Human behavior has a significant role in influencing anthrax transmission. This behavior is influenced by the knowledge, attitudes, and practices of affected communities. This study aimed to assess the knowledge, attitudes, practises, and consumption of meat of animals found dead in communities previously affected by anthrax in Kazo District, South-Western Uganda. The survey results indicated good awareness and adequate knowledge about anthrax among respondents. However, the good awareness and adequate knowledge about anthrax did not translate into good practices. In total, 94% had heard of anthrax and 70% knew it was zoonotic; 63% did not know any signs of anthrax in animals, though 73% knew transmission could occur through eating animals found dead. Only 16% (19) said they had lost their livestock suddenly in the last year; of these, 21% consumed the meat and 53% buried the carcasses. Overall, 77% had adequate knowledge about anthrax. Qualitative data indicated that farmers did not vaccinate their animals against anthrax due to cost, difficulty accessing the vaccine, and inadequate access to veterinary services. Poverty, limited access to protein, and economic challenges were cited as drivers for consuming meat from animals found dead despite the risk.
Even though 94% stated that they knew/had heard about anthrax, 43% had received information from other farmers, 40% from either friends, colleagues or relatives. This means that the most respondents are more likely to have poor access to media information and poor comprehension and compliance to health education messages. The study showed that most respondents accessed information from friends rather than public media. This is likely to interfere with public health messages as community members share misconceptions and myths surrounding the disease. This is as observed by Taverne (20) who postulated that disease epidemics arrive `ahead of themselves since interpretations and the social effects usually precede the disease itself.'
Even though the majority of the respondents knew that anthrax affects both humans and animals, there was a better understanding of anthrax in humans; susceptibility of humans to anthrax, signs of anthrax in sick human beings and common routes of transmission. The survey revealed a poor understanding of anthrax in animals; 63% didn’t know any signs of anthrax. Most respondents also didn’t know how animals get infected with anthrax; however, they reported on the importance of vaccination as a preventive measure. The qualitative results demonstrated a poor understanding of the disease overall in the community, especially regarding signs and symptoms in animals and the seasonality of anthrax. These study findings are consistent with those of a similar study in Zambia (15). On the contrary, Opare`s study in northern Ghana (21) showed that most respondents did not know the causes of anthrax but recognized the signs and symptoms of anthrax and the potential effectiveness of vaccinations. Respondents who knew anthrax to be zoonotic (91%) was higher than reported in Ghana and Zambia at 64.2% (15, 21). These differences could be attributed to fact that the investigation was conducted during an outbreak which minimized recall bias. The recognition of major clinical signs and transmission pathways in human and livestock does suggest public health education could be potentially effective in preventing anthrax.
Predominantly, most houses kept livestock. Correspondingly, the high levels of knowledge were not found to be consistent with the attitudes and practices of respondents in this study. Case in point; while quantitative data indicated that most respondents (73%), knew that anthrax could be transmitted to humans by eating meat from an animal that died suddenly, 21% of the respondents who lost their animals in the past year consumed the animal. The qualitative data revealed that the majority of community members believed that when meat is smoked and cooked for a long time, the bacteria die and the meat is safe for consumption. Contrary to this finding, the study done by Gombe et al in Zimbabwe revealed that respondents disagreed with statements that overcooking infected meat kills anthrax bacteria (14). From the qualitative survey, respondents indicated that they did not think eating meat from an animal that has died suddenly was risky because of how they prepare the meat, but also because they usually do not see any symptoms among themselves whenever they consume meat from diseased carcasses. This perceived low susceptibility to anthrax is likely to lead to risky meat consumption behaviors. This perception seems to be consistent with the propositions of the Health Belief Model, which proposes that persons who perceive a low risk of developing a health problem are unlikely to engage in behaviors to reduce their risk of developing the particular health problem (22).
According to qualitative data obtained, practises such as selling and consumption of meat from animals that have died suddenly were perpetuated by poverty and limited access to meat protein. The quantitative data indicated that livestock and farming were the main source of livelihood for the people of Engari Sub-county. Therefore, loss of cattle leads to economic losses and increases the likelihood of selling infected meat in order to make financial recoveries. This is worsened by the fact that farmers are not compensated for cattle losses. Consumption and selling of carcasses in which the animals died from anthrax was reported by other studies; this is not only to make financial return but also as a source of protein (14, 15, 21, 23).
Routine vaccination policy is one of the better strategies for prevention and control of anthrax (24). The “greater Kiruhura District” is endemic for anthrax but the vaccination status in Kazo District was not satisfactory. Majority of respondents, 95% felt that anthrax was a serious disease and 83% of them believed that vaccination could prevent the disease in animals; however, 64% had never vaccinated their animals. This is supported by a study conducted in Ghana which indicated that high levels of knowledge about vaccination had not been actualized into practices by farmers in Tamale Municipality. Qualitative information suggested that very few farmers had their animals vaccinated. Participants in the focus group discussions cited various reasons for failure to have their animals vaccinated; inability to pay for vaccination, difficulty in accessing the vaccine, and inadequate access to veterinary services in their communities. Likewise, in a review paper on the ecology and epidemiology of anthrax in cattle and humans in Zambia (13), inadequate technical and administrative support, erratic funding and supply of logistics were cited as major constraints of anthrax control in Zambia.
Disposal of the carcass of animals is a source of concern for anthrax transmission. According to the World Health Organisation (WHO), in most countries, the preferred method of disposal of an anthrax carcass is incineration (2). Controlled heat treatment or “rendering” has been proposed, and where neither of these approaches is possible, for example owing to lack of fuel, burial is the remaining less satisfactory alternative. Of the farmers who lost their animals suddenly, only 53% buried their animals. From the qualitative data, it was still common for community members to slaughter and eat meat from animals that have died suddenly. Therefore, when cattle died, it was butchered and shared right from where it died. Incineration was rarely practiced. However, history has many examples of new outbreaks following disturbance of old burial sites. Periodic reports of viable anthrax spores at burial sites of animals that died many years previously, and incidents and outbreaks in animals associated with such sites, have testified to the unreliability of burial procedures for long-term control of the disease. Disturbance of such sites, for example by ploughing or laying drainage presumably brings the spores to the surface. Carnivores and birds play a vital role to drag contaminated meat over the areas, thus, increasing ground contamination with anthrax spore. Dogs themselves are resistant to anthrax but acts as a mechanical vector from field to household (25). In general, regarding the KAP of the respondents on anthrax, we observed that knowledge was better than attitude, and attitude was better than practise.
Study limitations and strengths
The study could be prone to recall bias because participants were asked about knowledge, attitudes, practices, exposure to deceased animals, as well as disease symptoms that occurred about 4 years prior to the interview date. Our findings may also be prone to social desirability bias in which knowledgeable respondents may have stated what was desirable rather than what they engaged in. Adherence to good practice in livestock production and anthrax control was self-reported by the respondents rather than observed by the investigators. Despite the limitations, by triangulation of quantitative and qualitative findings, we strived to ensure internal validity and reliability. Our investigation therefore highlights elements that would expose the community to anthrax in the event of an outbreak.