ARC Journal of Urology

AUTHOR DETAILS

Nwabueze SA¹, Amah CC², Azuike EC^*1,6, Anene JO³, Kadiri-Eneh NP⁴, Anameje OA⁵, Akudu AC<sup>1

1</sup>Department of Community Medicine, Nnamdi Azikiwe University Teaching Hospital Nnewi, Nigeria
²Department of Paediatric Surgery, University of Nigeria Teaching Hospital Ituku/Ozalla, Enugu, Nigeria
³Department of Health, Anambra State Local Government Service Commission Awka, Anambra State, Nigeria
⁴Department of Community Medicine, University of Portharcourt Teaching Hospital Portharcourt, Rivers State, Nigeria
⁵Deparment of Family Medicine, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria
⁶Foundation for Health and Development in Nigeria
*[email protected]

KEYWORDS

Knowledge, Attitude, practice, Ebola.

INTRODUCTION

Ebola virus is a 19kb long, non-segmented, single stranded RNA virus, which is a member of the viral family filoviridae and the causative agent of the Ebola viral disease1. Ebola viral disease is an example of a viral hemorrhagic fever. Hence the alternative name Ebola hemorrhagic fever. Viral hemorrhagic fevers are a diverse group of animal and human illnesses that may be caused by five distinct families of RNA viruses; Arenaviridae, Filoviridae, Bunyaviridae, Flaviridae and Rhabdoviridae. Other examples of viral hemorrhagic fevers are Crimean – Congo hemorrhagic fever, South American hemorrhagic fever, Dengue fever, Rift valley fever, Lassa fever and Yellow fever. All types of viral hemorrhagic fevers (VHF) are characterized by fever and bleeding disorders and all can progress to high fever, shock and death in many cases2. Before outbreaks are confirmed in areas of weak surveillance, on the local or regional levels, Ebola is often mistaken for malaria, typhoid fever, dysentery, influenza or various bacterial infections, which may be endemic to the region3. The Ebola virus causes an acute, serious illness, which is often fatal in humans. The average Ebola viral disease (EVD) case fatality rate is around 50%. However, case fatality rates have varied from 25% to 90% in past outbreaks. Ebola viral disease (EVD) first appeared in 1976 in two simultaneous outbreaks, one in Nzara (Sudan) and the other in Yambuku (Democratic Republic of Congo). The latter occurred in a village near the Ebola River, from which the disease takes its name. Five strains of the Ebola virus have been identified; Zaire, Bundibugya, Sudan, Reston and Tai forest. The Bundibugya, Zaire and Sudan Ebola Virus have been associated with large outbreaks in Africa. The virus that caused the 2014 West African outbreak belongs to the Zaire strain4,5. The most recent outbreak in West Africa (first cases noticed in March 2014) is the largest and most complex Ebola outbreak since the Ebola virus was first discovered in 19766,7. There have been more cases and deaths in this outbreak than all others combined. It has also spread between countries starting in Guinea, then spread across land borders to Sierra Leone, Liberia and Senegal and by air to Nigeria4,7. The most severely affected countries, Guinea, Sierra Leone and Liberia have very weak health systems, lacking human and infrastructural resources, Liberia and Sierra Leone having only recently emerged from long periods of conflict and instability. EVD is highly contagious owing to the fact that Ebola virus belongs to the group of enveloped viruses that generally have high infection rate. This is because the lipid envelop helps them to enter easily into the host's cells. However, the good news is that sound hygienic lifestyle with effective use of antiseptic materials can go a long way to prevent contracting the infection. The simple reason to this is that the lipid envelop covering of the virus can easily be destroyed by some chemical and physical agents (e.g. some solvents, heat, low temperature, oxidizing agents like bleach, detergents, 70% alcohol solution).

In view of the mode of transmission, some risk factors have been recognized. These include lifestyle behaviours that can predispose (expose) someone to this virus: Handling bodily secretions of an infected individual e.g. blood, urine, saliva, sweat, seminal fluid, vaginal fluids; Attending to a person sick with the virus; Visiting hospitals or homes where Ebola patients are hospitalized; Having handshakes with an infected individual; Exchange of personal belongings e.g. clothes, eating utensils, tooth brushes of someone infected with the Ebola virus; Coming in contact with sweat of infected person; Overcrowding; Handling of bush meat with bare hands/eating poorly cooked bush meat, etc. The incubation period, is 2 to 21 days, most often this is between 4 to 10 days8,9,10. Humans are not infectious until they develop symptoms.

A study done in Sierra Leone reported high levels of awareness regarding EVD, but low comprehensive knowledge on EVD. Also the preventive practices against EVD were low and there were a lot of misconceptions regarding EVD. Furthermore, there was very high level of stigma and discrimination towards EVD victims11. This study was carried out to assess the knowledge, attitude and practice regarding Ebola viral disease prevention measures among secondary school students in Nnewi North and Nnewi South Local Government Areas in Anambra State. This study was done durig the last ebola outbreak in Nigeria.

METHODOLOGY

Nnewi North is a local government area (LGA) in Anambra state, South-east, Nigeria. Nnewi is the only town in Nnewi North LGA. There are four villages that make up the town: Otolo, Uruagu, Umudim and Nnewichi. Nnewi has a population of 391,227 according to the 2006 National population census12. Nnewi North LGA hosts 8 government owned and 48 privately owned secondary schools. Nnewi South is a Local Government Area in Anambra State, South-east Nigeria, with its headquarters at Ukpor. Other towns that make up the LGA include Ekwulumili, Amichi, Azigbo, Unubi, Ezinifite, Osumenyi, Utuh, Akwaihedi, Ogbodi and Ebenator. Its population is approximately 233,360 according to the 2006 population census13. Nnewi South hosts 17 government owned and 22 privately owned secondary schools.

Study population: The study population were secondary school students in Nnewi North and South LGAs of Anambra State.

Study Design: This was a cross-sectional descriptive study

Sample Size Determination

The minimum sample size was calculated using the formula below14; Where;
N = minimum sample size
Z = standard normal deviate at 95% confidence level (ie 1.96)
P = proportion of target population estimated to have characteristic of interest;taken as 50% (0.5)
q = 1 – p ( ie 1 – 0.5)
d = margin of error, usually set at 5% (ie 0.05)

N =

1.962 x 0.5 x 0.5 0.052

= 384

• Attrition
An anticipated 10% attrition rate was assumed. Hence 10% of the calculated minimum sample size was added:


The final calculated sample size was 384 + 38.4 = 422. So 422 questionnaires (211 per LGA) were distributed. However only 400 questionnaires (200 per LGA), were included in data analysis.

Sampling Technique:

Multi-stage sampling technique was used:

Stage I: Simple random sampling technique was used to select three schools from each local government giving a total of six schools.

Stage II: Stratified sampling was used in selecting the respondents for the study.

Study Instrument: A Structured, self-administered questionnaire was distributed to the respondents after obtaining verbal consent from them. The questionnaire was divided into four sections. Section A contained socio-demographic data, section B: knowledge of the respondents, section C: attitude and section D: preventive measures practiced.

Data Analysis: Data obtained was analyzed using SPSS version 20, percentages were worked out and finally data was represented in tables.

Ethical Consideration: Approval was obtained from the ethical review board of the Nnamdi Azikiwe University Teaching Hospital Nnewi. The consent of the School Principals was obtained as well as that of the individual respondents.

Inclusion Criteria: Eligible respondents who gave their consent.

Exclusion Criteria: Students that were not in the selected schools. Students in the selected schools but were sitting for the Senior School Certificate exam during the study. Students who did not give their consent.

RESULTS

Table 1 shows the socio-demographic characteristics of the respondents. Out of the 200 respondents in Nnewi North, 73(36.5%) were males and 127(63.5%) were females. With regards to their family size, 45(22.5%) were 2 to 4 in the family, 103(51.5%) were 5 to 7 persons while 52(26.0%) were greater than 7 in the family. Out of the 200 respondents 197(98.5%) were Ibos, 2(1.0%) were Yorubas, none was Hausa, while 1(0.5%) was from other tribes in Nigeria. Most of the respondents 199(99.5%) were Christians, none of them was Islam or Traditionalist, while 1(0.5%) practice other forms of religion. With regards to the highest educational levels of the parents of the respondents, 6(3.0%) of fathers had no formal education, 20(10.0%) had primary education, 81(40.5%) had secondary education, 93(46.5%) had tertiary education. Also 2(1.0%) of the mothers had no formal education, 20(10.0%) had primary, 82(41.2%) had secondary education, 96(48.0%) had tertiary education. Thirteen (6.5%) of the fathers were farmers, 18(9.0%) were professionals, 11(5.5%) were bankers, 109(54.5%) were traders, and 49(24.5%) of the fathers had other forms of occupation. Six (3.0%) of the mothers were farmers, 60(30.0%) were professionals, 6(3.0%) bankers, 114(57.0%) were traders and 14(7.0%) had other types of occupation.

Table 1

Out of 200 respondents studies in Nnewi South, 104 (52.0%) were males while 96 (48.0%) were females. Thirty six (18.0%) had a family size of 2 to 4, 106 (53.0%) with a family size of 5 to 7, and 58 (29.0%) had a family size greater than 7. With regards to tribe/ethnicity, 195 (97.5%) were Ibos, 2(1.0%) were Yorubas, 1 (0.5%) was Hausa and 2 (1.0%) were from other tribes in Nigeria. Out of 200 respondents, 194 (97.0%) were Christians, 2 (1.0%) were Islam, and 4 (2.0%) practiced Traditional religion. With regards to the fathers' highest educational level, 4 (2.0%) had no formal education, 39 (19.5%) attended primary school, 91 (45.5%) had secondary education, 66(33.0%) had tertiary education. One (0.5%) of the mothers had no formal education, 28 (14.0%) went to primary school, 104 (52.0%) went to secondary school, while 67(33.5%) acquired tertiary education. With regards to the parents' occupation, majority of their fathers were traders 96 (48.0%), 36 (18.0%) were farmers, 29(14.5%) were professionals, 11 (5.5%) were bankers, 2 (1.0%) were hunters while 26 (13.0%) had other types of occupation, while 23 (11.5%) of the mothers were farmers, 44(22.0%) were professionals, 5 (2.5%) were bankers, 118 (39.0%) were traders, while 10 (5.0%) had other forms of occupation.

Table 2    Table 2.1


Table 2 shows the knowledge of the respondents regarding EVD. Table 2 shows that 190(55.0%) of the respondents in Nnewi North and 192(96.0%) in Nnewi South have heard of EVD, 27.0% in Nnewi North got their information from their parents, while in Nnewi South, 26.0% got the information from their parents, 45.0% (Nnewi North) and 57.0% (Nnewi South) through the radio, 61.0% (Nnewi North) and 47.5% (Nnewi South) through the television, 30% in Nnewi North and 30.5% in Nnewi South from the newspaper, 22.5% in Nnewi North and 21.0% in Nnewi South from the church, 26.5% (Nnewi North) and 19.0% (Nnewi South) from their schools, 27.5% and 15.0% of the respondents from Nnewi North and Nnewi South respectively got their information from their friends and 13.5% (Nnewi North) and 10.5% (Nnewi South) from the market place. On the other hand, majority of the respondents 72.5% and 77.0% from Nnewi North and Nnewi South respectively believed EVD existed in Nigeria. With regards to how EVD can be contracted or acquired, 88.5% in Nnewi North believed it can be acquired through eating bush meat while in Nnewi South 90.0% believed it can be acquired through eating bush meat; 88.0% (Nnewi North) and 83.0% (Nnewi South) through sexual intercourse; 84.0% (Nnewi North) and 77.0% (Nnewi South) through kissing; 93.5% in Nnewi North and 88.5% in Nnewi South through blood; 91.0% and 83.0% through sweat from Nnewi North and South respectively; 90.0% (Nnewi North) and 80.5% (Nnewi South) through saliva; 84.5% (Nnewi North) and 74.0% (Nnewi South) through urine; 94.5% (Nnewi North) and 88.0% (Nnewi South) through sharing of personal belongings; 83.5% (Nnewi North) and 85.0% (Nnewi South) through body contact while 87.0% (Nnewi North) and 85.0% (Nnewi South) through attending burial ceremonies that require touching the body of the dead suspected to have died of Ebola. Sixty one (30.5%) of the respondents in Nnewi North and 45.0% in Nnewi South believed EVD can be transmitted through mosquito bite while 52.0% from Nnewi North and 62.5% in Nnewi South believed it can be transmitted through the air.

Regarding how EVD can be prevented, 95.0% (Nnewi North) and 90.0% (Nnewi South) believed EVD can be prevented by avoiding consumption of bush meat, 95.0% (Nnewi North) and 90.5% (Nnewi South) by avoiding close body contact and contact with bodily fluids, 93.0% and 88.0% of the respondents from Nnewi North and South respectively by the use of hand gloves, 95.0% (Nnewi North) and 87.0% (Nnewi South) by hand washing, 94.5% (Nnewi North) and 87.0% (Nnewi South) by use of hand sanitizers while 45.5% from Nnewi North and 40.0% from Nnewi South by avoiding burial ceremonies. With regards to knowledge of symptoms of EVD, majority of the respondents have good knowledge of the symptoms; fever 45.5% (Nnewi North) and 43.0% (Nnewi South), weakness 41.5% and 35.5% Nnewi North and South respectively, muscle pain 21.5% and 14.5% respectively, vomiting 48.0% (Nnewi North) and 38.0% (Nnewi South), diarrhoea 23.0% (Nnewi North) and 15.5% (Nnewi South), rashes 30.5% and 24.5% respectively, and bleeding from the nose, mouth or anus 60.5% and 46.0% from Nnewi North and South respectively. Concerning treatment, 71.5% and 65.5% of the respondents from Nnewi North and South respectively believed EVD can be treated.

Table 3

Out of 200 respondents in Nnewi North, 9.5% would keep it secret if he or she had any of the symptoms of EVD, while out of the 200 respondents in Nnewi South, 18.5% would keep it secret. In Nnewi North 37.0% of the respondents would seat close to a person who recovered from EVD, while only 32.0% would do same in Nnewi South.

Table 4

In Nnewi North, 95.5% of the respondents and in Nnewi South 96.0% practice hand washing with soap and water. Ninety one percent of the respondents in Nnewi North agreed the school provided facilities for hand washing while in Nnewi South, 93.0% admitted the school provided them with facilities for hand washing.

DISCUSSION

On the knowledge of Ebola viral disease, the study shows that nearly all the respondents; 190 (95.0%) in Nnewi North and 192 (96.0%) in Nnewi South have heard of Ebola viral disease. Also, majority of the respondents, 145 (72.5%) from Nnewi North and 154 (77.0%) from Nnewi South believed Ebola existed in Nigeria. This is similar to the findings of studies done in Sierra Leone15,16 which reported that nearly every Sierra Leonean has heard about Ebola. With regards to the knowledge of preventive measures against the disease, 190 (95.0%) respondents from Nnewi North and 180 (90.5%) respondents from Nnewi South agreed EVD can be prevented by avoiding close body contacts and contact with bodily fluids. Such level of knowledge of prevention of EVD by avoiding contact with cases was also reported in Sierra Leone. However, in contrast to the situation in Sierra Leone where 85% of the respondents agreed with the statement that one can protect oneself by avoiding funeral or burial rituals that require handling the body of someone who died of Ebola, only 45.5% (Nnewi North) and 40% (Nnewi South) agreed with the statement in this study. On the misconception about transmission of Ebola viral disease, some respondents (30.5% in Nnewi North and 40.0% in Nnewi South) agreed EVD can be transmitted through mosquito bite. This shows that among the respondents some are yet to get the appropriate knowledge about EVD transmission.

On the attitude towards prevention of EVD, only very few of the respondents 9.5% (Nnewi North) and 18.5% (Nnewi South) would keep it secret if he or she had any of the symptoms of EVD, while 59.5% of respondents in Nnewi North and 63.5% in Nnewi South would not allow someone who had recovered from the disease into their homes. Also in Nnewi North and Nnewi South respectively, 37.0% and 32.0% of the respondents would seat close to a person who recovered from the disease. Furthermore, None of the respondents in Nnewi North would treat an EVD case at home, while 1.5% of the respondents in Nnewi South would treat an EVD case at home. In Guinea 33% of the respondents claimed they would treat the symptoms at home for at least 3-4 weeks6. Among the 200 respondents in Nnewi North 8.5% believed that bathing with salt water could prevent EVD but in Nnewi South 20.5% believed bathing with salt water could prevent or cure Ebola disease. A higher percentage (42%) was reported in Sierra leone.15 Bathing with salt water and drinking of salt water was wrongly propagated in Nigeria during the ebola outbreak. There were even cases of death from drinking salt water in Nigeria during the ebola outbreak. A great number of the respondents 95.5% and 96.0% from Nnewi North and Nnewi South respectively practice handwashing with soap and water. This is higher than the rate in Sierra Leone where 70% of respondents practice handwashing with soap and water in order to help prevent EVD.15 These high levels of practice of handwashing could be explained by the massive promotion of hand washing by the government and agencies during the outbreak of EVD in the country, which was also the period this study was conducted.

In conclusion, this study has demonstrated that almost all the students have heard of Ebola viral disease and knew it existed in Nigeria. A good number of them knew various modes of transmission and spread of the disease. They equally had good knowledge of the preventive measures and practice them. However a good number of them still believe dead bodies could not be a source of the infection, that EVD can be transmitted through mosquito bites and that bathing with salt water would prevent Ebola.

Based on these findings we recommend continued awareness campaigns on EVD and its preventive measures. We also recommend continuous periodic training of teachers on EVD so that they will transfer the knowledge to the students.