In 2014, the World Health Organisation stressed the serious and increasing threat of vector-borne diseases in the world including leishmaniasis with a slogan “Small bite, big threat” [18]. Hence, there is a need for intensified research to understand the knowledge, attitude and practices of communities living in the endemic areas about CL. We found most participants had seen CL and knew its clinical manifestations. Similar findings had earlier been reported in Ochello, southern Ethiopia [19]. Our findings on the community’s knowledge of CL are however better than reports from India where respondents recognised pictures of CL shown to them but did not have any lay perceptions about the disease [20, 21]. These differences could be due to differences in the approach to socio-cultural factors and prevention strategies between countries.
Knowledge on CL and its transmission
Knowledge on CL and involvement of sand flies had a significant correlation with implementation of sand fly control measures in Guatemala [22] and Colombia [23]. Knowledge on the disease resulted in behaviour directed towards its prophylaxis and treatment [24]. We observed gaps in the knowledge on the transmission of the disease and still there are people in the community who believe that the parasite is transmitted via mosquitoes and through direct contact with infected persons. Though our findings are lower than 37.5% and 59.7% in a study in India where respondents claimed the role of mosquitoes in the transmission of CL and direct transmission from one person to another through direct contact respectively [20], such beliefs need to be addressed and correct information provided to communities in order to reduce potential for stigmatisation of affected individuals.
The transmission cycle of Leishmania exhibits characteristics that are particular to each endemic area therefore, does not allow extrapolation of data from one region to another [25]. In this study some significant proportions of the respondents did not have the correct knowledge on the peak season and time when the insects (sand fly) bite. These results are consistent with the report in Pakistan where 54.8% of the participants were unaware of the time when the insect bites and 24.8% believed that the peak season for sand fly bites was summer [14]. In most endemic areas, the transmission of the disease is almost throughout the year peaking after rainy season. Understanding the period of the year and the period of the day when transmission is highest is important for communities to prepare themselves by putting in place necessary preventive measures.
Perception and attitude towards CL and its treatment
Studies have indicated a direct relationship between the knowledge of the population at risk of a disease and preventive measures [10]. In this study, majority of the participants believed that CL is a serious condition and were concerned about the cosmetic and disability consequences of the diseases. These findings are higher than those reported in Paraguay where only 10% of the participants perceived that CL was a problem [26]. Residence in rural areas significantly correlated with having seen a patient with CL, knowledge, attitude and practices about CL. Applying the Integrated Behaviour Model [27] which is grounded on the theory that an individual’s intention to engage in a behaviour is influenced by his/her attitude (experiential) towards the behaviour, our study indicates that high incidence, serious consequences of the disease and socioeconomic are key factors which have influenced concerns among rural residents about CL as presented with a significant association between rural residence and CL.
Usually CL heals spontaneously but in delayed treatment the disease can lead to serious tissue damage, secondary infection, disfiguring scar formation, impaired function and psychosocial consequences including depression. Delay in seeking treatment is associated with negative perceptions and attitude towards treatment options and lack of or inadequate information access about CL treatment have influence on the people’s treatment seeking behaviour [15, 19]. In many developing countries traditional healers play an important role in the delivery of health care and majority of the populations depend on them for most of their ailments [28]. We found that respondents believed CL is treatable and traditional medication was the best treatment option over modern treatment. Participants expressed positive experiential attitude towards traditional medicine because of its easy accessibility and expressed negative experiential attitude towards modern treatment because it is not easily accessible and the places where modern medicines can be accessed are far from the communities. A report on the review on various countries have suggested that traditional healers if properly trained can contribute positively to the primary health care teams and recommendations were made to take advantage of traditional healers as valuable resources to provide relevant and appropriate information and timely treatment in order to reduce consequences of delayed treatment of CL [29]. The government and other stakeholders involved in the provision of health services in Ethiopia should therefore bring the services closer to the affected populations by introducing mobile clinics, constructing health facilities in the endemic areas, making medications available at no or reduced cost and raising awareness of the community of the advantages of using modern treatment. Similarly, providers of health care in the affected areas should engage with traditional healers and determine effective ways of integrating traditional healers in the provision of care.
Perceptions on CL prevention and control
Most participants believed that CL is preventable and the most preferred preventive approach was personal hygiene. Education on CL and its consequences has been reported to be cost-effective and improves uptake of preventive measures [30]. In that regard, primary prevention like health education should be given priority through identification of population groups at risk including those involved in activities without using protection either by insecticides or clothing [31, 32]. On the use of bed nets, communities need to be educated that since sand flies are much smaller than mosquitoes impregnated bed nets with much smaller maze should be used. In addition, communities should be informed on how to reduce the natural reservoirs of Leishmania.
The epidemiology of leishmaniasis is influenced by several factors including suitable vectors, environmental conditions, socio-economic status, demographic and human behaviours [33, 34]. Poor housing, migration in search for employment, deforestation, immunosuppressive conditions like HIV and AIDS and malnutrition are some of the risk factors implicated on the prevalence of leishmaniasis [35, 36]. Like in many developing countries, these factors are also prevalent in Ethiopia. The country therefore, should put in place coordinate prevention, control and eradication programmes that would reduce public health and socio-economic impact of the disease to communities in endemic areas. The media including television, radio stations, printed media and political platforms should intensify raising community awareness on CL and because of the strong beliefs communities have on traditional medicine, the government should attempt to authenticate traditional healers and research should be carried out to determine the efficacy and safety of traditional medicines used to treat CL.
Limitations
Limitations of this study include limited number of open ended question which would have helped the respondents to add more information to the provided questions, and the findings may not necessarily be generalizable to the whole country because of differences in the population dynamics like environment, economy, and educational status. In addition, immunosuppression and co-morbidity CL could influence the manifestation and severity of the diseases.