Description of study area
Eastern zone is among the seven zonal administrative units of Tigray regional state which consists of 9 districts. Of which two are town districts while the remaining 7 are rural districts. Adigrat is the capital town of the zone. The zone is located at 14016’N 39027’E longitude and 14016’N 39027’E latitude; with an altitude ranges from 2000–3000 meter above sea level. The average annual rainfall is 552 mm and that of temperature is 16oC. The study was conducted in three districts of Eastern zone, namely, Adigrat town, Ganta Afeshum and Gulomkada (Fig. 1).
- Zone is a large political administrative unit next to regional state.
- Ketena and Kushet (urban and rural, respectively) are the smallest administrative units in the study region, Tigray – both are synonymous with parish.
- Tabia is an administrative units larger than Ketena and Kushet but smaller than districts.
- Community member: in this paper, community member used only to differentiate respondents who are not professional/experts, FGD participants and key informants.
The study used a mixed-method design employing both quantitative and qualitative methods. A cross-sectional survey was concurrently conducted with FGD and KII from May 2019 to April 2020.
Sample Selection And Healthcare Sector Description
The study districts were selected purposively. In total, 10 tabias were included in the study. Three from each district, were randomly selected: Adigrat (01, 03 and 05 tabias), Gan-afeshum (Bizet, Bahrasehita and Hagereselam) and Gulomkada (Fatsi, Kokobtsibah, Anbesetefikada). One tabia (Sebeya) from Gulomkada which had anthrax outbreak in 2018 was purposively included. All parishes under the selected tabias were included. Inclusion criteria were logistic feasibility and history of anthrax outbreak. Initial survey was conducted to collect the number of households and populations from each selected tabia and parish. Besides, animal and human healthcare sectors were identified. In animal healthcare sector, there were three clinics, one for each district. They provided veterinary service based on clinical signs with few broad spectrum medicaments. Rural tabias had no permanent veterinary facilities. They were reached from the respective district center/clinic for vaccination and sometimes for case management. Healthcare coverage is better in human than animal sector. Formal clinical services were provided through health posts, clinics/health centers and hospitals. Our rural study tabias had one health center each except Bahrasehita and Anbesetefikada which got healthcare from the neighbor tabias. Adigrat town had one general hospital and two health centers. Lists of households were not available. Hence, Respondent households were selected using systematic random sampling while all health professionals available at the time of visiting were included.
Structured-questionnaire with mostly close-ended questions was prepared. It was translated into local language, Tigrigna, and translation was done back into English to keep the consistency. Enumerators, with University degree whose mother tongue and currently spoke Tigrigna, were selected. Training for enumerators was given. In addition to the content of the questionnaire, enumerators were tutored about the disease by using some supportive pictures which showed some clinical signs including cutaneous lesion in human and bleeding from natural orifices from dead animals. The authors themselves participated in data collection. Data collection format was prepared for individual case. The questionnaire was tested in both rural and urban residents. In this study, a total of 862 respondents were interviewed. Of which, 800 were urban and rural dwellers. While 62 were professionals/experts working at animal and human health service institutions: 49 human health practitioners (HHPs) and 13 animal health experts (AHEs). For the community, one person per household with age of ≥ 18 years old was interviewed - Interview was held face to face by the enumerators. While health workers were given the questionnaire and allowed to answer the questions by themselves.
The questionnaires were of two types: one for the community members (Additional file: Questionnaire A) and another one for professionals (Additional file: Questionnaire B) with slice differences for animal and human professionals. The first questionnaire comprised: socio-demographic information of the respondent (age, sex, educational status, occupation, religion), animal ownership, questions related to knowledge (e.g. knowledge on the disease, source/cause of the disease, signs of the disease in animal and human, transmission routes to animal and human, prevention methods in animal and human), attitude (e.g. seriousness of the disease in animals and humans and the importance of vaccination) and practice related questions (e.g. animal vaccination and frequency and medication of animal and humans). The second questionnaire aimed at assessing the knowledge of the disease amongst health professionals. Majority of the questionnaires’ components were the same with the first one. However, some additional questions were incorporated: questions related to knowledge (e.g. etiology of the disease, form of anthrax, transmission route form each form), questions related to outbreak and case admission to animal and human healthcare centers (e.g. occurrence of outbreak in animal and human, number of cases admitted in animal and human healthcare center, number of recovery and death in animal and human).
Knowledge on anthrax/ Megerem
Different local name of the disease in animals in different locality
The researchers approached the participants by using the local name Megerem which is commonly known in Tigray. However, the researchers gave opportunities to the participants to name their own local name of the disease by telling the clinical signs of the disease in animals and humans when they failed to recognize the name Megerem. Because farmers usually named diseases based on their clinical signs and lesion/pathology they found in animals.
… I do not know the disease Megerem, but I have heard about it. But I know Lalish and Gulbus in animals (male participant, Sebeya). This participant called another person for help, a deacon male participant. The second participant had given similar opinion with some clarifications.
…I do not know Megerem in animals. Perhaps we can learn from you. But in cattle, there are other diseases I know. One is “Lalish”, enlargement of the spleen. Moreover, there is another fatal disease called “Gulbus” showing cramp like symptoms and shivering. This disease may sometimes be confined around the head (neck swelling), in this case animal may not die soon (the deacon male participant, Sebeya). This idea was supported by most of this FGD (Sebeya) participants. The FGDs participants from Ganta-afeshum district had similar understanding about the disease. A 78 age male participant named the disease in animals Tafia (enlargement of spleen) (Hagereselam tabia, Ganta-afeshum district). Similar suggestions had been given in Bizet tabia of the same district. Especially, a female participant told that Lalish was a sever disease of cattle (Bizet tabia, Ganta-afeshum district).
Anthrax/Megerem perceived only as human disease
The deacon participant from Sebeya said that Megerem appears in the neck/face of humans and could not be cured without treatment (modern medication). Another female participant from the same area shared her knowledge about human Megerem. …My daughter (one year old) was sick (swelling in the wrist). My daughter was waiting without medication for few days. When the swelling has become bigger and bigger, I took my daughter to health center. After medication, she cured but she was suffered.
The researcher asked: What look likes the swelling? The same female participant responded: the swelling starts with small size. Then it increases in size with depressed black eschar in the center.
The researcher added another question: Do you think that this disease can attack animals? I do not know. Where your daughter acquired the disease from? …I did not know its origin or from where it came. If I had known that I could have prevented and/or taken quick measure for my daughter during her suffering.
Indeed, the second female participant from the same group partially supported the idea of the first female participant but she had different view in the characteristics of the disease. This participant did not agree with the first female participant, especially with the nature of the lesion (depressed black eschar) in the center of the swelling. She said that the swelling had no depressed black eschar (Sebeya tabia, Gulomkada district). A female participant from Bizet tabia fanatically said that it should not be talking about Lalish in front of animals because animals could be panic when they heard the word Lalish – indeed; she reflected the belief of the community. However, she failed to relate with human Megerem (Bizet tabia, Ganta-afeshum district).
Anthrax perceived by the participants after they had been told its clinical signs
Most FGD participants from Fatsi and Anbesetefikada tabias (both from Gulomkada district) told that they did not know the disease Megerem/anthrax, and the disease has not occurred in their locality. However, after the researchers had explained the nature/signs of the disease in animals and humans, few individuals tried to share what they have heard/known about the disease.
…I have seen bleeding from natural orifices of dead animals. But I do not know the name of the disease (male participant, Fatsi). Other participants said that they have seen bleeding through natural orifices and absence of rigor mortis of dead animals but they did not relate to Megerem (Hagereselam and Bizet, Ganta-afeshum district).
Knowledge on the causative agent, transmission and control/prevention methods on anthrax/ Megerem
Most FGDs participants did not know the causative agent, transmission and control/prevention methods of anthrax/Megerem in animals and humans. Some of the participants associated Megerem in animals with the local belief, Weqh’e (unidentified cause but they told that it caused sudden death): but the participants believed that it can be transmitted to humans through consumption of meat. Some of the participants also believed that the disease could occur in humans when there was stress (e.g. thirst, starvation), and consumption of meat and alcohol might exacerbate the disease. According to these participants, the disease was commonly seen in poor body condition animals, and exacerbated when diseased animals had consumed water. Few participants mentioned that the disease was caused by germs. Regarding the control/prevention methods, FGDs participants agreed that though the disease had been treated using traditional medicine, nowadays modern medication has become their best option in animals and humans. However, some of the participants still believed in traditional medicine – heating, the spleen using hot iron or, around the bottom part of the neck if there was swelling and bloodletting in animals were commonly used. All the FGDs participants did not recognize the GIT and pulmonary forms of the disease in human.
Data Management And Statistical Analysis
Quantitative data were run using STATA statistical software (version 14.0, Stata Corp, college station, Texas 77845 USA) for analysis. To ensure quality, data were crosschecked independently by the researchers. The effects of socio-demographic factors (such as age, sex, educational level, district, occupation, religion and animal ownership) on knowledge of the disease, and its causative agent, zoonotic nature, symptoms, transmission and control/prevention methods were analyzed using descriptive statistics. Moreover, with 95% confidence intervals, logistic regression model was used to evaluate the association between the outcome (e.g., knowledge on the disease its zoonotic nature) and the aforementioned socio-demographic variables. A P-value < 0.05 was considered statistically significant.
Qualitative data collected through audio recorder first were transcribed into computer files and then were translated from the local language Tigrigna into English. Thematic analysis was used as described in Graneheim and Lundman . The narratives were read several times to understand the whole sense of the text. After setting the major themes, texts were extracted and brought under each theme. Illustrative quotations that clearly represented the themes were used in the results.