Socio-cultural aspects of Kala-azar among Masalit and Hawsa tribes.

El Sayed, Dr. Sumaia M. ; Ahmed, Sara E.

This study deals with the socio-cultural aspects in relation to visceral leishmaniasis or Kala-azar. The objective of the study is to determine the social and cultural factors influencing knowledge, attitude and practices towards Kala-azar in two communities in the Eastern Sudan where Kala-azar is endemic, and to assess the knowledge about the disease and its transmission, symptoms, complications and prevention.

The study is qualitative using focus small group discussion with villagers, personal Interviews with patients and direct observation. The target populations are members of Masalit and Hawsa tribes.

Knowledge about the causative agent of the disease and means of transmission were lacking, but clinical manifestations are well recognised, particularly among the Masalit among whom the disease is more common than Hawsa.

In this study area, introduction of multi-drug therapy and health education, raising awareness and enriching knowledge of the people about the disease, changing of some culture and traditional behaviour can be of use for area prevention and control programme.

Due to poor or non-existing medical services in these remote areas, some people use traditional treatment like mihaia, ground neem leaves and fish oil.

The results, of this study shows that high prevalence of the disease exists among children at the age of 5-15 years.

[LANGUAGE NOT REPRODUCIBLE IN ASCII]

[LANGUAGE NOT REPRODUCIBLE IN ASCII]

Introduction

Visceral Leishmaniasis. (VL) or Kala-azar is an endemic disease in several parts of the Sudan. It was first described by Naeve in 1904 and later on by Bayomi (1979), and Elhassan (1998). Sudan is among five countries in which 90% of VL occurs (Desjeux 1993). The main area of VL is in the Eastern and Central States, and extends to the South to include foci around Malakal in the Eastern Upper Nile.

The epidemiology of VL in Sudan has been extensively studied in the past and several severe outbreaks were recorded over the years. It appears that those outbreaks occur in cycles of every 8-10 years (De Beer 1991).

In the endemic area of Eastern Sudan, VL is a disease of young children. In longitudinal study in Umsalala village, the mean age was 6:6 years and the male/female ratio was 1.8:1. The annual incidence rate in consecutive years in the village was 38.4/1000 and 28.5/1000 respectively. VL occurred only on individuals who had not contracted the disease before (Zijlstral 1994).

The spread and persistence of this disease has been partly attributed to the existing socioeconomic structure and as in the case of other tropical diseases is closely associated with poverty.' Most people living in endemic areas of Kala-azar have a low level of education and income and poor quality housing (Kaendi, 1989). Malnutrition may be an important factor in susceptibility to Kala-azar, since well fed individuals have a higher resistance to the disease (Wijers, 1975). This view was also shared by Muting (1988), who noted that children with sign of malnutrition are more likely to get the disease.

Socio-cultural factors are of importance in relation to attitude of the patient towards the disease. The success of Kala-azar control programme depends to a certain degree on understanding of the patient and society of the aspects related to the cause, prevention, transmission, and the situation in which an individual is believed to have Kala-azar.

Objectives

- To investigate the perception, attitude, and practice, of villagers towards Kala-azar.

- To identify the relationship between socio-cultural aspects and Kala-azar infection, transmission, and prevention.

- To document socio-cultural attitudes related to treatment of Kala-azar

Methodology

This study was conducted in Eltob-elahmar and Bazoura villages where Masalit and Hawsa tribes reside. The two villages are known VL endemic areas in Gedarif State. These two villages are located 600, and 400 km South East and South West of Khartoum respectively. The nature of the villages is characterised by dry and wet seasons of variable duration, the typical common trees are Acacia seyal and Balanaitus eagyptica which are known to be the breeding and resting sites of the vector.

Eltob-elahmar village's population is about 3900 people (Census conducted during the study). These are mainly Masalit, originating from Darfur at the borders with Chad and with areas inhabited by other tribes such as Noba, Tama, and Falata Bargo Ombararo. They have migrated to this area due to the drought that hit Darfour in the 1980's. The inhabitants are labourers and subsistence farmers living in grass huts under poor hygienic conditions. Women work in the fields and other jobs such as wood cutting in addition to household work.

Bazoura village is situated in Northwest Eltobelahmar and has been established by members of the Hawsa tribe from Nigeria, who are farmers, fishermen or traders. Their standards of living and level of nutrition are much higher than Masalit in Eltobelahmar. Furthermore, the Hawsa are more religious and men dominate the society; girls marry at the age of 12-14 years and stay at home and are not being allowed to work outside their home.

Fifty patients with Kala-azar infection from Masalit and Hawsa tribes were randomly selected. The methods used were a variety of socio-anthropologically proven rapid assessment procedures (RAP) that generate a lot of information in a relatively short time. Investigations were conducted through focus group discussion (12 men 10 women), with key informants and community individuals. Interviews were conducted with the 50 patients from the two villages. Structured, pre-tested questionnaire was used to investigate the knowledge attitudes and practices (KAP) of the two tribes.

Results and analysis

In this study, data was collected from the respondents through interviews with patients in addition to a questionnaire, group discussion and direct observation. The data was analysed through epidemiological information program (Epi, 6inf programme) and statistical analysis system (SAS) to calculate the predictive value (P.V).

The majority of the respondents with Kala-azar were males (52%). Most of them (52%), were 5-15 years of age (26%) were more than 15 years old and (22%) were between 1-5 years old.

Most of the respondents (54%), were illiterate (36%) studied in Khalwa and only (10%) studied until primary school.

The majority (46%) of the respondents had an income between 5000-7500 dinars, (24%) greater than 10000 dinars, (16%) between 7500-10000 dinars and (14%) earn less than 5000 dinars, per annum.

The only source for information on the causes, transmission, prevention and control of the disease is the hospital. Sixty two percent of the respondents called this disease Kala-azar and only (38%) called it Elsaeed disease.

Fourty-two percent, of the respondents spent between 7500-10000 dinars on food, 28% spent more than 10000 dinars, 14% spent less than 5000 dinars, 12% spent about 5000-7500 dinars, and only 4% did not spend money on food or got it free from the hospital. Fifty eight percent spent between 1000-2000 dinars on transportation, 30% less than 1000 dinars, 2% more than 20000 dinars, and only 10% did not spend money on transportation.

Table 1 shows that the majority of respondents (60%) do not know the causative agent of the disease, 20% said it was caused by sandflies, 10% caused through dirtiness, 4% of the respondents think that the disease is caused by mosquitoes, 4% attributed to insects and 2% believed through washing in the canal. Also the majority of them (70%) did not know the mode of transmission, 12% of the respondents said it was transmitted through sleeping with patients, 12% said it was transmitted by sandflies, and (6%) said it was transmitted through eating and drinking with patients.

Table 1

Knowledge of respondents about the causative agent of disease

Knowledge No. of respondent Percentage

Sand fly 10 20
Mosquito 2 4
Dirtiness 5 10
Washing in the canal 1 2
Insects 2 4
Know-nothing 30 60
Total 50 100%

Fourty-six percent of the respondents go to the hospital after 30 days from illness and (34%) on 30 days and (20%) before 30 days, due to wrong diagnosis of the disease (88%), difficulty on the transportation (6%), starting treatment in their home (4%) or lack of money(2%).

Table 2

Time before going to hospital

Time duration No. of respondent Percentage

More than month 23 46%
Month 17 34%
Less than month 10 20
Total 50 100%

The study shows that the majority of the respondents (88%), prefer medical treatment, because it is quick and sure and (12%) because no traditional treatment was found useful for this disease.

Most of the respondents (82%), did not use traditional treatment, 18% used a certain type of traditional treatment in the form of ground neem leaves; or 33.3% drink fish oil, while (22.2%) used mihaia, 11.1% apply bleeding, but only 33.3% from those using traditional treatment had recovered.

Also the study shows that, 52% of the respondents have difficulty in reaching the place of treatment, due to difficulty in transportation during the rainy season, while 38.5% due to lack of money (table 3).

Table 3

Difficulties facing the patients to reach the medical treatment

Difficulties No. of respondents Percentage

Yes 26 52
No 24 48
Total 50 100%

Fifty percent of the respondents avoid certain types of food; 44% of these avoid it because they believe that the food causes recurrence of the disease, and 40% believe that it increases the severity of the disease. Eight percent believe that it increases the temperature of the body and the rest (8%) said it increases abdominal pain, although most of the food avoided, contained high nutritive value.

The majority of the respondents(66%) do not know the methods for prevention. The rest (14%) assume that it can be done through cleanliness, (12%), using mosquito bed nets (4%), spraying insecticide (2%) water purification or spraying stagnant water with pesticides(2%).

Table 4

Component of food avoided by the respondents

Item Energy Protein Fat CHO Ca Iron Vit A Vit C

Onion 41 1.2 0.1 6.1 19 1.4 90 18
Pumpkin 23 -- 0.1 5.5 23 0.4 3565 8
Fish 119 21.6 3 -- 32 1.7 trace --
Groundnut Oil 884 -- 99.9 -- -- -- -- --
Chicken 140 20 6.5 -- 10 2 200 --
Lemon 29 0.1 0.4 8.8 25 0.5 -- 40
Meat beef 202 19 14 -- 10 3 -- --
Tomato 21 1 0.2 4.8 -- 0.6 75 26
Green rocket 28 2 0.3 4 80 2.5 300 50

(*)CHO: - Carbohydrates

Ca: - Calcium

Vit: - Vitamin

No significant difference in income between the two tribes was found p.v. = 0.684

A significant difference (p.v. 0.99)was found between the two tribes, because Hawsa are more educated than Masalit. There was no significant difference (pv = 03321) on the knowledge about the disease. Avoidance of food did not differ (pv 0.000) although Hawsa are not selective in comparison to Masalit.

Discussion

The Socio-cultural factor is one of the most important factors that affects the incidence and prevalence of tropical diseases. Therefore, it will also be of importance to know the attitude of the patient towards the disease.

Identification of the related Socio-cultural aspects could be of importance as strategy for eradication of the disease. Many studies found that the rate of literacy correlated positively with- the prevalence of the disease; increase in the level of education leads to increase in the level of health and decrease in the level of the education leads to decrease in the level of health.

Health education can also be of help in strengthening the knowledge, and skills. It can be of help to improve health related to basic hygiene for children, prevention and management of tropical and chronic.

Tropical diseases are usually prevalent in the developing region of the world, due to absence of medical services and malnutrition. The spread of Kala-azar has been attributed to famine, migration to endemic areas and lack of disease surveillance.

Customs and traditions affect the degree of awareness of the community and the level of knowledge to better health care. Traditional medicine is widely used in the Sudan for treatment of many diseases (Browne, 1994) including Kala-azar. Primitive communities depend on traditional medicine for treatment.

In general, people accept and reject food according to certain beliefs. In this study, patients with Kala-azar avoided many types of food despite their high nutritive value because they assumed that food increases severity of the disease by increasing body temperature, abdominal pain and causes recurrence of the disease (table 4).

Conclusions and recommendations

- Due to lack of health education inhabitants in rural areas rely on cultural and traditional remedies.

- Lack of knowledge is one of the main reasons behind wide spread of the disease.

- The study showed an imbalance between income of people and money spent during illness.

- Despite the abundance of clinical and technical information, diseases continue to proliferate. There is a need for effective discussion on the necessity of addressing the Socio- economic aspects of diseases. Health recommendations need to be connected to the recommendations for controlling the diseases.

- The socio-economic status could be a determinant for exposure, to the disease.

- There is a need to develop more cost effective interventions.

- There seems to be a problem in identification of the disease by community members, and in determining which of the diseases is considered to be curable and how?

- There is a great need for biomedical research on Kala-azar as well as availability of information concerning prevention and treatment strategies. The present information often does not reach the community under risk.

References:

Bayomi. A (1979) History of Sudan Health Services. Geneva, Switzerland.

Desjeuxi, P.H.(1993) The Leishmaniasis. WHO Document CTD/Mp/WP. Geneva, Switzerland.

De Beer, P. et al. (1991) Kala-zar Outbreak in the Sudan. Lancet, 335-224.

El Hassan. A.M.(1998) Recent observations on the epidemology of Kal-azar in the Eastern and Central State of the Sudan. Trans. R. Soc. Trop Med. Hyg. 87-395-398

Kaendi, J.M. (1989) Gender issues in the prevention and control of Leishmaniasis and malaria.

Institute of Development Studies, Kenya.

Wijers, D. and Minter, D (1975) studies on the vector of Kala-azar in Kenya. Ann. Trop. Med. and Parasitology.60 11-21.

World Development Report (1994) Investing in Health. Geneva, Switzerland, 870zfa