 household heads prior to the actual data collection for consistency.The sampled household head or the next oldest member of the family in the absence of the household head was interviewed.Data collectors were selected from Ochello for this purpose.The interview was conducted in a suitable place one by one.Local name for CL was documented during the pilot study and hence，the local name for CL was“Bolba”.

2.4.Scoring

Scores for knowledge ranged from 0 to 6 where scores≤3 assumed poor knowledge and gave a score value of 0 whereas scores＞3 were considered as positive and gave a score value of 1.The attitude to CL was assessed using 6 questions where attitude scores ranging between 0 and 3 were considered as poor attitude whereas attitude scores＞3 were considered asconstructive attitude.Practice to CL was evaluated using 5 questions where scores≥ 3 were regarded as good quality practice to manage CL.

Figure 1.Location of the study area，Ochello of Gamo Gofa Zone in Southern Nations，Nationalities，and Peoples Regional State，South Ethiopia.

2.5.Ethics

Institutional Review Board of the College of Health Sciences of the Addis Ababa University and National Research Ethics Review Committee approved the procedures of this study.As most of the study populations were illiterate，Institutional Review Board recommended getting oral consent of the participants.Thus，verbal consent was taken immediately after the objectives of the study were explained.Those infected with CL were informed to go to Arba Minch Hospital for leishmaniasis treatment.After the interview source of infection，clinical signs and protection techniques of CL were explained to the study participants.Confidentiality of the information was maintained.

2.6.Data analysis

Information collected was entered into SPSS version 20 and analyzed.Descriptive statistics such as percentage was used to express the level of community member's KAP.

3.Results

3.1.Sociodemographic characteristics

A total of 392 individuals were involved in this study；225 （57.4%）of the respondents were males and 167（42.6%）were females.The age of participants varied between 19 and 60 years where the medium age was 35 years.Participant's major occupation was farming［285（72.7%）］.Majority of the participants［332（84.7%）］were married，388（99.0%）owned farmland and Orthodox Christianity was the dominant religion ［271（69.1%）］in Ochello.Of the study participants，225（57.4%）were able to read and write while 91（23.2%）of the participants neither read nor wrote.All of the study participants were Gamo by ethnicity.Regarding their residency，all of the study participants resided in the area for more than three years and none of them traveled out of their area within 6 months during the study period.The general sociodemographic characteristics of the study participants were presented in Table 1.

Table 1Sociodemographic characteristics of study participants in Ochello，Gamo Gofa Zone，South Ethiopia.

3.2.Participants'knowledge on CL

From the total study participants，265（67.6%）knew CL，and 127（32.4%）responded that they did not hear of CL.Most of them （77.2%）responded that CL was transmitted by mosquitoes.Nearly 20%of the study participants had no knowledge about CL transmission.About 59.6%of the participants responded that the main clinical symptom of CL was swollen legs，while 11%acknowledged that they did not know any symptom.The majority of the participants［234（59.7%）］responded that lesion（kuselet）occurring on the face was the main symptom of CL and 215（54.8%）believed that CL was one of the health problems in the area.In this finding，265 （67.6%）of the participants indicated that most of CL patients went to traditional healers for treatment.Among the 225 male study participants who heard about CL，153（68%）were knowledgeable；whereas from 167 female participants who heard about CL，112（67.1%）were well-informed.Hence，based on the scoring results，265（67.6%）study participants were knowledgeable（Table 2）.

Table 2Knowledge on CL among study participants in Ochello，Gamo Gofa Zone，South Ethiopia.

3.3.Attitude related to CL in Ochello

Out of the 392 contestants who heard about CL，most of them［215（54.8%）］had the attitude that CL was a problem in their area and had no positive attitude towards the treatment of CL whereas 137（34.9%）had no any attitude whether CL was treatable.Regarding their treatment preference，the majority ［235（59.9%）］had the attitude that treatment from traditional healers was effective.Of the respondents，225（57.4%）had the attitude that CL had disfiguring outcome on the body where it occurred.Of the respondents，192（49.0%）indicated that sandfly bite was the main way of transmission while 63 （16.1%）responded that transmission was by flies and 77.3% indicated that it bred in the vegetation.Of the participants，375 （95.7%）did not participate in the CL control activities （Table 3）.

Table 3Attitude towards CL among study participants in Ochello，Gammo Goffa Zone，South Ethiopia.

3.4.The practice of study participants towards CL prevention and control in Ochello

Among the total respondents，215（54.8%）replied that CL was preventable.Regarding methods of prevention，they used bed net（21.7%）and DDT（19.4%）.Majority of the respondents did not sleep outdoors and did not practice sleeping near vegetation with or without bed net.Concerning their work time preference，majority of them performed their farm activities during day time［375（95.7%）］（Table 4）.

Table 4Practice of respondents towards CL prevention and control in Ochello，Gamo Gofa Zone，South Ethiopia.

4.Discussion

CL is known to occur in undetermined magnitude in different areas in Ethiopia.This finding provides detailed analysis of KAP on CL by the communities in Ochello，one of CL endemic sites in Southern Nations，Nationalities and Peoples Regional State，South Ethiopia.The data collection was focused mainly in Ochello.However，the results and analyses can be extrapolated to the other parts of the country having similar socioeconomic characteristics.This study in Ochello was conducted to assess the KAP of endemic communities with a considerable number of community samples.In addition，experienced individuals were used for data collection especially in administering the questionnaire.These individuals are indigenes to Ochello，speak the local language of the study participants and interact directly with the target population，which could facilitate compliance and cooperation of the participants to give honest information required［14］.Furthermore，all the survey activities were supervised by the researchers.

According to the recommendations of World Health Organization，the implementation of KAP surveys is basic for health promotion campaigns，as the surveys help programs adjust health education messages to build public knowledge and awareness［15］.KAP study in relation to CL infection varies among regions and is heavily influenced by socio-cultural settings.Very little information is available how individual communities integrate knowledge of the origins and impacts of CL into local knowledge systems.This KAP study on indigenous adults of Ochello who lived 3 or more years in the area was the first to be performed.

This study naked that although the study area is categorized as CL endemic area，the 127（32.4%）of the participants were not aware of that status and 177（45.2%）did not know that CL was a health problem，revealing that information about CL was not efficiently communicated to the community.Hence，there were people who had poor or no understanding of CL.The majority of the respondents［192（49.0%）］indicated that CL was caused by sandflies whereas 184（46.9%）indicated that housefly was the cause of CL and 16（4.1%）indicated that poor hygiene caused CL.The implication of this discrepancy of information is that families may not take suitable actions to protect their family members.

In this study，most of the participants［244（62.2%）］knew that the most common signs of CL include lesions on the face （59.7%），forehead（5.1%），arms（1.5%），legs（1%）and ears （0.8%）.Thirty-two point four percent of the participants had no information on the signs and symptoms of CL.About 6.4%of the participants knew one or more signs and symptoms of CL.

This survey indicated that most of the participants（67.6%）preferred traditional remedies during illness，indicating that the consciousness on the usage of modern treatment centers such as health centers/hospitals is low.However，approximately 28.1% and 4.1%of the participants still consider health centers and health posts for CL treatment，respectively.Although，some of the participants preferred health center treatment，their knowledge of the drugs used in the treatment of CL was poor，showing awareness on CL in the population is low.

The attitudes of the participants related to CL showed that most of them，54.8%，of the participants view CL to be problematic disease.In addition，the participants of the study had varied views regarding the significance of CL as a health problem，with participants viewing CL as a medical，social or aneconomic problem.The fact that slightly more than half of the participants indicated that they view CL to be a problem shows that awareness and knowledge of CL is lacking among the residents of this endemic community，Ochello.Thus，there is a need to increase efforts to improve education of the residents to ensure efficient control of CL.

The majority（54.8%）of the participants assumed that CL is not treatable，34.9%did not know whether CL is treatable and only 10.2%believed that it could be treated and cured completely.This showed that the community attitude towards the treatment of CL is low.In our study，a considerable proportion of the population sought treatment from local traditional healers.This might increase disease duration and in turn，increase the chance of transmission of CL.This might be due to different reasons like poor community awareness creation activities.This finding is similar with the study conducted in Iran by Sarkari et al.［16］.

Nearly half of the respondents（49%）said that leishmaniasis is transmitted through sandfly bite，30%indicated it is transmitted through other means，16.1%said it is transmitted by flies and 4.3%indicated bodily contact with CL patient could transmit leishmaniasis.Majority of the respondents（77.3%）indicated that sandflies bred in vegetation whereas 18.4%replied that sandflies bred in houses.Approximately 95%of the respondents did not believe that CL could be controlled through community participation，and 4.3%of the respondents have no idea.More than half （57.4%）of the participants indicated the disability is the outcome of CL if not treated，only 5.1%indicated self cure and 2.6% replied death is the outcome of CL if not treated.When the overall attitude of the study participants are considered，they have favorable attitude towards CL that is a health problem but attitude to its treatment and transmission is poor.Similar study conducted by Nandha et al.［17］indicated poor attitude of the community favored the increase in the occurrence of CL.

About 34.8%of the study participants indicated that preventability of CL is unthinkable；none of them mentioned that CL is preventable and the others（45.2%）did not know whether it could be preventable.People's knowledge about the preventability of the disease is very low.Similarly，low prevention practice was reported by Saberi et al.［18］.In order to prevent sandfly bites，21.7%of the participants used only bed nets，19.4%used only DDT，while 58.9%of the participants did not use any prevention methods against sandfly bites.This might be due to poor awareness of the community in Ochello. Of the participants，40.8%slept outdoors in farm land and 21.4%used bed nets when sleeping outdoors.About 95.7%of the respondents used to work during the day and very few of the respondents（4.3%）preferred to work at night.This might be due to socioeconomic status of the population，absence of electric light supply，and the people's tradition to work at day time.

In conclusion，our study indicated that the inhabitants of Ochello were conscious and had constructive attitude on CL，however，the practice they had for the control and prevention of CL was found to be very low.Hence，this finding suggested persistent activities towards behavioral change and social mobilization.

Conflict of interest statement

We declare that we have no conflict of interest.

Acknowledgments

The authors would like to acknowledge the Aklilu Lemma InstituteofPathobiologyandSchoolofPublicHealth，AddisAbaba University for financial support（Thematic Grant No:ALIPB/392/ 14）.The authors are also thankful to participants of the study.

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*Corresponding author:Nigatu Kebede，Aklilu Lemma Institute of Pathobiology，Addis Ababa University，P.O.Box 1176，Addis Ababa，Ethiopia.
Tel:+251 112763091
Fax:+251 112755296
E-mails:nigatukebede@yahoo.com，nigatu.kebede@aau.edu.et
The study protocol was performed according to the Helsinki declaration and approved by Institutional Review Board of the College of Health Sciences of the Addis Ababa University and National Research Ethics Review Committee.Informed written consent was obtained from the participants.
Foundation Project:Supported by Aklilu Lemma Institute of Pathobiology and SchoolofPublicHealth，AddisAbabaUniversity（ThematicGrantNo:ALIPB/392/14）.
Peer review under responsibility of Hainan Medical University.The journal implements double-blind peer review practiced by specially invited international editorial board members.