Knowledge, Attitude, and Preventive Practice Related to Onchocerciasis and Associated Factors among Resource-Limited Selamogo Woreda Residents, South West Ethiopia, 2021

Introduction Ethiopians work very hard to control and eradicate the vector and the parasite of Onchocerciasis. However, some hard-to-reach areas are not adequately covered by interventions that have previously taken place in various endemic sites in the country. This study aimed to assess knowledge, attitude, and preventive practice of Onchocerciasis among Selamogo residents to enhance the expansion of interventions. Methods We used a survey questionnaire to capture the data on 572 Selamago residents. We checked, cleaned, entered the data into EPI Info v.7, and analyzed it in STATA v.15. We fitted a binary logistic regression model to examine the associated factors. Variables significant at P < 0.20 were included in the model. We declared association at P < 0.05. Results Of the 578 residents we approached, 572 (99%) responded to the interview. We found 48.30% of poor knowledge, 90.90% of poor attitude, and 85.70% preventive practice related to Onchocerciasis. Factors like Amhara ethnicity (AOR = 2.35, 95% CI: 1.05, 5.27), Orthodox Christianity (AOR = 1.87, 95% CI: 1.12, 3.10), Muslims (AOR = 2.28, 95% CI: 1.05, 4.94), secondary school (AOR = 2.31, 95% CI: 1.50, 3.55), diploma (AOR = 10.34, 95% CI: 4.62, 23.16), and preventability of Onchocerciasis (AOR = 3.02, 95% CI: 1.39, 6.55) were associated with KAP. Other factors like medical treatability, admission history to the health facilities, sex, and the number of households were also associated. Conclusion The KAP related to Onchocerciasis is very poor compared to the indicators and evidence in the country. An intervention that considers local resources like taking the experience of groups with good knowledge, attitude, and preventive practice led by educated plus positive attitude people regarding the preventability and treatability of Onchocerciasis might be mandatory to improve the status.


Introduction
from the parasite, and areas freed from infection have increased in the last 30 years [11]. In East Africa, a program focused on Southwestern Uganda reported the disappearance of microfilaria in 2012 [12]. Kenya eliminated vectors in the 1960s without treatment [13]. In Ethiopia, the 2017 status review report showed Onchocerciasis is endemic in 188 districts [14]. One report showed that the drastic environmental change caused the disappearance of the parasite in the Tigray region [15].
In developing countries like Ethiopia, knowledge, attitude, and preventive practice are important in communities to control and eradicate Onchocerciasis [16]. e first-ever epidemiological assessment in Ethiopia was done in the 1970s in Illubabor, where the prevalence rate of Onchocerciasis was 51.4% and 66.7% in two areas [17]. Like all African countries, Ethiopia has a plan of eradicating Onchocerciasis by 2030 through CDTI, vector control, and other methods [18]. In one study in Southwest Ethiopia, 64.4% of participants had the disease but only 36.5% thought Onchocerciasis was transmissible [19]. Nigeria, Senegal, and Mali eliminated Onchocerciasis only by ivermectin intervention at least in some parts of their countries [9]. e ivermectin strategy outways the vector controlling mechanism that is complicated by the long-living worms in human skin (0-15 years).
ere are even many programs (OCP, APOC, and CDTI) trying to control Onchocerciasis, which are successful in West Africa. e OCP is specially confined to the region [20]. e knowledge of the disease, attitude, and preventive practices have been very important parameters for community campaigns to control Onchocerciasis and to bring the matter to the community [21]. In North West Ethiopia, the misconceptions regarding the disease and the poor knowledge, attitude, and practice were identified as obstacles [16]. In other words, the status review showed that community readiness comes after the direct increase in community awareness, attitude, and preventive practices [14]. For the 2025 plan of Onchocerciasis eradication, community participation is forwarded as the crucial strategy in Africa [22]. Without understanding experience in every hard-to-reach area of the countries, improving knowledge, attitude, and preventive practice regarding Onchocerciasis might be impossible to facilitate interventions. e study in the Bench Maji zone showed that many years of treatment with ivermectin did not reduce the prevalence of the disease in the area, which might be a good indication of the necessity of improving knowledge, attitude, and practice [23,24]. ere was no status evidence and no other studies have ever been conducted on Onchocerciasis in the current area despite its endemic nature. us, this study aimed at assessing knowledge, attitude, preventive practice, and associated factors in Selamago woreda to uplift the attention of stakeholders and policymakers.

Study Design and Setting.
e community-based crosssectional study design will be employed in the South Omo zone, Selamgo Woreda, from March 2021 to January 2022.
South Omo Zone is one of the 15 zonal administrations of Southern Ethiopia. Selamago is one of the woredas in the zone. As a part of the Debub Omo Zone, Selamago is bordered on the south by Nyangatom on the west and north by the Omo River, which separates it from the Bench Maji, Keffa, and Konta. In the northeast, it is bordered by the Gamo Gofa, on the east by the Basketo and Bako Gazer, and on the southeast by the Usno River, which separates it from Bena Tsemay. e Mago River defines a part of the boundary with Bako Gazer. e administrative center of Selamago is in Hana. David Turton describes this area as one of the most isolated in Ethiopia. e Omo and Mago rivers make access difficult, and the conquering armies of Menelik II bypassed them. Although the occupying Italians briefly occupied a military post along the Omo in what later became Selamago in 1940, it was not until the 1970s that direct Ethiopian administration reached this area [25].

Participants.
We selected 6 kebeles (smallest administrative level) from a possible 14, and households from the randomly selected kebeles' were randomly included. All individuals in the randomly included households during the data collection period whose age was ≥ 18 years old and who has been a resident for at least 6 months were eligible for a face-to-face interview. We excluded residents who were physically or mentally unable to communicate with the interviewer and when there were no other possibilities of obtaining their information.

Sample Size Determination and Sampling Procedures.
We calculated the sample size using the single population proportion formula. e prevalence rate of knowledge, attitude, and practice is considered 50% since no previous study has been obtained in this specific area. Considering 95% CI, a 5% margin of error, and adding a 10% of nonresponse rate, the final sample size calculated using EPI Info 7 was 578. To achieve the selection, we used systematic sampling methods. We randomly selected kebeles and proportionally allocated samples to each kebele using sample fractions depending on the population of each kebele. We obtained individual households by dividing the number of households by sample size as 2000/578 � 4 : 1. Using the lottery method, the first household from 1 to 4 was drawn, and every 4 th household that fulfilled the inclusion criteria for the interview was chosen.

Variables of the Study.
e outcome variables of this study were knowledge, attitude, and preventive practices. To address the knowledge, 6 item questions regarding clinical manifestations, organs affected, cause, and transmission of the disease were considered. All items were measured through yes/no. Yes (present, known, accepted. . .) scored as "1" and No (do not know, not agree, not true or others) scored as "0". e combination of the items' scores becomes "1" to mean good and "0" to mean poor knowledge.
To address information on attitude, 7 parameters were prepared regarding the presence/absence of stigmatization and the preferable place for treatments and others to indicate a good or poor/low attitude. All items were measured using yes/no. Positive attitude responses were categorized as good/ positive attitude [1] and poor/negative or low attitude (0). We combined as we did under knowledge. Prevention practices were collected using three questions "When a member of your family suffers from Onchocerciasis, what did she/he use to treat the disease?", "Where did he/she seek help drug/others," and "do you use preventive methods to avoid Onchocerciasis" with the responses drug/other, HC/ Hospital/others, and yes/no, respectively. e correct answer was coded "1" which is good practice, and "0" represented the incorrect answer as poor/low practice [21]. In some of the questions like where to seek help, the answer can be health center (HC), or hospital, and others; however, we combine 1 and 2 as 1 and others as 0. is is similar in both practice and attitude measurements. For all three correct answers, more than half the score was taken as good.

Data Collection Instruments and Data Quality.
e instrument for data collection was designed after a vigorous literature review in the disease domain. It contains 6 knowledge-based questions, 7 questions about attitudes, and three questions on preventive practice along with sociodemographic variables [21].
Twelve (diploma) trained data collectors who know the local language participated based on their previous experience in data collection and research. We assigned three supervisors (MSc) to follow the process and handle the fieldwork. e questionnaire was translated to Amharic and back to English to see the consistency. Before data collection, the tool was tested on 5% of the population in far unselected kebeles. Issues related to understanding, language, and consistency during completing questionnaires were corrected and included in the final questionnaire.

Data Processing and Analyses.
After completion of the field checkup, the principal investigators received, checked, and entered the data into EPI Info version 7. We used binary logistic regression to examine the factors that affected knowledge, attitude, and practice. All analyses were performed in STATA 15. P value <0.20 was used to include variables in the model and P value <0.05 was used to declare association. We presented descriptive statistics using numbers, means, standard deviation (±SD), and percentages. Using 95% CI and adjusted odds ratio, we presented association data.

Ethical Consideration.
Primarily, we obtained ethical clearance from the Institutional Review Board of Arba Minch University with issue number AMU-IRB/1123/2021, and then the permission letters were collected from the Zonal Health Departments and Selamago woreda health office. Verbally, consent was secured from each participant, and the right to refuse or participate was granted and respected. e information obtained from the study was kept confidential.

Descriptive Statistics.
Of 578 residents approached, 572 (99%) responded to the interview. We found 48.30% of poor knowledge, 90.90% of poor attitude, and 85.70% of poor preventive practice related to Onchocerciasis among Selamago woreda residents. Descriptive statistics indicate that participants had an average household income of 698.53 ± 92.9, a mean age of 37.55 ± 8.25, an average number  Figure 1).

Discussion
From the analysis of the data, we found 48.30% of poor knowledge, 90.90% of poor attitude, and 85.70% poor preventive practice related to Onchocerciasis among Selamago woreda residents. is is less than the finding from the study conducted in South-Western Ethiopia which showed poor knowledge of 33%, poor attitude of 36%, and poor practice of 39.6% [19]. e inconsistency might be associated with the hard-to-reach nature of the current area causing the gap. e area was out of road access from both the federal and the regional government before the recent opening of the sugar factory, which came with the opportunity. e pastoralist lifestyle, accessibility of services, and availability of Onchocerciasis-related information might be the reason that both regional and federal governments are unable to reach the area. Only 7.30% of the respondents think Onchocerciasis is a preventable disease. Another study in Southwest Ethiopia showed that 88.2% of the respondents perceived Onchocerciasis as preventable [26]. Furthermore, 93.3% of participants from the study conducted in Northwest Ethiopia believed that Onchocerciasis is preventable [16]. e lower perception of preventability of Onchocerciasis might be due to the socio-demographic differences and poor access to health education information. In other words, 71% of respondents believed Onchocerciasis is medically untreatable. From other studies, 94.0% of participants think Onchocerciasis is treatable [22 ] and 90.3% of participants from another study also think Onchocerciasis is treatable [19]. e current study area is one of the hard-to-reach areas in the country.
is might limit access to and from resourceful areas and cause poor socio-economic development. More than half (54%) of the participants were illiterate. e study in the Southwest indicated that 21.8% of the participants were illiterate [19]. is might show how the current study area is lagging in basic socio-demographic factors.
e poor educational achievement might be the cause for other poor achievements in other socio-demographic factors. In every aspect, the targets to eliminate Onchocerciasis by 2025 and 2030 might be in big trouble, as reaching them will be impossible without sufficiently covering such hard-to-reach areas [27,28].
Participants with larger households showed good knowledge related to Onchocerciasis; however, there is no evidence to support this information from previous studies. In other words, people who had good knowledge do not exactly think Onchocerciasis is preventable. e finding is supported by other studies [16,26]. e consistency might be due to the lack of objective knowledge obtained from credible sources to rely on. It might indicate, the poor objective knowledge regarding the disease in the community. Educational achievement was associated with both good knowledge and attitude related to the disease. is is supported by many previous studies [19,23,29,30]. e consistence might indicate that educational status is an independent predictor of knowledge and attitude related to Onchocerciasis, which is a good opportunity for further intervention. Both ethnic groups Mursi and Amhara had good knowledge and attitude; however, ethic Mursi had poor preventive practice [16]. is might show that local strategy to increase KAP toward Onchocerciasis is possible through using rich experiences among different ethnic groups. Similarly, female participants showed a good attitude but practically males were great. is is also supported by another study in the country [16]. Sex is one of the factors that cause prevalence differences in groups in Ethiopia [24].
is consistent information shows that sex is another persistent predictor to consider during interventions. e knowledge and attitude toward medical treatability of Onchocerciasis are well associated with the knowledge and attitude of the participants; however, in practice, it is poor. From other studies, a large proportion of respondents believe Onchocerciasis is a preventable disease [16,19]. is might indicate that even though knowledge and attitudes might be good, the need for improving practice might require another gear. Additionally, participants with a history of previous admission had poor attitudes but had good preventive practices for Onchocerciasis [31].
is might mean that having experience in service taking can improve attitude but practice might need objective intervention. In other words, the Orthodox Christian religion was associated with both good knowledge and practice. is is not supported by the study in the Bench Maji zone [23]. A small group of people who mostly migrated from other places Journal of Tropical Medicine 5 practice the orthodox religion and they might have experience and practice they acquired probably from other areas. is also shows that local resources to reach other groups are available in the woreda. Despite all the important findings, the study has also some limitations. We used a questionnaire for all dependent variables that might not be good to assess practice, experience, and educated from the same area for data collection. We picked questions that can easily assess practice and attitude without the requirement of observation and data collectors from each Kebele which helped us to achieve a full capture of information.

Conclusion
e knowledge, attitude, and preventive practice related to Onchocerciasis are very poor compared to indicators and other evidence. e target Elimination of Onchocerciasis by 2025 in Africa might not be achieved in such hard-to-reach areas in Ethiopia. Factors like sex, ethnicity, educational status, religion, and medical treatability of Onchocerciasis were associated with the KAP. An intervention that considers local resources like the experience of groups, attitude, and preventive practice led by educated people who have positive attitudes regarding preventability and treatability of Onchocerciasis might be mandatory to improve the current status.
e support of religious leaders, a community committee with a sufficient number of female members, and other stakeholders might be vital to the success of the efforts. Data Availability e data used in this study are available unrestrictedly and can be supplied with the final submission of the accepted manuscript.

Abbreviations
Disclosure e funder had no influence on data collection.

Conflicts of Interest
e authors declare that they have no conflicts of interest.