Investigation of an onchocerciasis educational intervention for improving knowledge, attitude, and prevention practices among endemic communities in Ghana

Background: Despite substantial efforts to eliminate onchocerciasis, the disease remains a significant public health problem in endemic communities in Ghana. We investigated the suitability of an educational intervention as an effective tool to strengthen onchocerciasis knowledge, attitudes, and prevention (KAP) among residents in endemic communities in southern Ghana.

Methods: The intervention consisting of a pre-test, a PowerPoint presentation covering the agent, vector, symptoms, groups at risk, treatment, prevention practices, and misconceptions of onchocerciasis, and a post-test was conducted in nine communities of three districts from June to August 2024.

Results: Four hundred and eighty residents participated in the study. Comparison of pre-test with post-test scores showed significant improvement in KAP for 17 of the 21 questions. Scores related to the organism and vector for onchocerciasis increased from 11.0% and 35.2%, respectively, on the pre-test to over 95.0% for both on the post-test. Regarding symptoms, while 69.4% reported itching of the skin, only 6.3% knew that eye disease and blindness was a major symptom; these responses increased to 97.0% and 86.6%, respectively, on the post-test. No respondent knew the correct breeding places of blackflies on the pre-test compared to 92.0% on the post-test. Participants’ scores also improved significantly regarding attitude and prevention questions, such as whether they would try to prevent onchocerciasis, methods to prevent blackfly bites, and willingness to participate in the next mass drug administration (MDA) of ivermectin. On the post-test, the majority of participants felt they were better prepared in preventing onchocerciasis (99.1%), and in educating others (98.5%).

Conclusion: This educational intervention improved the KAP of residents and seems to be an effective tool for strengthening onchocerciasis literacy and prevention practices in vulnerable communities. Follow-up of the intervention along with timely MDA of ivermectin should lead to a decrease in onchocerciasis transmission and eventual elimination of the disease.

1 Introduction

Onchocerciasis, also known as river blindness, is a neglected tropical disease caused by the parasitic worm Onchocerca volvulus (1). The larvae of the worm called microfilariae are transmitted by bites of infected blackflies (genus Simulium) which breed in highly oxygenated bodies of water, such as fast flowing rivers and streams (2). Clinical indicators/symptoms of onchocerciasis include nodules on the skin containing the adult worms, intense itching and rashes that can lead to leopard skin, and scaring of the eyes leading to blindness caused by the larval microfilaria. These symptoms take 2–3 years to manifest themselves depending on the individual. Although these symptoms are not life-threatening, they can cause long term chronic pain and disability in affected people (3).

The World Health Organization (WHO) approximates that 25 million people are infected with onchocerciasis worldwide, 90% of whom reside in sub-Saharan Africa (4). More specifically, onchocerciasis remains a significant public health crisis in Ghana as the country has the highest endemicity in western Africa (5). Agriculture is the second largest employment sector in Ghana, with 38.3% of residents supporting their livelihoods through agriculture (6). Rural agricultural communities in southern Ghana are close to rivers that are known to be active breeding grounds for blackflies and for onchocerciasis disease transmission (7).

Vector control activities conducted by the Onchocerciasis Control Program (OCP) from 1974 to 2002, along with treatment using ivermectin beginning in 1997 have diminished the transmission of onchocerciasis in Ghana (7). However, while these strategies significantly reduced the number of cases of the disease, transmission of onchocerciasis by blackflies remains a public health concern within endemic areas. Despite the introduction of community-directed treatment with ivermectin (CDTI), inadequate funding and ineffective management have resulted in uneven distribution of the drug, lowering the effectiveness of the treatment and limiting ivermectin coverage in endemic communities (7). Additionally, lack of community awareness regarding the availability and benefits of mass drug administration (MDA), has hindered community participation. Oftentimes, mass distribution of ivermectin would take place during workdays when community members were working on their farms and unable to participate (8).

Studies conducted on knowledge, attitude and prevention practices regarding onchocerciasis in endemic areas of countries in Africa have shown that although approximately 50-57% of respondents had adequate knowledge of onchocerciasis (9–11), the majority of residents lacked accurate knowledge of the causative agent, the vector, transmission, and symptoms of the disease (10–13). Accurate knowledge of these key features of the disease, and proper understanding of the disease risk, and the ensuing disability are important for residents to implement and sustain practices that decrease disease transmission and burden. In these reported studies, appropriate attitude ranged from 9-42% of participants and good prevention practices ranged from 14-47% (9–11). Regarding factors associated with onchocerciasis prevention practices, one study found that participants with good knowledge were more likely to have positive attitudes and good preventive practices (11) and another study found that knowledge of the mode of transmission, consequences of the disease, and preventive measures were significantly associated with prevention practices (10). This educational intervention was conducted in onchocerciasis endemic communities of southern Ghana to investigate its suitability as an effective tool to provide accurate knowledge and promote positive attitude and effective prevention practices that could lead to decreasing disease transmission in the communities.

2 Methods

2.1 Study area

The educational intervention was conducted in three districts in southern Ghana, namely, Asante Akim, Bosome Freho and Adansi, South. Recruitment was conducted in three communities in Asante Akim, two in Bosome Freho, and four in Adansi South. Figure 1 is a map of this region showing the districts studied. The three districts are mainly forested and crossed by several rivers creating suitable breeding habitats for blackflies. Most communities depend on these rivers for agricultural and some domestic use, which increases exposure to blackflies and onchocerciasis transmission. The rural nature, limited health infrastructure, and moderate literacy levels make the communities appropriate settings for community-based health education interventions. The economy of these districts is dominated by agriculture employing about 70% or greater of the working population. The major crops grown in the three districts are cocoa, plantain, cassava, and maize. Oil palm is an additional major crop grown in Adansi South (14). Asante Akim South Municipality has an estimated population of 123,633 (15). Bosome Freho District is largely rural and has a population of about 62,259 (16). Adansi South District has a population of approximately 98,437 (14). Access to healthcare and education is limited in some communities due to poor infrastructure and distance to facilities.

Figure 1

Figure 1. Map of the Ashanti Region showing the study districts.

2.2 Study design, sampling method and instruments

A cross-sectional educational intervention study was conducted from June to August 2024 using a convenience sampling method. The intervention included a pre-test, a 15 slide PowerPoint presentation, and a post-test. The PowerPoint presentation covered onchocerciasis-related topics such as the causative agent of the disease, the mode of transmission, symptoms, groups at risk, treatment and prevention, and misconceptions of the disease. It was pilot tested for clarity, cultural sensitivity, and effectiveness amongst eight community health workers and revised before it was used. A questionnaire that collected data on socioeconomic characteristics of participants, such as age, education, occupation, income, housing type, marital status (13 questions) and the pre-test on participants’ KAP regarding onchocerciasis (21 questions) was administered before the PowerPoint presentation. The presentation was then given, and the post-test (23 questions) was administered. Both tests were divided into three sections. The knowledge section had nine questions, the attitude section had six questions, and the prevention section had six. The post-test had two additional questions at the end related to participants’ opinion of whether the intervention helped them to be better prepared in preventing onchocerciasis and in educating others.

2.3 Sample size

Based on reported estimated proportion of residents with adequate knowledge of onchocerciasis (50-57%) in studies conducted in endemic communities in African countries (9–11), 50% was used to calculate the sample size for the current study and it was determined that a minimum of 385 participants was needed with a 95% confidence limit and 5% margin of error. Our larger sample size of 480 participants increases precision, improves our statistical power, and enhances generalizability of our results. This sample size was calculated using the online calculator EpiTools by Ausvet^© (http://epitools.ausvet.com.au).

2.4 Ethical approvals

The study protocol was submitted to the Committee on Human Research, Publication and Ethics of the Kwame Nkrumah University of Science and Technology (KNUST), Kumasi, Ghana and the Institutional Review Board of the University of Alabama at Birmingham for review and approval before the study was conducted (IRB Protocol-300012791-003). Permission was also sought from the Ashanti Regional Health Director responsible for neglected tropical diseases, and Directors of Health Services for the selected districts.

2.5 Training of community health workers/promoters

Community health workers/promoters were trained by the research investigators in presenting the educational materials and in answering possible questions from participants. The training was conducted in rooms reserved in healthcare facilities or other suitable building(s) in the communities on the first day that the research investigators visited a community. The objectives of the training were to improve community health workers/promoters’ KAP regarding onchocerciasis control and to prepare them in educating members of their respective communities. The health workers/promoters were given the pretest and post-test prepared for the educational intervention and incorrect answers were discussed with them by the research investigators. The research investigators ensured that health workers were prepared to conduct training of study participants and remained with them during the training and testing in the communities.

2.6 Participant recruitment and data collection

All residents ≥18 years of age who lived in the selected communities for at least a year were eligible to participate. Residents less than 18 years old, those from outside of the community, and temporary residents or visitors were excluded. Community residents were informed of the study and of the time and place by community health workers, volunteers, and local leaders. The date, time, and place of the educational sessions were announced in advance. A designated location that was easily accessible to community members, and that had the necessary equipment such as projectors and microphones was identified in each community. At recruitment those attending were told of the purpose of the study and asked if they would be willing to participate. Upon expression of willingness to participate, the potential participant was asked to read and sign a consent form. The consent form was read to those who could not read, and they were asked to give a thumb print signifying their consent. Signed informed consent was obtained from all study participants. Following enrollment in the study, the questionnaire collecting data on demographic characteristics and the onchocerciasis pretest was administered to each participant. The PowerPoint slides were then presented, and participants were encouraged to ask questions during and after the presentation. The post-test was then administered to each participant. Participant feedback was encouraged, and community members were informed of how they can stay informed and get involved in ongoing onchocerciasis intervention programs. Additionally, onchocerciasis informational pamphlets designed by the research team were distributed to community members who participated in the study and to others who requested them.

2.7 Data analysis

Appropriate descriptive measures were used to describe sociodemographic characteristics of the study population. McNemar’s tests were used to determine whether there were significant differences in pre- and post-test answers for each question related to the causative agent, mode of transmission, symptoms and disease manifestation, groups at risk, treatment, prevention and misconceptions. The number of participants with correct or incorrect answers on the pre- and post-tests questions related to knowledge, attitude and prevention were then summed to generate total numbers and percentages for each question. A paired t-test was used to assess the change in mean cumulative scores between the pre- and post-test and alpha of 0.05 was used to determine statistical significance. All analyses were conducted using Statistical Analysis System (SAS; Cary, North Carolina, USA) software version 9.4.

3 Results

3.1 Demographic characteristics of participants

The mean age was 50 ± 17 years, 64.6% were female and 35.4% were male. Most (81.0%) had lived in their community for over ten years (Table 1). Majority of participants (85.6%) belonged to the Akan ethnic group and 10.7% were Ewes; most (46.9%) had completed junior high school, while 22.7% had received no schooling. Approximately 95% of respondents were Christian and 2.7% identified as Muslim. Sixty percent were married, 19.0% were single, and 12.5% were widowed. Most participants were uncertain (51.7%) of their income and 25.8% provided no answer. About 37.0% reported that they belonged to households of four to six people and another 31.0% to households of 10 or more people. In terms of occupation, 72.4% were in agriculture or farming, 9.2% were unemployed and 5.0% were self-employed. Majority of participants reported that their main sources of water for domestic household use were community wells (58.3%) or centralized taps (41.3%). Only 0.4% reported stream or river as their main water source.

Table 1

Table 1. Sociodemographic characteristics of study participants from onchocerciasis-endemic communities in southern Ghana (N = 480).

3.2 Comparison of pre-test and post-test scores

Comparison of pre-test with post-test scores showed significant improvement in post-test scores for 17 of the 21 questions. Regarding the knowledge questions, significantly higher scores were observed for seven of the nine questions on the post-test compared to the pre-test (Table 2, Figure 2). On the pre-test, only 11.0% of participants knew of the organism causing onchocerciasis compared to 95.4% on the post-test (p<0.0001). Approximately 35.0% of participants knew the insect responsible for transmitting onchocerciasis on the pre-test (30.8% selected the mosquito, and 32.1% did not know); the score for this question improved to 95.7% on the post-test (p<0.0001) While 69.4% of participants knew that itching of the skin was a symptom of onchocerciasis, only 6.3% knew that eye disease leading to blindness was a major symptom. These responses increased to 97.0% and 86.6%, respectively on the post-test (p<0.0001). Percentage scores related to the abundance and biting habits of blackflies on the pre-test and post-test did not differ significantly. About 84% responded that blackflies were more abundant during the wet seasons on both tests. Similar proportions (41.0% and 45.8%) believed that the flies were more likely to feed both day and night or were active only in the daytime on both tests. None of the participants knew the correct breeding places of blackflies on the pre-test, 53.2% stated that the flies breed in dirty/stagnant water, one percent selected animal waste, and 45.7% did not know. The correct response of “fast flowing rivers/streams” increased to 92.0% on the post-test (p<0.0001) (Table 2, Figure 2).

Table 2

Table 2. Knowledge, attitude and prevention pre- and post-test scores of participants from onchocerciasis-endemic communities in southern Ghana (Correct answers indicated by *).

Figure 2

Figure 2. Percentages of participants giving correct answers to knowledge questions on pre-and post-tests. (All values significant at P<0.0001).

Participants scored significantly better on the six questions related to attitude on the post-test compared with the pre-test (Table 2, Figure 3). On the pre-test 64.2% of participants believed that onchocerciasis was present in their communities, 93.1% believed onchocerciasis was a serious illness, and 96.5% were receptive to the use of ivermectin to prevent the disease. These percentages increased to 82.3%, 99.8%, and 99.8%, respectively, on the post-test (p<0.0001 for all). Participants’ responses were high on the pre-test for questions related to their concern that they or their family members might get onchocerciasis (95.2%), that they were willing to try to prevent onchocerciasis for themselves and their family members (98.3%), and that they would not avoid contact with their family and community members if they got onchocerciasis (84.4%). These scores increased to 98.9% (p<0.0009), 99.8% (p<0.05), and 94.2% (p<0.0001), respectively, on the post-test.

Figure 3

Figure 3. Percentages of participants giving positive answers to attitude questions on pre-and post-tests. (Values significant at p<0.05).

Regarding prevention questions, participants’ scores increased significantly for four of the six questions (p<0.0001 for all; Table 2, Figure 4). Regarding methods to prevent blackfly bites, 82.5% of participants selected wearing long sleeved clothing and trousers on the pre-test compared to 98.1% on the post-test. Smaller percentages selected use of insect repellants and applying herbal ointments and leaves on the pre- and post-tests as prevention methods. Regarding the medication used to prevent onchocerciasis, 67.9% of participants knew that it had to be taken once or twice per year for up to 15 years and only 30.8% knew that the name of the medication was not Chloroquine on the pre-test. The percentages increased to 98.9% and 81.9% on the post-test. When asked to select a method that would help to prevent onchocerciasis, 48.5% of participants correctly selected “Participate in mass drug administration” on the pre-test. This score increased to 83.4% on the post-test. The scores were high and did not increase for the two prevention questions asking whether participants would seek clinical care promptly if they developed symptoms of onchocerciasis and whether they would participate in the next mass drug treatment with ivermectin. On the post-test, 99.1% of participants felt they were better prepared in treating or preventing onchocerciasis and 98.5% felt they could educate others on onchocerciasis.

Figure 4

Figure 4. Percentages of participants giving correct answers to prevention questions on pre and post-tests. (P <0.0001 for four of six questions; two questions not significant).

4 Discussion

The study showed that important aspects of knowledge and prevention of onchocerciasis, such as the organisms that cause and transmit the disease, the breeding places of the vector, symptoms of the disease, the drug used in prevention, and frequency of administration, was poor to average among residents in the communities prior to the intervention, and that the intervention was effective in significantly improving participants’ knowledge and understanding in these areas. These significant increases are important in that, with accurate knowledge of the agent and vector of the disease and of the benefit of MDAs, community members will be better able to prevent infection. An important factor is that nearly one third of participants believed that the infection is transmitted by the mosquito. With the existence of malaria and other vector-borne infections in these areas, residents do not have a clear understanding of the different disease vectors. Similar to this finding, the mosquito and various other modes of transmission were given in studies conducted in other countries (10, 11, 13). Another interesting finding is that only small proportions of participants in our study and other studies identified blindness as a symptom of onchocerciasis (10, 13). Blindness due to onchocerciasis occurs after many years if the disease is untreated (17). With the significant reduction in cases of blindness as a result of onchocerciasis control programs and community distribution of ivermectin (18), residents in these communities with ongoing onchocerciasis transmission are unaware of blindness as a debilitating and incapacitating effect of the disease. Members of these communities need to be reminded of the devastating effect of vision loss and blindness in order to increase their militancy in preventing onchocerciasis infection.

A very striking finding in this study is that prior to the educational intervention, none of the participants knew of the breeding sites of the blackflies, with more than half believing that the flies breed in dirty or stagnant water, and the remainder reporting animal waste or did not know. This finding may be due to the fact that participants knew that some mosquitoes breed in pools of stagnant water and think that this was the same for blackflies. Although participants reported that their main water sources for household use were wells or centralized tap systems, their interactions with highly oxygenated bodies of water such as fast flowing rivers and streams occurred during agricultural and domestic activities such as washing clothes, recreation, and bathing. After the intervention it was gratifying to see that most participants selected fast flowing rivers/streams as the correct breeding sites.

There were no significant changes in respondents’ selection of the season that blackflies are most abundant or the time of day that blackflies feed from the pre-test to the post-test. Most responded that blackflies were more abundant during the wet season on both tests and similar proportions believed that the flies were more likely to feed both day and night (evening) or only in the daytime. A research study conducted in Ghana reported higher monthly biting rates of blackflies in the wet season ​ (19). Similarly, participants in a study from Nigeria reported increased biting activities in the wet seasons ​ (20)​. Contrary to these studies, however, a study conducted in the Bono East region of Ghana (250–342 kilometers outside of our study sites), reported that the highest abundance and biting rates of blackflies occurred in the drier months ​ (21). Therefore, a specific study on blackfly abundance would need to be conducted in our study area to resolve this issue. Prior research suggests that blackflies generally feed during the daytime (22), and that peak hours for feeding are typically between 8:00 AM and 11:00 AM (23). It has also been reported that different species of blackflies display different biting patterns with some species such as S. damnosum showing bimodal biting activity, while other species such as S. squamosum displaying unimodal (afternoon) biting peaks (19). Therefore, the reports of community members may be accurate, and specific research would have to be conducted in the communities to identify any discrepancies.

Regarding measures to prevent blackfly bites, there was a significant increase from pre-test to post-test in participants’ choice of long-sleeved clothing. However, there was a slight decrease regarding the use of insect repellent despite this method being stressed in the presentation. It is important to note that spray-on insect repellants are not readily available or affordable in many rural areas of Ghana. Instead, individuals living in rural and/or financially limited areas are more likely to utilize mosquito coils, a cost friendly option, to protect themselves from vector-borne diseases (24). With regard to local means of treating onchocerciasis, some participants said that they knew of medicinal plants that could potentially treat onchocerciasis. A small portion of participants believed that herbal remedies such as Acheampong leaves (Chromolaena odorata), and elephant grass (Cenchrus purpureus, synonym Pennisetum purpureum) could help to protect them against the disease. Acheampong leaves, which is an anti-inflammatory (25), would be useful in treating the body’s inflammatory response to dead microfilariae, providing some alleviation of symptoms in infected persons. Additionally, elephant grass is an anti-parasitic that can counteract ocular disease by targeting infectious microfilariae that migrate to the eye and can also help treat subcutaneous parasitic infections (26). Citronella oil, which is derived from different species of Cymbopogon, is a natural occurring pesticide that can repel pests such as blackflies, mosquitoes, and ticks (27). This was not mentioned by participants but can be explored in future prevention interventions. In a study conducted in Cameroon, small proportions of participants reported using topical application of plant extracts such as palm oil and lemon juice as repellants (12). Using local remedies can be cost effective and aid in both disease prevention and treatment (28).

After the intervention, almost all participants felt that they were better prepared in treating and preventing onchocerciasis and better equipped with the knowledge to educate their peers on the disease. Participants’ attitudes towards participating in ivermectin treatment remained highly positive and increased slightly after the intervention. However, ivermectin distribution has become extremely limited as efforts to eliminate the disease have faltered in Ghana (29). Financial constraints in the country, and hence in the communities, result in decline in ivermectin distribution and treatment. Community health workers/drug distributors are not well compensated for their work. This is demotivating in their attempts to provide ivermectin, further limiting collective efforts of eradicating onchocerciasis (30).

5 Conclusion and recommendations

We found significant increases in participants’ knowledge, attitude, and prevention scores as a result of this onchocerciasis educational intervention. This shows that a culturally appropriate, community-based educational intervention addressing gaps in KAP of onchocerciasis can be effective in improving KAP of residents in the short term, and could be an effective tool for improving onchocerciasis literacy and prevention practices in vulnerable communities. Addressing gaps in knowledge of the cause, vector, and symptoms (especially blindness) of the disease, and clearing up misconceptions about the breeding sites of the blackfly are crucial in controlling transmission. The highly significant increases in participants’ attitude and prevention practices scores after the intervention indicate that participants were better prepared in preventing onchocerciasis and in educating others in the community. We recommend a longer term follow-up of the intervention to assess sustainability of knowledge and implementation of prevention practices, as well as, repeating this educational intervention in other endemic communities. The presentation should be updated to include information on the occurrence of the temporary and self-limiting side effects of ivermectin (itching, edema, musculoskeletal pains, and worsening rash) due to the acute inflammatory response (Mazzotti Reaction) from the drug’s microfilaricidal effect (31, 32) as well as the more serious adverse events such as postural hypertension (31, 32) and neurological events (33) and their management. Emphasizing the length of survival of the adult worms in the skin and the need for recurrent long-term administration of ivermectin to clear the infection and prevent serious disease manifestations is important in helping community members understand the need for continued biannual participation in MDAs.

6 Limitations

There are limitations of this study that should be considered in interpreting the results. The study recruited a convenience sample and so the findings are not generalizable to all members of the communities. Also, community members who were away from their homes or at their farms during the times the study was conducted could not participate, limiting the generalizability of results. Further, residents who self-selected to participate in the study may differ from non-participants in ways significant to the research and can affect interpretation of the results. The short time between the intervention and the KAP post-test evaluation is a limitation of this study since it may have influenced the positive results obtained and does not allow for examination of retention and implementation of KAP practices. Another limitation is that the PowerPoint presentation used for the intervention is limited in producing sustainable impact. However, we prepared and handed out pamphlets containing information used in the presentation that might serve to reinforce and constantly remind community members about the cause, transmission, and measures of prevention of onchocerciasis. There is also the likelihood of recall bias and social desirability bias by participants in answering some questions. Important strengths of the intervention is that local Community Health Workers/Promoters were trained by the study investigators and were supported in conducting the tests and giving the PowerPoint Presentation. These Community Health Workers/Promoters also have access to the pamphlets designed by the research team and handed out to study participants and other community members and can serve as a source of continued implementation of KAP activities in the communities.

Data availability statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Ethics statement

The study involving humans was approved by University of Alabama Institutional Review Board and the Kwame Nkrumah University of Science and Technology Committee on Human Research, Publication, and Ethics. The study was conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.

Author contributions

JT: Investigation, Methodology, Writing – original draft, Writing – review & editing. ED: Investigation, Methodology, Writing – review & editing. SK: Conceptualization, Methodology, Project administration, Supervision, Writing – original draft. MA-K: Methodology, Conceptualization, Writing – review & editing. PO: Investigation, Methodology, Writing – original draft. EA: Investigation, Methodology, Writing – original draft. SF: Conceptualization, Formal Analysis, Writing – review & editing. EL: Investigation, Methodology, Writing – original draft. PJ: Conceptualization, Funding acquisition, Investigation, Project administration, Supervision, Writing – original draft, Writing – review & editing.

Funding

The author(s) declare financial support was received for the research, authorship, and/or publication of this article. This study was supported by the Minority Health Research Training (MHRT) grant no. T37-MD001448 from the National Institute on Minority Health and Health Disparities, National Institutes of Health (NIH), Bethesda, MD, USA.

Acknowledgments

We thank the Regional Health Directorate, the District Directors and Educators for their support in making the study possible. We thank the community members for their participation.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Generative AI statement

The author(s) declare that no Generative AI was used in the creation of this manuscript.

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