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

Background and study aim: Lindi District is among hotspots area for lymphatic filariasis (LF) after eleven rounds of mass drug administration (MDA) in Tanzania. Though transmission has remarkably been reduced, lymphoedema has remained a public health problem. The frequency of the community participation in the MDA, their knowledge, attitudes, and practices (KAP) regarding lymphoedema management has not been fully established. This study examined the frequency of community participation on the MDA and their KAP on lymphoedema management in the Lindi district. Methods: A quantitative cross-sectional study was conducted in July 2020. A total of 954 individuals were interviewed on their KAP on lymphoedema management and MDA by using an interview schedule. Data were analyzed by using Statistical Package for Social Sciences version 22. The community KAP was summarized into frequency tables and proportions. The chi-square test was used to compare proportions at the significance level of 0.05. Results: The large majority (83.9%) participated in the

Background and study aim: Lindi District is among hotspots area for lymphatic filariasis (LF) after eleven rounds of mass drug administration (MDA) in Tanzania.Though transmission has remarkably been reduced, lymphoedema has remained a public health problem.The frequency of the community participation in the MDA, their knowledge, attitudes, and practices (KAP) regarding lymphoedema management has not been fully established.This study examined the frequency of community participation on the MDA and their KAP on lymphoedema management in the Lindi district.

Methods:
A quantitative cross-sectional study was conducted in July 2020.A total of 954 individuals were interviewed on their KAP on lymphoedema management and MDA by using an interview schedule.Data were analyzed by using Statistical Package for Social Sciences version 22.The community KAP was summarized into frequency tables and proportions.The chi-square test was used to compare proportions at the significance level of 0.05.

Results:
The large majority (83.9%) participated in the previous MDA rounds, with more than three-quarters of them (78.5 %) having participated in ≤ 5 rounds.More than half of the community members had an inadequate level of knowledge (60%) and negative attitudes (53.7%) regarding MDA and lymphoedema management, with about three quarters (74.2%) doing inappropriate lymphoedema management practices (74.2%).Age groups, marital status and residence were significantly associated (p<0.000) with the appropriateness of community practices for lymphoedema management.

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.
Globally, over 120 million people in 72 countries were estimated to be infected with lymphatic filariasis, and over 40 million people were disfigured with either hydrocele (25 million men) or lymphoedema (17 million people).Also, almost 1.3 billion people are at risk of infection [2,5].
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][7][8][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.

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 nonresponse 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 selfconstructed 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 (sociodemographic 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 threequarters 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).

DISCUSSION
In this study, the large majority of the participants reported swallowing Ivermectin and Albendazole (anti-filarial drugs), which is in contrast with the previous studies which reported low uptake of anti-filarial drugs in different areas of Tanzania including, the Lindi municipality [18].In the LF endemic areas, the recommended IVM and ALB coverage is at least 65% [22].The coverage of Ivermectin and Albendazole in the Lindi district has been reported to be above 65% for the five consecutive years now.However, the anti-filarial drugs cannot reduce the burden of filarial lymphoedema which is responsible for the morbidity.The upholding of the recommended coverage in the Lindi district is due to previous experience with MDA activities such as better timing of the MDA distribution, understanding of habits of community members, good MDA delivery system [23,24].The community member at risk need to swallow the drugs annually for five or more years to reduce the transmission of the diseases [25].The findings from the study showed more than three quarters of participants participated up to five rounds of the previous MDA.This could be the reason for the remarkable reduction of lymphatic filariasis from 55% to 7.2% in the Lindi district [14,15].
It was observed that the majority of the study participants had an inadequate level of knowledge on filarial lymphoedema, and its management which is similar to the findings from Nepal and Sri Lanka, which showed the majority (75%) and more than half (60%) of the study participants respectively, had a low level of knowledge on filarial lymphoedema and its management [26,27].The misconception on the causative agent of lymphoedema, its treatment and management could be partially contributed by inadequate knowledge provided to the community members on the subject.The adequate knowledge on the lymphoedema management is very crucial for the success of the morbidity management.Hence, there is a need to raise the community awareness and knowledge on the lymphoedema management and treatment in the Lindi district.The literature has reported that the introduction of the lymphoedema management programs in the communities has contributed to the raise of the awareness, knowledge, attitudes and practices on the management of filarial lymphoedema in different LF endemic areas [28].
More than half of the respondents had negative attitudes towards MDA, filarial lymphoedema, and its management which made participation in MDA rounds be ≤ 5 out of 11 MDA rounds in the Lindi district.The misconception that the MDA causes sexual impotence and death as side effects could affect the coverage and uptake of the IVM and ALB.Hence, the continuation of the LF transmission in the community and the hindrance of success the LF elimination program in the Lindi district.Also, the community had negative attitudes on the filarial lymphoedema that it can be spread to another person after washing their affected limbs and can be cured by traditional mark.This could affect the proper management of the filarial lymphoedema.The observed misconception on the mode of transmission has been reported in another study in Tanga, Tanzania, which showed acquiring of the lymphoedema by living with the infected person (0.7%), by witchcraft (0.8%), and by inheritance (0.3%) [8].
The findings of this study showed that close to three quarters of participants had inappropriate practices for lymphoedema management in the Lindi district.The inappropriate practices are due to due to inadequate knowledge and poor attitudes observed among the participants.The issue of inappropriate practices for lymphoedema management has been observed and reported in sub-Saharan Africa including, Tanzania [5,9,10,13,14].In this study, less than a half of respondents washed the affected limbs and performed it once in a day which is comparable to the study which was done by [9,10].The practice of washing the limb only once a day is contradicted with recommended one and could results to the progression of the lymphoedema.Also, less than quarters of community members inspect the entry lesion, elevate, exercise, and use the appropriate footwear on affected limbs.This means more than three-quarters do not follow the recommended ways of proper management of the affected limbs.Hence, the higher risk for the development of advance stage of lymphoedema which causing disability and decrease the quality of life.The majority of the participants had inappropriate practices on lymphoedema management which are contributed by the lack of a community-based lymphoedema management program in Lindi, inadequate knowledge on the subject, and negative attitudes on lymphoedema.

Limitations of the study:
The major limitations of this study were due to the cross-sectional study design which cannot determine if the measured outcomes had an impact on the management of filarial lymphoedema among community members in Lindi District.Another limitation was the recall bias from the participants because some of the questions on the uptake of IVM and ALB and its frequency required the participant to remember the information from the previous years.Also, the qualitative exploration of community knowledge, attitudes, and practices on lymphoedema management was not done.Hence, missing the in-depth perceptive of the community experiences and challenges on the study.

CONCLUSIONS:
The study shows that despite the large majority of respondents who participated in previous rounds of MDA, the community members had inadequate level of knowledge, and negative attitudes on MDA, filarial lymphoedema, and its management as well as inappropriate practices for lymphoedema management.Therefore, there is a need to provide health education in the community with the focus on the importance of the MDA and lymphoedema management to increase compliance of MDA as well as lymphoedema management to the community.study, as well as individuals' right to withdraw from participation at any time during the study without negative consequences.Moreover, informed consent for participation was sought from each respondent after giving them sufficient information.

Highlights:
 There is high coverage and uptake of Ivermectin and Albendazole in this Lindi community.The high coverage and uptake is a good sign in terms of the control of the Lymphatic filariasis because it will halt the transmission of the disease. The Lindi community had misconceptions on several aspects of lymphoedema management, such as lymphoedema is transmitted by washing the limbs and can be cured by traditional marks.The ongoing misconceptions will affect the individual efforts of managing the morbidity associated with lymphatic filariasis. The small group of community members who believed mass drug administration may cause sexual impotence and death as a side effect, there is a chance, they won't take Ivermectin and Albendazole hence serve as the reservoir of the infection.This will compromise the ongoing efforts to control lymphatic filariasis.

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)