Characteristics of the study population
Key informants and migrant workers were interviewed between June to October 2019. Seventeen FGDs with 8-12 migrant workers were conducted with 187 participants from 11 farms (large and small). The mean (±SD) age of the FGD participants was 23 (±4.66) years. Their education level varied from no formal education to secondary education. All FGDs discussants were male migrant workers. In addition, a total of 16 individual interviews were conducted. Among the interview participants, the mean (±SD) age was 31 (±6.75) years. Over half of the participants had tertiary and secondary educational status (see Table 1).
Table 1. Socio-demographic characteristics of participants of Focus group discussion and interviews in Metema -Abuderafie, 2019.
FGD participants
|
Interview participants
|
Characteristics
|
N
|
%
|
Characteristics
|
N
|
%
|
Total
|
187
|
100
|
|
16
|
100
|
Gender
|
Gender
|
Male
|
187
|
100
|
Male
|
15
|
93.7
|
Female
|
|
|
Female
|
1
|
6.3
|
Age (mean (SD)
|
Age (mean (SD)
|
23 (±4.66)
|
31(±6.75)
|
Type of participants
|
Type of participants
|
Students
|
55
|
29.4
|
Health office heads
|
2
|
12.5
|
Farmers
|
114
|
60.9
|
Health extension worker
|
1
|
6.3
|
Forest workers
|
7
|
3.7
|
Malaria and vector born officer
|
1
|
6.3
|
Milisha
|
8
|
4.4
|
Public health officers
|
1
|
6.3
|
Others
|
3
|
1.6
|
Farm (owners, managers, and leaders)
|
11
|
68.6
|
Ethnicity
|
Ethnicity
|
Amhara
|
171
|
91.4
|
Amhara
|
10
|
62.5
|
Tigray
|
13
|
7.0
|
Tigray
|
6
|
37.5
|
Oromo
|
3
|
1.6
|
Oromo
|
|
|
Religion
|
Religion
|
Orthodox Christian
|
178
|
95.2
|
Orthodox Christian
|
15
|
93.7
|
Muslim
|
9
|
4.8
|
Muslim
|
1
|
6.3
|
Leishmaniasis endemicity at the permanent resident
|
Leishmaniasis endemicity at the permanent resident
|
Low land endemic areas
|
20
|
10.7
|
Low land endemic areas
|
11
|
68.7
|
High land endemic areas
|
167
|
89.3
|
High land endemic areas
|
5
|
31.3
|
Educational status
|
Educational status
|
Non formal education
|
82
|
43.9
|
Non formal education
|
1
|
6.3
|
Formal education
|
105
|
56.1
|
Formal education
|
15
|
93.7
|
The Health Belief Model (HBM) constructs
The findings for the selected HBM constructs, perceived susceptibility and seriousness, perceived barriers and benefits, self-efficacy and cues to action are depicted below, and verbatim statements from participants are provided in detail for each construct. In general, Leishmaniasis is viewed as a low threat to well-being. Likelihood of action (Perceived benefits and barrier) is empowered by beliefs that leishmaniasis prevention results by utilizing ITN (Insecticide-treated net), but disabled by beliefs about the seasonality, cost, individual and institutional barrier, inconvenience, perceived ineffectiveness, lack of awareness, ITN insufficiency, competing priority and beliefs that the advantage can be accomplished through traditional method use. The migrant workers rarely showed a sense of self-efficacy, and the central cue was the rise in sandfly bite irritation other than those offered by health workers and Medicines San Frontier – Holland (MSF-Holland). Every component is explained in Fig.1.
Perceived susceptibility and seriousness of Leishmaniasis
There was a widespread agreement about vulnerability to Leishmaniasis of the participants, and minimal variation in the responses showed. Participants who had Leishmaniasis previously, or knew about workers diagnosed with Leishmaniasis, believed more vulnerable to Leishmaniasis than workers without a history of Leishmaniasis. Following that experience, the workers perceived that they were vulnerable to Leishmaniasis. Moreover, many migrant workers referenced that Leishmaniasis is a problem for them considering that the disease is prevalent in the area. The migrant workers noticed that the sandfly lives in the area where they work and have bitten them. However, they did not refer to any ill health effects.
" We hear the previous workers suffered a lot from sandfly bite…. We are susceptible to sandfly bites, and as a result, it will be irritating…. We are at risk for sandfly bite because we are working in a place where it is home for sand fly and prepare food and sleep anywhere in the farmland." (FGD, Migrant worker, from large and small farmland area).
However, other discussants perceived less risk of leishmaniasis disease and did not worry about sandfly bites. This was considerably more clearly expressed by the migrant workers in the weeding and harvesting season FGDs, and they said they accepted that "God, not the ITN, forestalls leishmaniasis and it is brought about by spirit".
Although the migrant workers believed that they are susceptible to sandfly bites or Leishmaniasis, the severity of the disease was considered minimal. One migrant worker summed up the migrant worker's sentiments: "Almost everybody realizes they are vulnerable; however, no one treats it seriously". Many participants viewed Leishmaniasis as a mild disease that can undoubtedly be cured if timely and appropriate treatment is given. Instead, an illness locally known as "Mich", inexactly deciphered as "sunstroke", was viewed as a more severe issue than Leishmaniasis. During harvesting season, practically all migrant workers spend the night in an open field inside the farm because of the hot nature of the daytime and fear of acquiring the disease "Mich".
"nowadays…. some of the workers when they get some kind of sign and symptom. They suspect as it is malaria and we send them to the health centre for treatment, but when they go to MSF, they are told they have got Kalazar….we do not know about Kala-zar. (KII, HEW).
Other consequences of Leishmaniasis were the costs associated with looking for care. When a migrant worker was sick, economic consequences included spending money for transport, diagnosis, treatment, and loss of workdays.
Perceived benefit and barrier to protective measure usage (ITN)
Our participants acknowledged the benefit of using protective measures (ITN) as protection against Leishmaniasis. During the weeding season, sleeping in Gebaza (where migrant workers sleep, a sub shelter made of straw and grass) and staying warm under the ITN was an advantage. Some of our participants mentioned that the number of sandflies was seen to be higher in the weeding season, influencing both the perceived intensity of leishmaniasis burden and sandfly bite irritation. The sandfly bite irritation influences the perceived added benefit of the ITN as protection against sandfly bites.
Our participants mentioned various barriers that make them not use ITN to keep away from sandfly bites. The highest-level barriers to bed net use across farmland areas are mentioned in Table 2 and showed visually in Fig. 2.
Table 2: Top reasons for non-consistent protective measures (ITNs) from free listing and ranking activity in Metema -Abuderafie,2019.
Participants
|
Abuderafie district
|
Metema district
|
Large Farmland areas
|
Small farmland areas
|
Large Farmland areas
|
Small farmland areas
|
Migrant workers
|
Seasonality
|
Seasonality
|
Seasonality
|
Fumigation, spray
|
Mental barriers
|
Discomfort to hang
|
Inconvenience
|
Lack of awareness
|
Discomfort to hang
|
Cost
|
Distribution problem
|
Cost
|
Inadequacy of net
|
Mental block
|
Ineffectiveness
|
Fatigue
|
Fatigue
|
lack of awareness
|
Cost
|
Spraying
|
Awareness problem
|
Stress
|
Insufficiency
|
Distribution problem
|
Farmland owners and managers
|
Inadequacy of net
|
Seasonality
|
Seasonality
|
Heat
|
Lack of awareness
|
fumigation sprays.
|
Ineffectiveness
|
Laziness
|
Ineffectiveness
|
Laziness
|
Lack of awareness
|
Difficulty in hanging
|
Health workers
|
Lack of awareness
|
Lack of awareness
|
Seasonality
|
discomfort to hang it
|
Discomfort to hang it
|
fumigation
|
fumigation
|
Stress (mental barriers)
|
Fatigue or laziness
|
Cost
|
Farm leader (Koberary)
|
Seasonality
|
Seasonality
|
Insufficiency
|
ineffectiveness
|
Fatigue or laziness
|
Fumigation,sprays
|
Cost
|
Laziness
|
Discomfort to hang
|
Discomfort to hang
|
Seasonality
|
Lack of awareness
|
The most reported barrier to ITN use was that they were uncomfortable hanging it in the farmland areas. Participants reported that they did not use ITN because it is inconvenient to use it due to their communal and outdoor sleeping arrangements during their time on the farms. During harvesting season, almost all migrant workers spend the night in an open field inside the farm. These nighttime activities are when the sandflies are active [39], but ITN use is not feasible. Moreover, fatigue levels resulted in demotivation to hang and utilize ITNs. Migrant workers discussed "absence of rest" or being "feeling exhausted" as crucial patrons.
"…. we are aware of the benefit of a bed net. Therefore, we brought a few bed nets to the farm, and we always kept them inside our bags. Not using the ITN is challenging to install, especially during harvesting season, we spend the night inside the farms. (FGD, migrant worker, large farmland).
Another major factor that decreased continued ITN use was seasonality, which was stated to vary due to harvesting and weeding seasons. For example, sleeping under a net in the harvesting season was perceived to make it difficult to sleep due to the heat, a barrier that appeared to be vital for the participants ITN use. On the other hand, the ITN was perceived as protecting against sandfly bites in the weeding seasons. In the perspective of the HBM, this can be viewed as a reasonable illustration of how perceived benefits and barriers are weighed against one another [46].
"…Even if we want to use the bed net, it is too hot, difficult to hang in the farm area and Gebaza …..." (FGD, migrant worker from large farmland area).
The previously mentioned belief in other causes of Leishmaniasis also caused a reluctance to use ITNs. Apart from sandfly, Leishmaniasis was perceived to be caused by sexual intercourse, open defecation, filthy drinking water, bad food, and being ravenous. Prevention for these causes included eliminating water ditches, eating good food, and focusing on their cleanliness. Simultaneously, some migrant workers announced utilizing fumigation (burning of woods or tires) to control sandflies in and around their sleeping areas (the farm areas). These lead to possible incorrect use of non-proven protective measures [47]. Consequently, they did not see the requirement for the prevention behaviours:
"By using bed nets, we cannot prevent. We can prevent it by using smoking, tradition herbal, not sleeping in the ground can help us prevent the bite".
"Leishmaniasis is caused by sexual intercourse…poor hygiene, sanitation, eating bad food ". and we prevent leishmaniasis by eating clean foods, by drinking clean water…..". (FGD, migrant worker, large and small farmland area).
Although all farmland owners/managers mentioned that they got free ITNs from the government to be given to the migrant workers, it was felt that these ITNs were inadequate. Besides, many migrant workers mentioned limited access to ITN to specific corruption (social vices) accepted to be expected in how the ITN are distributed. These incorporate bribery, mismanagement, and partiality at the district health office levels. A few respondents blamed health authorities for collecting the ITNs, just to be sold later to landowners or vendors in the market who purchase and sell them at more exorbitant costs. Furthermore, the costs of ITN were mentioned as a barrier to ITN ownership as the expense of 150 Ethiopian Birr (5 dollars) for ITN was viewed as unaffordable, even if the migrant workers they think of to buy from the market:
"Government provides ITN freely…but the owners give us some of them…. there are also rumours of distribution problems ...the bed net is given not equally, given to whom your favourite person is…they sold it also to businessman…. We are highly willing to have sandfly bite protective tools [ITN], but we need the cost of the material to be affordable." (FGD, M.W., from large farmland).
Though the prevalence of kala-azar disease is high and the consequence is severe, none of the key informants reported that priority is given to prevent and control this disease. Approximately 200,000 ETB (Ethiopian Birr) ($6061) is allocated for spraying insecticide to prevent and control malaria.
" We have no budget and plan to prevent and control leishmaniasis disease…..For other diseases, for example, like the onchocerciasis, we get funds from NGO's. For malaria control, especially for the spraying purpose, we allocate up to 200,000 ETB ". (KII, member of district Health Office, HEW, Farm owners).
Self-efficacy and cues to action
Regardless of the high perceived self-efficacy, there was a solid reliance on the government to give ITN or other protective measures. Efficacy was also problematic when migrant workers needed to discuss the risk of Leishmaniasis and the use of protection with their partners or essential others. Many migrant workers reported they would use ITN if a farm manager/owner insisted. Furthermore, external influence from friends, farm leaders, and managers was seen to have a higher value in building self-efficacy or persuasion toward using protective measures (ITN).
The central cue to utilizing protective measures (ITN) was the rise in sandfly bite irritation. Additional cues to ITN use or other protective measures included being advised to do so by MSF-HOLLAND staff members, village health extension workers, farm owners, managers, and leaders.
Modifying factors
A few participants noticed that they did not have a clue how to read. A few elements impacted migrant workers choices on whether to utilize protective measures (ITN). For example, educational level seemed to change the decision-making process from various perspectives. All migrant workers believed that being educated simplified it to use protective measures. A few of them from the KII knew that sandfly bites are related to Leishmaniasis. Most participants expressed monetary difficulties in paying for their schooling, fertilizer, and food costs not to decide to buy ITN or other protective measures.
Intervention Modality
Health Extension Workers and Health workers and farmland owners and leaders
|
Cues to action
Self-efficacy
|
Likelihood of action
Availability and accessibility
Competing priority
|
Perceived threat
Perceived benefit
Availability and accessibility
|
screening and
surveillance
as reminder
- Health education
- Posters and stickers
distributed to the
migrant workers and
community
|
- Available prevention and treatment
products/services and services
providers
- Appropriate distribution of ITN
- Integrated vector control
- Accept referrals
- Increase appropriate utilization
of protective measures and
services
- Increase demand for products
and services.
- preventive practices should
be strengthened through
the provision of IEC materials,
- local capacity-building, the
traditional/mass media, and
farmland owner support
- Dispel rumors about ITN
- Intersectoral collaboration
|
through outdoor media (banners,
stickers, announcements)
- Change perceptions/beliefs
- Increase knowledge
- Introduce more effective vector
- control tools.
- Screenings of Leishmaniasis film
at the place where the migrant
workers gather
- Encouragement of ITN use
- Improve design of “Gebaza” to
avoid heat and for appropriate
protective measure use
|
- All migrant workers have a good knowledge and improved risk perception
- All migrant workers use vector control protective tools
|
- Protective use initiated and maintained by all migrant workers
|
- Recognition of sign and symptoms continued at home
|
Health facility staffs and farmland owners, leaders, and managers
|
Health Extension and Health Workers and Health Development Army
|
Health worker and Farmland owners, leaders, managers
|
Health system and research strengthening
- Linkage of facilities and migrant workers
- Ensure environmentally sound approaches to leishmaniasis prevention and related products
- Conduct further research to identify appropriate protective measures
|
The intervention for the prevention and control of Leishmaniasis among migrant workers could be implemented at three levels: pre-arrival, arrival, and departure (Figure 3).
- Pre-arrival - the aim at this level is awareness creation throughout door media (posters, stickers, billboards) and screening to address the misperception about the real causes for Leishmaniasis and its transmission. A few migrant workers realized that sandflies cause Leishmaniasis, but simply knowing that does not prohibit other potential causes. Therefore, education campaigns with a comprehensive scientific explanation need to be considered to educate migrant workers about the transmission and why sandflies only cause Leishmaniasis and mention it is not GOD. This will require learning how to increase protective measure use and ensure the early identification of migrant workers through screening at arrival so that they are effectively referred to a health facility for initiation of treatment.
- At-arrival– the aim at the arrival level is to promote the use of protective measures. The most reported barrier to ITN use was that they were uncomfortable hanging it in the farmland areas. Therefore, we need to identify local solutions to hang the nets. In addition, ITN that is self-supporting, accessible in a range of sizes, and does not occupy a great deal of space might be preferable. Moreover, increasing demand for products and services: recommending the cost of ITN should be decreased to be generally utilized. This could be accomplished by mass buying, local tailoring, community-based mechanisms of dissemination, and public appropriation. Integral leishmaniasis control strategies include wearing long sleeves during nighttime, utilizing local and modern fans, and utilizing mosquito loops, moisturizers, and sprays. This will require learning how to ensure all migrant workers receive ITN or other protective measures early, and those migrant workers can continue using ITN or other protective measures when they go to farmland areas or Gebaza.
- At-departure – the aim at the departure level is to inform about the recognition of late signs and symptoms and the use of the protective measure. Because most social cues are learned from peers, health care providers should employ migrant workers peers to disseminate prevention information. This will require learning how to recognize the late symptoms of Leishmaniasis and the continued use of ITN.