Community Participation in the Mass Drug ‎Administration and their Knowledge, ‎Attitudes, and Practices on Management of Filarial Lymphoedema in Lindi District, ‎Tanzania: A Cross-Sectional Study‎

INTRODUCTION

Lymphatic filariasis, one of the neglected tropical diseases, is caused by a nematode parasite of different species namely Wuchereria bancrofti, Brugia malayi, and Brugia timori, and a second leading cause of disability worldwide [1]. The disease is transmitted by different types of mosquito species in endemic areas for example Culex species in urban and suburban areas, Anopheles species in rural areas and Aedes species in the pacific islands [2]. The clinical manifestations of the lymphatic filariasis include acute dermatolymphangioadenitis (ADLA) and lymphoedema, followed by hydrocele and elephantiasis of limbs; the chronic manifestations lead to social stigmatization, financial hardship, and mental illness [3,4].

Lymphatic filariasis is endemic in Africa, tropics, and sub-tropics of Asia, South America, the Western Pacific, and parts of the Caribbean.

Tanzania ranks third among countries in sub-Saharan Africa with a high burden of the lymphatic filariasis, commonly along the coast of the Indian ocean with circulating filarial antigen levels of 45-60% before the initiation of the national lymphatic filariasis elimination program (NLFEP); among those infected, 12.5% develop lymphoedema and subsequently elephantiasis [6–9].

With the burden of lymphatic filariasis in Tanzania, the national lymphatic filariasis elimination program was launched in 2000 with a primary goal to eliminate the lymphatic filariasis by 2020 through interruption of the lymphatic filariasis transmission by using annual Ivermectin and Albendazole MDA. The rate of community participation in MDA should be more than 85% and sustained for a period of 4 to 6 years to stop transmission and development of the new case of lymphoedema or hydrocele. The use of Ivermectin helps to reduce the microfilariae density in the bloodstream and prevent the spread of parasites to mosquitoes. However, it has limited effects on adults. Hence, the need for combination with Albendazole, which has adverse reactions to adult worms, causing death [5].

The secondary goal was to alleviate suffering from the chronic manifestations and prevention of disability by introducing basic measures, such as foot hygiene for those with lymphoedema and by providing surgery for men with hydrocele [10–12]. Through preventive chemotherapy with Albendazole/Ivermectin, Tanzania has made remarkable achievements in reducing LF transmission to very low levels to near elimination, however, preventive chemotherapy has no impact on the lymphoedema of limbs; and the related complications such as recurrent filarial fevers[13].

In Lindi district transmission has been reduced from 55% to 7.5%, however, lymphoedema have persisted[14,15]. Little is known on what the community does regarding the management of lymphatic filariasis-lymphoedema and associated factors such as ADLA as well as the rate of participation in preventive chemotherapy with Albendazole/Ivermectin. The success of an intervention for the management of filarial lymphoedema and associated complications among affected community depend on their knowledge and attitudes, as well as day to day practices regarding management of filarial lymphoedema. This study was set out to explore rate of community uptake of preventive chemotherapy with Albendazole / Ivermectin, as well as their knowledge, attitudes, and practice regarding management of lymphoedema and ADLA attacks. Findings on the MDA, community knowledge, attitude, and practices, on the management of lymphoedema, will be used to guide future strategies in building a stronger community-based lymphoedema management program as well as to improve MDA coverage.

METHODS

Study design and settings:

A quantitative community-based cross-sectional study was conducted in selected wards of the Lindi district to determine community participation in the mass drug administration and their knowledge, attitudes, and practices on mass drug administration and management of filarial lymphoedema. The Lindi district is one among five districts in the Lindi region, Tanzania. The district has approximately a population of 194,143 whereby females are 102,496 and males are 91,647 with an average household size of 3.7 people [16].  The district has thirty-one (31) wards, hundred and forty (140) registered villages. The Lindi district council was selected because it’s among the endemic coastal areas with the persistence of transmission of the lymphatic filariasis despite eleven rounds of MDA according to Tanzania unpublished neglected tropical diseases control report of 2018.

Study population:

The study population was the community members aged 18 years and above living in the Lindi district. Only the community members who were willing to participate in the survey and signed the informed consent were included. Participants who did not sign the written informed consent and unable to communicate due to medical reasons such as stroke, mental disability and dementia were excluded from participating in this survey.

Sample size determination and sampling procedures:

The sample size the study was determined using the formula n = z² P (100-P)/ε², whereby; n= minimum required a sample size, p=prevalence of filarial lymphoedema, estimated as 16% (prevalence of filarial lymphoedema in Tanga (17). Z=Standard normal deviate of 1.96 on using a 95% confidence interval and ε =margin of error, =3%. The minimum sample size obtained (574) was adjusted by 10% of non-response rate and the designing effect (1.5) to a minimum sample size of 957. It was assumed that each household comprises of three people [16], therefore 319 households was surveyed in order to get 957 people.

The multi-stage cluster sampling was used to enroll 957 respondents in the community. In the first stage, the ward was considered as the first cluster and eight (8) wards were randomly selected from thirty (30) registered wards in the Lindi district [16]  which were Kilangala, Kitomanga, Mtama, Mtua, Nyengedi, Nyangao, Majengo, and Kiwalala. In the second stage, a household was considered as a second cluster and probability proportional to size was used to get the number of households to be recruited from each of the selected wards. The total number of households (X) in each ward were 1294, 1889, 2080, 3501, 1756, 1151, 1633, 1684 for Mtama, Mtua, Nyangao, Kiwalala, Kilangala, kitomanga, Nyengedi, and Majengo ward respectively obtained from the national bureau of statistics and summed up (X1+X2+X3+….X8) to get 14988 (which is the summation of the total households in the study area). The number of households to be recruited from each ward was calculated by the formula: ward sample size (n)/N*Xn), whereby n/N gives sampling fraction. The numbers of the households recruited were 40, 26, 64, 75, 37, 25, 35, and 36 from Mtama, Mtua, Nyangao, Kiwalala, Kilangala, Kitomanga, Nyengedi, and Majengo ward respectively. Households were selected randomly in each selected village. Also, in each of the selected households, participants were randomly selected.

Data collection tool:

The structured questionnaire was self-constructed and used to collect information on the socio-demographic characteristics of the community members, the uptake of preventive chemotherapy, community knowledge and attitudes on the role of MDA, causes of lymphoedema, and its management, and practices on the use of preventive chemotherapy, and lymphoedema management. The questionnaire was pre-tested in the Kiswahili language in non-selected wards of the Lindi district council before data collection for the amendment of the questionnaire. The Cronbach’s alpha test was used to measure the reliability, and the obtained value was 0.69.  The data was collected for one month (July 2020) electronically using mobile phones (Open data kit) and submitted daily to the central server at the neglected tropical disease control program offices in the national institute of medical research in Dar es Salaam Tanzania.

Data analysis:

The collected data was analyzed using the statistical package for social sciences (SPSS) version 22 (IBM Corp., Armonk, NY, USA). The socio demographic characteristics of the participants, knowledge, attitudes as well as practices on the use of preventive chemotherapy and on the lymphoedema management were summarized in the frequency tables with the proportions and their 95% confidence intervals.

The level of knowledge and practices were assessed using six multiple choice questions for each question one point was allocated for a correct answer and zero for incorrect answer. The total score was 6 whereas a score ≤ 2 indicated inadequate/inappropriate practice, and ≥ 3 = adequate knowledge/appropriate practices based on the average score which was 3. The attitudes were assessed using five statements in a likert scale ranging from agree (1 point) or disagree (3 points). The levels were categorized based on the mean attitude scores of 19. The score of ≤ 19 indicated negative attitudes and ≥ 20 = positive attitudes. The association between the dependent variable (MDA uptake and the frequency of MDA uptake, knowledge, attitudes and practices) and independent variables (socio-demographic characteristics) was assessed using Pearson’s chi-square statistical test at the significance level of < 0.005.

RESULTS:

Socio-demographic characteristics of the study participants:

A total of 954 study participants were recruited with a response rate of 99.7%, their ages ranged from 18 to 87 years. More than a half of the participants were less than 38 years (56.8%), female (56%), married (51.9%), and nearly half of the respondents (48.4%) had attained a primary school level of education (Table1).

The frequency of community participation in the mass drug administration for the lymphatic filariasis elimination:

Out of 954 participants, the large majority (83.9%) reported having participated in the previous MDA rounds with more than three-quarters of them (78.5 %) participated in ≤ 5 rounds while 21.5% participated in ≥ 6 rounds since the launching of the LF elimination program (Figures 1 and 2). There was a statistically significant association between the residence and participation on IVM and ALB rounds (p< 0.00) and frequency on IVM and ALB uptake (p< 0.00) (Table 2).

Community knowledge on the MDA, filarial lymphoedema and its management:

Nearly half of the participants (48.7%) mentioned that worms are the cause of filarial lymphoedema and more than half of the participants (53%) mentioned long-term use of the anti-filarial drugs (MDA) as treatment of filarial lymphoedema. On the management of the filarial lymphoedema, less than a half (42.5%) of participants knew limb elevation and exercise as the correct measure to reduce swollen limbs. Furthermore, few (10.5%) participants knew inspection and treatment of entry lesions as the method for the protection of swollen limbs from dirt and germs (Table 3).

The level of community knowledge on MDA, filarial lymphoedema and its management according to the socio demographic characteristics:

Of the total participants, 572 (60%) had an inadequate level of knowledge while 382 (31.7%) had an adequate level of knowledge about the uptake of the MDA, filarial lymphoedema, and its management. There was no statistically significant association between the levels of knowledge and socio-demographic characteristics (Table 4).

Community attitudes toward the MDA, filarial lymphoedema and its management:

More than half of the participants (50.5%) agreed that the MDA causes sexual impotence and may cause death as a side effect (53.9%). The respondents had misconceptions on the management of lymphoedema such as lymphoedema is transmitted by washing the limbs (48.2%), and can be cured by traditional mark (50.3%) (Table 5).

The level of community attitudes on MDA, filarial lymphoedema and its management according to the socio demographic characteristics:

Of the total participants, more than half 512 (53.7%) had negative attitudes towards the MDA, filarial lymphoedema and its management while the rest 442(46.3%) had positive attitudes. There was a statistically significant association between the residence (p<0.000) and the levels of community attitudes on MDA, filarial lymphoedema, and its management indicating, the community members of the Kilangala ward had high levels of negative attitudes compared to the rest (Table 6).

Community practices for lymphoedema management:

Less than one-third of the participants (29.6%) washed the affected limbs as part of the lymphoedema management. However, close to two thirds (62.4%) clean the affected limb only once in a day. Also, the majority (77.4%) doesn’t inspect the entry lesion and exercise the affected limb (75.1%) (Table 7).

The level of community practice on filarial lymphoedema management according to the socio demographic characteristics:

Of the total participants, close to the third quarter 708 (74.2%) had inappropriate practices for filarial lymphoedema management, while 246(25.8%) had appropriate practices for lymphoedema management. The age groups (p<0.000), residence (p<0.000), and marital status (p=0.001) were statistically significantly associated with the community practices on lymphoedema management (Table 8).

The influence of knowledge and attitudes on the community practices for lymphoedema management:

The majority of the participants (78.7% and 79.2%) with inadequate knowledge and positive attitudes on the role of MDA, lymphoedema, and its management had inappropriate practices on lymphoedema management. Also, there was a statistically significant association between level of knowledge (p<0.000) and attitude (p=0.001) with the community practices for lymphoedema management (Table 9).

Table (2):   The influence of socio-demographic characteristics on the IVM + ALB uptake and their frequency (n=954)

^* Statistically significant (p<0.005)

Table (3): Community knowledge on the MDA, filarial lymphoedema and its management (n=954)

Table (4): Influence of socio demographic characteristics on the community level of knowledge on MDA, filarial lymphoedema and its management (n=954)

Table 5: Community attitudes toward the MDA, filarial lymphoedema and its management (n=954)

Table (6): Influence of socio-demographic on the community level of attitude towards MDA, filarial lymphoedema and its management (n=954)

^* Statistically significant (p<0.005)

Table (7): Community practices on the management of filarial lymphoedema (n=954)

Table (8): Influence of socio demographic characteristics on the community practices for lymphoedema management (n=954)

^* Statistically significant (p<0.005)

Table (9): The influence of knowledge and attitudes on the community practices for lymphoedema management (n=954)

^* Statistically significant (p<0.005)

DISCUSSION