Assessment of Knowledge, Attitudes, and Practices about Visceral Leishmaniasis in Endemic Areas of Malda District, West Bengal, India

INTRODUCTION

Visceral leishmaniasis (VL), also known as kala-azar (KA), is one of the world’s most important neglected tropical diseases, affecting mainly the poor people of developing countries. Globally, an estimated 50,000–90,000 VL cases were reported each year, prevailing in 98 countries. ¹ The most affected countries are India, Brazil, Ethiopia, Kenya, Somalia, South Sudan, and Sudan. In WHO-Southeast Asian region, VL is endemic in India, Nepal, and Bangladesh, and they accounted for 50% of the global burden. ² India contributes the major share, particularly from four adjoining states—Bihar, Jharkhand, West Bengal, and the northern part of Uttar Pradesh. ³ The disease is characterized by prolonged fever, weight loss, anemia, hyperglobulinemia, enlargement of the spleen and liver, and darkening of the skin, and is usually fatal if left untreated.

In the Indian subcontinent, VL is anthroponotic in nature, caused by the protozoan parasite, Leishmania donovani, and transmitted by the infected female sand fly, Phlebotomus argentipes. ⁴ Three adjoining countries India, Bangladesh, and Nepal initiated a regional alliance to eliminate KA supported by the WHO with a target to eliminate it from this part of the world by 2015. ^5,6 The target was to decrease the incidence of KA so that it no longer remains a public health problem. Later, the initiative was revised; two more countries, Bhutan and Thailand, were included, and the deadline was extended to 2020. ⁷ The National Vector Borne Disease Control Program (NVBDCP) of India framed a regional strategy for VL elimination having five components. The most important components were early diagnosis and complete treatment of VL and post kala-azar dermal leishmaniasis cases through passive and active case detection for reduction of the source of transmission and integrated vector management for reducing human–vector contact. ⁸

Despite the implementation of various control measures, a reduction in the occurrence of KA has been found to be difficult. This is partly due to inadequate information about the various risk factors associated with the disease. It has been found that poverty may not be a direct risk factor for KA transmission, but it led to poor health, bad housing conditions, lack of preventive measures such as nonuse of mosquito nets and illiteracy. Thus, poverty could be a major determinant of the continued transmission of KA. Regarding housing conditions, mud wall or mud plastering of walls was found to be significantly associated with KA transmission. ^9,10 The vector, sand fly, is endophagous in nature and breed inside cowsheds and human dwellings. ¹¹ Mud walls and peri-domestic vegetation make favorable humid conditions for sand fly breeding. ¹² The dampness of mud-house acts as a risk factor, that has been reported from West Bengal and Nepal. ¹³ Improvement of housing conditions in KA-endemic areas could reduce the disease transmission by decreasing the conditions suitable for the breeding of sand flies inside the houses. ^10,14 Cattle rearing is another risk factor of VL transmission, particularly where the cattle sheds are located inside or in close proximity to the houses. This close coexistence of human and cattle allows easy vector–human contact, accelerating disease transmission. ¹⁵ Besides this, occupation also has an important role in disease transmission. Seasonal migration of laborers between VL endemic and non-endemic regions, combined with biological, environmental, and socioeconomic risk factors may be responsible for the spread of the disease. ¹⁶

From the interdisciplinary perspective of public health, the KA disease ideally should be dealt with a multidimensional and intersectional approach. The integrative paradigm that needs to be encompassed is that the curative approach should be directly supplemented by the preventive and health promotive practices, that is, preventive best practices, promotion of awareness, and enhancement of health-seeking behavior. Considering the vector is a significant component, one also needs to understand that the environment and the host of the epidemiological triad are important stakeholders. Community participation is the most important prerequisite for the success of any disease control program. The cooperation of the affected population is very essential for the successful implementation of different program activities. Program implementers need to assess the disease-related knowledge, attitude, and practices of the community because these are important determinants of community participation. Few reports are available from India regarding KA-related knowledge, attitude, and practices of the community living in KA-endemic areas, ^15,17–19 but such study from West Bengal is very rare. ¹⁸ After the implementation of different preventive measures against the disease KA, it is necessary to find out the overall impact of this at the community level, through assessing their knowledge, attitude, and practice toward disease prevention. Therefore, the present study was undertaken and designed to access the knowledge, attitude, and practice in KA-endemic areas of Malda district, West Bengal, India.

MATERIALS AND METHODS

RESULTS

DISCUSSION

In this study, we have assessed knowledge, attitude, and practice toward the prevention of KA in an endemic area of Malda district of West Bengal, India. The study revealed that overall the participants had poor knowledge about the disease KA and vector sand fly, whereas they possess overall good attitude and practice toward prevention of the disease. The knowledge of the population may be improved through health education.

A positive association was noticed between knowledge about the disease with literacy and socioeconomic status. Regarding knowledge, we noted that most of the respondents had heard about the disease KA, which was similar to other studies from India ¹⁷ and abroad. ²¹ This was higher than the results reported from other parts of the country. ^19,22 Most of them were unaware of the outcome of the disease if left untreated, contrary to observations of other Indian studies. ^17,19,23 Most of the respondents were aware of the sign and symptoms of KA, which was similar to previous reports. ^17,19,21,24 Fever as the most common symptom and sign of KA was reported by most of the respondents, whereas other symptoms such as splenomegaly and hepatomegaly were reported by a significant portion of respondents, which is higher than the reports from Bihar, India. ^17,19,24 Although most of the respondents knew about the requirement of blood examination for the diagnosis of KA, the majority were unaware about its treatment.

Regarding the transmission of the disease, about half of the respondents answered correctly as sand fly to be the vector, whereas a certain proportion had the wrong notion that mosquitoes transmit the disease. This finding is in agreement with results of studies from other parts of India ^17–19 as well as different parts of the world. ^25,26 Other misconceptions about transmission of KA prevailing in the community include pig rearing and consumption of contaminated food, whereas about a quarter did not have any knowledge. This low level of knowledge about disease transmission increases the chance of human–vector contact and reflects the problem associated with KA elimination in this part of India.

Similar to the earlier observation made by Govil et al. ¹⁹ and Alemu et al., ²³ almost all of the respondents were unable to identify the vector sand fly. Vector control plays a pivotal role for controlling any vector-borne diseases such as KA, where knowledge about biting time and breeding place of the vector is important for adequate measures taken against it. ²⁴ Although most of the responders knew about the biting time of sand fly, a significant proportion did not know its breeding place. This is similar to the observations made by Govil et al. ¹⁹ and Alemu et al. ²³

The overall knowledge about the disease and vector sand fly was poor among the respondents despite a long history of KA endemicity in the area. This poor knowledge could be due to poor level of education. Similarly, the association between poor educations with low knowledge about KA was also reported from KA-endemic areas of Bihar. ^17–19

We observed the knowledge about KA was higher among males which might be due to higher level of education than females. Similar observation was also reported by Govil et al. ¹⁹ and Berhe et al. ²¹ Individuals belonging to BPL showed a low level of knowledge.

To evaluate the overall attitude of the responders toward KA, they were asked about diagnostic methods for this disease, preferred place for treatment, and use of preventive measures. Almost all of them agreed to complete treatment for the successful cure of KA. This observation is in conformity with other similar studies. ^19,21,23 This could be due to the good accessibility of the healthcare workers and appropriate sensitization of them about KA. It was noted that most of them preferred government hospitals as a place of treatment that reflects their reliance toward the existing government treatment facility and the health system. Maximum respondents agreed to participate in community meetings about KA elimination, its treatment, and preventive methods that would improve their level of knowledge. Most of them also agreed that they would allow the diagnosis of disease by a blood test. This high level of appropriate attitude for diagnosis and treatment was in accordance with reports by others. ^19,21,23 Besides, nearly half of them opted for mosquito net as a preventive measure, whereas the majority agreed to allow spray in their house. The overall attitude toward KA disease was good, which is in accordance with a study by Govil et al. ¹⁹

Most responders practiced using mosquito nets while sleeping at night that would protect them from the bite of vector sand fly, although they preferred to sleep outside rooms, which were similar with observations of other studies. ^17,19,21 Animal rearing was a common practice among the tribal-dominated study population. Two-third of the study subjects had animal sheds adjacent to their living rooms on the same house which were an important risk factor for acceleration of the disease progress by enhancing human–vector contact. ²¹ The humid environment of the mud house along with the presence of nearby cattle shed near to the living room is preferable for the survival of sand flies. The overall practice index was found to be good among most of the population, which was similar to other studies. ^21,23 We did not observe any association between overall practice index toward KA elimination with sociodemographic parameters.

While discussing disease control programs, there is argument that the successful implementation of such programs depends on various factors such as the target population, awareness and information among the target population, distribution of information regarding the existing harms, and relative benefits of behavior and practice modification. The contribution of the Ottawa Declaration with respect to health promotion is imperative here to understand gradual capacity building to adapt to behavior change and practice in communities, advocating health as a major resource for social, economic, and personal development and an important dimension of quality of life. Enabling includes a secure foundation in a supportive environment, access to information, life skills, and opportunities for making healthy choices. Mediation in health promotion focuses on procedural aspects of supportive supervision and continuous monitoring and evaluation. Moreover, health promotion strategies and program should be adapted to the local needs and possibilities of individual countries and regions to take into account differing social, cultural, and economic systems.

Srinivasan et al. ¹⁸ showed that improvement of knowledge through behavior change communication (BCC) was helpful to educate the community about the disease and motivate them to take active participation and cooperation for the elimination of the disease.

Despite the implementation of activities toward the elimination of KA, a significant number of cases continue to occur in the study area. Poor knowledge about the disease might be an important factor for the maintenance of disease endemicity. So the improvement of knowledge about different risk factors of KA among the common people would be helpful to reach the goal set by the NVBDCP of India. Leishmaniasis needs to be dealt with at the individual, family, and community level because it has direct scope for potential intervention as mentioned earlier. The disease needs to be understood with the locality development approach, that with respect to the epidemiological triad, if the enhancement of environmental and host base of the triad is focused on, then the disease is manageable because an integrative paradigm of the curative approach sufficiently supported with the preventive best practices and promotive awareness, preventive behavior, and health-seeking behavior has come into the functioning framework. Small sample size is a limitation of this study. There is a need for further studies with a large number of respondents from other KA-endemic regions of India to assess the knowledge, attitude, and practice and community participation following BCC in KA-endemic areas of India.