Considering the effectiveness of BASNEF training model, factors associated with Cl in the earthquake-affected areas (Qasr-Shirin and Sarpol-Zahab) were surveyed to provide comprehensive information on the status of these factors. The BASNEF model is derived from two models (precede and behavioral intention model) and was designed to study behavior and program to determine effective factors in behavior and facilitated behavior alteration[11]. The transmission of CL is highly dependent on climate conditions and on the ecology of vector/reservoir hosts [12]. The level of education has an important and undeniable effect on the health of individuals, which has been emphasized in several studies [5]. Certain characteristics of families, such as level of education and income influence their perceptions of illness, severity, treatment, health status and the use of health services [13]. Furthermore, economic situation or social factors and climate variability may have substantial effects on the epidemiology of CL. In view of CL control, it seems that ecological and environmental factors that spread the disease and thus improve preventive and control measures are of utmost importance [14, 15]. Environmental factors (such as inappropriate sanitary conditions), inadequate environmental health measures (namely landfill and dumping of construction and demolition wastes), environmental changes (namely agricultural development), natural disasters (such as floods and earthquakes) and the construction of residential areas close to rodent nests can be the cause of spread of CL in tropical regions [16]. In terms of the economic situation of the society, the highest income was between 10 and 30 million Rial. Leishmaniasis more often occurs in areas that are poor in terms of economic and social conditions, because poverty often contributes to poor environmental conditions (lack of sewage and waste disposal systems), which increase the potential of contagious diseases such as CL spreading [17, 18]. The discharge of waste, sewage and animal waste in villages provides a suitable environment for propagation of sandflies and the accumulation of rodents. Therefore, control measures such as environmental sanitation, improvement in human and animal living conditions, collection of animal manure and construction waste from the rural environment and separation of human and livestock living places can reduce abundance of CL carriers [7]. Most families participating in the study discard excess water and sludge (all wastewater generated in households without fecal contamination) on the surface of the yard and alley, which gradually penetrates the courtyard, creates a shelter for sand flies and thereby increases the incidence of CL. By implementing new and collaborative-innovative activities such as wastewater treatment systems based on families’ needs, the disease can be prevented [17].
Based on this study, 23.43% of patients disposed of waste via dumping, which requires serious intervention in order to control vector sand fly. Easy preparation and low cost waste bags and bins for a proper daily waste collection by families for sanitary landfill disposal in a remote area are required [19, 20]. Factors such as accumulation of waste, construction waste around habitat, accumulation of sludge on the grounds of residential properties as well as keeping animals and also sandflies in the area can make the disease endemic in the region [17]. Effective fight against rodents, use of personal protection methods such as insecticide-treated nets (usually permethrin), chemical barriers (repellents) and toxic bait are among other ways of controlling the disease [20]. For example, in case of canine Leishmaniasis (CanL) the use of topical pyrethroids (deltamethrin, permethrin, or flumethrin), with or without other insecticides, such as Caneline, one of local-commercial insecticides, was one of the best preventive control measures because of their synergistic effect on insects [13].
There was no meaningful difference in the knowledge structure in relation to other structures in the BASNEF model investigation. These results are consistent with similar studies in this field [21]. The mean of attitude score in participants was low. Increasing knowledge and correcting false beliefs in individuals can be considered as one of the reasons for raising mean score of participant attitude in the study group [19]. The reason for difference in the impact of education on people's attitudes in various studies may be that attitude and practice more than consciousness are usually influenced by various environmental and social factors. Therefore, education and informative programs alone are not able to correct them. Thus, it can be stated that solely increasing knowledge is not enough to improve the attitude [10]. To investigate the relationship between BASNEF model constructs, Pearson correlation and linear regression were used. There was a direct correlation between behavioral constructs (control measures) with intentional behavior, enabling factors, and abstract norms which was statistically meaningful (P < 0.05) [22].
The roles of enabling factors and intentional behavior with regression coefficients of 0.179 and 0.177 were the most accurate predictors of CL preventive behaviors, respectively, which is consistent with the results reported by Zhang et al., and other studies regarding the important role of enabling factors and intention to behave in the prediction of control measures [23, 24]. One of the most important factors influencing behavior in any society is the abstract norms (influential individuals). In this study, family members were the most influential people in preventing CL. Therefore, it is necessary to have the highest attention on education of families in order to obtain the best results for these behaviors [10, 21]. In the behavioral structure and behavior that involves control measures, the least frequent preventive behavior was the use of insecticides, the installation of nets and using bed-nets impregnated with insecticide. The reason for this is that most households stated inappropriate economic situation to purchase a net and the improper installation (because some people were living in dwellings and tents). This was confirmed by study of socioeconomic status of people in the earthquake affected areas. To promote this preventive behavior, the need for cooperation and participation of other institutions, such as health centers, is necessary [25, 26]. Regarding the level of preventive behaviors and the importance of factors contributing to these behaviors, provision of enabling factors, especially through educating family members, as the most influential individuals, can be effective in preventing seizures [27].
The availability of financial resources to buy mosquito nets and insecticides had the least effect in enabling factors. Therefore, in this important part of structure, intervention is needed to convert intention to behavior. For example, the purchase of appropriate insecticides or mosquito nets, or their free distribution by health centers in sensitive areas, as well as providing subsidies for the purchase of mosquito nets could improve health status [28]. Measures such as inter-sectoral cooperation and inter-organizational collaboration can somehow be effective in controlling the disease. Providing financial support and equipment by researchers and experts can improve health status and subsequently, to some extent, reduce the burden of the disease [21].