Knowledge, Attitude, and Prevention Practices on Visceral Leishmaniasis Among Residents of Kacheliba Division, North Pokot Sub County, West Pokot County, Kenya

KNOWLEDGE, ATTITUDE AND PREVENTION PRACTICES ON VISCERAL LEISHMANIASIS AMONG RESIDENTS OF KACHELIBA DIVISION, NORTH POKOT SUB COUNTY, WEST POKOT COUNTY, KENYA.

ROTICH LOKROLE JESSE

Q32S/17231/2013

A RESEARCH PROJECT SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENT FOR THE AWARD OF THE DEGREE OF BACHELOR OF SCIENCE ENVIRONMENTAL HEALTH IN THE SCHOOL OF PUBLIC HEALTH OF KENYATTA UNIVERSITY.

JUNE 2017

DECLARATION AND APPROVAL

This project is my original work and has not been presented for degree or any award in any university.

Signed’date”

Rotich Lokrole Jesse

Q32s/17231/2013

University Supervisor: this project has been submitted for examination with my approval as university supervisor.

Signed”date’

Anthony Wanjohi

Department of Environmental and Occupational Health.

ACKNOWLEDGEMENT

First, am grateful to God who gave me good health to undergo the entire course. I would like to acknowledge the support extended to me by my university supervisor; Mr. Anthony Wanjohi who offered invaluable guidance during the research project process. Special thanks to the respondents to this research and to all who played role in ensuring this research project becomes a success. God bless you all.

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TABLE OF CONTENT

DECLARATION AND APPROVAL ii

ACKNOWLEDGEMENT iii

LIST OF TABLES vi

LIST OF FIGURES vii

OPERATIONAL TERMS ix

CHAPTER ONE: INTRODUCTION 1

1.1Background to the study 1

1.2 Problem Statement 2

1.3 Justification of the Problem 3

1.4Research Objectives 3

1.4.1 Broad Objective 3

1.4.2 Specific Objective 4

1.5Research Questions 4

1.6Research Hypothesis 4

1.7 Significance of the Study 4

1.8 Limitations and Delimitations 5

1.9 Conceptual framework 5

CHAPTER TWO: LITERATURE REVIEW 7

Early evidence of the endemicity of visceral leishmaniasis (VL) in southern Ethiopia came from Cole et al. as quoted by Ahmed Ali, who described 31 cases in a military battalion traveling in south-western Ethiopia, northern Kenya and south-eastern Sudan. In a report of 136 cases in a brigade operating in northern Kenya, claimed that 11 cases had been acquired on the Moyale-Addis Ababa road, just inside Ethiopia; eight further cases were reported in troops who passed through an unspecified area near the southern border. 7

These evidences supported by later works of prominent epidemiologists who amassed a considerable knowledge and experience in the field began an eight year long intensive study in southern Ethiopia where visceral leishmaniasis is endemic, 142 cases were recorded till 1990. The cases were very unequally distributed between the six villages studied, with more than 90% in the four which were closest to the uninhabited valley of the Segen River. In a year long intensive study, annual incidence of disease was estimated at 6.9/1000 in the whole population. The annual incidence, taken into account, the previous works was calculated as 1.9% while the rate of immuno-conversion was 5.6 times greater. 7

2.1 Knowledge, attitude and practice towards visceral leishmaniasis. 7

2.2 Socio-demographic factors 8

2.3 Socio-economic factors 8

2.4 Social-cultural factors 10

2.5 Knowledge gaps 11

CHAPTER THREE; MATERIALS AND METHODS 15

3.1 The study design 15

3.2 Study Variables 15

3.3 Study Area 15

3.4 Study population 16

3.4.1 Inclusion Criteria 16

3.4.2 Exclusion criteria 16

3.5 Sampling techniques 16

3.6 Sample size determination 16

3.7 Data collection techniques 17

3.8 Pilot study and pre-testing 17

3.9 Validity 17

3.10 Reliability 18

3.11 Data analysis 18

3.12 Ethical considerations 18

CHAPTER FOUR: RESULTS 19

4.1 Social demographic characteristic of the study participants. 19

4.2 Knowledge on VL among study subjects. 21

4.3 Attitude towards VL among participants in Kacheliba division. 23

4.4 Practice of respondents towards VL prevention and control in Kacheliba division. 24

CHAPTER FIVE: DISCUSSIONS, CONCLUSIONS AND RECOMMENDATIONS 26

5.5 CONCLUSIONS 28

5.6 RECOMMENDATIONS 29

REFERENCES 30

APPENDIXES 36

APPENDIX I: SURVEY QUESTIONNAIRE (ENGLISH) 36

APPENDIX II: INFORMED CONSENT FOR THE HOUSEHOLD KAP RESEARCH. 44

APPENDIX III: WORK PLAN 45

APPENDIX IV: BUDGET 46

APPENDIX V: LEISHMANIASIS COVERAGE IN KENYA AND MAP OF STUDY AREA. 47

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LIST OF TABLES

Table4.1: Social demographic characteristic of the study participants’…’.17

Table 4.2: Knowledge on VL among the study participants in Kacheliba division’….19

Table 4.3: Attitude towards VL amongst the study participants’..20

Table4.4: practice responsible towards VL prevention and control in Kacheliba division’.’.’.”.’.”21

LIST OF FIGURES

Figure 1.9: conceptual framework. Showing factors related with visceral leishmaniasis”5

ACRONYMS

ASAL – Arid and Semi-Arid Lands

WHO – World Health Organization

V.L – Visceral Leishmantiasis

DNDI – Drugs for Neglected Diseases Initiative

MSF – Medical Sans Frontiers

NTDS – Neglected Tropical Diseases

KAP – Knowledge, Attitude and Practices

ITMN – Insecticide Treated Mosquito Nets.

NGOS – Non Governmental Organizations

DALYS ‘ Disability Adjusted Life Years

SPSS – Statistical Package for Social Sciences

Kalaazar – Synonym for visceral leishmaniasis

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OPERATIONAL TERMS

There are a number of operational definitions that frame and help guide this research project this includes:

‘ Knowledge-the ability of a person to have the correct understanding of V.L in terms of causative agent, mode of transmission, signs and symptoms, treatment and prevention practices.

‘ Attitudes towards V.L- beliefs on susceptibility, seriousness and threat of the visceral leishmantiasis

‘ Practice of visceral leishmantiasis prevention- routine activities and actions of individual or group for prevention of V.L this include the use of ITNS.

‘ Community – refers to a group of people living in a particular area and having shared values, cultural patterns and social problems

‘ Visceral leishmantiasis control-is the process that requires eradicating carrier sandfly or reducing man vector contact so as to cut the life cycle of the parasite.

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Abstract

Visceral Leishmaniasis (VL) commonly known as Kalaazar is a systemic disease caused by parasitic protozoan of species of genius leishmania and transmitted by species of phlebotomus sand flies. It is mainly found in tropics and subtropics and in southern Europe. It is classified as neglected tropical disease (NTD) by WHO. VL is found in areas that are remote areas. Large outbreaks in densely populated areas, especially in war and conflict zones, refugee camps and settings where there are large scale migration of populations. The risk factors are poverty, malnutrition, population displacement, poor housing, weaknesses in immune system and lack of resources. It occurs mostly in children and young adults. Recurrent epidemics of VL in East Africa especially Ethiopia, Kenya, southern Sudan and Sudan have caused high mobility and mortality in the affected communities. The WHO reports an estimated 300,000 new cases of VL with 20,000 to 30,000 deaths worldwide annually. The main objective of the project is to assess the level of knowledge, attitude and practices in relation to VL among residents of the endemic Kacheliba division and the specific objectives are to determine the level of knowledge on VL among residents of kacheliba division, to determine the attitude towards VL and to assess the practices related to VL among kacheliba division residents. Community based cross-sectional study was conducted among residents in Kacheliba division from December 2016 to January 2017. A total of 323 households were selected by using simple random sampling techniques from five villages in the division. Data was collected using structured Questionnaire. For knowledge, attitude and practice variables each right response was given a score of 1 while a wrong or unsure response was scored 0. Data were double entered using Microsoft excel 2013 and analyzed using SPSS-15 statistical software. The frequency distribution of both dependent and independent variables were worked out. Descriptive statistics such as mean, frequencies and percentages were used to summarize data. Data were presented using tables. From a total of 323 study participants (116 males and 207 females), 96% have heard of the disease kala-azar. From participants who heard about kala-azar 93.5% females and 86.7% males had awareness about the disease. The majority (81.1%) of participants had favorable attitude towards the treatment of kala-azar whereas 22.9% didn’t use anything to prevent it. More than half of the respondents (60.7%) did not practice proper methods for the prevention and control of kala-azar in the study area. In general the findings showed that the residents had good awareness and favorable attitude about the disease, but their overall practice about prevention and control of the disease was low. Therefore, call for continued and strengthened behavioral change communication and social mobilization related activities.

CHAPTER ONE: INTRODUCTION

1.1Background to the study

Visceral Leishmaniasis (VL) is the most severe form of leishmaniasis and the world’s second killer parasitic disease after malaria. It is caused by the two leishmanial species, L. donovani or L. infantum.the parasite is spread to humans through the bite of infected female sandflies.it attacks the immune system and is almost always fatal if not treated. Due to its broad and persistent prevalence throughout ancient times as mysterious disease of diverse symptomatic outcomes, visceral leishmaniasis has been dubbed with various names ranging from ‘white leprosy’ to’ black fever’. Some of these names suggest links to negative cultural beliefs or mythology, which still feed into social stigmatization today. Depending on the geographical areas, L. infantum infects mostly children and immune suppressed individuals, whereas L. donovani infects all age groups. Human beings are the only reservoir and phlebotomus sand flies being the only vector.

Largely unknown in high income countries(though present in Mediterranean basin) its endemic in 76 countries, 90% of cases occurs in Bangladesh, India, Ethiopia, Sudan and Brazil.If the disease is not treated, the fatality rate in developing countries can be as high as 100% within 2 years. An estimated 900,000 to 1.3 million new cases and 20,000 to 30,000 deaths occur annually globally.in 2015 MSF treated 5400 people for visceral leishmaniasis. It has been about 80 years since VL was discovered in Kenya. Since then, VL has been recognized as an endemic disease in most lowland and arid and semi-arid regions (ASALs) in the country. The disease mainly occurs in Baringo, Machakos, Kitui, Meru, Pokot, Turkana and Elgeyo Marakwet. Management of VL has been mainly by NGO’s and Multi-Lateral institutions such as MSF and DNDi. About 12 million people are currently infected in 98 countries and about 2 million new cases each year. About 200million people are at risk of visceral leishmaniasis worldwidethis occurs mainly in developing countries. 72 of the 98 countries are the developing countries.

VL was first detected in Kenya in 1935 in the northern frontier districts of Mandera and Wajir. It seems to have been imported into Kenya by soldiers returning from southern Ethiopia after the Second World War. The disease spread with epidemic resurgence in different foci during the years that followed. Since 1980’s the number of reported cases increased considerably and expanded into new areas, that is, Baringo, Pokot, Turkana and Elgeyo Marakwet areas. There is continuous endemicity which affected the very poor tribal nomadic population. In other areas, VL occurs in outbreaks that are associated with periods of drought and when the rate of malnutrition is high. The outbreaks are probably related to people’s movement from high endemic to low endemic areas due to lack of food security.

Risk factors for VL have been studied and a good correlation was established between the proximity of houses or temporary settlements to termites hills and the risks of transmissions, having a low socio-economic status, lack of resources, population displacement and weaknesses in human systems were also identified as some important risk factors for VL. Children are at greatest risks at their age they have not yet developed immunity to the disease. Many adults in endemic communities are reservoirs of the infection facilitating continuing transmission of disease to those without immunity. In 2000-2001, VL outbreak with over 349 suspected cases confirmed in Eastern and Northern Province of Wajir and Mandera districts. In 2006, another outbreak of VL was reported in Isiolo and Wajir districts with a total of 82 suspected cases (48 were confirmed).

1.2 Problem Statement

Kenya has adopted the Sustainable Development Goals (SDGs) that has replaced the Millennium Development Goals (MDGs).SDG 3 ‘Good health and Wellbeing has mandated all the ratified countries to ensure healthy lives and promote wellbeing for all at all ages for theircitizens. Kenya in her Vision 2030 has a goal of developing a population that is healthy and productive and able to fully participate in and contribute to other sectors of the economy. Despite the above Government efforts there is persistent prevalence of VL in Kacheliba division of Kenya. Prevalence of VL in the human population of West Pokot, Kacheliba Division is still endemic. MSF opened VL treatment centres for free of charge for all in Kacheliba Hospital. Between 200-2010, MSF diagnosed and treated 4831 patients with VL in the Pokot region straddling the border with Uganda and Kenya. Between 2006 and 2010, 2301 cases of VL were diagnosed at Kacheliba Hospital. Despite MSF, Government and DNDi efforts in the area, there is no considerable outcome and cases VL stands at an average of 400 annually at Kacheliba Hospital. Recently, new cases have been reported in Kacheliba division of West Pokot County and the prevalence is 30%. VL still while there is evidence that VL is prevalent in west pokot, the level of community awareness and knowledge isunknown. There is need to assess community’s KAP before any intervention program is introduced. This will enhance informed decision in community entry and approach which intern determines thecorporationand participation towards achievement of intended goals of the intervention programs. Failure to know the community’s perceptions, beliefs and attitudes’ before intervention program will lead to resistants.it leaves gaps within the implementation program.

1.3 Justification of the Problem

Kacheliba division is in west Pokot County, North pokot sub-county.it is the Region that have suffered greatly from VL.According to MSF (2013) the area have constant cases of VL.The condition is prevalent in the region despite government and MSF efforts to curb the situation.MSF have set up treatment Centrefor VL in Kacheliba hospital. This project aimed to assess the KAP of Kacheliba residents in relation to VL.Vision 2030 health goal in Kenya is to develop a population that is healthy and productive and able fully to participate in and contribute to other sectors of economy. It has been about 80 years since VL was discovered in Kenya. Since then, VL has been recognized as endemic in ASAL regions of Kenya. This includes Pokot, Turkana and Baringo. VL is the second deadliest parasitic killer disease in the world after Malaria and it is responsible for an estimated 200,000 to 400,000 infections each year, worldwide and causes between 20,000 and 30,000 deaths annually.VL prevalence in Kacheliba stands at 30% (joseph lotukoi, 2012) .the morbidity statistics at Kacheliba Hospital shows an average of 400 cases of VL annually. Most risk factors of VL are modifiable thus most of its deaths or disease burdens can be averted. The main challenge is there is little knowledge of the disease among the public and health workers.

It Attempts to come up with important predictor of safer knowledge and practices so that future planners of effective health education and intervention programs use to mount effective prevention and control programs. It aims to call for the continued and strengthened behavioral change and communications (BCC) and social mobilization related activities. To decrease the risk of being bitten, avoid activities especially from dusk to dawn when the sand flies are generally most active, minimize the uncovered skin, and control the vector by spraying with insecticide

1.4Research Objectives

1.4.1 Broad Objective

To assess the level of knowledge, attitude and practices towards visceral leishmaniasis among residents of Kacheliba division.

1.4.2 Specific Objective

i) To assessthe level of knowledge on visceral leishmaniasis among residents of kacheliba division.

ii) To determine the attitude of Kacheliba division residents towards visceral leishmaniasis.

iii) To identify practices of kacheliba division residents related to visceral leishmanias.

1.5Research Questions

i) What is the level of knowledge on visceral leishmaniasis among kacheliba division residents?

ii) What is the attitude of kacheliba division residents towards visceral leishmaniasis?

iii) What are the practices related to visceral leishmaniasis among kacheliba division residents?

1.6Research Hypothesis

i. There is little knowledge on VL among the residents of Kacheliba division.

ii. Kacheliba division residents have negative attitude towards VL.

iii. There is huge relationship between kacheliba division resident’s practices and VL.

1.7 Significance of the Study

Findings and recommendations of the study will help the decision and policy makers on making informed decisions and formulating relevant policies so that future planners of effective health educations and intervention programs will use to mount effective prevention and control programs. It aims to call for continued and strengthened behavioral change communications and social mobilization related activities.

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1.8 Limitations and Delimitations

The study has limitations and delimitations that include:

The study targeted the head of household as a proxy to KAP held by all members of the household. Therefore, the results may not accurately represent the community’s perspective as a whole.KAP survey brings about ‘I don’t know’ answers because of failure to translate questions about knowledge into meaningful local categories that participants can understand. it calls for fluency in language.

Interviews and the questionnaires captured self-reported information and relied primarily on respondents providing the right information. Misreporting by respondents was not ruled out. Limited prior research studies on the topic .time and funding constraints.

1.9 Conceptual framework

Figure 1.9: conceptual framework. Showing factors related with visceral leishmaniasis.

Source: developed from literature review.

The illustration above shows the relationships between the independent, intervening and the dependent variables. It shows factors that affects adoption of VL preventive practices. These factors include socio-demographic characteristics, the community’s knowledge on VL and their attitude towards VL prevention and control.

CHAPTER TWO: LITERATURE REVIEW

These evidences supported by later works of prominent epidemiologists who amassed a considerable knowledge and experience in the field began an eight year long intensive study in southern Ethiopia where visceral leishmaniasis is endemic, 142 cases were recorded till 1990. The cases were very unequally distributed between the six villages studied, with more than 90% in the four which were closest to the uninhabited valley of the Segen River. In a yearlong intensive study, annual incidence of disease was estimated at 6.9/1000 in the whole population. The annual incidence, taken into account, the previous works was calculated as 1.9% while the rate of immuno-conversion was 5.6 times greater.

2.1 Knowledge, attitude and practice towards visceral leishmaniasis.

To date there is no literature that tried to assess the knowledge, attitude and practice of either indigenous or migrant communities towards visceral leishmaniasis in west pokot and there are even few literatures worldwide. Knowledge and practices related to Visceral leishmaniasis was conducted among inhabitants of 7 communities in Colombia.. Only 6.7% of respondents knew the disease by the name leishmaniasis; the local names were bejuco or Yatevi. 47% believed visceral leishmaniasis is caused by the bite of a worm and 35% by a mosquito bite. 94% recognized bejuco as a skin disease. 41% of respondents combined different treatments. Women were significantly less likely than men to know any treatment. Another study done to assess the level of KAP about kala azar and its sandfly Vector In rural communities of Nepal showed that the villagers had poor knowledge about the transmission of kala azar, with most villagers perceiving that mosquitoes, instead of sandflies, were responsible for the transmission of the infection. Majority of The respondents, 78% in Titaria and 48.4% in Haraincha were aware that the condition can be treated.. The residents of the two villages were highly responsive to a program to spray houses with insecticides.

2.2 Socio-demographic factors

Since 1990, South Asia has experienced a resurgence of kala-azar (visceral leishmaniasis). To determine risk factors for kala-azar, a cross-sectional survey was performed over a 3-year period in a Bangladeshi community. By history, active case detection, and serologic screening, 155 of 2,356 residents had kala-azar with onset from 2009 to 2012. Risk was highest for persons 3’45 years of age, and no significant difference by sex was seen. 70 per cent of kala azar patients are children and it affects more men than women because they spend more time outside looking after animals in the fields this is according to research done in karamoja region of Uganda 2013 (M.Odoyo). Kala -azar affects not only the most vulnerable in the community such as children and those weakened by HIV and tuberculosis, but also healthy adults and economically productive social groups (Boelaert et aI., 2000; Khalil et al 2002).In endemic areas children below the age of 15 years are commonly affected in sporadic and epidemic cases of Kala-azar, people of all ages are susceptible with males at least twice more likely to contract the disease than females, except those who have conferred immunity due to past infection (WHO 2009; Griekspoor et aI., 1999; MSF 2010).

According to (J.Lotukoi, 2009),a cross sectional survey conducted among 71 randomly selected residents of Kacheliba division, the key factors associated with the community being predisposed to Kala-azar include: Age, gender, educational level, presence of large number of termite mounds all over the area (76.4%), low usage of bed nets ( 25%) , inaccessibility to health services and lack of proper knowledge on transmission of the disease. Also, human activities such as hunting and deforestation (53.3%), resting or sitting near termite mounds (80.2%) and dancing at night -Adong,o ( 62.5%), when the sand flies are active. There was a significant association between age, low economic status, and inaccessibility to health services, abundant presence of termite mounds that harbor sand flies and the community’s different beliefs about transmission are risk factors.

2.3 Socio-economic factors

The social, economic, and behavioral factors play an important role in establishing both individual and population-wide vulnerability to the disease. Leishmaniasis is a neglected vector-borne tropical infection that is considered a disease of the poor .Concentrated in poverty-stricken countries within Southeast Asia, East Africa, and Latin America; it is also endemic in several Mediterranean countries [2]. On a global scale, ‘350 million people live in areas characterized by active transmission of Leishmania, with 14 million people directly affected by disease.

Visceral leishmaniasis (VL) (known as kalazaar) is associated with low socioeconomic status, and patients are among the poorest. More than 90% of global visceral leishmaniasis cases occur in six countries: India, Bangladesh, Sudan, South Sudan, Ethiopia and Brazil. As reported by Alvar et al. [6], the number of cases of visceral leishmaniasis (VL) is calculated to be as high as 0.2’0.4 million people per year, with more than 90% of these occurring in India, Bangladesh, Sudan, Ethiopia, and Brazil, with a mortality estimated at 10%’20%, especially in poor areas. Kala-azar affects poor communities, generally in remote rural areas. The disease is mostly endemic in countries that are among the least developed in the world such as Nepal or in the poorest regions of so-called middle-income countries such as Kenya and Bihar State in India. Patients and families affected by Kala-azar in such countries become poorer because of the high indirect costs (for example, the costs of Kala-azar diagnosis and treatment) and indirect costs (for example loss of household income) of the disease.

India, Nepal and Bangladesh harbor an estimated 67% of the global Kala-azar disease burden (Seaman et al; 1996; Alvar et al; 2006; Aliluwalia, 2003; Rijal et al; 2006 The poorest segments of rural populations in Southern Asia, Eastern Africa and Brazil are also mostly affected in that access to appropriate diagnosis and treatment is difficult. Malnutrition is a predisposing factor for progression from leishmanial infection to disease and delays in diagnosis and treatment hence increases the risk of severe morbidity and mortality (Hotez, 2010). Those most likely affected or infected are the poor living in villages without seeking treatment. It has been demonstrated that many may decide to stay at home due to anticipated lack of drugs hence acting as reservoir of infections. Poverty increases the risk for leishmaniasis. Poor housing and domestic sanitary conditions (such as a lack of waste management or open sewerage) may increase sand fly breeding and resting sites, as well as their access to humans. Sand flies are attracted to crowded housing as these provide a good source of blood meals. Human behavior, such as sleeping outside or on ground, may increase risk. Diets lacking protein-energy, iron, vitamin A and zinc increase the risk that an infection will progress to kala-azaaar (A.Adam, Suleiman,-Gedaref-Sudan).

In Sudan visceral leishmaniasis is one of the most important infectious diseases with an estimated 20,000 cases annually; 80% in Gedaref State This is according to KAP research done Sudan with an aimof determining the socioeconomic and behavioral risk factors among head of the households regarding infection with visceral leishmaniasis. The transmission of the infectious diseases is determined by the complex interactions between environmental and socioeconomic factors. Environmental factors are predicted to have a significant impact on disease transmission; moreover, socioeconomic factors modify the magnitude and direction of these impacts. (AdhikariSR1, Supakankunti S, Khan MM). No difference was seen by income, education, or occupation; land ownership or other assets; housing materials and condition.

2.4 Social-cultural factors

The mentioned communities’ devised strategies to cope with the disease include bloodletting to reduce headaches and fever, sitting by the fireplace, use of bitter herbs, visiting of witchdoctors and traditional healers. It is estimated that between 50-80% of the people in many communities predisposed to Kala-azar first visit traditional practitioners before going to the hospital (Brabin et al . 1985; Hahn, 1995)practices Many communities like America, Nepal, Bangladesh, Sudan and Kenya; especially the areas of Kitui, Machakos, North Eastern, East Baringo and West Pokot, have multifactorial explanation of ill health due to Kala-azar. They believe variables such as social class, economic position, religion, gender, life events can be correlated with the incidence and distribution of the disease.

Many associate Kala-azar ill health with misfortune that is believed to result from supernatural forces like sorcery, witchcraft, breaking of taboos, curses and spirit disturbances. Sudden changes of weather from wet to dry, exposure to dry air during hot seasons are also believed to cause the disease (Manderson 1998; Marmot et a!., 1981). Arrangement of living space and type of house, social isolation of certain sub-groups such as within a rigid caste system, population movements such nomadic life style are also believed to cause the disease Leishmaniasis, tends to affect the poorest people and marginalized societies particularly those people that are close to water resources, live in humid houses, and are in vicinity of accumulated rubbish, sewerage and farms of livestock. Individuals in under-developed houses for example mud or thatched rooms with cracked walls and low socio-economic status have been found at risk for leishmaniasis and the recent risk factors contribute to the growth and multiplication of sandfly. Other studies have shown that the risk of leishmaniasis has been associated with mud house, cattle density, presence of rodent, dog, other leishmaniasis cases and poor socio-economic status and which may have difficulties in accessing treatment. However, infected individuals may play an important role in sustaining transmission in these areas and result in endemicity of leishmaniasis in poor communities The role of domestic animals mainly cattle in proximity of the houses has been emphasized as a risk factor for leishmaniasis

2.5 Knowledge gaps

In most countries, Kala-azar affects the poorest among the poor. The very poor have little knowledge about the disease and hence they are unlikely to seek early treatment and most of those who start treatment cannot afford to complete it. The occurrence of the diseases drags them further into the downward spirit of poverty from which they are unable to recover (WHO, 2011). In a study in Pacific Ocean on knowledge, attitude and practice by gender on Kala-azar, 94% of the population believed that the disease appears as a skin disease; more men affected and more women did not know the mode of its transmission and 35% of the respondents connected the disease to the bite of an insect but did not know what the etiologic agent was; and thought that the bite was infected by a worm that lives in the mountains. Great variety of treatment used to cure the disease was also based on plants, chemical substances, burning the lesion and to a lesser degree drugs. About 45% did not know how to prevent the disease.(MSF, 2012).

The biting time of the sand flies lie between 6.30 p.m. and 7.00 p.m. at dusk. At this time people sit outside their homesteads at night. Children play on termite hills during the day and possibly early morning, between 6.00 a.m. to 10.00 a.m. that is the biting period of the sand flies at dawn (WHO, 2006, Stephen, 2006). A pilot entomologic study conducted in 2004 in Uganda demonstrated that termite mounds are important for vector breeding and 25 resting sites and that sitting on termite mounds increases the risk of infection (MSF, 2005). Knowledge, attitudes, and practices (KAP) about Kala Azar in two villages in Nepal ‘ Titaria and Haraincha. The authors (Koirala et al. 1998) investigated patient’s knowledge on transmission of the disease and how they thought the disease could be treated and prevented. According to the study, participants had little knowledge about the disease. Most did not know how Kala azar is transmitted; a small number believed mosquitoes transferred it. Only a small number associated fever and change of skin colour with Kala Azar (Koirala et al. 1998:488) they thought treatment by healers would help. Predominantly, participants indicated to seek help at government health facilities. Also local private doctors, hospitals and ‘traditional faith healers’ were consulted. A study carried out in Kitui revealed a significant correlation between Kala-azar incidence and the presence of termite hills within 100 yards from homesteads. Of those with Kala-azar, 30 had a termite hill present while 116 did not. Latter studies by Southgate found that 70% of homesteads close to termite hills were infected compared to only 20% of those without (WHO,2007).

2.6 Current infections, treatment and diagnosis of visceral leishmaniasis

This immuno compromising parasitic disease is likely to be accompanied by bacterial super-infections, in a clinical or post mortem diagnosis of VL cases among 33 hospitalized patients in Brazil, 13 (33.9%) had respiratory infection, 4 (12.1%) had skin infection, 4 had urinary tract infection, 3 (9%) showed ear infection and 2 (6.6%) had infection of the oral cavity.

Bacterial super infection in 22 (41%) of 54 patients was found among children admitted to the pediatric Hospital of Shiraz University of Medical Sciences in Iran where respiratory tract infections and septicemia were the most common types of infections, 18.5% and 13% respectively ..A report of 60% of bacterial infections of VL cases was noticed in a study done by Andrade.

Leishmaniasis is an insect-borne disease that is showing resistance to the highly toxic, heavy metal based antimonials. A cluster of 130-150 patients treated annually in one center of India with locally made sodium antimony gluconate, life threatening cardiotoxicity was observed in 8 patients (6.2%) after 3-28 days of therapy. Reports of unresponsiveness to pentavalent sodium antimony gluconate started in the 1970s. Worldwide up to 15% therapeutic failures occur with antimonials .In Italy sixteen (10.1%) of 158 patients treated with meglumine antimoniate, irrespective of age and geographical locations failed to respond. Five of them showed primary unresponsiveness or experienced acute toxicity and the rest 11 relapsed in 3-11 months.. A recent investigation in Sicily showed that the antimony associated death rate was 7% among HIVnegative adults with or without underlying disease]. In an undetermined role of the drug sodium antimonty gluconate 7 out of 67 died in pundit Ka Puriva village, in Uttra Pradesh with a case fatality rate of 10.5% [36]. In southern Sudan debilitated patients treated with antimonials 10.9% died, (death rate higher than the expected 10% or less 3% relapsed and 3.2% defaulted .Antimonials are no longer useful in north eastern state of Bihar, where as many as 65% of the previously untreated patients fail to respond to or promptly relapse after therapy with antimonials

Sbv has been for 5-6 decades the main stay in the treatment of visceral leishmaniasis throughout the globe, but has now proven to be at varying degree less efficient in the treatment of visceral leishmaniasis owing to administration of the drug by quack doctors, misuse like splitting the daily recommended dose and unrestricted availability. The arrival of some promising drugs like miltefosine, liposomal amphotercine B, paromomycine and others though, they need to be further substantiated, could possibly play a role in resolving the problem of resistance either individually or in combination. But, socio-economic and cultural conditions have a tremendous bearing on the prevalence of VL, hence the cost and current precise resistance to Antimonials in the place needs to be identified before replacement takes hold .

This disease of the underserved and of less profit potential has been neglected for years and the diagnosis remains difficult in rural endemic areas. In recent years, there has been no development in the manufacturing of new drugs and diagnostic tools.

2.7 Prevention and control of visceral leishmaniasis Sand fly.

Breeding sites are generally difficult to find in nature, so control measures that act specifically against immatures are not feasible. Sandflies generally bite various hosts and should be considered as opportunistic manbiters rather than anthropophilic. Their flight, ranges are limited to a few hundred meters. Because of their wide host range, small size and silent, nonhovering flight, people in leishmania endemic areas may be unaware of sandfly presence and its role in the epidemiology of the disease, a fact that may compromise leishmaniasis control efforts through community participation. The use of ITNs may represent the most sustainable method of reducing intradomiciliary transmission of leishmania in communities surrounded by forests, where the diurnal resting sites of vectors are unknown or inaccessible.

Areas where leishmania transmission is extra domiciliary and leishmaniases are an occupational hazard, use of insect repellents or protective clothing may be the only preventative measures available. The latter may be impractical in the tropics and prohibitively expensive while repellents are also relatively costly and may be potentially harmful after prolonged use. As such they should only be considered for use by people who are at risks of leishmania only temporarily, such as tourists, soldiers and hunters. Fortunately Phlebotomine remain susceptible to all major insecticidal groups except partially to DDT.. The DDT that was extensively used to control mosquito was also effective against sandflies, the vector of visceral leishmaniasis. Discontinuation of the malaria control programme led, however, to an increase in the sandfly population, and a resurgence of kala azar in Nepal.

A study done in Colombia to see the effectiveness of delthametrin impregnated bed nets in killing sandflies revealed that 95% of the vector population died after 10 hours of exposure in the experimental room and 72 hours of post exposure follow up while only 10% died in the room with an unimpregnated bed nets. The current control programs involve spray of houses with residual insecticide and the killing of dogs, early detection and treatment including patients with PKDL and community education. However, new ideas such as insecticide-impregnated bed nets and dog collars may have a promise.

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CHAPTER THREE; MATERIALS AND METHODS

3.1 The study design

The research used cross- sectional study design. The source of data was obtained from use of structured questionnaire interview and observations the questionnaire was administered to 323 randomly selected households. The data were expressed as simple frequencies and percentages calculated using Microsoft excel 2013.

3.2 Study Variables

The study variables included the dependent variables (VL), the outcome variables (socio-demographic, socio-economic and socio-cultural) and the intervening variables (knowledge, attitude and practices. Independent variables were measured using the responses to the questions on socio demographic, socio economic and socio cultural factors contained in the interviewer administered response. Dependent variables were the disease status, measured considering the prevalence and incidence as well as its mortality.

3.3 Study Area

The study was conducted in West Pokot County, Kacheliba Sub County and among the residents of Kacheliba division. The area was chosen for the research because it is one of the highest levels of Visceral Leishmaniasis in Kenya. (See the map-Appendix).West Pokot County is one of the 14 counties in the North rift along Kenya’s western boundary with Uganda Border. The County is bordered by Turkana county to the North and North East, Trans Nzoia county to the South, Elgeyo Marakwet county and Baringo county to the South East and East respectively. The county lies within longitudes 340 47′ and 350 49′ East and latitude 10 and 20 North. The county covers an area of approximately 9169.4 km2 stretching a distance of 132 km from North to South. West Pokot County has majority of its land coverage about 74.5 percent classified under Arid and semi-arid land (ASAL).The specific study area will be the stretch of Kopoch and Kacheliba division Pokot north sub-county in west Pokot County where prevalence of Visceral Leishmaniasis is still endemic since 2oth century. It is the area where the referral hospital for Kaalazar cases is situated in the entire west Pokot County. The economy of Kacheliba depends largely on livestock (cattle, goats, sheep and camels) and agriculture (maize) in small scale.

3.4 Study population

The study populations were the residents of kacheliba division who have resided in the area for not less than six months, between the ages of 18-60 years.

3.4.1 Inclusion Criteria

Individuals were eligible for participation if they met the following criteria;

i) were willing to participate in the study and sign a consent form

ii) If they have been residents of kacheliba division for the last 6 months.

iii) Aged between 18-60 years

3.4.2 Exclusion criteria

Selection was made based on;

i) Individuals were not eligible for inclusion if they did not met the pre-test requirements of consent, age and residency.

3.5 Sampling techniques

The county was purposively selected because it contains the population of interest. The division was also purposively selected because according to MSF survey of 2011 in the area, the area has high prevalence of visceral leishmaniasis compared to other divisions in the region.

Households were selected from the division by use of random sampling. The list was obtained from leaders and was used as sampling frame.

Simple random sampling was employed to select from each village from household registry using a table of random numbers. Household heads of each randomly selected household who lived for at least six months in the village were included and when the selected household was inconvenient, the households before or after the indicated one was sampled for replacement.

3.6 Sample size determination

Sample size was determined by the fisher et al (1998), as follows;

N = Z2 P QD

Where N = number of study subjects (households) enrolled in the study

Z = Test statistic which allows to calculate the result with 95% confidence level (1.96)

D = the level of precision (level of Accuracy)

P = proportion of the target population estimated to have a particular characteristics i.e. Kacheliba division has a Kalaazar prevalence of 30%.

Q = 1-P

Thus N = 1.962 x 0.3×0.7

0.052

= 323 respondents that were interviewed (head of households)

3.7 Data collection techniques

The study assessed the knowledge and practices gap among the members of the Pokot community in Kacheliba division, a Visceral Leishmaniasis endemic region. It formulated questions on demographic characteristics.Assessed the Visceral Leishmaniasis prevention practices and attitudes as informed by knowledge, determined factors that predisposed an individual to Visceral Leishmaniasis. The primary source of data came from questionnaires administered. Community based cross-sectional study was conducted among residents in Kacheliba division from December 2016 to January 2017.A total of 323 households were selected by using simple random sampling techniques from five villages of Kacheliba division.. Data was collected using structured questionnaire.

3.8 Pilot study and pre-testing

The pilot study was carried out prior to data collection using the structured questionnaire to test the relevance, objectivity and validity of the questions asked. This was conducted to evaluate feasibility, time, cost, adverse events and effect site prior. Analysis of the information obtained in pilot study provided away of testing validity. This was conducted in Kacheliba Hospital, a referral Centre for VL patients.

3.9 Validity

A good research design should be valid and be able to produce reliable results. Regular consultation of experts and key informants in the study area and review of the questionnaire by supervisors was done to ensure data’s validity.

3.10 Reliability

Reliability of this study was achieved through close supervision and constant follow up on data collectors selected. Cultural similarities of the researcher/ research assistants and people of Kacheliba division played a role in the credibility of the study. The researcher of this study was well familiar with the culture, economic activity and health beliefs as well as the phenomena related to the study thus increasing the credibility of the study. Research assistants selected to aid in data collection were trained in questionnaire administration and interview techniques.

3.11 Data analysis

To achieve the purpose and objectives of the study, Microsoft excel 2013 was applied in data analysis and presentation. The data collected were summarized in tables. The data were analyzed quantitatively by describing it. Community based cross-sectional study was conducted among residents in Kacheliba division from December 2016 to January 2017.A total of 323 households were selected by using simple random sampling techniques from five villages of Kacheliba division.. Data was collected using structured questionnaire.

The findings were presented in the form of short discussions, percentages and tables. The recommendations and conclusions of this study were based on the findings.

3.12 Ethical considerations

Clearance was sought from Kenyatta University and permission sought from department of health services in west Pokot County. Informed consent was sought from residents before participating in the study. Confidentiality was guaranteed throughout the study.

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CHAPTER FOUR: RESULTS

4.1 Social demographic characteristic of the study participants.

A total of 323 individuals (heads of households) were involved in this study, 116 (39.3%) of the respondents were males and 207 (60.7%) were females. The mean age of participants was 39 year. More than three quarter of the participants (289, 54.3%) were married, 109 (31.5%) were government employees and orthodox Christianity was the dominant religion 282 (81.5%) in the area. Regarding their level of education 312 (34.1%) participants were unable to read and write.

All of participants 323 (100%), were Pokots by ethnicity. Regarding the year of residency, the majority 312 (90.2%) lived in the area since more than 3 years. The total respondents were 237 residents of the area. Mean age of participants was 39 and more than half of the respondents were in the age group of 31-40. Males constituted 172 (72.5%) of subjects whereas 65 (27.5%) of participants were female. The majority of the respondents (84.3%) were literate. From these educated respondents, 89 (37.5%) had more than 12 years of education. Illiterates constituted 16.7% of the participants.

Considering the occupational status of the participants, most of people were self-employed while 5.9% were unemployed. About 11.3% of respondents were single and 88.7% were married. (Table.1) shows the details of sociodemographic characteristics of respondents.

Table 1: Social demographic characteristic of the study participants.

Variables Frequency N=323 Percentage (%)

Age 18-25 19 5.9

26-33 77 23.8

34-41 124 38.4

42-49 72 22.3

50-60 31 9.6

Sex Male 116 35.9

Female 207 64.1

Marital status Single 13 4.0

Married 289 89.5

Widowed 21 6.5

Divorced None

Occupation House wife 194 60.1

Farmer 119 36.8

Government employee 6 1.9

Student 4 1.2

Others None

Religion Muslim None

Protestant 122 37.8

Orthodox 201 62.2

Others None

Educational status Unable to read and write 312 96.6

Elementary 4 1.2

Secondary school 7 2.2

Only read and write 11 3.4

Ethnicity Pokot 323 100.0

Others None

Years of residency <1yrs None

1-2 years 14 4.3

>3 years 309 95.7

4.2 Knowledge on VL among study subjects.

Among the total participants, 303 (87.6%) had heard of the disease, 182 (60.1%) knew that the disease is infectious, and 128 (68.1%) responded that sand fly bite is the main way of transmission. The majority of the respondents (293, 96.7%) knew that if the disease is left untreated the outcome will be death. More than half (188, 62%) knew more than one sign and symptom of the disease, and 57 (18.8%) said that abdominal swelling was the only sign and symptom of the disease. From the 123 male participants who heard about kala-azar, 115 (93.5%) were knowledgeable; on the other hand, from the 180 female participants who heard about kala-azar, 156 (86.7%) were knowledgeable. Generally, according to scoring results, 271 (89.4%) participants were knowledgeable (Table’2).

Table 2: Knowledge on VL among the study participants in Kacheliba division.

Variables Frequency N=323 Percentage (%)

Heard about Kalazar Yes 310 96.0

No 13 4.0

Infectiousness of the disease No 39 12.1

I don t know 74 22.9

Yes 210 65.0

Mode of transmission Malaria mosquitoes 19 5.9

Worms 6 1.9

Sleeping with infected person 29 9.0

Sand-fly 231 71.5

I don’t know 33 10.2

Others 5 1.5

Signs and symptoms Weight loss 6 1.9

Abdominal swelling 217 67.2

Fever 4 1.2

Fatigue 12 3.7

Don’t know 9 2.8

More than one answer 99 30.7

House hold roof materials Straw 311 96.3

Corrugated iron 12 3.7

Use of bed nets Yes 53 16.4

No 270 83.6

Sleeping outdoor Yes 116 35.9

No 207 64.1

Work time preference Day time 302 93.5

Night time 9 2.8

Both 12 3.7

Overall practice Good 127 39.3

Poor 196 60.7

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CHAPTER FIVE: DISCUSSIONS, CONCLUSIONS AND RECOMMENDATIONS

5.1 Introduction.

This study was conducted in rural populations because in Africa VL is mainly transmitted in rural settings and, as stated in the objectives of the Sixtieth World Health Assembly of 2007, one of the means to combat leishmaniasis is to improve knowledge about, and skills to prevent, the disease among people in rural areas.

Understanding the beliefs and practices of people is a pivotal step in the successful implementation of VL control activities in VL-endemic areas. It is important to know the level of KAP of a community and improve it to a satisfactory level before introducing any disease control program to get the most support from the community. By acquiring these data a successful control program can be planned. The current study aimed to evaluate the disease-related KAP of people in an endemic area of VL in West Pokot County. Results of this study can help the health authorities for better implementation of the programs related to the control of VL in Kacheliba division. Moreover, findings of this study can be used for proposing a culturally sensitive and appropriate plan for prevention and control of VL in this area.

5.2 knowledge on visceral Leishmaniasis

The result of this study showed that majority of the respondents (96.0%) have heard about Termes (local name for VL) and 82.7% of them were knowledgeable. This result is lower than that from a study conducted in Uganda where 97.9% participants have heard of kala-azar the variability between studies might be due to a lack of community health education, community awareness and socioeconomic status of the different areas.

The fact that kala-azar is an infectious disease and can be transmitted from one person to another person was known by 65.0% of the respondent, whereas 22.9% of the respondents didn’t know its infectiousness, and 81.1% knew that a complete cure of the disease is possible. 71.5% of the participants said that the causative agent of the disease was transmitted through sand fly bite and 10.2% of the respondents didn’t know about the mode of transmission. This result is higher than that found in Sudan where only 6% indicated that the disease is transmitted by sand fly bite.

2.8% of the respondents had no idea of the sign and symptoms of the disease. This is below a study conducted in rural areas of Bihar state India (16.1%). 18% of the respondents in the study knew at least more than one sign and symptoms of the disease. The majority of the participants (89.2%) knew that if the disease is left untreated the outcome will be death, and only 2.2% of the respondents said that the outcome will be self-cure. People’s knowledge about the outcome of the disease is high; this might be due to an increased attention towards leishmaniasis in Kacheliba health center.

More than three forth of the respondents (82.7%) said that preventability of the disease is possible, only 17.3% of the respondents said that the disease couldn’t be prevented. People’s knowledge about the preventability of the disease is high. This might be due to the fact that as people knows about the preventability of malaria (the fact that both are vector-borne diseases), they would conclude that leishmaniasis can also be prevented.

5.3 Respondents Attitude on Visceral Leishmaniasis

When the overall attitude of the study subjects is taken into account, 81.1% had a favorable attitude towards transmission and prevention of VL. The majority of the respondents (72.8%) were aware that the disease can be treated, while only 6.5% believed that it can’t be treated at all. This result is less than that of a study conducted in rural areas of Nepal, where 78.9% (Titaria) and 88.8% (Haraincha) were aware that the condition can be treated, while less than 20.7% didn't know whether the disease is treatable or not. The Kacheliba health center and Medicines sans frontiers gives special attention to diagnosis and treatment of kala-azar, allowing people to know about the treatability of the disease, or can be due to difference in the settings (Nepal is an urban area while the study in Kacheliba was conducted in rural areas).

The majority (81.1%) of the respondents believed that a complete cure of the disease is possible, and only 13.6% believed that it can’t be cured completely and 5.3% didn't know. Therefore, people’s attitude about the complete cure of the disease is high. This might be due to different reasons like community awareness, and the people’s tradition towards patients, which helps to know more about kala-azar. Only few of the respondents (8.0%) preferred to seek treatment from traditional healers, whereas 92.0% of the respondents preferred to seek for treatment from health facilities. This result is similar to that from a study conducted in a highly endemic rural area of India (95%)

5.4 Prevention Practices towards VL.

In the present study it was found that 39.3% of the respondents practiced well, while 60.7% of the respondents didn’t practice well for the prevention and control of the disease. For the prevention of sand fly bites, 27.6% of the respondents use only bed nets, 3.4% only DDT, while 22.9% of the respondents didn’t use any prevention methods against sand fly bites. This result is less than those from rural areas of Nepal; where 58% of villagers in Titaria and 36.8% in Haraincha used bed nets and rural areas in Bihar state India (23.9%).This might be due to the fact that the government given bed nets to people for the control and prevention of malaria in this area of Kacheliba are used for other purposes than intended or to differences in time of investigation, in the socioeconomic status of the people and people’s awareness.

35.9% of the respondents slept outdoors, while 64.1% did not Slept outdoors. 2.8% of the respondents used to work at night when the temperature is high, but majority of the respondents (93.5%) still preferred to work during the day even with high temperatures. This might be due to socioeconomic status of the population, low electrical light supply, and people’s tradition to work at day time.

Thus to avert the spreading of disease to areas that are non-endemic for kala-azar in West Pokot county, the results of this study emphasize the need for increasing awareness activities through the involvement of health workers, and of the school in the community on a massive scale.

5.5 CONCLUSIONS

In general, findings showed that people are knowledgeable about the disease, but knowledge about transmission, sign and symptoms and the infectious origin of the disease was still not very high. Concerning disease control, the people’s attitude towards complete cure of the disease, treatability of the disease and control of the disease through community participation were favorable. Even though the people’s knowledge about the disease was good, their overall practice about prevention and control of the insect vector (sand flies) indicates that there is still a gap in implementation of their knowledge. Therefore, this investigation calls for continued and strengthened behavioral change communication and social mobilization related activities.

5.6 RECOMMENDATIONS

Are:

1) To conduct sensitization talks in the affected communities, to increase the level of knowledge pertaining VL.

2) To instruct VL patients and relatives while their stay in the hospital so they can act as health agents in their communities and eliminate the negative attitude towards VL.

3) To follow up the maintenance of bed nets and the use of any other prevention measure like household spraying or environmental sanitation Such as destroying the ant hills within the residential environment.

‘

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Adhikari SR, Supakankunti S, Khan MM (2010) Incidence of kala-azar in Nepal: estimating the effects of individual and household characteristics. Trans R? Soc Trop Med Hyg 104.

Ahluwalia IB, Bern C, Costa C, Akter T, Chowdhury R, Ali M, Alam D, Kenah E, Amann J, Islam M, Wagatsuma Y, Haque R, Breiman RF, Maguire JH (2003) Visceral leishmaniasis: consequences of a neglected disease in a Bangladeshi community

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APPENDIXES

APPENDIX I: SURVEY QUESTIONNAIRE (ENGLISH)

Date : _______________________________

Household Number: ____________________________

Demographics

1. Name of village: _____________________________________

2. Gender of interviewee

Female ‘ Male ‘

3. How old are you? (Tick only one box)

18 – 20 ‘

21 ‘ 30 ‘

31 ‘ 40 ‘

41 ‘ 50 ‘

51 ‘ 60 ‘

4. What is the highest level of education that you have achieved? (Tick only one box)

No formal schooling ‘

Incomplete primary school ‘

Complete primary school ‘

Incomplete secondary school ‘

Complete secondary school ‘

Post-secondary e.g. certificate, diploma, degree

Degree and above ‘

5. How many people live in your household including you? (Includes biological children or other dependents, tick only one box)

Six or more ‘ Four or five ‘

Three

Two ‘

One ‘

6. What is your relationship to the head of the household? (Tick only one box)

I am Head of household ‘

Spouse/partner ‘

Son/daughter ‘

Grandchild ‘

Parent ‘

Brother /sister ‘

Not related ‘

Other ‘

If ‘other’ describes:

7. Do all children ages 6 to 18 currently attend school? (Government, private, NGO/religious, or boarding, tick only one box)

Not all attend ‘

All attend government schools ‘

No children ages 6 to 18 ‘

All attend, and one or more attend a private, NGO/religious, or boarding school ‘

8. What is the highest grade that the female head/spouse completed? (Tick only one box)

No female head/spouse ‘

Primary ‘

Secondary

Not attended school’

College ‘

University ‘

9. What is the major construction material of the roof? (Tick only one box)

Thatch, straw, or other ‘

Iron sheets, or tiles ‘

10. What is the main source of lighting in your dwelling? (Tick only one box)

Firewood ‘

Paraffin lantern, or electricity (grid, generator, solar)’

11. What is the type of toilet that is mainly used in your household? (Tick only one box)

Bush (none) ‘

Covered pit latrine (private or shared), VIP latrine (private or shared), uncovered pit

Latrine, flush toilet (private or shared), or other ‘

12. Does any member of your household own electronic equipment (e.g. TV, radio, cassette, etc.) at present? (Tick only one box)

No ‘ Yes ‘

13. Does every member of the household have at least two sets of clothes? (Tick only one box)

No ‘

Yes ‘

14. Does every member of the household have at least one pair of shoes? (Tick only one box)

No ‘

Yes ‘

15. What is your main source of income?(Tick only one)

Formal employment (e.g. nurse, teacher, secretary, accountant, etc.)’

Trading, commerce, selling (e.g. wholesalers, retailers, petty traders, etc.) ‘

Agriculture, livestock, forestry, fisheries (e.g. subsistence farmers, market vendors, etc.) ‘

Craft/creative workers (e.g. tailor, hairdresser, building, wood trades, metal and machinery) ‘

Transport industry (boda boda, taxi, bicycles, etc.) ‘

Casual or wage labour (construction workers, farm labourers, etc.)

Support from friends/family (husband/wife, students, remittance from friends/family)’

Support from institutions (government, NGO payments, pensions, etc.) ‘

Basic knowledge about Kala-azar

1.Have you ever heard about Kala-azar?

Yes ‘

No ‘

2. Which vector can transmit Kala-azar to humans? (Tick one only)

Flea ‘

Mosquito ‘

Cockroach ‘

Rat ‘

Sand fly ‘

I don’t know’

3 .Kala-azar can be transmitted to humans by?

Drinking contaminated water ‘

Eating contaminated food ‘

Bites of sand flies ‘

Bite of mosquito ‘

Coming into close contact with a Kala-azar patient ‘

4. Do you think Kala-azar can kill you if it’s untreated?

Yes ‘

No ‘

I don’t know ‘

5. What do you think are the most common signs and symptoms of Kala-azar infection? (Tick all that apply)

High temperature/Fever ‘

Loss of weight/ energy ‘

Skin blackening ‘

Sweating ‘

Headache ‘

Body weakness ‘

Enlargement of spleen/liver ‘

Loss of appetite ‘

Chills ‘

Dizziness ‘

I don’t Know ‘

Other ‘

If ‘other’ describe:

6. Which of these are ways to prevent and control Kala-azar? (Tick all that apply)

Sleeping in bed nets ‘

Wearing long sleeved clothes ‘

Making fire and smoke ‘

Spraying insecticide ‘

Avoid areas with sandflies ‘

Cleaning dark corners in the house ‘

I don’t Know ‘

7. When do sandflies feed? (Tick only one)

Daytime ‘

Night time ‘

Mostly dusk and dawn ‘

Don’t Know ‘

8. What personal protection measures do you use to guard against Kala-azar? (Tick all that apply)

Use insect repellents ‘

Wear long sleeved clothes ‘

Use doom ‘

Burn cow dung/leaves ‘

Close windows and doors ‘

Avoid outdoor activities from dusk to dawn ‘

Use mosquito nets ‘

Attitudes towards Kala-azar

Strongly

Disagree Disagree Agree Strongly

Agree

1..I think that Kala-azar is a serious and life-threatening disease [1]’ [2] ‘ [3] ‘ [4] ‘

2..Kala-azar can be transmitted from one person to another like the common cold [1]’ [2] ‘ [3] ‘ [4] ‘

3. I think the best way to prevent myself getting Kala-azar is to avoid getting sand fly bites [1]’ [2] ‘ [3] ‘ [4] ‘

4..I am sure that anyone can get Kala-azar [1]’ [2] ‘ [3] ‘ [4] ‘

5.I believe sleeping under a mosquito net during the night is one way to prevent myself getting Kala-azar [1]’ [2] ‘ [3] ‘ [4] ‘

6. I am sure that I can treat myself if I get Kala-azar [1]’ [2] ‘ [3] ‘ [4] ‘

7.In my opinion, only children and pregnant women are at risk of Kala-azar [1]’ [2] ‘ [3] ‘ [4] ‘

8.I think that one can recover spontaneously from Kala-azar without any treatment [1]’ [2] ‘ [3] ‘ [4] ‘

9.If someone has got Kala-azar, people should avoid having close contact with him/her [1]’ [2] ‘ [3] ‘ [4] ‘

10..I might be at a greater risk of getting Kala-azar if I work and sleep overnight in the garden or forest [1]’ [2] ‘ [3] ‘ [4] ‘

11.I think that it is dangerous when Kala-azar medicine is not taken completely [1]’ [2] ‘ [3] ‘ [4] ‘

12.I can buy Kala-azar drugs from the drug shop/pharmacy to treat myself when I get Kala-azar [1]’ [2] ‘ [3] ‘ [4] ‘

13.I think that I should go to the health Centre/clinic to have my blood tested as soon as I suspect that I have suffered from Kala-azar [1]’ [2] ‘ [3] ‘ [4] ‘

.I will seek for advice or treatment when I get Kala-azar [1]’ [2] ‘ [3] ‘ [4] ‘

14.In my opinion, Kala-azar has close relationship with ant/termites hills. [1]’ [2] ‘ [3] ‘ [4] ‘

Practices towards Kala-azar prevention

Always Sometimes Never

1. How often do you sleep in a mosquito net? [1]’ [2] ‘ [3] ‘

2.How often do other members of the household sleep in mosquito nets? Or use insecticide sprays [1]’ [2] ‘ [3] ‘

3.How often do you check for holes/repair cracks on walls of homes? [1]’ [2] ‘ [3] ‘

4.How often do you minimize the exposed skin during outdoor activities? Especially from dusk to dawn [1]’ [2] ‘ [3] ‘

5.How often do you use insect repellent on your skin? [1]’ [2] ‘ [3] ‘

6.How often do you clean/cut bushes around your house? [1]’ [2] ‘ [3] ‘

7.How often do you clear the ant and termites hills if any around your house? [1]’ [2] ‘ [3] ‘

8.How often do you visit the health Centre when you fall sick? [1]’ [2] ‘ [3] ‘

‘

APPENDIX II: INFORMED CONSENT FOR THE HOUSEHOLD KAP RESEARCH.

Introduction and purpose of the research;

Good morning/afternoon/evening. My name is Jesse Lokrole, student at Kenyatta University.am conducting a research on Knowledge, Attitude and Practices towards Kalaazar in Kacheliba division. The purpose of the study is to determine the level of knowledge and attitude and asses the practices in relation to Kalaazar in the region among the residents of kacheliba division. The information you provide will be highly valued and appreciated.it will be useful in designing intervention programs in relation to kalazaar.

The information you provide will be highly protected. Hence your name will not appear in the final report and initials will be used so as to protect your privacy while conducting the study.

Your signature”.date”..

Researchers signature”..date’.

‘

APPENDIX III: WORK PLAN

Process steps

Schedule

November December January February March

Preparation of project and submission

Data Collection

Data analysis

Project writing

‘

APPENDIX IV: BUDGET

Stage Item Quantity Cost per unit (kshs.) Total cost (kshs.)

Project writing Duplicating papers

Files

Biro pens

Stapler pins

Stapler

Wipe out

Flash disk

Typing and type setting

Printing

Photocopy

Binding of projects

3 reams

3 packets

12 units

12 units 700

100

600

150

1,000

3,000

1000

100

50 2100

200

100

300

600

150

1000

3,000

1000

1200

600

Data collection

Designing of research instruments, typing, printing and photocopy

Transport to study site

Lunch

3000

2500

Data analysis Lunch

Typing, printing and photocopy 500

5000

Project writing

Typing, type setting and printing

Binding of report 70 pages

3 copies 20

300 1,400

900

GRAND TOTAL 26,550

APPENDIX V: LEISHMANIASIS COVERAGE IN KENYA AND MAP OF STUDY AREA.

Essay: Knowledge, Attitude, and Prevention Practices on Visceral Leishmaniasis Among Residents of Kacheliba Division, North Pokot Sub County, West Pokot County, Kenya

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