Assessment of Knowledge, Attitudes, and Practices Towards Urogenital Schistosomiasis Among Primary Schoolchildren in Abobo, Amibara and Kurmuk Districts, Ethiopia

doi:10.21203/rs.3.rs-5192793/v1

Introduction: Urogenital schistosomiasis is a neglected tropical disease caused by Schistosoma haematobium and it is one of the public health problems in Ethiopia. When developing specific schistosomiasis control intervention program, the existing knowledge, attitudes and practices (KAPs) must be taken into account. This study aimed to assess the KAPs of primary schoolchildren towards urogenital schistosomiasis.

Methods: A cross-sectional study was conducted through questionnaires to assess KAP on urogenital schistosomiasis among primary schoolchildren. A total of 1171 study participants aged 5 to 15 years were selected randomly.

Results: Of the 1171 interviewed schoolchildren, 654, or 55.8%, said they had heard of urogenital schistosomiasis. Among all respondents, 13.9% of stated that their primary supply of household water came from rivers or dams and 28.9% of them had history of urogenital schistosomiasis. Using river or dam water for household consumption had a significant association with urogenital schistosomiasis infection history (P = 0.001). Logistic regression analysis showed that males had significantly higher risk of having urogenital schistosomiasis infection history compared to females (OR = 3.01, P < 0.001). Children in low socio-economic status had higher risk of having urogenital schistosomiasis compared to high socio-economic status (OR = 2.81, P < 0.001). Compared to urban dweller, children in rural area had higher risk of having urogenital schistosomiasis (OR = 4.34, P < 0.001). Respondents who used river water (OR = 2.48, P = 0.005), and lake or dam water (OR = 3.33, P = < 0.001) are at more risk of urogenital schistosomiasis infection. Furthermore, respondents swimming or playing in river water had high risk of urogenital schistosomiasis infection history (OR = 1.62, P = 0.005).

Conclusion:This study showed that there was knowledge gap in schoolchildren about urogenital schistosomiasis causes, transmission, symptoms and prevention. Therefore, appropriate health education and behavioral change intervention is needed to create better knowledge among schoolchildren regarding its transmission, control, and prevention.

Infectious Diseases

Parasitology

Urogenital schistosomiasis

knowledge

attitude

practice

schoolchildren

Ethiopia

Schistosomiasis is one of neglected tropical disease (NTD) of public health importance in many tropical and subtropical developing countries [1]. Globally, more than200 million people are infected and about 700 million people are at risk of schistosomiasis infection [2, 3]. Human schistosomiasis is caused by six species of schistosome i.e. Schistosoma mansoni, Schistosoma haematobium, Schistosoma japonicum, Schistosoma intercalatum, Schistosoma mekongi and Schistosoma guineesis; and is endemic in 78 countries [4]. Of all these six species, S. mansoni and S. haematobium are widely distributed in Africa and cause intestinal schistosomiasis and urogenital schistosomiasis, respectively[5, 6]. Schistosomiasis affects the poorest of the poor and infections are particularly abundant among people living in rural or deprived urban or peri-urban areas [7]. These populations typically have low socio-economic status with limited access to safe water and with inadequate sanitation provision[8, 9].

Schistosomiasis has received little attention over the years particularly in Sub-Saharan Africa (SSA) perhaps because of its mortality rate is considered low compared with many other infectious diseases. However, over the past decade, effort to control the disease has been scaled up [10] following World Health Assembly resolution 54.19 encouraging endemic countries to annually deworm at least 75% of school aged children and high-risk communities [11]. The WHO has set goals for controlling schistosomiasis morbidity (defined as prevalence of heavy-intensity infection < 5% aggregated across sentinel sites) and achieving elimination as a public health problem (defined as prevalence of heavy-intensity infection < 1% in all sentinel sites) in all endemic countries by 2025. By 2009, 21 countries out of 76 endemic countries had initiated their control programs [12]. Even though several efforts are done to control morbidity due to helminthiasis with specific emphasis on regular school-based treatment of primary schoolchildren [12], it should be borne in mind that community perception, knowledge and practices have a major role in sustainable control interventions. WHO recommends that any control measure for soiltransmitted helminthiasis (STHs) and schistosomiasis should involve three main components: drug treatment, improved sanitation, and health education and behavioral change intervention aimed at reducing transmission and re-infection by encouraging self-protective health behaviors [13].

Ethiopia, one of the countries with high burden of schistosomiasis, has conducted schistosomiasis mapping survey in all regions of the country. The national control program was prepared to achieve elimination of schistosomiasis as main public health problem (2020) and to achieve transmission break by 2025. Two forms of schistosomiasis (intestinal and urinary) are the major public health problem of the country. According to Kassa et al. [14] both Schistosoma. haematobium and Schistosoma mansoni are endemic in Ethiopia. Schistosoma mansoni is widely distributed in many parts of the country while S. haematobium is restricted in lowland areas such as Kurmuk district, middle and lower Awash valley, and Wabe-Shebele valleys [15]. Recently, S. haematobium infection is also reported in Abobo district (Gambella region), western Ethiopia [16].

In Ethiopia nationwide mass drug administration (MDA) launched in 2015 against STHs and schistosomiasis. The MDA targets 17 million school-aged children (5–14 years). About 56 million people live in schistosomiasis endemic areas in Ethiopia. Schoolchildren carry the majority of schistosomiasis morbidity, which impairs their nutritional, physical and mental development. [17].

The WHO recommends that school age children should be the target group in the control of schistosomiasis because of their risky behaviors like water contact, and should normally be the study population for the baseline survey and for monitoring and evaluation of intervention strategies [18]. Knowledge, Attitudes and Practices in relation to the disease are critical in establishing effective control measures. However, data on the knowledge, attitude, and practices (KAP) of schoolchildren in endemic areas in Ethiopia with regard to schistosomiasis are scarce. Community awareness and involvement are considered as one of the cardinal tools for the success and sustainability of any disease control program [19]. In light of this, the study aimed to assess primary schoolchildren knowledge, attitude and practices (KAP) towards urogenital schistosomiasis in three urogenital schistosomiasis endemic areas of Ethiopia.

Study area

The study was conducted in three urogenital schistosomiasis endemic areas or districts: Amibara district in Afar region, Kurmuk district in Benishangul-Gumuz region and Abobo district in Gambella region. In the three selected districts eight villages were chosen purposively. Six primary schools (Hassoba & Bure in Amibara, Abobo and Perbongo in Abobo and Horzehab and Kurmuk in Kurmuk district) were selected for the study. Hassoba village is about 290 km east of Addis Ababa with geographical coordinates 9°33’N and 40° 28' E and an altitude of 725 m above sea level (masl). Kurmuk is about 878 Km west of Addis Ababa and near Ethio-Sudanese border and located at 10° 34' N and 34° 21' E. The altitude of Kurmuk is 733 masl. Abobo is 822 km from Addis Ababa and located at 7° 51′ N and 34° 33′ E and it has an altitude of 461masl.

Study design

A cross-sectional study recruiting primary schoolchildren in Abobo, Amibara and Kurmuk district was carried out during 2022.

The study population:

The study population was selected based on previous studies showing endemicity of urogenital schistosomiasis in the area from the three villages (Hassoba, Kurmuk and Abobo). In these villages six primary schools were selected and the schools have a total of 2,694 schoolchildren during the data collection time.

Sampling procedure

Three districts in Gambella region, Afar region and Benishangul Gumuz region were selected purposively because in these districts urogenital schistosomiasis is endemic [15, 16, 22]. These districts have a total of 55 villages. Eight villages from 55 villages chosen purposively for the study. Selection based endemicity for schistosomiasis infection and village location to irrigation canals, dam water, rivers, marshy areas, and streams. Children living in Abobo villages5/6 rely on Alwero dam and Alwero river water. In Hassoba and Buri village the main source of water is Awash River which is used mainly for irrigation, washing clothes and bathing. Children in Kurmuk villages also depend on two major water bodies such as stream and pond water. Therefore, schoolchildren in selected village with 5 to 15 years of age were eligible to be included in study. student registration book in the school was used as sampling frame and then the participants were chosen using a simple random sampling method. During sampling gender balance was taken into consideration.

Sample size determination

The sample size was estimated for each study site using formula:

and taking the none response 10%, where n is the sample size, Z is 95% confidence interval (1.96), P is expected prevalence (referring to previous prevalence of S. haematobium) and d is precision or margin of error (5%) [20]. Accordingly, urogenital schistosomiasis prevalence was 37.0% in Hassoba [21], 50% in Kurmuk (no recent report) and 35.9% in Abobo [16]. Based on these prevalence report 1,171 study participants were chosen from such areas. That is 389 from Abobo, 387 from Hassoba, and 395 from Kurmuk.

Questionnaire survey

The questionnaire was developed in English and then translated to local language (Amharic, Agnua, Afar, and Berta language). Pretested structured questionnaires were administered with closed ended questions. Participants asked about their age, sex, socio-economic status, household water source, location (residence), history of schistosomiasis infection and anti-schistosomal treatment. Moreover, schoolchildren knowledge about schistosomiasis aetiology, transmission, clinical symptoms, prevention and control, attitude towards schistosomiasis, and risky practice regarding urogenital schistosomiasis infection was assessed by questionnaire.

Data analysis

Data were entered in to Microsoft Excel spreadsheets and analysed using SPSS statistics version 20.0 (IBM corporation, NY, USA). General knowledge of schistosomiasis, attitude and practices were analyzed in proportions. Descriptive statistics including mean, frequencies and proportions were appropriately generated and Chi square test and logistic regression was used to test associations between variables. Association between different variables were analyzed using odds ratio. P-value less than 0.05 at 95% CI was considered statistically significant.

Ethical Consideration

Ethical approval letter was obtained from ethical review board of Jimma University (Ref No. IHRPGD /3006/18) and the methods used to collect the presented data followed the recommended standard operating procedures, relevant guidelines and regulations. The district health officials, head of administrative, the school directors and leaders of the villages were contacted to get permission to conduct the study. Informed written consent was obtained from the parents/guardian of children and verbal assent from children. The schoolchildren participated in the study on voluntary basis after being informed about the purposes of the study and giving their consent/assent. During data collection children were informed and guided to apply COVID-19 prevention control protocols.

Socio-demographic characteristics of the respondents

Among the total 1171 respondents, 50.2% were males and 49.8% females. The ages of the participants ranged 5–15 years with a mean age of 12 ± 1.94 years. The majority of schoolchildren were in age group of 14–15 (57.8%). About one-fourth of the participants had relatively low socioeconomic level. Of the total study participants, 162 (13.8%) depend on river, dam/lake and stream water for domestic consumption. Among the total respondents, 363 (31.0%) had history of urogenital schistosomiasis infection while living in the area and 338 (29.9%) had anti-Schistosoma treatment history in the last seven years (Table 1).

Table 1

Socio-demographic characteristics of the study participants in Hassoba, Kurmuk and Abobo primary school children, Ethiopia, 2022
Variable	Response	No. of respondents (%)
Sex Age group (years) Socio-economic level Main household water source Residence of respondents History of urogenital schistosomiasis while living the village History of schistosomiasis treatment while living the village	Male Female 5–7 8–10 11–13 14–15 High Medium Low Tap/piped Well River Stream Lake/dam Urban Rural Yes No Yes No	588 (50.2%) 583 (49.8%) 23 (2%) 85(7.3%) 386 (33.0%) 677 (57.8%) 196 (16.7%) 668 (57.0%) 307 (26.2%) 894 (76.3%) 115 (9.8%) 68 (5.8%) 36 (3.1%) 58 (5.0%) 660 (56.4%) 511 (43.6%) 363 (31.0%) 833 (71.1%) 338 (28.9%) 808 (69.0%)

Knowledge about urogenital schistosomiasis

Table 2 shows knowledge of schoolchildren about urogenital schistosomiasis symptoms, causative agent, and transmission and prevention methods. Among the 1,171 participants, 517 (44.2%) participants had heard about schistosomiasis and 654 (55.8%) did not hear about schistosomiasis. The level of knowledge about urogenital schistosomiasis between male and female respondents was similar. Among the 1171 respondents, 449 (38.3%) of the study participants knew that the cause of schistosomiasis is the schistosome worm but 722 (61.7%) did not know the aetiologic agent. About 309 (26.4%) respondents reported that contact with water from a river or dam contaminated with feces and urine are risk factors for contracting urogenital schistosomiasis whereas others did not know how the disease is transmitted. Furthermore, 468(40.0%) knew haematuria as the major symptoms of urogenital schistosomiasis. Concerning knowledge about prevention of urogenital schistosomiasis, 440(37.6%) children said stopping contact with river or dam water help to prevent schistosomiasis transmission whereas others did not know how to prevent urogenital schistosomiasis transmission.

Table 2

Knowledge of respondents about the causes, symptoms, transmission and prevention of urogenital schistosomiasis in Hassoba, Kurmuk and Abobo primary school children, Ethiopia, 2022
Variables (questions)	Response	N(%)
Heard about urogenital schistosomiasis?	Yes No	517 (44.2%) 654 (55.8%)
Causes of urogenital	Schistosoma worms	449(38.3%)
schistosomiasis	Growing up	92(7.9%)
	Mosquito	65(5.6%)
	Drinking water used by cattle	147(12.6%)
Transmission/Risk factors for contracting urogenital schistosomiasis Symptoms of urogenital schistosomiasis Preventive measures for urogenital schistosomiasis	Jumping over fire Don`t know Contact with water from river/dam- contaminated with feces/urine Body contact with infected person Walking across water bare-footed Eating unwashed fruits and vegetables Don’t know Blood in urine Blood in stool Diarrhea Fever and headache Don`t know Staying indoors Avoid direct contact with river/dam water Avoid direct contact with rain water Eating balanced food Don’t know	88(7.5%) 330(28.2%) 309(26.4%) 153(13.1%) 211(18.0%) 123(10.5%) 375(32.0%) 468(40.0%) 73(6.2%) 114(9.7%) 105(9.0%) 441 (35.1%) 121(10.3%) 440(37.6%) 93 (7.9%) 181(15.5%) 336(28.7%)

Schoolchildren attitudes towards urogenital schistosomiasis

Table 3 presents the attitudes of respondents towards urogenital schistosomiasis. Among the total study participants, 28.7% strongly believed that schistosomiasis is part of growing up. Majority of respondents (83.5%) strongly agreed that defecating in the toilet is very important. Onethird ofthe total participants agreed that urinating in water was not a risky behaviour. Most of participant s (54.1%) reported that learning about schistosomiasis is important. Of the total participants, 84.6% agreed on going to clinic for treatment when they notice blood in urine. About 45.2% schoolchildren still showed positive attitude for swimming and playing in dam and river water, whatever the risk of schistosomiasis would be. Among the total participants, 55.7% believed that schistosomiasis can reoccur whereas 44.3% respondents disagreed.

Table 3

**The respondents’ attitude towards urogenital schistosomiasis in Hassoba, Kurmuk and Abobo primary school children, Ethiopia, 2022**
Variable(question)	Response N(%)
Variable(question)	SA	A	D	SD
Urogenital schistosomiasis is part of growing up	336 (28.7%)	270(23.1%)	274(23.4%)	291(24.9%)
One outgrows urogenital schistosomiasis simply	295(25.2%)	285(24.3%)	361(30.8%)	230(19.6%)
Defecating in toilet is very important	693(59.2%)	277(23.7%)	110(9.4%)	91(7.8%)
It doesn`t matter if I urinate in water	185(15.8%)	214(18.3%)	328(28.0%)	444(37.9%)
It is important to learn about schistosomiasis	633(54.1%)	339(28.9%)	109(9.3%)	90(7.7%)
It is important to periodically screen for schistosomiasis	543(46.4%)	420(35.9%)	131(11.2%)	77(6.6%)
It’s important to take anti-schistosomiasis tablet	540(46.1%)	373(31.9%)	146(12.5%)	112(9.6%)
When I pass blood in urine/stool I should go to hospital	658(56.2%)	332(28.4%)	114(9.7%)	67(5.7%)
I can swim and play in water anyhow	242(20.7%)	287(24.5%)	370(31.6%)	272(23.2%)
Urogenital schistosomiasis can reoccur	247(21.1%)	405(34.6%)	291(24.9%)	228(19.5%)

A, agree; D, disagree; SA, strongly agree; SD, strongly disagree.

Risk practices related to urogenital schistosomiasis among schoolchildren

Table 4 presents risk practices towards urogenital schistosomiasis. Among the total participants, 746 (63.7%) had reported that they swim/play in dam/river water. A total of 384 (32.8%) respondents reported that they urinate in dam/river water during playing or swimming and 505 (43.1%) participants claimed that they pass stool and urine in a bush or nearby environment. From the total participants, 261 (22.3%) used always water from a river/dam as main household water source. Most of respondents (70%) reported that they did not wear protective clothes when in contact with river/dam water. Furthermore, 44.0% of schoolchildren never took anti-schistosomal drugs at school and 13.6% were found actively passing blood in urine. In terms of treatment-seeking behavior, 76.6% of respondents mentioned that they went to the nearest clinic/health facility for treatment when urogenital schistosomiasis symptoms/haematuria appeared whereas 23.4% did nothing. Only 269 (23.0%) children reported that they used boiled water for drinking always whereas 902 (52.3%) never used boiled water for drinking.

Table 4

Risk practices of respondents towards urogenital schistosomiasis in Hassoba, Kurmuk and Abobo primary school children, Ethiopia, 2022
Variables (questions)	Response (%)
	A	S	N
Swim/play in river/dam water	230 (19.6%)	516 (44.1%)	425 (36.3%)
Urinate in water	162 (13.8%)	222 (19.0%)	787 (67.2%)
Use water from river/dam for domestic purposes	261(22.3%)	342(29.2%)	568(48.5%)
Boil water for drinking	269 (23.0%)	289 (24.7%)	613 (52.3%)
Cross a river to school or visiting	240 (20.5%)	157 (13.4%)	774 (66.1%)
Use protective waterproof clothes when in contact with water	352 (30.1%)	231 (19.7%)	588 (50.2%)
Go to health facility when passing blood in urine	601 (51.3%)	296 (25.3%)	274 (23.4%)
Take anti-schistosomiasis deworming tablets at school	262 (22.4%)	394 (33.6%)	515 (44.0%)
Pass stool/urine in a bush or water	238 (20.3%)	267 (22.8%)	666 (56.9%)
Pass blood in urine now	159 (13.6%)	167 (14.3%)	845 (72.2%)
A, always; S, seldom; N, never

Associations between risk factors and urogenital schistosomiasis infection

Risky practices and socio-economic status of schoolchildren (Table 1 & Table 4) are associated with schistosomiasis infection. There was an association between low socio-economic status and urogenital schistosomiasis infection history (P = 0.001). Urogenital schistosomiasis infection history was also more associated to rural dweller that urban dweller (P = 0.001). There was an association between sex and urogenital schistosomiasis infection history i.e., males had more infection history than female (P ˂ 0.001). There was a significant association between children who use dam/river water as main household water source and urogenital schistosomiasis infection history (P = 0.001). Swimming and playing practice were strongly associated in male than females (P ˂ 0.001) but urination on water showed no difference with gender (P = 0.06). Blood in urine was significantly associated with respondents age group of 14–15 (P ˂ 0.001) but not associated with sex (P ˃ 0.05). A respondent who passes blood in urine is a significant predictor of urogenital schistosomiasis infection (p = 0.045). Majority of school children (74.7%) claimed that they went to health facility when passing blood in urine but taking anti-schistosomiasis deworming tablets at school was not common practice.

As shown in Table 5, logistic regression analysis showed that males had significantly higher risk of having urogenital schistosomiasis infection history compared to females (OR = 3.01, P < 0.001). Children in low socio-economic status had higher risk of having urogenital schistosomiasis compared to high socio-economic status (OR = 2.81, P < 0.001). Compared to urban dweller, children in rural area had higher risk of having urogenital schistosomiasis (OR = 4.34, P < 0.001). Respondents crossing river when go to school regularly had risk of 1.8 times than other (P = 0.006). Respondents who used river water and lake/dam water were at more risk of urogenital schistosomiasis infection (OR = 3.33, P < 0.001 and OR = 2.48, P = 0.005) respectively. Furthermore, respondents swimming or playing in river water regularly had high risk of urogenital schistosomiasis infection history (OR = 1.62, P = 0.005).

Table 5

Association between respondents’ socio-demographic characteristics and practices regarding urogenital schistosomiasis infection history, Ethiopia, 2022
Variables		Adjusted odds ratio	95% CI	P value
Gender	Male	3.01	2.24–4.06	< 0.001
Gender	Female	Ref	-	-
Socio-economic level	High	Ref	-	-
	Medium	1.37	2.00-3.94	0.09
	Low	2.81	0.95–1.97	< 0.001
Residence of respondents	Urban	Ref	-	-
Residence of respondents	Rural	4.34	3.31–5.69	< 0.001
Main household water source	Tap/piped water	Ref	-	-
	Well	1.06	0.68–1.66	0.78
	River	2.48	1.29–3.79	0.005
	Stream	0.56	0.28–1.12	0.1
	Lake/dam	3.33	2.19–4.57	< 0.001
Swim/play in river/dam water	Always	1.62	0.75–2.86	0.005
	Seldom	1.3	0.97–1.75	0.07
	Never	Ref	-	-
Cross a river to school or visiting	Always	1.81	1.18–2.77	0.006
	Seldom	1.87	1.31–2.67	0.001
	Never	Ref	-	-

The aim of this study was to assess KAPs among primary schoolchildren regarding urogenital schistosomiasis in Abobo, Amibara and Kurmuk primary schoolchildren. In such areas, urogenital schistosomiasis is prevalent among schoolchildren [16, 21, 22]. In this study, one-fourth of the participants has relatively low socioeconomic status and depends on river, dam/lake and stream water for domestic consumption that might be a hazard for urogenital schistosomiasis infection. There is evidence that schistosomiasis affects the poor and the disease infections is especially common among people living in peri-urban or rural areas [7]. These populations typically have low socio-economic status with limited access to clean water and with inadequate sanitation provision [8, 9].

Our finding showed that level of knowledge about urogenital schistosomiasis between male and female respondents was similar. This is in agreement with the study done in Yemen [23]. In contrast, studies from Malawi, Zanzibar and South Darfur reported a significantly better knowledge about the disease among male participants compared to females [24, 25, 26].

This study showed significant difference regarding urogenital schistosomiasis infection history between male and female respondents. History of urogenital schistosomiasis was associated to males compared to females. This might be due to some religious and cultural beliefs such as females are not permitted to swim or bathe in the open water and are not allowed in fishing and irrigation activities [27, 28] resulting in less chance to be infected.

This study showed that one-third of respondents had history of urogenital schistosomiasis infection and most of them did not get treatment (69%). This might be due to many reasons such as lack of money and not enough awareness about the disease [29, 30].

This study showed 44.2% participants had heard about urogenital schistosomiasis but 55.8% had no information /knowledge about schistosomiasis. Similar study showed that limited knowledge, negative attitudes and risky water related practices among schoolchildren were common [31]. Moreover, KAP study in Zimbabwe showed that misconceptions about the causes and control of schistosomiasis exist among schoolchildren. Maseko et al. [32] also indicated that practices of certain children were risky and involved some misconceptions. A study conducted in Yemen also showed that the rural people lack sufficient knowledge regarding the cause, transmission, symptoms, and prevention of schistosomiasis [33]. In this study, majority of schoolchildren had no knowledge of causative agent, symptoms, transmission and prevention of urinary schistosomiasis. These findings are in agreement with previous studies from other schistosomiasis-endemic countries; poor awareness about schistosomiasis has been reported in Malawi [34], Zimbabwe [35] and Western Kenya [36]. Our findings disagree with previous studies in Brazil [37], Egypt [38] and Kenya [39] that reported a high level of awareness of schistosomiasis among schoolchildren.

This study also revealed many mistaken beliefs about schistosomiasis as a large number of the respondent demonstrated misconceptions about the transmission and prevention of schistosomiasis. For instance, some of participants believed that schistosomiasis is transmitted by mosquito bite and jumping over fire and half of the total respondents believed that when one grows simply developed schistosomiasis. Similar studies in Northern Côte d’Ivoire and southern Mauritania showed that knowledge about the aetiology, transmission, symptoms, prevention and treatment of schistosomiasis among the populations was based on their local culture and believes [40].

This study showed higher level of risky practices in schoolchildren regarding urogenital schistosomiasis. Majority of children agree that swimming/playing in water and urinating in water had no risk for urogenital schistosomiasis transmission. Furthermore, 43.1% of respondents claimed that they defecate in open field that also play a role for transmission of schistosomiasis. This finding is in agreement with previous study in Yemen that reported presence of higher level of risky practices in children [23].

Behavioral change intervention plays an important role in people’s perceptions and practices of controlling schistosomiasis [41]. Significant achievements in understanding of urogenital transmission and individual risk, preventative methods for schistosomiasis, and self-reported changes in risk behaviors were reported by students who had undergone the health education and behavioral changes (HEBC) interventions [53]. Expanding HEBC interventions to schools in high-risk areas and supplementing them with MDA can assist to lower the prevalence of urogenital schistosomiasis and increase the likelihood that the disease would finally be eradicated [53]

Recently, the WHO called for a global effort to eliminate human schistosomiasis by 2025, with mass drug administration as a main intervention [42]. However, this call has underscored the need for more emphasis on snail-related research [43]. Despite the possibility of drug resistance developing in the schistosomes [44], MDA has been used for generations as the main pillar and the most cost-effective intervention to control schistosomiasis; however, chemotherapy alone may never achieve transmission control or elimination [45, 46]. Thus, other interventions, such as snail control and health education among schistosomiasis endemic communities are essential and should be implemented in parallel with MDA [47, 48]. Great success has been achieved in many countries, like China and Egypt, in reducing the transmission, prevalence and morbidity of schistosomiasis [49, 50, 51]. The MDA-based approach in school is important for success together with health education campaigns and the trained personnel working in rural health units or involved in reducing the roles of humans and animals as sources of infection for snails [50, 51]. Similar success can also be achieved in Ethiopia through an integrated national control approach that should consider the MDA, snail control and health education. In 2015, Ethiopia launched schistosomiasis control program using school-based MDA. Before MDA intervention urogenital schistosomiasis prevalence was reported as 24.5% [22], and 37% [21] in Hassoba, 35.9% in Abobo [16] and 5.7% in Kurmuk [15]. However, a study conducted after intervention in 2022, reported urogenital schistosomiasis prevalence among schoolchildren in Hassoba, Kurmuk, and Abobo villages as 7.0%, 5.6%, and 24.2%, respectively [52]. Prevalence of urogenital schistosomiasis showed no decline over such a longer period of time in Kurmuk but a surprising declined in Hassoba and Abobo.

Ethiopia had launched a large-scale nationwide mass drug administration (MDA) in 2015 to controls schistosomiasis. Schistosomiasis control as well as elimination using MDA is difficult since MDA cannot prevent re-infection. Currently, health education and behavioral change intervention have been prioritized in the first among national comprehensive program for schistosomiasis control. In this study, schoolchildren knowledge about schistosomiasis transmission and prevention was poor. Furthermore, several risky practices related to schistosomiasis was reported. Integrated strategies including preventative treatment and morbidity management, health-seeking and risk-reducing behaviors, water, sanitation, and hygiene (WASH), and snail intermediate host management are essential for long-term schistosomiasis control and elimination. Therefore, in Ethiopia the current schoolbased deworming program should be integrated with health education and behavioral change intervention, water sanitation and hygiene, and snail management as national control strategy.

Limitations of the study

Some schoolchildren had trouble answering the questions. Some of the responses might have been impacted by the teachers' assistance. The languages used to develop the survey tools and carry out the survey are yet another limitation. It's probable that details were lost in the translation process from English to Amharic, then to Afar, Berta, and Anuak language, despite the fact that the quality of the translations of data collecting instruments and researcher training materials was pre-tested.

This study showed that the level of schoolchildren knowledge about the cause, transmission, prevention, and control of urogenital schistosomiasis is low. Increasing knowledge among children about schistosomiasis transmission, control and prevention is fundamental. Thus, health education and behavioral change intervention is recommended in order to enhance urogenital schistosomiasis prevention and control and impart better knowledge onto schoolchildren. Health organizations and policy makers should contribute to improve knowledge at the school as well as community levels.

KAP- Knowledge, Attitude and Practices

NTD- Neglected tropical diseases

SSA- Sub-Sahara Africa

STH- Soil Transmitted helminthiasis

MDA- Mass Drug Administration

WASH-Water, sanitation and Hygiene

Ethical approval and consent to participate

The protocol for this study was reviewed and approved by the Institutional Review Board (IRB) of Jimma University Health institute. Urine samples used for this study was collected from school children aged 5-15years after getting permission from districts administrator and consents from parents/guardians and assents from children.

Consent for Publication

Not applicable

Availability of data and material

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article

Funding

Financial support for this research was provided by Jimma University for the support of PhD training program. The funder had no role in the study design, data collection and analysis, preparation of manuscript.

Authors’ contributions

KD: Designed the study, collected the data, analyzed the data and made inputs in manuscript write-up. ZM and DY supervised data collection, critically reviewed the manuscript.

Acknowledgements

The author acknowledges the cooperation and support of school children and their parents and guardians in Abobo, Kurmuk and Amibara districts. The author also appreciates Health personnel, head teacher and teachers who participate in this study.

* Corresponding author: [email protected]

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The authors declare no competing interests.

Assessment of Knowledge, Attitudes, and Practices Towards Urogenital Schistosomiasis Among Primary Schoolchildren in Abobo, Amibara and Kurmuk Districts, Ethiopia

Status:

Version 1

Abstract

Introduction

Material and method

Study area

Study design

The study population:

Sampling procedure

Sample size determination

Questionnaire survey

Data analysis

Ethical Consideration

Results

Socio-demographic characteristics of the respondents

Knowledge about urogenital schistosomiasis

Schoolchildren attitudes towards urogenital schistosomiasis

Risk practices related to urogenital schistosomiasis among schoolchildren

Associations between risk factors and urogenital schistosomiasis infection

Discussion

Conclusions

Abbreviations

Declarations

Acknowledgements

References

Additional Declarations

Status:

Version 1