Short communication

Impact of farmer education on their knowledge, attitudes, and practices in southern Tanzania: a case for Taenia solium control

H A Ngowi, E M Mkupasi, F P Lekule*, A L Willingham III** and S M Thamsborg**

Department of Veterinary Medicine and Public Health, Sokoine University of Agriculture, P. O. Box 3021, Morogoro, Tanzania
h_ngowi@yahoo.com
* Department of Animal Science and Production, Sokoine University of Agriculture, P. O. Box 3004, Morogoro, Tanzania
** WHO/FAO Collaborating Center for Research and Training on Neglected and other Parasitic Zoonoses, Department of Veterinary Disease Biology, The Faculty of Life Sciences, University of Copenhagen, Dyrlægevej 100, 1870 Frederiksberg C, Denmark

Abstract

A comparative study was conducted with pre- and post-intervention assessments on the same subjects to evaluate a health education intervention administered to smallholder pig farmers in Iringa Rural (n = 750) and Chunya (n = 700) districts, southern Tanzania. A total of 366 respondents (249 in Iringa Rural, 117 in Chunya) undertook a self assessment questionnaire regarding knowledge on Taenia solium, its impact and mode of transmission, and attitudes towards consumption of infected pork. McNemar and Bhapkar Chi-square P values were computed in SPSS and MH to assess significant differences.

The study revealed that health education intervention significantly improved the knowledge and attitudes towards Taenia solium control (P < 0.001) and thus would reduce the consumption of infected pork. It recommends that health education, particularly to women be integrated as an essential component of prevention and control programmes for Taenia solium infections.  The Government of Tanzania should revise its pork inspection regulations to include practical ways of controlling porcine cysticercosis.     

Key words: Health education effect, paired analysis, porcine cysticercosis control

Introduction

The tapeworm Taenia solium causes cysticercosis in human and pigs through larval infections. Major impacts are on public health as a result of human neurocysticercosis (disabilities and fatalities) and related economic losses of pig farmers resulting from control, condemnation or lowered value of infected pigs (Ngowi et al 2007; Mutua et al 2010).  Human being is the definitive host who harbours the adult tapeworm in the small intestine. An individual infected with the adult tapeworm passes eggs or egg-containing segments via faeces, which can contaminate feeds and the environment if not properly disposed. These eggs are the source of larval infections in humans, pigs and a few other animals (e.g. dogs). The primary manifestation in humans is neurocysticercosis that is characterised by various neurological manifestations, including epileptic seizures, but also serious headaches, mental confusion, blindness, and stroke. Both, humans and pigs play an important role in the maintenance of the life cycle of the parasite in many endemic areas, because pigs are relatively mostly consumed by human as compared to other Taenia solium intermediate hosts such as dogs. 

Community education on the cause, mode of transmission, economic and social impact and ways to prevent Taenia solium infections has been found valuable in reducing transmission of the parasite in endemic areas (Sarti et al 1997; Ngowi et al 2008; Mutua et al 2010). This approach can be used alone to reduce transmission of the parasite where other control strategies are not available, or, it can be coupled with other strategies such as treatment of human tapeworm carriers for ultimate elimination of the parasite. Nevertheless, many previous public health education intervention studies failed to establish the link between health education with changes both in disease prevalence and farmer knowledge, attitude and practices. A previous randomised field intervention trial in Mbulu district, northern Tanzania, found significant improvement in the knowledge related to Taenia solium transmission and control following health education of smallholder pig farmers and their public and animal health service providers. However, the effect of the health education on farmer knowledge was not statistically significant, presumably because of information contamination (Ngowi et al 2008). Nevertheless, this improvement was accompanied by important reduction in the incidence rate of cysticercosis in sentinel pigs.

The present study used a pre- followed by a post-intervention assessment of same study subjects (cohort) to assess the effect of health education intervention on knowledge and attitudes related to Taenia solium transmission and control in Iringa Rural and Chunya districts, southern highlands of Tanzania.

Methods 

Study areas and background

Iringa Rural district is situated in Iringa region while Chunya district is situated in Mbeya region. Both regions are located in the southern highlands of Tanzania, which receive substantial precipitation during rainy seasons. Nevertheless, some parts of Chunya district are situated along the Rift Valley and characterised by scanty rains. Small scale pig rearing is popular in both districts and a large number of pigs are transported to urban centres (including Dar es Salaam city) for consumption.

The intervention

In 2008, a health education package previously developed and used in Mbulu district, northern highlands of Tanzania was adapted to the southern districts of Iringa Rural and Chunya. The health education package consisted of training by a trained livestock extension officer, a video show, and distribution of a leaflet and a booklet to each participating smallholder pig farmer. Adaptation of the health education to the southern districts settings consisted of mainly revision of some terminology. For example, while Taenia solium cysts were commonly referred to as “fini” in the northern context, they were commonly referred to as “chenga” and “funza” in Iringa Rural and Chunya districts, respectively. While epilepsy would be better understood using the local term “ararangw” in the northern context, the national language (Kiswahili) term “kifafa” was well understood by the communities in the southern districts. The actual implementation of the intervention was similar to the one in the northern district and consisted of a one day training of local livestock extension officers who later trained the pig farmers in specifically organised village meetings. Between May and September 2008, approximately 30 smallholder pig farmers were invited from each of the 47 villages (25 in Iringa Rural, 22 in Chunya) that were involved in previous epidemiological studies on porcine cysticercosis (Boa et al 2006). Smallholder pig farmers were advised to adhere to eight recommendations to control Taenia solium infections: (a) build pig pens and always house all pigs in the pens; (b) dig and use an enclosed pit latrine with a closing door; (c) immediately dispose of children’s faeces in the pit latrine; (d) thoroughly wash hands after using latrines and before eating anything; (e) boil water for drinking purposes; (f) never eat or sell infected pork; (g) consult medical services when showing signs of worm infection or epilepsy; and (h) consult a livestock extension officer when discovering cysticercosis in any of their pigs. 

Intervention evaluation

This was a quasi-experimental study design with pre- and post-intervention assessments of same respondents to obtain paired data. In each village, ten to twelve respondents were selected at random and requested to fill in a five-item questionnaire shortly before the health education. The number of respondents selected per village depended on the number of farmers that attended the training, with more respondents included when attendance was higher.  The questionnaire was designed to assess respondents’ knowledge and attitudes related to Taenia solium. Specifically, each respondent was examined on his/her knowledge on the nature of the pig cyst, how a pig could acquire cysticercosis, whether the pig cyst could cause any problem to human, if yes the respondent was to list down two important problems, and what would be done if pork intended for consumption was recognised to be infected with cysticercosis. The last question was used to measure one’s attitude towards consumption of infected pork.  For example, if a person indicated consumption in any form of infected pork, the person was considered to have a positive attitude towards consumption of infected pork.  Otherwise, the person was considered to have a negative attitude.  The same respondents were asked to fill in another similar questionnaire after the health education. Two individuals in Iringa Rural districts were unable to read and write, and therefore, assisted to fill in their questionnaires. The pre- and post-intervention assessments were carried out within 30 minutes before and after the intervention, respectively.

Ethical consideration

The original intervention protocol was approved by the Tanzania National Institute for Medical Research ethics review board (Reference NIMR/HQ/R.8a/Vol.IX/88) and it is registered with the Australian New Zealand Clinical Trials Registry (Reference ACTRN12609000190202), one of the WHO International Clinical Trials Registries.  We obtained verbal consents from all study participants and their village authorities after the principal researcher had explained the purpose of and possible benefits from the study, as well as the freedom of the farmers to refuse participation.  All information from individual participants was kept confidential.

Statistical analysis

Non-parametric tests were used to analyse data from this study. For dichotomous variables, McNemar’s Chi-square tests were computed in SPSS 12.0. For two variables with three values, the data were summarised in 3 x 3 table in Microsoft Excel and analysed in MH 1.2 to compute Bhapkar Chi square with P < Bonferroni-adjusted significance criterion of 0.025 to preserve the 95% confidence level.

Results 

Table 1 presents the general information of study populations in Iringa Rural and Chunya districts, southern Tanzania, for the study to control Taenia solium infections.

More subjects were included in Iringa Rural than in Chunya district because the previous epidemiological studies included more villages and farmers in the former district. More men than women were interviewed in both districts. This was based on more attendance of men than women in both districts despite general invitations to the training. Most of respondents were older than 20 years of age and the age was comparable between the two districts.

Results of paired analyses to compare pre- and post-intervention proportions of different factors in Iringa Rural district were similar to those in Chunya district.  Therefore, data from the two districts were pooled and analysed together.  Table 2 shows results of these analyses.

The health education intervention significantly improved the knowledge and attitude variables examined in this study, with most McNemar/Bhapkar P < 0.001. Before the health education, the smallholder pig farmers had little knowledge on the nature of the pig cysts, how porcine cysticercosis was transmitted, and the actual impact of the parasite to humans. This led to most of the people consuming infected pork. Nevertheless, 23.9% of respondents had prior knowledge on Taenia solium-related disease conditions such as tapeworm infestation, epilepsy, cysticercosis, and blindness. There was negligible knowledge on the economic impact of the parasite, which was not improved even after the health education. Surprisingly, despite the health education on the danger of consuming infected pork, 28.4% of the respondents informed that they would still consume it (Table 2).

Discussion 

One of the strengths of this study is the use of paired samples in which each individual served as their own control. This helped to eliminate many confounders that could occur as a result of between group variations. In addition, because both pre- and post-intervention assessments were carried out shortly before and after the health education intervention, respectively, and because only one treatment was used, the carry-over effect was controlled. With this study design it was also possible to examine change in knowledge and attitudes at individual level despite the administration of the intervention at village level. Furthermore, the potential implementer bias was minimised by the self-administration nature of the questionnaire. 

In this study, there were significant improvements in knowledge and attitude related to transmission and control of Taenia solium that could be attributed to the health education. Change of attitude towards rejection of infected pork in response to improved knowledge, is an indication of perceived threat (Chen and Land 1986) associated with consumption of infected pork that was addressed during the health education. Nevertheless, to assess the impact of the improved knowledge and attitude on actual behaviour changes needs be followed-up through studies taking into account that behaviour change is a several-step process including an individual’s contemplation of the problem, preparation to change, and finally institution and maintenance of the recommended actions (USDHHS 1996). In a study in northern Tanzania, despite lack of significant positive effect of health education on knowledge and observed practices, the incidence rate of porcine cysticercosis was reduced by 43%, an indication of possible change in practices that could not be measured by the study (Ngowi et al 2008). This emphasizes the need to impart required knowledge on the parasite mode of transmission and control measures, and let the community institute what is possible under their local situation. Community-led total sanitation (CLTS) is one such initiative in which the target community is collectively sensitized to recognise its sanitation deficiencies and take its own decision to stop open defaecation (Kar 2005).   

Despite the significant change in attitudes in favour of rejection of infected pork after the health education, a large proportion of respondents still informed that they would cook and consume infected pork. This is likely an indication of poverty and the value of pork to the community as a source of meat. A similar observation was found in northern Tanzania in which pig farmers still reported selling infected pigs even after the education on the public health impact of Taenia solium infection. These observations call for the government of Tanzania to review its pork inspection guidelines, which currently recommend total condemnation of infected pig carcasses (URT 1962). This seems to be an unrealistic practice, especially in rural areas. The present study advises the government to recommend better ways to make infected pork safe for consumption as in the case of bovine cysticercosis caused by Taenia saginata in order to safeguard public health. Surprisingly, in the present study economic incentive was not considered important in the prevention of porcine cysticercosis regardless of information provided during the training. This is different from northern Tanzania whereby over 70% of respondents mentioned loss of market as the major problem resulting from porcine cysticercosis even before the health education was offered (unpublished data).  The fact that the overall impact of Taenia solium infections to humans was well addressed during the health education in the present study, possibility for misunderstanding of the question by the respondents was ruled out by the fact that the post-intervention results were similar to those of pre-intervention. This calls for region specific emphases when promoting control of porcine cysticercosis.

In this study, fewer women than men responded to the questionnaire.  This was because relatively fewer women attended the training than men and the questionnaire was administered on the training stations.  This is an indication that women in rural areas stay at home most of the time as opposed to men.  This is supported by a similar finding in northern Tanzania whereby 61% of respondents were women when a questionnaire was administered at home (Ngowi et al 2009).  Considering that small scale pig production in rural areas of Tanzania is mostly a women's enterprise, this finding calls for careful planning of intervention programmes intended for promoting pig production in rural areas to ensure that women are reached. Studies are needed to explore better strategies to deliver information to women at their homes. Opportunities for using local radio programmes and mobile phones need to be investigated in addition to other suitable options.

Acknowledgements 

This work was supported by the Danish International Development Agency through Cross-disciplinary Risk Assessment of Cysticercosis in Eastern and Southern Africa (CESA) Project.

We are grateful to Prof. Jesper Monrad, Copenhagen University, who encouraged us to feedback study communities with research findings and provide them with necessary information to control Taenia solium infections.  We acknowledge cooperation shown by study participants and their authorities in Iringa Rural and Chunya districts, southern Tanzania.

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Received 25 August 2010; Accepted 12 November 2010; Published 5 January 2011

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