The Knowledge and Self-efficacy of Healthcare Workers in Kwara State on the Detection and Reporting of Yellow Fever Cases

doi:10.21203/rs.3.rs-4344938/v1

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The Knowledge and Self-efficacy of Healthcare Workers in Kwara State on the Detection and Reporting of Yellow Fever Cases

https://doi.org/10.21203/rs.3.rs-4344938/v1

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Yellow fever is a potential cause of public health emergencies of international concern. Nigeria has the highest burden of yellow fever primarily due to her large population size, high vulnerability to infections, the low rate of vaccination uptake and sub-optimal preparedness. There is also limited record of capacity assessment of the epidemic preparedness for yellow fever in Nigeria. This study therefore aimed to assess the knowledge and self-efficacy of healthcare workers in detecting and reporting yellow fever in Kwara State.

A cross-sectional study was conducted among 177 Health care workers. The LGA DSNOs, ADSNOs and Health Facility Surveillance Focal Persons from the 16 LGAs of Kwara State were interviewed using a pre-tested interviewer administered structured questionnaire. Data analysis was done using Microsoft Excel 365 and SPSS 20. Respondent's knowledge of yellow fever and self-efficacy in detecting and reporting yellow fever cases were assessed. Knowledge was assessed on a point scale on which good knowledge was ≥ 5/9 and self-efficacy was assessed on a point scale on which good self-efficacy was ≥ 4/8. Chi-square was used to test association between dependent and the independent variables.

Majority, 125 (70.6%) of the respondents were female and 171 (96.6%) of them were married. The mean age of the respondents was 44.28 years (SD = 8.28) and majority, [129 (72.9%)] were above 40 years of age. Most, [131 (74%)] of the respondents were Yoruba. Majority, [132 (74.6%)] work in primary health care institutions, Health Record Officers, [90 (50.8%)], Surveillance Focal Persons [131 (74.0%)] and 84 (47.5%) have been in their present designation for 1 to 4 years. Most of the respondents, 146 (82.5%) had good knowledge of yellow fever and 176 (99.4%) had good self-efficacy on yellow fever detection and reporting.

The knowledge of yellow fever and self-efficacy in detecting and reporting cases of yellow fever among the health workers in Kwara State were good. Continuous training and retraining of health workers are recommended.

Knowledge

Yellow fever

Kwara State

Self-efficacy

Health care worker

Yellow fever is an acute viral haemorrhagic disease caused by the virus of the Flavivirus family. It is primarily transmitted to humans and other primates through the bite of Aedes and Haemagogus species of mosquitoes. The yellow in the name refers to the jaundice that affects some infected individuals due to acute liver failure (WHO, 2017). Sporadic cases have been reported in rural areas but when introduced to urban communities, it can cause large epidemics. (WHO, 2013)

About 88% of cases are asymptomatic, 9–10% will present with fever only while 2–3% will present with fever and jaundice (acute liver failure) or haemorrhage (WHO, 2017). Symptoms can vary from mild symptoms that subside within few days to severe symptoms such as high fever, jaundice, abdominal pain, vomiting and bleeding from body orifices. The mortality rate in individuals with severe symptoms can be as high as 50% (Garske et al., 2014)

Diagnosis is by Polymerase chain reaction, Enzyme linked immunosorbent assay or Sero-neutralization. (WHO 2017). There is no specific treatment for yellow fever. Symptomatic, supportive treatment and treatment of associated conditions/secondary infections is given to infected individuals. During an outbreak, reactive vaccination, community mobilisation, vector control, active case search and case management are the prioritized control measures. (WHO, 2017). The epidemic threshold is a single case of yellow fever.

The global strategy to eliminate yellow fever epidemics (EYE) is a multi-component and multi-partner strategy with a 10-year target – 2017–2026. The components include protection of at-risk populations, prevention of international spread and rapid containment of outbreaks. (WHO, 2017). Routine immunization activities are organised for children below the age of 1 year to prevent yellow fever among them.

The World Health Organization (WHO) estimates that globally, 84,000–170,000 severe cases of yellow fever occur with about 60,000 deaths annually. More than 90% of all cases of yellow fever occur in Africa (Krishna, 2017) (WHO, 2017).

Many African countries and regions have reported series of yellow fever outbreaks over the past years (Muanya, 2016). In December 2015, Angola reported a large outbreak of yellow fever, 6890 cases were reported with 492 deaths (WHO, 2016). The Angola outbreak spread to the Democratic Republic of Congo (DCR) and China making the first yellow fever outbreak in China.

Nigeria has recorded series of yellow fever outbreaks. The earliest yellow fever outbreak in Nigeria was reported in Lagos in 1864. Other outbreaks of yellow fever occurred in Lagos in 1894, 1905, 1906, 1925 and 1926 (Nwachukwu William et al., 2022). A large outbreak of yellow fever occurred in Jos in 1969 which spread to other parts of the country. Over 100,000 people were infected. Over 120,000 individuals were infected with yellow fever in Cross river, Plateau, Benue and Oyo States between 1987 and 1996. (WHO, 2021). Nigeria did not report any case from 1996 to 2016, thus the World Health Organisation (WHO) was planning to declare Nigeria yellow fever free.

However, after 21 years of recording no confirmed case of yellow fever in Nigeria, a case was detected in Ifelodun Local Government Area of Kwara State in 2017. (NCDC, 2020). The case was a 7-year-old nomadic Fulani who presented with fever and yellowness of the eyes. (NCDC, 2020). Immediately, the rapid response team (RRT) of the Nigerian Centre for Disease Control (NCDC) conducted yellow fever vaccination campaign for children less than 10 years. Active case search and evaluation of immunization records of children within this age range was conducted in addition to other response activities like risk communication and social mobilization. In December, 2018 another case of yellow fever was confirmed in Ifelodun Local Government Area of Kwara State. The response was carried out by the Kwara State Ministry of Health. (Awoyale et al., 2021)

Yellow fever can produce large outbreaks with a risk of international spread. It is a potential cause of public health emergencies of international concern that threaten the global public health security. More than 25 of the 54 African Countries including Nigeria are at high risk of the yellow fever, necessitating an improved preparedness.

Large outbreaks of yellow fever were reported in Angola and DRC which highlighted the gaps in preparedness, surveillance, and rapid diagnosis. In addition, factors like porous borders and increased migration, the widespread distribution of Aedes mosquitoes and lack of efficient health preparedness and surveillance system, favour this complex epidemiological scenario of re-emergence of yellow fever. (Ortiz-Martínez et al., 2017).

Yellow fever continues to cause several morbidity and mortality in Africa despite the availability of an effective vaccine for more than 70 years. This has been attributed to the sub-optimal level of preparedness (Nomhwange et al., 2021)(Fatiregun et al., 2021). Nigeria is considered as one of the high-risk countries for yellow fever in Africa. Nigeria has the highest burden of yellow fever primarily due to her large population size, high vulnerability to infections, the low rate of vaccination uptake and sub-optimal preparedness (Chime et al., 2021).

According to Centres for Disease Control and Prevention (CDC), yellow fever virus is estimated to cause 200,000 cases of disease and 30,000 deaths globally each year. On the average 84,000–170,000 severe cases of yellow fever occur with about 60,000 deaths annually. More than 90% of all cases of yellow fever occur in Africa (Krishna, 2017)(WHO, 2017). The mortality rate ranged from 0.1/100,000 in Nigeria to 2200/100,000 in Ghana while the case fatality rate associated with yellow fever outbreaks ranged from 10% in Ghana to 86% in Nigeria. The high case fatality rate associated with yellow fever outbreaks in Nigeria can be linked to the low level of preparedness (Nwaiwu et al., 2021).

It has been estimated that 20–50% of infected persons who develop severe disease die; however earlier detection and treatment has been shown to reduce mortality among the infected (WHO, 2017). This highlights the need for preparedness for the outbreak by health workers and health authorities.

Yellow fever preparedness is a proactive measure. The efficiency of the response mounted against the Ebola Virus Disease (EVD) outbreak of 2014 proved that indeed, though challenging, proactive, and effective outbreak response is possible. (WHO, 2016)

According to the World Health Organisation (WHO), Nigeria is one of only five members of the WHO African Region to report at least five public health events per annum. Over 20 public health emergencies and infectious disease outbreaks including yellow fever were reported from Nigeria between 2016 and 2018 alone. (WHO, 2019). Future pandemic preparedness is therefore essential if we are to find better solutions to potential outbreaks of either known or novel pathogens and to save future lives (Williams, Nicola. 2023).

The emergence of yellow fever outbreak in Kwara State, Nigeria after 21 years of not reporting any case of yellow fever affirms reports from other countries on the African continent that yellow fever is a re-emerging public health disease. (Nwachukwu William et al., 2022). Yellow fever can spread from one country to another. Kwara State shares boundary with the Republic of Benin that is also at a high risk of yellow fever outbreak. This raises the issue of the potential pandemic threat of yellow fever as it may spread across the border. Therefore, Studying the yellow fever epidemic preparedness of health care workers in Kwara State is crucial.

The importance of epidemic preparedness is illustrated in the study by (Kellerborg et al., 2020) in Sierra Leone in which it was found that 10,257 cases of Ebola virus disease and 8,835 deaths would have been averted if the interventions were four weeks earlier. Outbreaks of vaccine-preventable infectious diseases, such as meningococcal disease, yellow fever, and cholera, can have disastrous effects in areas with limited health infrastructure and resources, and where timely detection and response is difficult (WHO, 2023).

Preparedness for one epidemic will help in the response to another epidemic. Ebola response helped the response to COVID-19 (Olumade et al., 2020). In addition, the lessons from the Spanish flu of the 1820s also helped with the response to COVID-19 but there is also need to prepare specifically for epidemic of a defined disease because response to epidemic may differ by the disease aetiology (WHO, 2019)

Prompt detection of yellow fever and rapid response through emergency vaccination campaigns are essential for controlling outbreaks. (WHO, 2019). There is limited record of capacity assessment of the epidemic preparedness for yellow fever. However, a study conducted in Nigeria revealed that there is no formal document clearly outlining the coordination between the NCDC, the FMOH, parastatal agencies and partners at the national, State and LGA levels in terms of emergency preparedness and response (Oboma Eteng et al., 2022)

In 2017, WHO developed the Eliminating yellow fever Epidemic (EYE) strategy to improve high risk country preparedness for surveillance, detection, and response. Gaps and challenges in yellow fever preparedness therefore need to be identified and addressed to forestall the re-emergence of the yellow fever outbreak in Kwara State.

This study therefore aimed to assess the knowledge and self-efficacy of healthcare workers in detecting and reporting yellow fever in Kwara State.

The study was conducted in the 16 Local Government Ares of Kwara State, North Central, Nigeria.

Kwara State is bordered to the east by Kogi State, to the north by Niger State, and to the south by Ekiti, Osun, and Oyo States, while its western border makes up part of the international border with Benin Republic.(Onyeakagbu, 2021).

Kwara State has a total of 994 Health facilities: 3 tertiary healthcare facilities, 209 secondary healthcare facilities and 782 primary healthcare facilities. (National Health Facility Registry, 2019). The State has a Public Health Emergency Operations Centre (PHEOC) where all disease surveillance and response activities are coordinated. The PHEOC is located inside the State Ministry of Health, Ilorin.

A Cross-sectional study design was used to assess the knowledge of health care workers on yellow fever, and the self-efficacy of the health care workers in reporting yellow fever cases.

The study participants were the Local Government Disease Surveillance and Notification Officers (DSNOs) from the 16 LGAs, the Local Government Assistant Disease Surveillance and Notification Officers (ADSNOs) and the health facility Surveillance Focal Persons (SFPs).

Yamane formula was used to determine the sample size. A total of 177 respondents participated in the study. Response rate was 98.3%. Purposive sampling technique was used to select the study participants.

A structured interviewer-administered questionnaire was used to collect relevant data from the health workers. The questionnaire was developed from an extensive review of the literature. The questionnaire was divided into different sections; Socio-demographic characteristics of the respondents, knowledge of the respondents on yellow fever and self-efficacy of the health workers in detecting and reporting yellow fever cases.

This questionnaire was pretested on randomly selected HCWs, representing about 10% of the required sample size.

In this study, the Knowledge was assessed using 9 variables. A correct answer attracted a score of 1 while an incorrect answer was scored 0. A total score of 9 is the maximum score on the knowledge scale. Respondents who scored 5 and above were considered as having good knowledge. The self-efficacy score was assessed using 8 variables. Respondents who scored 4 (50%) of the 8 variables were considered to have good self-efficacy (Ossai et al, 2020).

The association between the independent and dependent variables was examined using Chi-square test analysis.

Data cleaning and coding was done on the collected data. The data were subsequently entered into Microsoft excel and SPSS for analysis.

Descriptive analysis such as frequencies and proportion of the variables (sex, age, ethnicity, marital status, educational level, cadre, knowledge of yellow fever, self-efficacy of the respondent on the detection and reporting of yellow fever, IDSR practices of the respondent, IPC practices of the respondents) were done. Chi Square analysis was used to test the association between the independent variables and the dependent variables.

Ethical approval

was obtained from the Kwara State Ministry of Health Ethical Review Committee on 17th May 2023 before the commencement of the study. The Ministry of Health Ethical Research Committee (ERC) Assigned Number was ERC/MOH/2023/04/106. Consent was obtained from participants after giving a detailed information about the study.

Socio-demographic characteristics of HCWs in Kwara State, 2023

A total of 177 respondents were enrolled from the 16 Local Government Areas of Kwara State. Majority, 125 (70.6%) of the respondents were Female and 171 (96.6%) of the respondents were married. The mean age of the respondents was 44.28 years (SD = 8.28) and majority, 129 (72.9%) were above 40 years of age. Most, 131 (74%) of the respondents were Yoruba. Majority, 132 (74.6%) work in primary health care institution, 90 (50.8%) were Health Record Officers, 131 (74.0%) were Surveillance Focal Persons in their Health facilities and a greater percentage of the respondents, 84 (47.5%) have been in their present designation for 1 to 4 years.

Table 1

Socio-demographic characteristics of HCWs in Kwara State, 2023 (n = 177)
Characteristics	Frequency (N)	Percentage
Gender
Male	52	29.4
Female	125	70.6
Age Group
20–29	8	4.5
30–39	40	22.6
40–49	71	40.1
50+	58	32.8
Marital Status
Married	171	96.6
Single	3	1.7
Widowed	3	1.7
Ethnicity
Yoruba	131	74.0
Nupe	26	14.7
Others	20	11.3
Type of Healthcare Institution
Primary	132	74.6
Secondary	12	6.8
Tertiary	33	18.6
Present Cadre
Health Record Officer	90	50.9
CHEW	54	30.5
Other HCWs	33	18.6
Designation
DSNO/ADSNO	38	21.5
Surveillance Focal Person	131	74.0
Others	8	4.5
Years spent at present designation
1–4	84	47.5
5–9	59	33.3
10+	34	19.2
Senatorial District
Kwara Central	53	29.9
Kwara South	74	41.8
Kwara North	50	28.3

Knowledge of yellow fever among the health care workers

All the respondents were aware of yellow fever, 141 (79.7%) of the respondents knew the causative organism of yellow fever to be a virus, 159 (89.8%) knew the vector (mosquito) of yellow fever. Less than half, 74 (41.8%) of the respondents knew the transmission of yellow fever while more than half of the respondents, 97 (54.8%) knew the symptoms (fever, yellow eyes, yellow skin, muscle pain, bleeding from orifices) of yellow fever. Majority of the respondents, 125 (70.6%) knew the complications (Bleeding, Liver failure, Death) of yellow fever. Less than half, 86 (48.6%) of the respondents knew that one case of yellow fever is an outbreak.

Almost all the respondents, 175 (98.9%) responded that they knew the case definition for yellow fever but only 111 (62.7%) selected the correct case definition of yellow fever (Any person with acute onset of fever, with jaundice appearing within 14 days of onset of the first symptoms). The grading of knowledge showed that majority, 146 (82.5%) of the respondents had good knowledge of yellow fever.

Table 2

Yellow fever knowledge of HCWs in Kwara State, 2023 (n = 177)
Variable	Response	Frequency (%) N = 177
Heard about yellow fever	Yes	177 (100%)
Causative organism of yellow fever	Correct	141 (79.7%)
Causative organism of yellow fever	Wrong	36 (20.3%)
Vector of yellow fever	Correct	159 (89.8%)
Vector of yellow fever	Wrong	18 (10.2%)
Yellow fever transmission	Correct	74 (41.8%)
Yellow fever transmission	Wrong	103 (58.2%)
Symptoms of yellow fever	Correct	97 (54.8%)
Symptoms of yellow fever	Wrong	80 (45.2%)
Common Complication of yellow fever	Correct	125 (70.6%)
Common Complication of yellow fever	Wrong	52 (29.4%)
Epidemic threshold of yellow fever	Correct	86 (48.6%)
Epidemic threshold of yellow fever	Wrong	91 (51.4%)
Knowledge of yellow fever case definitions	Yes	175 (98.9%)
Knowledge of yellow fever case definitions	No	2 (1.1%)
Case definition for a suspected case of yellow fever	Correct	111 (62.7%)
Case definition for a suspected case of yellow fever	Wrong	66 (37.3%)
Over-all Knowledge of Yellow Fever	Good	146 (82.5%)
Over-all Knowledge of Yellow Fever	Poor	31 (17.5%)

Perceived self-efficacy on yellow fever case detection and reporting.

Table 3 shows the perceived self-efficacy of the respondents on yellow fever detection and reporting. Almost all the respondents, 176 (99.4) said that the confirmation of yellow fever is done through a laboratory test. Most of the respondents, 129 (72.9%) said they have been involved in the investigation of a suspected case of yellow fever before. Almost all the respondents, 166 (93.8%) reported that the sample taken for yellow fever confirmation is blood. Most of the respondents, 173 (97.7%) said that the health facility where they work is a surveillance focal site. All the respondents, 177 (100%) reported that they have community informants but only 147 (83.1%) call their community informants at least once a week. Few, 35 (19.8%) of the respondents reported to have seen a suspected case of yellow fever in the last 3 months preceding this study. Majority of the respondents, 141 (79.7) said the form that is used for the investigation of a suspected case of yellow fever is IDSR-001.

Grading of self-efficacy revealed that majority, 176 (99.4%) of the respondents had good self-efficacy on yellow fever detection and reporting.

Table 3

The perceived self-efficacy of respondents on yellow fever case detection and reporting
Characteristics		Frequency (%) N = 177
Yellow fever confirmation	No	1 (0.6%)
Yellow fever confirmation	Yes	176 (99.4%)
Involvement in yellow fever case investigation	No	48 (27.1%)
Involvement in yellow fever case investigation	Yes	129 (72.9%)
Appropriate sample for yellow fever	Correct	166 (93.8%)
Appropriate sample for yellow fever	Wrong	11 (6.2%)
Health facility is a surveillance focal site	No	4 (2.3%)
Health facility is a surveillance focal site	Yes	173 (97.7%)
Regular communication with community informants	Regular	147 (83.1%)
Regular communication with community informants	Not regular	30 (16.9%)
Reported yellow a fever case in the last 3 months	No	142 (80.2%)
Reported yellow a fever case in the last 3 months	Yes	35 (19.8%)
Form used for yellow fever investigation	Correct	141 (79.7%)
Form used for yellow fever investigation	Wrong	36 (20.3%)
Perceived Self-efficacy	Good	176 (99.4%)
Perceived Self-efficacy	Poor	1 (0.6%)

Association between respondents’ characteristics and knowledge of yellow fever

Table 7 below show the association between knowledge and the characteristics of the respondents. There is a significant association between knowledge of the respondents and attendance of surveillance training by them, P = < 0.001. Majority of those who had surveillance training had good knowledge of yellow fever.

Table 4

Association between respondents’ characteristics and knowledge of yellow fever.
Characteristics	Level of Knowledge		Total	x²	p-value
Characteristics	Good (%) n = 146	Poor (%) n = 31
Cadre
CHEW	46 (85.2)	8 (14.8)	54 (100)	0.400	0.819
Health Record Officers	73 (81.1)	17 (18.9)	90 (100)
Other Health Workers	27 (81.8)	6 (18.2)	33 (100)
Designation
DSNO/ADSNO	34 (89.5)	4 (10.5)	38 (100)	3.853	0.146
Surveillance Focal Persons	104 (79.4)	27 (20.6)	131 (100)
Others	8 (100)	0 (0.0)	8 (100)
Years of Experience
1–4	66 (78.6)	18 (21.4)	84 (100	2.681	0.262
5–9	49 (83.1)	10 (16.9)	59 (100)
10+	31 (91.2)	3 (8.8)	34 (100)
Surveillance Training
Yes	124 (99.2)	1 (0.8)	125 (100)	*	< 0.001
No	22 (42.3)	30 (57.7)	52 (100)
*Fisher-Exact p-value

Association between respondents’ characteristics and self-efficacy in detection and reporting of yellow fever.

Table 8 shows the association between the characteristics of the respondents and the perceived self-efficacy in detecting and reporting yellow fever cases. There is no significant association between self-efficacy and the respondents’ characteristics.

Table 5

Association between respondents’ characteristics and self-efficacy in detection and reporting of yellow fever.
Characteristics	Self-efficacy		Total	x²	p-value
Characteristics	Good (%) n = 176	Poor (%) n = 1
Cadre
CHEW	54 (100)	0 (0.0)	54 (100)	4.388	0.111
Health Record Officers	90 (100)	0 (0.0)	90 (100)
Other Health Workers	32 (97.0)	1 (3.0)	33 (100)
Designation
DSNO & ADSNO	38 (100)	0 (0.0)	38 (100)	*	0.785
SFP & Clinicians	138 (99.3)	1 (0.7)	139 (100)	*
Years of Experience
1–4	84 (100)	0 (0.0)	84 (100)	2.011	0.366
5–9	58 (98.3)	1 (1.7)	59 (100)
10+	34 (100)	0 (0.0)	34 (100)
Type of Health Facility
Primary	132 (100)	0 (0.0)	132 (100)	*	0.254
Secondary & Tertiary	44 (97.8)	1 (2.2)	45 (100)	*
Surveillance Training
Yes	124 (99.0)	1 (0.8)	125 (100)	*	0.706
No	52 (100)	0 (0.0)	52 (100)	*
Knowledge of Yellow fever
Good	145 (99.3)	1 (0.7)	146 (100)	*	0.825
Poor	31 (100)	0 (0.0)	31 (100)	*
* Fisher-Exact p-value

This study revealed that 82.5% of the respondents had good knowledge of yellow fever. Our findings are like the findings of a study in Abakaliki, Southeast Nigeria in 2020 where 60% of the respondents had good knowledge of Lassa fever, a Viral Haemorrhagic Fever(Ossai et al., 2020). The findings from this study are however in contrast to the result from research carried out among healthcare workers in Owo, Ondo State which reported that 52.3% of the respondents had appropriate knowledge(Ukwenya et al., 2021). The findings of our study are also in contrast to that of a study conducted in Ondo State in 2018 which reported that 41.6% of the participants had good overall knowledge on Lassa fever(Ijarotimi et al., 2018). As well as findings from research conducted in Sokoto (Fidelis and Olajolumo, 2021) which indicated that 40% of the health workers had very low knowledge about VHF. It was also found in this study that a higher proportion of the respondents with good knowledge have been trained in the last one year.

Since the COVID-19 pandemic, NCDC and other partners have conducted series of trainings and re-trainings across the nation. The good knowledge yellow fever found in this study may be linked to the trainings.

The overall perceived self-efficacy of the health workers in the detection and reporting of case was 99.4%. This may be due to the excellent IDSR practice observed during this study.

Generally, the knowledge of yellow fever among the healthcare workers in Kwara State was good but there is need for continuous training of surveillance officers and clinicians in the State. Frequent health education interventions are needed to bridge the gap of misperceptions about mode of transmission among health care workers.

Recommendations

There is a need for regular multi-hazard risk assessment using a standard tool like the WHO Strategic Tool for Assessing Risk (STAR) for Kwara State.

The governments should provide their health institutions with adequate funding, facilities, and coordination to ensure adequate preparedness toward effective management of yellow fever.

Author Contribution

OA and MD conceptualized the study. OA and OF participated in data collection. OA conducted data analysis and wrote the first draft of the manuscript. MD, AF, OF and OF revised the manuscript for critical intellectual content. All authors approved the final version of the manuscript.

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No competing interests reported.

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The Knowledge and Self-efficacy of Healthcare Workers in Kwara State on the Detection and Reporting of Yellow Fever Cases

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