• 1

    Guerin PJ, Olliaro P, Sundar S, Boelaert M, Croft SL, Desjeux P, Wasunna MK, Bryceson AD, 2002. Visceral leishmaniasis: current status of control, diagnosis, and treatment, and a proposed research and development agenda. Lancet Infect Dis 2 :494–501.

    • Search Google Scholar
    • Export Citation
  • 2

    Desjeux P, 1996. Leishmaniasis. Public health aspects and control. Clin Dermatol 14 :417–423.

  • 3

    World Health Organization, 1998. Life in the Twenty First Century: A Vision for All. Geneva: World Health Organization.

  • 4

    Murray HW, 2002. Kala-azar progress against a neglected disease. N Engl J Med 347 :1793–1794.

  • 5

    World Health Organization, 2003. World Health Report 2003: Shaping the Future. Geneva: World Health Organization.

  • 6

    Bora D, 1999. Epidemiology of visceral leishmaniasis in India. Natl Med J India 12 :62–68.

  • 7

    Lal S, Saxena N, Dhillan G, 1996. Kala-azar cases and deaths. Manual on Visceral Leishmaniasis (Kala-azar) in India: Annexure VII. New Delhi: National Malaria Eradication Programme, 167–177.

  • 8

    Sundar S, More DK, Singh MK, Singh VP, Sharma S, Makharia A, Kumar PC, Murray HW, 2000. Failure of pentavalent antimony in visceral leishmaniasis in India: report from the center of the Indian epidemic. Clin Infect Dis 31 :1104–1107.

    • Search Google Scholar
    • Export Citation
  • 9

    Ministry of Health and Family Welfare of India, 2002. National Health Policy. New Delhi: Ministry of Health and Family Welfare of India.

  • 10

    Office of Registrar General, India, 2001. Census of India: 13–14.

  • 11

    Sen Gupta PC, 1975. Return of kala-azar. J Indian Med Assoc 65 :89–90.

  • 12

    World Health Organization, 1996. Manual on Visceral Leishmaniasis Control. Geneva: Division of Control of Tropical Diseases.

  • 13

    Ahluwalia IB, Bern C, Costa C, Akter T, Chowdhury R, Ali M, Alam D, Kenah E, Amann J, Islam M, Wagatsuma Y, Haque R, Breiman RF, Maguire JH, 2003. Visceral leishmaniasis: Consequences of a neglected disease in a Bangladeshi community. Am J Trop Med Hyg 69 :624–628.

    • Search Google Scholar
    • Export Citation
  • 14

    Koirala S, Parija SC, Karki P, Das ML, 1998. Knowledge, attitudes, and practices about kala-azar and its sandfly vector in rural communities of Nepal. Bull World Health Organ 76 :485–490.

    • Search Google Scholar
    • Export Citation
  • 15

    Boelaert M, Criel B, Leeuwenburg J, Van Damme W, Le Ray D, Van der Stuyft P, 2000. Visceral leishmaniasis control: A public health perspective. Trans R Soc Trop Med Hyg 94 :465–471.

    • Search Google Scholar
    • Export Citation
  • 16

    Bern C, Joshi AB, Jha SN, Das ML, Hightower A, Thakur GD, Bista MB, 2000. Factors associated with visceral leishmaniasis in Nepal: Bednet use is strongly protective. Am J Trop Med Hyg 63 :184–188.

    • Search Google Scholar
    • Export Citation

 

 

 

 

KNOWLEDGE, ATTITUDE, AND PRACTICES RELATED TO KALA-AZAR IN A RURAL AREA OF BIHAR STATE, INDIA

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  • 1 Kala-azar Medical Research Center, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India

The Indian Government aspires to eliminate Kala-azar by 2010. Success of any disease control program depends on community participation, and there is no published data about the knowledge, attitude, and practices of the community about Kala-azar in endemic regions of India. For this knowledge, attitude, and practices (KAP) study, the heads of 3,968 households in a rural area, consisting of 26,444 populations, were interviewed using a pre-tested, semi-structured schedule. Most of the study subjects (97.4%) were aware of Kala-azar. Fever (71.3%) and weight loss (30.5%) were the most commonly known symptoms. The infectious nature of the disease was known to 39.9%. The majority believed that the disease spreads by mosquito bites (72.8%). For 63.6%, the breeding site of the vector was garbage collection. Only 23.6% preferred the public health sector for treatment, and 55.9% believed that facilities at primary health centers are not adequate. Poor knowledge of the study subjects about the disease and breeding sites of the vector underscores the need for health educational campaigns if the elimination program is to succeed.

INTRODUCTION

Visceral leishmaniasis (VL), popularly known as kala-azar (KA) in Hindi, is caused by a protozoa, Leishmania donovani, and transmitted by the female sandfly Phlebotomus argentipes in India. It is endemic in 62 countries, with ~200 million people at risk.1 It is estimated that annually ~500,000 cases of VL occur,1,2 with a prevalence of 2.5 million.3 More than 90% of VL cases occur in five countries: India, Bangladesh, Nepal, Sudan, and Brazil.2,4 It is a dreaded disease, and if left untreated, it is fatal. It is also estimated that in 2003, the worldwide deaths caused by VL was 51,000.5

In India, VL is a major public health problem in the state of Bihar and some adjoining districts of neighboring states like West Bengal, Jharkhand, and Uttar Pradesh.6 The disease is also endemic in the neighboring countries Bangladesh and Nepal. The state of Bihar accounts for > 90% of the cases in the country.68 The government of India aspires to eliminate VL by 2010 from India.9 For the success of prevention and control programs of any disease, the most important prerequisite is community participation. Cooperation of the affected population is essential in the implementation and use of program activities. Program implementers need to understand the disease-related knowledge, attitude, and practices (KAP) of the community, because these are the important determinants of community participation. There are no data from India focusing on these aspects, and thus this study presents the information on KAP related to Kala-azar in India.

MATERIALS AND METHODS

This study was carried out in the Muzaffarpur district of Bihar State, India. The total population of the district is 3.734 million, with 3.4 million as the rural population (census 2001). There are 14 Block Primary Health Centers (PHCs) in the district and Kanti Block, with a total population of 337,670 selected for this study. There are 48 sub-centers in this Block PHC, each catering to a population ranging from 6,000 to 10,000. For this study, a cluster of three contiguous sub-centers was selected randomly. The selected three sub-centers cater to 14 villages, with a total population of 26,444 in 4,083 households. House-to-house survey was done to collect the data about household socio-demographic and environmental characteristics from September 2000 to March 2001.

The head of each household was interviewed to assess his KAP related to KA. The head of the household was chosen as the study subject because he/she plays the main role in any decision-making process at the household level in this part of the country. If the head of the household could not be contacted after repeated visits, another adult member of the household was interviewed. The data were collected on a pre-tested, semi-structured schedule by trained field staff with a sociology background. Of 4,083, it was possible to interview 3,968 households, giving a response rate of 97.18%. Written informed consent of the interviewee was taken after explaining the objectives and methodology of the study in detail. The study was approved by the Ethical Committee of the Institute of Medical Sciences, Banaras Hindu University.

RESULTS

Characteristic of the study population.

In the study area, men constituted 53.5% of the total population, giving a sex ratio of 869 women per 1,000 men (Table 1A). Children < 15 years of age were 41.9%, and only 15.1% population was > 45 years of age. Households having per capita annual income of Indian national rupees (Rs) ≤ 5000 (US $108.00) were 53.8%, whereas only 13.6% had > Rs10,000 (US $216.00). Of the total households, 15.2% had less than four members and 44.6% had four to six members. The average household size was 6.8. More than one half of the population > 5 years of age was illiterate (53.2%). This is similar to the state literacy rate of 47.53%.10 Those educated up to the fifth class were 24.7%, and only 4.6% were graduates. In the population > 5 years of age, 11.6% worked in agriculture. Unskilled and skilled laborers constituted 12.5% of the population, whereas 6.1% and 4.4% were engaged in service and business, respectively.

Characteristic of the study subjects.

More than one half (50.8%) of the respondents were in the age group of 26–45 years, and 43.8% were > 45 years of age (Table 1B). Most of the respondents (97.0%) were men. The majority of the respondents (52.4%) were illiterate, and only 3.18% had graduated from school.

Knowledge about the disease.

This study revealed that 97.4% of the respondents were aware of the disease, and 16.1% had no idea of the signs and symptoms of the disease (Table 2). Fever and loss of weight were the most common symptoms, known to 71.3% and 30.5% of the respondents, respectively. Liver enlargement (9.9%), splenic enlargement (5.8%), and black pigmented skin (5.7%) were the other clinical features acknowledged by a minority. The fact that KA is an infectious disease and can be transmitted from one person to another was known only to 39.9% of the respondents, whereas 93.2% knew that a complete cure of the disease is possible. Approximately three fourths (72.8%) of the respondents said that the disease spreads through mosquito bites, followed by an insect bite (9.6%) and sandfly bites (2.8%). All three responses as modes of transmission of the disease were considered correct answers (85.2%).

Knowledge about vector.

According to the interviewee, the breeding sites of the vector were cattle sheds (63.5%), polluted water (63.6%), dark places in the house (39.0%), and garbage collection sites (12.1%) (Table 3). For the biting time of the vector, 46.8% thought that it bites during dusk, whereas 39.7% and 12.5% said midnight and anytime whether day or night, respectively. The fact that family members could be protected using bed nets was known to most of the study subjects (92.8%), whereas only 16.7% and 17.3% knew that the same was possible using insecticides and repellents, respectively.

Kala-azar–related attitude and practices.

More than 70% (71.0%) of respondents believed that KA is a more serious disease compared with malaria, whereas 19.8% thought it to be an equally serious disease (Table 4). Private doctors were the first choice for treatment by 47.6% of the respondents if a suspected case of Kala-azar occurred in the household, followed by non government organizations (NGOs)/charitable hospitals (24.0%), district hospital/medical college (13.1%), and PHCs (10.5%). That DDT spray can control the disease was believed by 53.7% of the subjects. Only 12.9% were of the opinion that PHCs are well equipped to manage the cases of KA, whereas 55.9% did not believe this. Only 23.9% of the households had at least one usable bed net.

DISCUSSION

In this study, heads of the households were chosen as the study subjects because they have the decision-making capacity for the household. In the traditional Indian social setup, in most situations, the eldest male member of the household holds this responsibility. To seek household and community participation to make a disease control program successful, understanding of such local customs and traditions is very important. Understanding the KAP of the community regarding Kala-azar can be the key to the success of an elimination program launched by the Government of India.

Most of the respondents (97.4%) had heard the name Kala-azar, and most of them (93.2%) knew that the disease is completely curable. These are not strange findings, because Muzaffarpur is one of the districts with the consistently highest endemicity in the state for > 30 years,6,11 and can be considered to be the epicenter of the kala-azar epidemic. Awareness about the signs and symptoms of a disease prompts patients to seek early treatment. However, in the study population, the knowledge about the signs and symptoms of the disease was very poor despite the fact that the disease has been endemic for such a long time, and fever and splenomegaly are present in almost every patient with kala-azar in India.12 In contrast to this finding, Ahluwalia and others13 reported that people from Bangladesh had accurate knowledge about symptoms.

Lack of knowledge about the involvement of humans in the transmissibility and infectious nature of the disease in the majority of the subjects (60.1%) is a matter of concern for adoption of preventive measures against the disease. It is important for the people to be aware of these facts.

There was a complete lack of knowledge about the transmitting vector, the sandfly, although 85.2% attributed it to sandfly/mosquito/insect bites. Even this knowledge at the community level is encouraging because preventive measures against the disease will remain the same (use of mosquito nets, insecticide spray, mosquito repellent, etc.).

It is important for the community to know the breeding sites/habitat, biting time, and preventive measures to reduce the chances of vector–human contact. Cattle sheds as a breeding site was known to 39.0% of the respondents. However, habitats of the vector were poorly known to the community. The fact that the sandfly bites mostly at midnight needs to be made known to the community. Although most of the people were aware of the protective role of mosquito nets, the role of insecticide spray was known to only one half of the population. This is a matter of concern because this makes the population indifferent to the public sector efforts of insecticide spray, even disallowing the sprayers entry into the house for flimsy reasons of inconvenience or bad odor, thus leading to inefficient spraying. An incomplete spray can be disastrous, leading to quick build up of the vector. A successful insecticide spray holds the key to the success of the control/elimination program, and the affected population has to be made aware of its importance. In the neighboring country of Nepal, in a similar study, it was found that virtually no one knew how the disease could be prevented.14 It has been found that the communities affected with VL perceive it as a very threatening disease, and the demand for treatment is high.15 In this study, the majority (71.0%) of respondents perceived it as a more serious disease than malaria.

Only a small minority preferred public health facilities for treatment because of their views of inadequacy of the health system to manage KA cases. Primarily, in the public health system, PHCs are supposed to treat the cases of KA, and difficult cases are referred to the district hospital or medical college. Major reasons for people turning away from the public health system are abysmal facilities and receiving toxic and ineffective drugs (sodium stibogluconate) at PHCs. Two years later (in 2003), we reassessed the preferred health facilities, and only 13.5% rated public health facilities as their first choice (data not shown). Although it is difficult to extrapolate these findings to the entire state of Bihar, the level of KAP about VL is not likely to be substantially different in other parts, because the study area is the oldest focus of VL in Bihar and expected to have maximum awareness about the disease.

Although the majority of households had at least one bed net in good condition, its acceptability and efficacy against KA need to be ascertained. A case control study in Nepal identified use of bed net as protective against KA.16

Overall, these findings suggest ineffective information, education, and communication efforts of the public health system and other agencies responsible for it. Even after such a prolonged and incessant disease transmission in the area, this lack of knowledge, indifferent attitude, and incorrect practices are indicators showing poor commitment of the health policy planners for the disease.

It is important to know the level of KAP of a community and to improve it to a satisfactory level before launching any disease control program to get the maximum support from the community. In this study, poor knowledge of the study subjects about symptoms, infectious nature, mode of transmission, and preventive measures of the disease, and breeding sites of sand flies emphasizes the need for health educational campaigns. To increase the use of public health facilities, it should be fully equipped to deal with cases of kala-azar.

Table 1A

Characteristics of the study population in Kanti Block, Muzaffarpur district

Study population
Characteristics (n = 4,083)CategoriesNumberPercentage
* Includes housewives, students, and elderly persons unable to do anything.
1. Sex (n = 26,444)Male14,16053.5
Female12,28446.5
2. Age (years) (n = 26,444)0–44,19815.9
5–146,88226.0
15–4411,37143.0
45+3,99315.1
3. Household per capita annual income (in Rs)≤ 2,40068716.7
2,401–5,0001,51037.1
5,001–10,0001,33032.6
> 10,00055613.6
4. Total members in the household≤ 362215.2
4–61,82044.6
7–91,06626.1
10+57514.1
5. Educational status (age > 5 years) (n = 22,246)Illiterate11,83553.2
Up to 5th class5,48924.7
Up to 12th class3,89817.5
Graduation and above1,0244.6
6. Occupation of the population (age > 5 years) (n = 22,246)Agriculture1,2675.7
Agriculture labor1,3225.9
Service1,3636.1
Business9694.4
Unskilled labor2,35810.6
Skilled labor4201.9
Others*14,54765.4
Table 1B

Characteristics of the study subjects selected from the households for KAP study

Characteristics (n = 3,968)GroupsNumberPercentage
1. Agei. ≤ 25 years2145.4
ii. 26–45 years2,01650.8
iii. 46+ years1,73843.8
2. Sexi. Male3,84797.0
ii. Female1213.1
3. EducationIlliterate2,08152.4
Up to 5th class92123.2
Up to 12th class84021.2
Graduation and above1263.2
Table 2

Knowledge of respondents about Kala-azar in Kanti Block, Muzaffarpur district (n = 3,968)

Item*ResponsesNumberPercentage
* Denominator for items no. 2 to 5 is 3,866 (those aware of KA).
† Considered as correct answer.
1. Awareness about KAi. Aware3,86697.4
ii. Not aware1022.6
2. Signs and symptomsi. Fever2,90171.3
ii. Loss of weight1,21030.5
iii. Spleen enlargement2375.8
iv. Liver enlargement4069.9
v. Black pigmented skin2215.7
vi. Abdominal discomfort/pain972.4
vii. Others421.0
viii. Don’t know65616.1
3. KA is an infectious disease, transmitted from one person to anotheri. Yes1,62839.9
ii. No1,28031.3
iii. Don’t know95828.8
4. Complete cure of the disease is possiblei. Yes3,60193.2
ii. No471.2
iii. Don’t know2185.6
5. Kala-azar spreads throughi. Polluted water2336.0
ii. Polluted air571.5
iii. Mosquito bites†2,81372.8
iv. Sandfly bites†1072.8
v. Insect bites†3709.6
vi. Others220.6
vii. Don’t know2646.8
Table 3

Knowledge about vector

Item (n = 3,290)ResponsesNumberPercentage
1. The mosquitoes/sandfly insects breed ini. Polluted water2,09063.5
ii. Cracks and crevices in the house3089.4
iii. Cattle sheds1,28239.0
iv. Garbage collection sites2,09463.6
v. Dark places in the house40112.1
vi. Humid places2367.1
vii. Do not know1083.3
2. Biting time of Kala-azar mosquito/sandflyi. During dusk1,54046.8
ii. During midnight1,30639.7
iii. During day time50.1
iv. Any time41112.5
v. Do not know1283.9
3. Family can be protected from this mosquito bite byi. Use of mosquito nets3,05292.8
ii. Use of insecticides55016.7
iii. Use of mosquito repellents56917.3
iv. Other methods983.0
v. Do not know1013.1
Table 4

Kala-azar related attitude and practices

ItemResponsesNumberPercentage
1. Seriousness of the disease as compared to malaria (n = 3,866)i. More serious disease2,74471.0
ii. Equally serious disease76619.8
iii. Less serious disease451.2
iv. Can’t say3118.0
2. Kala-azar can be controlled by DDT spray (n = 3,866)i. Yes2,07553.7
ii. No1403.6
iii. Partially1,24132.1
iv. Don’t know41010.6
3. First choice of health system for treatment of suspected Kala-azar (n = 3,866)i. Primary health centre40610.5
ii. District hospital/medical college50613.1
iii. Private doctor1,83947.6
iv. NGOs/charitable hospital92624.0
v. Can’t say1894.8
4. Facilities at PHCs are adequate to manage KA cases (n = 3,866)i. Yes49812.9
ii. No2,15955.9
iii. Partially69918.1
iv. Don’t know51013.2
5. Availability of at least one usable mosquito bed net (n = 3,968)Yes3,02176.1
No94723.9

*

Address correspondence to Shyam Sundar, Department of Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221 005, India. E-mail: drshyamsundar@hotmail.com

Authors’ addresses: Shri Prakash Singh, Reader in Community Medicine, Institute of Medical Sciences, BHU Varanasi 221005, India. Dandu Chandra Shekhar Reddy, National Professional Officer (HIV/AIDS), WHO, India, New Delhi 110011, India. Rabindra Nath Mishra, Division of Biostatistics, Department of Community Medicine, Institute of Medical Sciences, BHU Varanasi 221005, India. Shyam Sundar, Professor of Medicine, Institute of Medical Sciences, BHU Varanasi 221005, India.

Financial support: This work was supported by WHO/World Bank/UNDP Special Programme for Research and Training in Tropical Diseases (ID 99106).

REFERENCES

  • 1

    Guerin PJ, Olliaro P, Sundar S, Boelaert M, Croft SL, Desjeux P, Wasunna MK, Bryceson AD, 2002. Visceral leishmaniasis: current status of control, diagnosis, and treatment, and a proposed research and development agenda. Lancet Infect Dis 2 :494–501.

    • Search Google Scholar
    • Export Citation
  • 2

    Desjeux P, 1996. Leishmaniasis. Public health aspects and control. Clin Dermatol 14 :417–423.

  • 3

    World Health Organization, 1998. Life in the Twenty First Century: A Vision for All. Geneva: World Health Organization.

  • 4

    Murray HW, 2002. Kala-azar progress against a neglected disease. N Engl J Med 347 :1793–1794.

  • 5

    World Health Organization, 2003. World Health Report 2003: Shaping the Future. Geneva: World Health Organization.

  • 6

    Bora D, 1999. Epidemiology of visceral leishmaniasis in India. Natl Med J India 12 :62–68.

  • 7

    Lal S, Saxena N, Dhillan G, 1996. Kala-azar cases and deaths. Manual on Visceral Leishmaniasis (Kala-azar) in India: Annexure VII. New Delhi: National Malaria Eradication Programme, 167–177.

  • 8

    Sundar S, More DK, Singh MK, Singh VP, Sharma S, Makharia A, Kumar PC, Murray HW, 2000. Failure of pentavalent antimony in visceral leishmaniasis in India: report from the center of the Indian epidemic. Clin Infect Dis 31 :1104–1107.

    • Search Google Scholar
    • Export Citation
  • 9

    Ministry of Health and Family Welfare of India, 2002. National Health Policy. New Delhi: Ministry of Health and Family Welfare of India.

  • 10

    Office of Registrar General, India, 2001. Census of India: 13–14.

  • 11

    Sen Gupta PC, 1975. Return of kala-azar. J Indian Med Assoc 65 :89–90.

  • 12

    World Health Organization, 1996. Manual on Visceral Leishmaniasis Control. Geneva: Division of Control of Tropical Diseases.

  • 13

    Ahluwalia IB, Bern C, Costa C, Akter T, Chowdhury R, Ali M, Alam D, Kenah E, Amann J, Islam M, Wagatsuma Y, Haque R, Breiman RF, Maguire JH, 2003. Visceral leishmaniasis: Consequences of a neglected disease in a Bangladeshi community. Am J Trop Med Hyg 69 :624–628.

    • Search Google Scholar
    • Export Citation
  • 14

    Koirala S, Parija SC, Karki P, Das ML, 1998. Knowledge, attitudes, and practices about kala-azar and its sandfly vector in rural communities of Nepal. Bull World Health Organ 76 :485–490.

    • Search Google Scholar
    • Export Citation
  • 15

    Boelaert M, Criel B, Leeuwenburg J, Van Damme W, Le Ray D, Van der Stuyft P, 2000. Visceral leishmaniasis control: A public health perspective. Trans R Soc Trop Med Hyg 94 :465–471.

    • Search Google Scholar
    • Export Citation
  • 16

    Bern C, Joshi AB, Jha SN, Das ML, Hightower A, Thakur GD, Bista MB, 2000. Factors associated with visceral leishmaniasis in Nepal: Bednet use is strongly protective. Am J Trop Med Hyg 63 :184–188.

    • Search Google Scholar
    • Export Citation
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