Knowledge, attitude, and practices of the community about Chikungunya in selected Districts of Afar Region, Northeast Ethiopia; its implications for controlling the disease: a community-based quantitative and qualitative cross-sectional study

Abstract

Background

Chikungunya (CHIK) is a viral disease spread by Aedes mosquitoes in tropical and subtropical countries, including Ethiopia. It is important to educate communities and implement behavioral and social interventions to prevent and control the spread of disease. This study assessed the community’s knowledge, attitude, and practices (KAP) about CHIK disease in the Afar Region, Northeast Ethiopia.

Methods

A community-based quantitative and qualitative cross-sectional study was conducted between September 2022 and January 2023 in two districts in the Afar Region, Ethiopia. A household survey (HHS) using a structured questionnaire was conducted through face-to-face interviews for the quantitative study. For the qualitative research, focus group discussions (FGDs) were conducted using a semi-structured questionnaire. Data was analyzed using descriptive statistics, Pearson’s correlation coefficient, and multiple linear regressions.

Results

The study included 296 and 116 adult community members for quantitative and qualitative studies, respectively. Of 296 respondents, 67.3% had previously heard of CHIK, and of those who heard of it, 44.7% knew that CHIK is caused by a virus. While a majority (68.8%) of participants believed that CHIK could be prevented, only 45.6% considered it a serious illness. Additionally, over half (56.8%) of the respondents knew that not all mosquitoes transmit CHIK. About 48.7% were able to identify the Aedes mosquito, but only 16.5% of those knew that Aedes mosquitoes bite during the daytime. The overall mean correct/positive response scores for knowledge, attitudes, and practices were 63.2%, 60.0%, and 60.0%, respectively. Being a student and having educational levels of grade 9-12th and college or above were associated with good knowledge while being single, having an educational level of 9-12^th, and being within the age group of 45–59 years old were found to be associated with positive attitude scores.

Conclusion

The study revealed a limited understanding of CHIK and the role of the Aedes mosquito in the study area. The community had uncertainty about the disease, its transmission, and prevention measures. The lack of understanding may affect attitudes towards the disease and risk perceptions, leading to less practice in prevention and control measures. The findings suggest the need for community-based educational initiatives to improve awareness and promote prevention and control measures.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-024-20987-8.

Background

Chikungunya(CHIK) is a disease due to infection with Chikungunya virus (CHIKV)and it is the second most common Arboviral disease after dengue fever [1]. The virus is a ribonucleic acid (RNA) virus belonging to genus Alphavirus of family Togaviridae and transmits to humans via the bite of infected mosquitoes: Aedes (Ae.) aegypti and Ae. Albopictus [1, 2]. The CHIKV infection has been neglected but highly spreading worldwide, primarily in tropical and subtropical countries since its first isolation in Tanzania in 1952 [3]. Currently, over 110 countries and territories in Asia, Africa, Europe, and the Americas have reported autochthonous vector-borne transmission and sporadic outbreaks [1, 3]. In the last two decades, the outbreaks of CHIK are more frequent and spreading widely owing to viral adaptation to allow Ae. albopictus to spread the virus more efficiently [3]. However, despite the increasing number of outbreak reports in Africa, including in Ethiopia, the true burdens have not yet known clearly due to under-diagnosing and under-reporting of the cases and outbreaks of CHIKV infection [2], leading to difficulty in estimating the public health impact of the disease. Moreover, the transmitting vector, geographical distribution, and clinical features of CHIK are overlapping with other various arboviral diseases like dengue fever, yellow fever, Zika and tropical febrile infectious diseases like malaria, which frequently leads to misdiagnosis.

In Ethiopia and bordering countries like Sudan and Kenya, significant outbreaks of autochthonous transmission of CHIKV infections were reported during the past decade [1, 4]. The first case of CHIK was identified in Ethiopia in the Suuf district of the Somali region in June 2016 [5]. Since then, various suspected and confirmed CHIK outbreak cases have been documented in different parts of the country, primarily in the Somali region, Afar region, and Dire Dawa city administration, as well as in the Dauro zone southern Nation Nationality and Peoples region of Ethiopia [6, 7]. Recent serological studies have also revealed the infection’s circulation in considerable prevalence in other parts of the country where outbreak cases were not yet reported, such as in South Omo and the Gambella area of southwest Ethiopia, with reported seroprevalence of 43.6% and 15.6%, respectively [8, 9].

From July to October 2019, the Ethiopian Public Health Institute (EPHI) identified a large and unprecedented outbreak of CHIK and dengue fever with about 41,162 suspected and confirmed cases in the Dire Dawa City Administration. This three-month outbreak spread to surrounding districts of the Afar region such as Gewane, Amibara, and Awash Sebat city administration, increasing the total number of cases to more than 52,118 [6, 10]. Moreover, in the Afar region, where various CHIK outbreaks have been reported, inspection of artificial mosquitoes breeding containers showed that around 36-49.4% and 12.4% of the containers identified with Ae. aegypti and Ae. africanus, respectively [11, 12].

In areas susceptible to outbreaks of CHIK and other arboviral diseases, such as the Afar Region, it is essential to evaluate the community’s awareness, behaviour, and perception towards these diseases. Understanding the community’s knowledge, attitude, and practices (KAPs) towards the disease’s etiology, mode of transmission, vector, clinical signs and symptoms, and control and prevention methods is critical when developing disease intervention strategies to prevent and control the spread of CHIK [13, 14]. Therefore, it is crucial to assess the community’s KAP levels before developing evidence-based social and behavioural interventions to prepare communities for potential public health measures, promote risk reduction strategies, and implement prevention measures [15]. Despite multiple CHIK outbreaks in the Afar region, there are no studies that evaluate the KAP levels of CHIK among community members. Thus, this study aims to assess the knowledge, attitudes, and practices of the community regarding CHIK in the Afar region, Northeast Ethiopia.

Methods

Study design and area

A community-based quantitative and qualitative cross-sectional study was conducted in the Afar region, Northeast Ethiopia, between September 2022 and January 2023. The region has predominantly tropical and subtropical climates and has been increasingly affected by extreme weather variability, recurring droughts, disease outbreaks, conflicts, and chronic water shortages [16]. The majority of the population of the region are pastoralists, relying on their livestock for their livelihood. The Afar Region comprises five administrative zones, each containing 5 to 7 districts and city administrations. For this study, Amibara and Awash Sebat City Administration Districts were purposefully selected from Zone-3 of the region due to the recent CHIK and dengue fever outbreaks [6]. From each district, two kebeles (the lowest administrative unit), namely Awash Arba and Sidafage kebeles from the former, and Ragale and Kedeba kebeles from the latter district, were selected according to their accessibility and proximity to the roads.

Sample size estimation and sampling

The study recruited community members aged 18 years or older for quantitative and qualitative studies and representative samples of community members from the selected Kebeles of the districts based on their proportional size. In the quantitative study, 296 household members were selected to participate. The process involved conducting a social mapping exercise to identify households located within a 50-meter radius of each site. Subsequently, a maximum of 25 households were systematically sampled by moving toward four to six geographical opposite directions until a maximum of 25 households was obtained from the centre within the radius of the selected site [17]. A head of household or an eligible family member was then chosen by lottery to participate from each of the identified households for the interview. If the total number of households identified was fewer than 25, no movements were made in more than six directions. Houses with no eligible participants or those that were closed during data collection were excluded. Household members who had a migration history to other districts or countries within the past year were excluded to keep the consistency of the result within the study area and those who were not well enough to respond to the questions appropriately were also excluded. For qualitative data, 116 relatively more informed adult community members were recruited with the assistance of village and clan leaders.

Data collection

Data collection was conducted through a face-to-face household survey (HHS) using a structured questionnaire to obtain quantitative data while focus group discussion (FGD) was conducted to collect qualitative data. Eight FGDs of 10–15 members (three FGDs with females) were organized with members of same gender to ensure homogeneity. The data collections were conducted by data collectors that were selected based on their understanding of the local norms, customs, and languages. The data collectors were trained on how to collect data through HHS and FGDs. The questionnaire was translated into the national language, Amharic, and then orally into the local language, Afar language. In the study area, CHIK is known by the name ‘Tilobign’ and mosquito is known by its Afar name ‘kagna’ata’. So, these local names were used during questionnaire-based data collection.After the objectives of the survey were explained and discussed with the informants to ensure their consent to participate, data collection were conducted. The data collectors were given no information on the correct answers to survey questions to minimize interviewer bias during data collection.

The HHS questionnaire was developed by reviewing studies previously conducted for arboviral diseases such as dengue and CHIK, and employed the Health Belief Model as a theoretical framework which helps to identify cues for action for the intended population [18–20]. The content, wording, and cultural appropriateness were adjusted by reviewing the literature and consulting with experts as described in the supplementary file (Additional file 1). The questionnaire contains two sections. Section one: sociodemographic and common febrile illness-related information consisting of 12 questions that gather study participants’ sex, age, ethnicity, religion, marital status, occupation, educational level, common febrile illness in the area, information about dengue fever and CHIK, and source of information. Section two was the KAP section. The section consisted of 22 closed-ended items for knowledge questions that addressed the CHIK disease, etiology, common signs and symptoms, transmission modes, and prevention of CHIKV infection. The attitude items contained 15 close-ended questions with a 5-point Likert scale. The items included the community’s beliefs on CHIK disease, its preventability, and risks of perceptions. The final practice section contained 13 close-ended itemswhich consisted of questions to address preventive measures against CHIKV infection, primarily practices employed to reduce human-mosquito contacts and breeding opportunities of mosquitoes. The questionnaire’s validity was confirmed by experts in the field, who suggested excluding questions related to the management of CHIK since the study districts did not consider it a major public health issue, except for the history of outbreaks. To ensure the questionnaire’s reliability, a pilot study was conducted with a group of 20 participants. The pilot study was used to assess internal consistency reliability using Cronbach’s alpha, and the questionnaire demonstrated adequate internal consistency reliability (Cronbach’s alpha = 0.67). Similarly, FDGs were conducted using semi-structured questionnaire. The questionnaire was developed by reviewing various publish literature and consulting experts in the field. The contents of discussion included awareness such as the commonly existing febrile illnesses including mosquito-borne diseases in the area, knowledge about CHIK including its signs and symptoms, similarities and differences with malaria, transmissibility, prevention methods, health-seeking behaviours, and finally, the health intervention about CHIK and malaria diseases, modes of transmissions, and controls and prevention as described in the supplementary file (Additional file 2). The discussion was supported by images of Aedes and Anopheles mosquitoes.

Ethical consideration

The study was conducted as part of a research project that ethically approved by the Institutional Review Board of Aklilu Lemma Institute of Pathobiology, Addis Ababa University, Ethiopia (ALIPB IRERC/88/2014/22) in accordance with the Declaration of Helsinki. Permissions to study were obtained from each study districts. Informed consent was obtained from all participants before participating in the study. Participation was completely voluntary and participants might choose to discontinue participation for any reason at any time while completing the survey.

Data analysis

Quantitative data analysis

The data was entered into Epi Data Version 3.1 and analyzed using Stata/SE 14.2 software. To determine the KAP score for CHIK for each participant, one point was given for every correct answer, while zero points were given for incorrect answers and “not sure” responses [18]. Knowledge and practice questions were scored with 0 for wrong or not-sure answers and 1 for correct answers. The attitude questions had a scale response of 1 for Strongly Agree, 2 for Agree, 3 for “not sure,” 4 for Disagree, and 5 for Strongly Disagree, which was then dichotomized into 1 for positive (1 and 2) and 0 for negative (3, 4, and 5) answers. However, for the specific question “Do you agree that health service stakeholders are the only entity responsible for reducing larvae and adult mosquitoes in your home?” the responses of 1, 2, and 3 were considered as 0, while 4 and 5 were considered as 1. To assess participants’ levels of each KAP domain, the following steps were undertaken: Total Score Calculation: The total score for each domain was determined by summing the number of correct or positive responses to the corresponding questionnaire items. Maximum Cumulative Score (MCS): The maximum achievable score for each domain was established as follows: 22 for knowledge, 15 for attitude, and 13 for practice. Mean Score Calculation: The mean score for each domain was calculated by dividing the individual’s total score by the MCS. Percentage Calculation: The percentage of correct or positive responses was calculated as (score obtained / MCS) × 100. Overall Mean Correct or Positive Response Rate: The overall mean correct or positive response rate was determined by calculating the proportion of participants who achieved a total score equal to or greater than the mean score for each KAP domain. Level Determination: Participants’ levels in each domain were categorized based on their mean scores: “Good” for scores ≥ 70%, “Fair” for scores between 50.1% and 69.9%, and “Poor” for scores ≤ 50% [21, 22]. Respondents who had never heard of CHIK were excluded from the KAP score analysis. The Shapiro-Wilk W test was used to identify the normality of the KAP data. The knowledge and practice domains were found to be normally distributed (p > 0.05) while the attitude domain was found not normally distributed (p < 0.001). However, skewness (0.0001) and kurtosis (0.0709) values of attitude were within acceptable limits, between − 2 and + 2, for deciding the use of parametric analysis to confirm or reject research hypotheses [23]. Pearson’s correlation coefficient (r) was analyzed to determine if there is a relationship between the KAP domains. Multiple linear regression analysis was conducted to study the relationship between KAP factors as outcome variables and sociodemographic factors as explanatory variables and reported in beta coefficient (β). All p-values less than 0.05 were considered statistically significant.

Qualitative data analysis

The qualitative data was complemented the quantitative data. A conventional content analysis approach was employed for qualitative data analysis [24]. Firstly, we recorded and transcribed the FGDs into Amharic and later verbatim in English. We created a topic-based classification of themes and sub-themes based on the literature’s findings to process the transcripts. After that, we coded the transcripts with the defined categories to highlight the demonstrated topics. We grouped similar codes to establish categories and specified each category as a sub-theme, creating a theme. We added emerging themes that arose during the FGDs. We extracted all coded material per category to summarize the FGDs per category. The main themes relevant to the study’s research goals and objectives are presented in Table 1.

Table 1.

Summary of the Focus Group discussion’s main themes on knowledge, attitude and practice study about Chikungunya (CHIK) in selected districts of Afar Region, Northeast Ethiopia

Probed themes in discussion	Identified key themes
Knowledge and awareness	Common febrile illness in the area, common mosquito borne illness and awareness about CHIK, sign and symptoms of CHIK, vectors, transmission and prevention: Malaria as Anopheles borne and common febrile illness, followed by typhoid, typhus, cough; CHIK as currently emerged disease and locally known as ‘Tilobign’; Fever, joint pain and headache as common signs of CHIK, very few identified military rangers-like striping mosquito (Aedes) but not knew as it’s responsible for transmitting CHIK
Attitude about CHIK disease	Perceived risky population, seriousness, public health importance, management: all age groups are at risk, a killer, and a rare public health problem
Prevention and control of CHIK	Almost all do not know where the vector Aedes reproduce, rest, and bite and how protect

Results

General sociodemographic information

In the quantitative study, a total of 296 community member participants, with 63.2% males and ages ranging from 19 to 80 years with a mean (± SD) of 34.2 (± 10.6) years participated. Most of the participants (81.4%) were married, and almost half (48.3%) were between the ages of 30–44 years. In the qualitative study, a total of 116 participants, with 63.8% males and ages ranging from 18 to 80 years, organized into eight FGDs of 10–15 members participated. Three of the FGDs comprised only females. The majority of the participants (41.4%) were aged between 30 and 44 years, and only a small proportion of participants (11.2%) had formal education (Table 2).

Table 2.

General characteristics of study participants conducted on knowledge, attitude and practice about Chikungunya inselected districts of Afar Region, Northeast Ethiopia

General characteristics		Number of participants (%)
Household survey participants ( N = 296)
Sex	Male	187 (63.2)
	Female	109 (36.8)
Age groups (years)	18–29	109 (36.8)
	30–44	143 (48.3)
	45–59	35 (11.8)
	60 or above	9 (3.0)
Religion	Muslim	179 (60.5)
	Orthodox	102 (34.5)
	Protestant	15 (5.0)
Ethnicity	Afar	125 (42.2)
	Oromo	27 (9.1)
	Amhara	58 (19.6)
	Others	86 (29.0)
Marital status	Married	241(81.4)
	Single	55 (18.6)
Education status	Illiterate	92 (31.1)
	Grade 1-8th	74 (25.0)
	Grade 9-12th	78 (26.3)
	College or above	52 (17.6)
Occupation	Agro/pastoralist	70 (23.7)
	Government/private worker	186 (63.1)
	Housewife	30 (10.2)
	Students	9 (3.0)
Districts	Amibara	157 (53.0)
	Awash Sebat	139 (47.0)
Kebeles	Awash Arba	124 (41.9)
	Sidafage	32 (10.8)
	Regale	78 (26.3)
	Kedeba	62 (21.0)
Focus Group Discussion participants(N = 116)
Sex	Male	74 (63.8)
	Female	42 (36.2)
Age group (years)	18–29	42 (36.2)
	30–44	48 (41.4)
	45–59	14 (12.1)
	60 or above	12 (10.3)
Education status	Illiterate	103 (88.8)
	Primary and above	13 (11.2)

Knowledge about common febrile and mosquito-borne illnesses

Majority of the study participants (91.2%) reported malaria as the most prevalent febrile and mosquito-borne disease. Typhoid was mentioned as the second most frequent febrile illness (68.9%), followed by typhus (44.6%). About 39.9% of participants said that CHIK is a frequent febrile illness in the area. Of the total number of community members who participated in the HHS study, 199 (67.3%) reported that they heard about CHIK disease locally called Tilobign. Among those who had heard about CHIK, only 2 (2.0%) were also aware of dengue fever. About half (49.3%) of the participants reported that they obtained information about CHIK at a health facility during a previous outbreak. Others heard about CHIK through “Dagu” (information-sharing system by the local people) (34.2%), while very few obtained the information through media and meetings (Table 3).

Table 3.

Participants’ knowledge about frequent febrile illnesses and information about Chikungunya in selected districts of Afar Region, Northeast Ethiopia (N = 296)

		Number of respondents (%)
What are/is Common febrile illness in this area?	Malaria	270 (91.2)
	Typhoid	204 (68.9)
	Typhus	132 (44.6)
	Dengue	0
	Chikungunya	118 (39.9)
	Other non-specific disease like cough, pneumonia, etc.	67 (22.6)
Have you heard about CHIK and DEN diseases?	Yes	199 (67.2)
	No	97 (32.8)
About which diseases did you hear?	Only CHIK	197 (99.0)
	Both CHIK and DEN	2 (1.0)
Source of information	Media	22 (11.1)
	‘Dagu’*	68 (34.2)
	Teacher/Education	3 (1.5)
	Seminar/meeting	8 (4.0)
	In health facility during outbreaks	98 (49.3)

CHIK = Chikungunya, DEN = Dengue, *traditional information sharing system of the Afar community

During the FGD, it was observed that the participants were familiar with malaria as a common febrile illness and a disease that is transmitted by mosquitoes. However, some participants believed that malaria could also be contracted through physical contact (sleeping with a patient who has a fever). The majority of the participants identified Anopheles mosquito, which they called ‘kagna’ata’, as the primary vector of malaria. It was generally agreed upon that CHIK is a newly-emerged disease, potentially originating from Eastern Ethiopia, Dire Dewa city administration, and is locally known as ‘tilobign’. However, the participants had no information on how it is transmitted.

A 40-year-old man shared his experience of bringing his 9-year-old daughter to a health centre due to fever and joint pain. At the centre, he observed many patients with similar symptoms as his daughter. He was told for the first time that it was an outbreak of a disease called CHIK, locally known as “Tilobign.” However, he did not hear how it transmits to humans or whether it would affect him or his other family members.

Knowledge regarding chikungunya and its prevention

The study showed that both quantitative and qualitative data revealed similar results. In the quantitative study, the overall mean CHIK knowledge score was 13.9 (SD: ±3.0), with a range of 5–20 out of 22. The overall mean correct response rate of study participants was found 63.2% (13.9/22*100), indicating fair knowledge domain. Within the knowledge questions, the percentages of respondents who answered item correctly varied from poor with the lowest percentage of correct response of 16.5% for the question “When does Aedes mosquito bite?” to good with the highest percentage of correct response of 90.9% for the question “Does CHIK cause joint pain?”.

Furthermore, the findings indicated that 44.7% of the participants correctly identified CHIK as a viral disease, and 56.8% knew that not all mosquitoes transmit CHIK. About 48.7% of the respondents were able to recognize the Aedes mosquito, from them only 16.5% knew that it bites during daytime. Most of the participants knew that CHIK is not spread by food and water (74.4%), ticks (73.9%), and flies (72.9%). However, 40.7% of the study participants believed that person-to-person contact could transmit CHIK. The majority of the participants (83.9%) knew that mosquitoes breed in stagnant water. Likewise, 83.4% and 62.8% of the participants believed that having window screens and bed nets, and using mosquito repellents respectively, could prevent mosquito bites. More than half of the participants (57.3%) recommended using pesticide sprays to control mosquitoes and prevent CHIK. They also mentioned that CHIK is a disease that occurs during the rainy season (64.3%) and can affect everyone, including children and adults (70.8%). Additionally, a large number of participants were able to identify the common symptoms of CHIK such as fever (89.9%), headache (89.5%), joint pain (90.9%), and muscle pain (75.4%) (Table 4).

Table 4.

Participants’ knowledge about Chikungunya etiology, transmission, signs and symptoms and preventions in selected districts of Afar Region, Northeast Ethiopia (N = 199)

Knowledge aspect questions used in the study		Number of respondents (%)
Is CHIK caused by virus?	Yes	89 (44.7)
	No	86 (43.2)
	Not sure	24 (12.1)
Can all mosquitoes transmit CHIK virus?	Yes	76 (38.2)
	No	113 (56.8)
	Not sure	10 (5.0)
Can you identify Aedes mosquito?	Yes	97 (48.7)
	No	102 (51.3)
When does Aedes mosquito bite?	Day time	16 (16.5)
	Night time	44 (45.4)
	Any time	37(38.0)
Do flies transmit CHIK?	Yes	39 (19.6)
	No	145 (72.9)
	Not sure	15 (7.5)
Do ticks transmit CHIK?	Yes	35 (17.6)
	No	147(73.9)
	Not sure	17 (8.5)
Do person to person contacts transmit CHIK?	Yes	81 (40.7)
	No	110 (55.3)
	Not sure	8 (4.0)
Is CHIK transmitted through food and water?	Yes	46 (23.1)
	No	148 (74.4)
	Not sure	5(2.5)
Do mosquitoes breed in stagnant water?	Yes	166 (83.4)
	No	31 (15.6)
	Not sure	2 (1.0)
Do window screen and bed net reduce mosquitoes?	Yes	167 (83.9)
	No	16 (16.1)
	Not sure	0 (0.0)
Do insecticide sprays reduce mosquitoes and prevent CHIK?	Yes	114 (57.3)
	No	79 (39.7)
	Not sure	6 (3.0)
Do tightly covering water containers reduce mosquito?	Yes	146 (73.4)
	No	52 (26.1)
	Not sure	1 (0.5)
Do mosquitoes repellent prevent mosquitoes’ bites?	Yes	125 (62.8)
	No	66 (33.2)
	Not sure	8 (4.0)
Is the rainy season when CHIK present?	Yes	128 (64.3)
	No	64 (32.2)
	Not sure	7 (3.5)
Does CHIKV affect infants, children and Adults?	Yes	141 (70.8)
	No	57 (28.6)
	Not sure	1(0.5)
Does CHIK cause fever?	Yes	179 (89.9)
	No	20 (10.1)
Does CHIK cause joint pain?	Yes	181 (90.9)
	No	18 (9.1)
Does CHIK cause headache?	Yes	178 (89.5)
	No	21 (10.5)
Does CHIK cause muscle pain?	Yes	150 (75.4)
	No	49 (24.6)
Does CHIK cause bone pain?	Yes	73 (36.7)
	No	126 (63.3)
Does CHIK cause nausea?	Yes	94 (47.2)
	No	105 (52.8)
Does CHIK cause rash?	Yes	55 (27.6)
	No	144 (72.4)
Overall knowledge score	Mean (± SD) = 13.9 (± 3.0); Range = 5–20

Note Those with bolds are correct answer responses

During the FGDs, it was noticed that most participants were aware of the common signs and symptoms of CHIK, which included fever, joint pain, headache, and back pain. However, their understanding of how CHIKV spreads and the role of the Aedes mosquito was limited. While some participants thought that the disease was caused by Allah (God), others believed that it could be spread through personal contact or bed-sharing with CHIK patients. Interestingly, the FGD participants gave some accurate suggestions on how to protect and control mosquitoes, such as using bed nets, clearing stagnant water, fumigating, and using indoor chemical insecticide spray. The summary of the FGD participants’ knowledge about CHIK and mosquitoes are highlighted as follows:

A 30-year-old woman shared her knowledge about two types of mosquitoes. She explained that the Anopheles mosquito is a carrier of malaria, locally known as ‘Danaso’. This mosquito usually bites during night and can be prevented by using bed nets. Anopheles mosquitoes breed on plants during the rainy season. But she had no information about the Aedes mosquito. Another 35-year-old woman described the Aedes mosquito, which can be recognized by its stripes that resemble military uniforms and is locally known as ‘kagna’ata’ similar to anopheles but differs in colour. This mosquito is known for its painful bite and can bite during the daytime. It breeds in the forest and is difficult to protect. She believed that this mosquito is transmitting diseases such as malaria, HIV, and TB, but she had no information whether it transmits CHIK. A 20-year-old man who holds a bachelor’s degree in business management explained that CHIK is a febrile illness similar to malaria, but it is characterized by joint pain. While it can affect people of all ages, it is more common in adults. CHIK is a newly emerging disease that originated from animals and is transmitted through personal contact.

Attitudes and perceived risk towards CHIK disease

In quantitative study, the correct (strongly agreed or agreed) rates for the 15 questions on the CHIK attitude domain varied from 45.3–73.9%. The mean attitude score was 9.0 (SD: ±3.1), range: 0–14). The overall mean positive response rate was found 60.0% (9.0/15*100), indicating fair positive attitude and perceived risk score towards CHIK disease. Among the attitude questions, the one with the lowest percentage (23.7%) of positive responses was “Do you agree that health service stakeholders are the only entity responsible to reduce larvae and adult mosquitoes in your home?” while the one with the highest percentage of positive responses (73.9%) was “Do you agree that every one with sign and symptoms of CHIK need to consult immediately community health services?”. Furthermore, a significant number of participants strongly agreed or agreed that CHIK can be prevented (68.8%) and everyone is a key in preventing CHIK (70.3%). While less than half of the participants (47.3%) strongly agreed/agreed that water around the house in discarded tires, broken pots, and bottles are breeding places for mosquitoes like Aedes, 64.8% of participants strongly agreed or agreed that controlling mosquito breeding places is an effective strategy to prevent CHIK (Table 5).

Table 5.

Participants’ attitude and perceived risks towards Chikungunya and transmitting vectors in selected districts of Afar Region, Northeast Ethiopia (N = 199)

Attitude aspect questions used in the study	Number of response of the participants (%)
	S/ agree	Agree	Not sure	Disagree	S/disagree
Do you agree that CHIK is a serious illness?	29 (14.6)	61 (30.7)	54 (27.1)	50 (25.1)	5 (2.5)
Do you agree that CHIK is preventable?	41 (20.6)	96 (48.2)	40 (20.1)	22 (11.1)	0 (0.0)
Do you agree that water around house in discarded tires, broken pots and bottles are breeding place for mosquitoes like Aedes?	35 (17.6)	59 (29.7)	101 (50.7)	4 (2.0)	0 (0.0)
Do you agree that controlling mosquitoes breeding places are good strategy to prevent CHIK?	34 (17.1)	95 (47.7)	57 (28.6)	13 (6.5)	0
Do you agree that communities should actively participate in controlling the CHIK vector?	31 (15.6)	85 (42.7)	56 (28.1)	27 (13.6)	0
Do you agree that everyone has a chance to be infected by CHIK?	43 (21.6)	88 (44.2)	36 (18.1)	31 (15.6)	1 (0.5)
Do you agree that every one with sign and symptoms of CHIK need to consult immediately community health services?	42 (21.1)	105 (52.8)	38 (19.1)	13 (6.5)	1 (0.5)
Do you agree that everyone is a key in preventing CHIK?	36 (18.1)	104 (52.3)	44 (22.1)	15 (7.5)	0
Do you agree that all CHIK patients have a chance for a full recovery?	37 (18.6)	99 (49.7)	39 (19.6)	22 (11.1)	2 (1.0)
Do you agree that health service stakeholders are the only entity responsible to reduce larvae and adult mosquitoes in your home? **	26 (13.1)	77 (38.9)	48 (24.2)	44 (22.2)	3 (1.5)
Do you agree that your neighbourhood is CHIK high risk area?	31 (15.6)	81 (40.7)	49 (24.6)	36 (18.1)	2 (1.0)
Community members are capable of preventing CHIK?	39 (19.6)	89 (44.7)	43 (21.6)	27 (13.6)	1 (0.5)
Do you agree that you are capable of preventing CHIK	32 (16.1)	99 (49.7)	40 (20.1)	28 (14.1)	0
Do you agree that government actions are needed to prevent CHIK?	28 (14.1)	99 (49.8)	35 (17.6)	33 (16.6)	4 (2.0)
Do you agree that you are responsible to prevent spread of mosquito in your home?	33 (16.7)	99 (50.0)	41 (20.7)	23 (22.1)	3 (1.5)
Overall attitude score	Mean (± SD) = 9.0(± 3.1); Range = 0–14

 S = Strongly; Answers with bolds are correct answer responses; **positive responses were S/disagree or disagree

During FGDs, a few participants believed and mentioned that CHIK is a severe disease that originated from somewhere like from Dire Dewa city and could potentially be fatal.

An 18-year-old high school student correctly identified CHIK as a new disease that originated from Dire Dawa city and is transmitted to humans through the bites of infected Aedes mosquitoes. In Amibara village a 28-year-old woman mentioned that there was a risk of CHIK in Awash Arba and Awash Sebat cities before 2–3 years. However, at present, the disease does not exist in the community. She admitted that she does not know how it spreads, but suggested that it was caused by Allah.

Practices regarding CHIK prevention and control

During the HHS based study and FGDs, several measures were discussed to reduce mosquito exposure. The overall mean practice score was 7.8 (SD: ± 2.5), ranging 1–13 and resulting 60.0% (7.8/13*100) overall mean correct response rates for CHIK practice for prevention and control. Cleaning of garbage/trash to reduce mosquito breeding sites (88.4%), draining ponds or degrading muddy/wet areas (81.4%), cutting down bushes (78.9%), disposing of water-holding containers such as tires, plastic, bottles, or broken pots (73.9%), and covering water containers around the home (70.3%) were commonly practiced measures to reduce mosquitoes. However, the measures attempted to avoid mosquito bites were relatively low, with 51.3% of respondents practicing using fans, 46.7% wearing long clothes when working in the bush, farm, and forest, and 36.2% using bed nets when sleeping during the day to protect mosquito bites (Table 6).

Table 6.

Participants’ ppractice related to preventive and control measures against Chikungunya in selected districts of Afar Region, Northeast Ethiopia (N = 199)

Practice aspect questions used in the study	Number of response of participants (%)
Do you drain ponds or degrade muddy/wet areas to reduce mosquitoes?	Yes	162 (81.4)
	No	37 (18.6)
Do you cut down bushes too short to reduce mosquitoes?	Yes	157 (78.9)
	No	42 (21.1)
Do you clean garbage/trash to reduce mosquito breeding sites?	Yes	176 (88.4)
	No	23 (11.6)
Do you dispose water holding containers like tires, plastic, bottles or broken pots?	Yes	147 (73.9)
	No	52 (26.1)
Do you cover water containers around in the home?	Yes	140 (70.3)
	No	59 (29.7)
Do you change the water of plant containers in the house every week?	Yes	68 (34.2)
	No	131 (65.8)
Do you check waste/garbage that can block water flow around the home?	Yes	118 (59.3)
	No	81 (40.7)
Do you participate in any of anti-chikungunya campaigns in the community?	Yes	79 (39.7)
	No	120 (60.3)
Do you checking and cleaning drains/gutters/roofs before the rainy season?	Yes	105 (52.8)
	No	94 (47.2)
Do you cleaning frequently water filled containers and draining around the house?	Yes	138 (69.3)
	No	61 (30.7)
Do you use fan to prevent mosquito biting	Yes	102 (51.3)
	No	97 (48.7)
Do you cover body with long sleeve clothes when working in the bush, farm, and forest	Yes	93 (46.7)
	No	106 (53.3)
Using bed net when sleeping during the day	Yes	72 (36.2)
	No	127 (63.8)
Overall Practice score	Mean (± SD) = 7.8 (± 2.5) Range = 1–13

Note Those with bolds are correct answer responses

During the FGDs, it was revealed that the participants were not taking enough preventive measures to protect themselves from daytime mosquito bites that can cause CHIK. They highlighted that the main reason for this was the lack of awareness about the risk of daytime mosquito bites and the fact that they did not consider this mosquito as a vector of CHIK. Additionally, some participants reported that the CHIK outbreaks in the area did not concern them.

Correlation between KAP domains

A Pearson correlation coefficient was analyzed to evaluate the linear association among the three KAP domains. The three variables showed positive correlations (p < 0.05). The highest correlation was observed between knowledge and attitude scores, with r(199) = 0.388 and p < 0.001(Table 7).

Table 7.

Pearson’s correlations between knowledge, attitudes and practices relating to Chikungunya in selected districts of Afar Region, Northeast Ethiopia

Variable	Observation	r	p value*
Knowledge- attitudes	199	0.388	< 0.001
Knowledge-practices	199	0.202	0.004
Attitudes- practices	199	0.342	< 0.001

*Correlation is significant at the 0.05 level

The KAP scores and characteristics in Sociodemographic factors

In the quantitative study, the mean scores for KAP were found to be 13.9 ± 3.0 (range 5–20), 9.0 ± 3.1 (range 0–14), and 7.8 ± 2.5 (range 1–13), respectively. A multiple linear regression analysis was conducted to examine the relationship between KAP scores and sociodemographic characteristics. The educational status significantly influenced knowledge, with participants in 9-12th grade (14.6 ± 3.9) showing a 1.6-point increase in scores (p = 0.020), and those with a college education or above (14.8 ± 3.0) showing a 1.8-point increase (p = 0.016) as in comparison with the illiterate, indicating a positive impact of education on knowledge scores. Additionally, being a student (17.3 ± 1.4) was associated with a 3.5-point increase in knowledge scores (p = 0.009) in comparison with agro/pastoralist participants, suggesting the value of study. Marital status was found to be significant for attitude, with being single (10.2 ± 2.4) showing a 1.5-point increase in scores (p = 0.033) in comparison with married participants, indicating a positive influence on attitude scores. while participants with the age group of 45–59 year old (9.68 ± 2.67) was associated with a 1.6-point increase in attitude scores (p = 0.040) in comparison with participants with the age group of 18–29 year old, participants with the educational levels of 9-12th (9.73 ± 2.93) was associated with a 1.4-point increase in attitude score in comparison to illiterate (p = 0.038). However, no significant association was found between practices and sociodemographic characteristics (Table 8).

Table 8.

The mean of knowledge, attitudes and practices scores and multiple linear regression analysis of KAP scores among sociodemographic factors in selected districts of Afar Region, Northeast Ethiopia(N = 199)

Variables		Knowledge score			Attitude score			Practice score
		Mean(SD)	β value	p value	Mean(SD)	β value	p value	Mean(SD)	β value	p value
Sex	Male	13.93(3.08)	1		9.12 (3.03)	1		7.71 (2.56)	1
	Female	13.97(3.00)	0.27	0.569	8.81 (3.28)	-0.03	0.99	8.06 (2.33)	0.74	0.067
Age (years)	18–29	14.35(2.63)	1		9.04 (2.82)	1		7.84 (2.21)	1
	30–44	13.88(3.17)	0.15	0.750	8.83 (3.43)	0.39	0.443	7.69 (2.72)	0.03	0.945
	45–59	12.56(3.40)	-0.77	0.284	9.68 (2.67)	1.57	0.040	8.32 (2.19)	0.84	0.164
	60 or above	13.25(3.53)	0.23	0.837	9.15 (3.80)	1.08	0.374	7.63(3.42)	0.02	0.984
Ethnicity	Afar	13.79(2.99)	1		8.70 (2.9.)	1		7.16 (2.52)	1
	Non-Afar	13.93(3.09)	-0.90	0.113	9.22 (3.23)	-0.3	0.378	8.22 (2.38)	0.35	0.458
Religion	Muslim	13.54(2.99)	1		8.79 (3.19)	1		7.42 (2.52)	1
	Christians	14.35(3.08)	0.72	0.196	9.37(2.99)	0.44	0.456	8.41(2.32)	0.52	0.263
Marital status	Married	13.61(3.12)	1		8.71 (3.22)	1		7.69 (2.54)	1
	Single	14.88(2.54)	0.53	0.350	10.21 (2.38)	1.46	0.015	8.33 (2.34)	0.61	0.202
Education status	Illiterate	12.33(2.90)	1		7.98 (2.85)	1		7.05 (2.57)	1
	Grade 1-8th	13.46(2.87)	0.84	0.210	9.10 (3.06)	0.93	0.192	8.04 (2.39)	0.53	0.345
	Grade 9-12th	14.62(3.90)	1.60	0.016	9.73 (2.93)	1.45	0.038	8.02 (2.55)	0.61	0.267
	College or above	14.77(3.00)	1.78	0.012	8.93 (3.47)	0.59	0.433	8.07 (2.33)	0.65	0.277
Occupational status	Agro/pastoralist	12.37(2.99)	1		7.37 (4.00)	1		7.00 (2.65)	1
	Gov./private worker	14.07(2.96)	0.88	0.223	9.34 (2.91)	1.38	0.074	8.13 (2.48)	0.34	0.572
	Housewife	12.95(3.15)	0.02	0.980	8.52 (2.83)	1.13	0.270	7.05 (1.93)	-0.87	0.282
	Students	17.29(1.38)	3.49	0.009	9.14 (3.29)	0.74	0.599	6.0 (1.63)	-1.87	0.095
Districts	Amibara	14.28(3.11)	1		9.04 (3.07)	1		8.04 (2.59)	1
	Awash Sebat	13.56(2.97)	-0.66	0.145	9.02 (3.17)	0.29	0.578	7.66 (2.39)	-0.06	0.874

Discussion

This study assessed the KAPs of the community members towards CHIK in the Afar Region, Northeast Ethiopia using quantitative and qualitative study methods. The quantitative and qualitative findings showed that the communities in the Afar region had similar levels of awareness and understanding about CHIK. Less than 50% of FGDs and about 67.2% of HHS participants had heard of CHIK. The finding is lower than studies conducted in Sudan and Bangladesh, where over 90% of respondents had information about CHIK [25, 26]. The main sources of information about CHIK were health institutes that diagnosed the disease during outbreak events (49.3%) and the “Dagu” information-sharing system (34.2%). However, a few respondents had learned about CHIK through media, seminars, or meetings. Typically, people gain information about newly emerging diseases like arboviral diseases from media sources such as TV and radio, as well as health education activities through campaigns and mass media [27–29]. Health information sharing through media sources and health professional campaigns is crucial to improve households’ understanding of the community about the diseases’ features, transmissions, and control and prevention strategies [30]. However, this study finding indicated that the community has gaps in professional-based health educational interventions in this study area.

In both HHS and FGDs findings, most of study participants believed that malaria was the most common febrile illness and mosquito-borne disease in the study area. About 91.2% of respondents from HHS believed that malaria was the primary cause of febrile disease, followed by typhoid and typhus, with 68.9% and 44.6% of respondents considering them as causes respectively. However, the study findings revealed that the community had limited knowledge about non-malaria febrile illnesses, including arbovirus diseases, and most fevers were believed to be caused by malaria. It is important to note that there have been reports of febrile illness cases and outbreaks caused by arboviral diseases such as CHIK and dengue fever in the study area and surrounding regions [6, 10, 12]. Seroprevalence studies conducted by Zerfu et al. found that the prevalence of CHIK (about 50%) [31] and dengue fever (about 25%) (Unpublished) were higher than that of malaria (about 10%) among healthcare-seeking febrile patients in the study area. The lack of awareness and consideration of febrile illnesses other than malaria, such as emerging arbovirus infections, can lead to significant but hidden public health issues in the area and the country in general.

Analyses of KAPs of HHS participants who heard about CHIK showed that most participants had satisfactory knowledge of CHIK, with 63.2% scoring a mean or above-mean overall correct knowledge response rate. The result has various agreements results with of previous studies reported correct knowledge response rates of 40–85% in different countries [30, 32, 33] though study conducted in Tanzania, where CHIKV was first isolated, reported unlikely low, only 3.2% of community members have heard about the disease and only 12.8% of healthcare workers heard about [19]. However, lack of sufficient knowledge about the etiology, transmission, prevention, and control of CHIK was found in this FGDs and HHS study participants. Some FGD participants believed CHIK was a new disease, while a few suggested it came from a neighbouring city and was introduced by Allah (God). Of HHS participants, only 44.7% knew CHIK is caused by a virus, while only 16.5% knew Aedes mosquito, which is a daytime biter, is responsible for transmitting the virus. On the bright side, most participants correctly identified the common symptoms of CHIK, such as fever, joint pain, headache, and muscle pain. The finding contradicted various previous studies. In India, for example, most people (85%) knew CHIKV is transmitted through mosquito bites but had inadequate knowledge of disease symptoms, with only 48% reported joint pain and fever being the most common symptoms [32]. Other studies, including those in Bangladesh (50%), Sudan (87%), and India (90.2%), found that study participants correctly answered that CHIKV is transmitted from mosquitoes to humans, specifically by Aedes mosquitoes [26, 34, 35]. The study showed that the community in the study area had variation and uncertainty in awareness and knowledge about CHIK. Health education about CHIK and other arboviral diseases ensure the community to better understand about the disease, its transmission, and preventive and control measures [19]. Therefore health intervening to advance community’s understanding of the disease and the transmitting vector is vital to reduce any future outbreaks of infections like CHIKV infections.

An analysis of the attitudes of participants in the HHS study showed that they had a moderate positive attitude towards CHIK, with 60.0% of the participants scoring a mean or above a mean overall correct attitude response. The high attitude score observed might be a result of the focus on the perceived risk and responsibility of the participants in individual and collective mosquito prevention and control. It has been reported before that risk perception influences emotional, behavioural, and social reactions [36]. This finding is similar to a study conducted in France, where the participants had a moderate level of attitude and perceived risk of contracting mosquito-borne diseases [37]. Most participants (73.9%) in this study believed that anyone with symptoms of CHIK should seek immediate help from community health services. However, only a few participants (45.3%) perceived CHIK as a serious illness. It is important to correct this misconception because joint pain and swelling can worsen and persist for months or even years, depending on the viral load and individual health status [38].

In this study, while most participants believed that CHIK could be prevented, addressing personal and general community activities, as well as government action, was considered crucial. Additionally, controlling mosquito breeding was viewed as an effective strategy, although there was some lack of awareness regarding specific breeding places for mosquitoes and the responsibility for reducing larvae and adult mosquitoes. Previous studies showed that most study participants in the Indian Ocean Islands believed CHIK was a controllable disease [39], while in another study conducted in India, less than half of the participants believed they were personally responsible for mitigating CHIK [40]. In La Réunion, about 55% of the study participants from the general public believed that public authorities were capable of doing everything in their power to stop the spread of CHIK and 54% did not believe that individually they had any control over the disease [41]. Meanwhile, management directives from health authorities were perceived as ineffective by 60.4% of health professionals to control [42]. The findings of this study showed that despite moderate attitudes and risk perceptions about CHIK, many community members had uncertain attitudes and risk perceptions about CHIK disease and its vector due to inefficient understanding of the disease, the risk of contracting the virus, the vector, and its breeding characteristics. Therefore, it is important to educate the community to develop a comprehensive understanding of preventing mosquito vectors.

Similarly, this study found that most of the participants had a fair level of overall practice (60.0%) in controlling and preventing CHIK. The participants reported frequently draining ponds or degraded muddy/wet areas (81.4%), cutting down bushes too short (78.9%), cleaning garbage or trash to reduce mosquito breeding sites (88.4%), disposing of water-holding containers like tires, plastic, bottles, or broken pots (73.9%), and covering water containers around the home (70.3%).However, the participants reported less frequently using a fan (51.3%), or bed net (36.2%), and covering their body with clothes when working in the bush, farm, and forest (46.7%). These findings align with a study conducted in Tanzania, which also reported the frequent draining of stagnant water and clearing of bushes around houses, with a small proportion of participants using bed nets [19]. However, the findings differ from a study conducted in Bangladesh, which reported that only about half of the participants practiced regular cleaning of their household water storage to prevent breeding, and almost all were found to use bed nets regularly to prevent mosquito bites [43]. This finding highlights that while the study participants did moderately well in eliminating mosquito-breeding areas and reducing mosquito resting sites, there were identified gaps in the community practices, particularly related to proper personal prevention of mosquito bites to control and prevent mosquito-borne diseases like CHIK.

Multiple linear regression analyses indicated that education significantly influences knowledge scores. This finding was consistent with previous studies, which indicated that education had a strong positive correlation with high knowledge scores towards arbovirus diseases [44, 45]. People with higher levels of education are more likely to participate in health awareness campaigns and educational initiatives, and have access to more information about the diseases [46]. The study also found that marital status was a significant factor for attitude scores. The finding disagrees with other studies that focused on dengue fever. Those studies reported a positive correlation between attitude and educational level [18, 47]. However, no significant association was found between preventive practices and sociodemographic characteristics. Unlike the findings of this study, other studies have also reported that the education was an independent predictor for practice scores, indicating the role of education in changing people’s attitudes [17]. Overall, the study highlights the importance of education and dedicated study in promoting knowledge and improving attitudes towards preventive practices.

The finding in this study showed that a strong positive correlation between the knowledge, attitude, and practice of the respondents. Although there were scarcity of similar studies to compare, the study’s findings were like previous studies conducted on related arboviruses, such as dengue fever, which also reported a similar positive correlation of KAP [46]. Some studies have found a link between knowledge and a positive attitude, as well as between a positive attitude and effective preventative practices toward arbovirus disease [45, 48]. This study’s findings suggest a way to convert information into community attitudes and practices that promote useful habits.

This study had some limitations. Firstly, the study was cross-sectional and only evaluated relationships based on a single point in time and did not account for any changes or dynamics in relationships between the factors analyzed. The survey was conducted via an interviewer-based using a structured questionnaire; might have led some respondents to give socially desirable answers, particularly in the attitude and practice domain [17, 49]. Observational longitudinal studies could provide a better understanding of population dynamics and practices. A complementary qualitative approach to this survey is essential. Additionally, the study was limited to a specific community area, which made it challenging to explore broader factors that influence behaviors, beliefs, and attitudes. Including participants from diverse backgrounds could provide a more comprehensive understanding of these factors. Nevertheless, the study provided crucial baseline information on the overall KAP of the community regarding CHIK and highlighted relevant differences between sociodemographic factors and KAP scores in the Afar region of Ethiopia.

Conclusion

In this study which was conducted after two and half years of large chikungunya and dengue fever outbreaks events in the area and surrounding regionsfound that among those who heard about, 64.1% had high knowledge, 62.0% had a positive attitude towards the disease, and 60.0% had good practices for controlling and preventing. However, even though the community had moderate positive attitudes towards chikungunya, they had uncertainty and lacked sufficient knowledge about the etiology, transmission routes, and the vector Aedes mosquito, including its biology, biting period, and breeding places. This has resulted in inappropriate attitude to the disease and perception of risks, leading to less practice in prevention and control measures. This lack of knowledge highlights the urgent need for massive CHIK awareness campaigns in the region as well as the country at large. The study also found that demographic factors had a different effect on these KAP factors. Policymakers and stakeholders are suggested to take measures so as to raise awareness through community-based educational initiatives and continuously evaluate and monitor the effectiveness of these campaigns. Further studies, including longitudinal studies in Ethiopia, are needed to make the findings more widespread and to mitigate the consequences of CHIK cases and outbreaks.

Electronic supplementary material

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Abbreviations

CHIK

Chikungunya

EPHI

Ethiopian Public Health Institute

FGD

Focus group discussion

HHS

Household survey

KAP

Knowledge, attitude, and practices

RNA

Ribonucleic acid

SD

Standard deviation

Author contributions

Conceptualization: BZ and ML; Data collecting: BZ and ML; Methodology: BZ, TK, GM and ML; Writing—original draft: BZ; Writing—review and editing: BZ, TK, GM and ML; Read and approved the final manuscript: all authors.

Funding

The Addis Ababa University provided support for data collection through its thematic research fund. The funder had no involvement in the conceptualization, design, analysis, decision publication, or preparation of the manuscript.

Data availability

Data is provided within the manuscript or supplementary information files.

Declarations

Ethics approval and consent to participate

The study was conducted as part of a research project that ethically approved by the Institutional Review Board of Aklilu Lemma Institute of Pathobiology, Addis Ababa University, Ethiopia (ALIPB IRERC/88/2014/22) in accordance with the Declaration of Helsinki. Permissions to study were obtained from each study districts. Informed consent was obtained from all participants before participating in the study. Participation was completely voluntary and participants might choose to discontinue participation for any reason at any time while completing the survey.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.