Socio-cultural factors in onchocerciasis control: a study of rural Southeast Nigeria

Abstract

Despite significant global and local efforts geared towards elimination of onchocerciasis, it has been observed that there are socio-cultural factor that make the disease to persist; especially in the rural areas.This study, therefore, investigated socio-cultural factors influencing the control of onchocerciasis in rural southeast Nigeria. The mixed methods research design was adopted for this study. Questionnaire and in-depth interview were the data collection instruments. The quantitative data were processed using the Statistical Package for Social Sciences (SPSS) and analysed using descriptive and inferential statistics. For the qualitative data, 23 in-depth interviews were conducted and analysed using content analysis method. The study established a negative correlation between cultural factors such as religions beliefs and participation in onchocerciasis control in rural South-East Nigeria. Thus, religious beliefs which reinforces onchocerciasis prevalence must be addressed for effective control and elimination of the disease in rural southeast Nigeria.

Introduction

Onchocerciasis is an eye and skin infection transmitted to humans through the bites of onchocerca volvulus infected black flies. The disease is also linked to epilepsy and nodules on affected people (Siewe et al. 2019). It is essentially a rural disease affecting communities sited along fast-flowing rivers with symptoms specially irritating and disabling, often related with long-term exposure to infection and this affects the social and economic activities of the inhabitants involved. After repeated exposure to black fly bites, the affected person may begin to show symptoms of the disease.

According to FMOH (2017), Nigeria has the largest number of onchocerciasis infected people in the global. The findings of a research conducted by Umeh et al. (2010) on the prevalence and distribution of river blindness in three ecological zones (Cross River, Taraba and Kogi) in Nigeria, onchocerciasis was the most prevalent cause of blindness; accounting for 30.2% of blindness in the study areas. Although there have been a lot of studies on the clinical symptoms of onchocerciasis (Oluwole et al. 2009; Carter Center 2010; Eezzuduemhoi and Wilson 2013; Eyo et al. 2013; Adebayo 2014), there are little or scanty information on socio-cultural factors that influence the control of onchocerciasis among rural dwellers in southeast Nigeria.

According to a study conducted by Okoye et al. (2011) in rural northeast Nigeria, men have special preference for women with palpable nodules of the lower extremities because it is believed that tingling the nodules improve libido and sexual excitement. This means that due to socio-cultural belief, nodule which is a symptom of onchocerciasis in such area is not seen as problem. In a study conducted by Afolabi et al. (2016) in Western Nigeria, the authors revealed that onchocerciasis (also called “nárun”) in the area is attributed to the “ubiquitous worms inside the body” which are believed to be harbored by everyone and to be necessary to stimulate fertility. This implies that onchocerciasis in the study area is not seen as a serious disease since some element of it is believed to stimulate fertility.

Belief that onchocerciasis is caused by the gods is another socio-cultural factor that negatively affects the disease control. According to Okereke and Amadi (2016) in a study on prevalence of onchocerciasis disease in Okigwe LGA in Imo State, Nigeria, community members tend not to take ivermectin and explain symptoms of the disease from religious and traditional point of view. This is because of the belief that the disease symptoms are signs of spiritual attack from evil men or punishment from the gods for wrong doing. The authors revealed that many of the people are totally ignorant of the effect of the drug (ivermectin), while others use religious (prayers) or local resources (herbs) for the treatment of the symptoms instead of realizing the actual cause of the disease.

Taking into cognizance the public health significance of onchocerciasis, such socio-cultural factors that can negatively affect WHO and the World Bank African Programme for Onchocerciasis Control (APOC) 2025 onchocerciasis elimination goal (WHO/APOC 2014) need to be carefully examined. It is against the backdrop of the foregoing problems that this study is positioned to investigate the socio-cultural factors influencing the control of onchocerciasis among rural dwellers in south-east Nigeria.

Hypothesis

1. There is a statistical significant positive relationship between religious beliefs and participation in the control of onchocerciasis in rural South-East Nigeria.

Methods

The study design was mixed methods research. Southeast Nigeria, which is made-up of five states (Abia, Anambra, Ebonyi, Enugu and Imo) with 95 Local Government Areas (Abia State has 17 LGAs; Anambra, 21; Ebonyi, 13; Enugu, 17; and Imo, 27) was the study area. The general population of the study is 24,265,421, being the projected 2018 population of southeast Nigeria. This was calculated using arithmetic population projection formula. However, the target population for the study is 19,553 which were drawn from a population categories in the study area designed for an inclusive representation of relevant stakeholders in the study. The population categories are: Community Farmers Cooperative Meeting, Community Men Town Union Meeting ((Ogbako Ndi Okenye Umu Nwoke), Community Women Town Union Meeting (Ogbako Ndi Okenye Umu nwanyi), Community Men Youth Meeting (Ogbako Ndi Ntorobia) and Community Women Youth Meeting (Ogbako Ndi Agbobia). A total of 1051 participants were proposed as the study sample size. This was determined statistically using Taro Yamane formula. However 969 copies of questionnaire were retrieved representing 92.2 percent of the respondents. This now represent the sample size of the study. For the qualitative data of the study, a total of 24 In-depth Interviews were proposed; however 23 IDIs were conducted.

The multi stage sampling method was adopted for this study. Firstly, based on hydrological (Nwoke 2011) and epidemiological results (Noma et al. 2014), Southeast States was purposively selected due to the endemicity of onchocerciasis disease in many communities in the area. Secondly, based on the prevalence of onchocerciasis disease among States in Southeast Nigeria, purposive sampling method was adopted to select three (3) States (Enugu, Ebonyi and Imo). Onchocerciasis prevalence rate in southeast Nigeria is as follows: Enugu (39.02), Ebonyi (33.35), Imo (26.8), Anambra (16.7) and Abia (3%) (Mbanefo et al. 2010; Okonkwo et al. 2010; Eyo et al. 2013; Okereke and Amadi 2016). Thirdly, three LGAs namely, Oji-River (43.58%), Ikwo (40.6%) and Okigwe (37%) were purposively selected from the three states based on high prevalence rate of onchocerciasis (Mbanefo et al. 2010; Okonkwo et al. 2010; Okereke and Amadi 2016). Fourthly, purposive sampling method was used to select one community from each selected LGAs that have high onchocerciasis prevalence in the area (Mbanefo et al. 2010; Okonkwo et al. 2010; Okereke and Amadi 2016). Thus, a total of three communities (Achi, Echia-Like and Amuru) were selected for the study. Furthermore, five population categories were created in the selected communities for inclusiveness of all relevant respondents in the study. The actual number of respondents was selected from the population categories using proportionate stratified random sampling method as shown in Table 1. Finally, questionnaire was administered to the actual respondents using purposive sampling methods at their place of work and residence. For the qualitative data, purposive sampling method was used to select 23 key interviewees. They are: 3 Traditional title holders (one from each community), 3 Community men leaders (one from each LGA), 3 Community women leaders (one from each community), 3 Community youth leaders (one from each community) 3 Farmers (1 from each community), 3 Clergymen (one from each community), 2 Orthodox health practitioners (one from each community) and 3 Traditional health practitioners (one from each community). Structured interview questionnaire and in-depth interview (IDI) were the study data collection instruments. The quantitative data were processed using the Statistical Package for Social Sciences (SPSS) version 20; while the data were analyzed using descriptive and inferential statistics. For the qualitative, content analysis method was used to analyze the interview transcript. Ethical principles of informed and voluntary consent, confidentiality, non-injury, and beneficence were fully observed throughout the data collection process.

Table 1.

Calculation of proportionate stratified random sampling

State/community	Population category	Total	Percentage	Proportionate calculation
Ebonyi/Echia-like	Community farmers cooperative union meeting	1344	7	$\frac{1344}{19553}$ × $\frac{1051}{1}$ = 72
	Community men town union meeting	1711	9	$\frac{1711}{19553}$  ×  $\frac{1051}{1}$= 92
	Community women town union meeting	2358	12	$\frac{2358}{19553}$  ×  $\frac{1051}{1}$= 127
	Community men youth meeting	1473	8	$\frac{1473}{19553}$  ×  $\frac{1051}{1}$= 79
	Community women youth meeting	1731	9	$\frac{1731}{19553}$  ×  $\frac{1051}{1}$=  93
Enugu/achi	Farmers cooperative meeting	1067	5	$\frac{1067}{19553}$  ×  $\frac{1051}{1}$=  57
	Community men town union meeting	1479	8	$\frac{1479}{19553}$  ×  $\frac{1051}{1}$=  79
	Community women town union meeting	1839	9	$\frac{1839}{19553}$  ×  $\frac{1051}{1}$=  99
	Community men youth meeting	1058	5	$\frac{1058}{19553}$  ×  $\frac{1051}{1}$= 57
	Community women youth meeting	1237	6	$\frac{1237}{19553}$  ×  $\frac{1051}{1}$=  66
Imo/Amuru	Farmers cooperative meeting	721	4	$\frac{721}{19553}$  × $\frac{1051}{1}$ =  39
	Community men town union meeting	869	4	$\frac{869}{19553}$  × $\frac{1051}{1}$ =  47
	Community women town union meeting	1023	5	$\frac{1023}{19553}$  × $\frac{1051}{1}$ =  55
	Community men youth meeting	701	4	$\frac{701}{19553}$  × $\frac{1051}{1}$ =  38
	Community women youth meeting	942	5	$\frac{942}{19553}$  × $\frac{1051}{1}$ =  51
Total		19,553	100	$\frac{19553}{19553}$  × $\frac{1051}{1}$ =  1051

Results

This section shows findings on socio-cultural factors that affect control of onchocerciasis in rural southeast Nigeria.

First, the following socio-demographic characteristics of the respondents were analysed in Table 2: Age, Sex, Education, Marital status, Religion and Occupation. The distribution of respondents by gender shows that 502 (51.8%) of the respondents are females while 467 (48.2%) are males. Table 2 also indicates that 268 (27.7%) of the respondents are aged between 18–29 years while only 107 (11.0%) are aged 66 years and above.

Table 2.

Socio-demographic characteristics of the respondents

Response	Frequency	Percentage (%)
Sex
Male	467	48.2
Female	502	51.8
Total	969	100.0
Age
18–29 years	268	27.7
30–41 years	237	24.5
42–53 years	199	20.5
54–65 years	158	16.3
66 +	107	11.0
Total	969	100.0
Educational level
None	141	14.6
Vocational	184	19.0
Primary/FSLC	204	21.1
Secondary	200	20.6
Higher/tertiary	240	24.8
Total	969	100.0
Marital status
Single	286	29.5
Married	571	58.9
Divorced	24	2.5
Separated	38	3.9
Widowed	50	5.2
Total	969	100.0
Occupation
Retired	26	2.7
Student	104	10.7
Farming/hunting	420	43.3
Trading	211	21.8
Artisan	89	9.2
Paid employment/salaried	119	12.3
Total	969	100.0
Religion
Christianity	720	74.3
Traditional	196	20.6
Islam	53	5.5
Total	969	100.0

In terms of educational level, the table shows that 240 (24.8%) respondents representing a majority of the study sample size have higher/tertiary education while only 141 (14.6%) of the respondents has no formal education. Table 2 also indicates that a majority of the respondents 571 (58.9%) were married while only 24 (2.5%) respondents were divorced. The data further show that majority of the study respondents 420 (43.3%) practice farming/hunting as their occupation while 26 (2.7%) respondents were retirees. In terms of religion, Table 2 shows that a majority of the respondents 720 (74.3%) are Christians while 53 (5.5%) representing minority of the respondents practice Islamic religion.

Table 3 shows that almost half of the respondents 431 (44.6%) indicated that belief onchocercias is caused by the gods is a major cultural factor that affect the disease prevalence and control in rural southeast Nigeria while only 34 (3.5%) of the respondents said sexual excitement gotten through tingling of nodules affect the disease control. This was corroborated in the IDI data. A respondent who is a community men leader and a farmer said:

In our community there are traditional believes. Sometimes something can happen to someone and it will be attributed to probably the gods or cause by spirits. So even when you give the person drugs his mind will not be at rest because he belief that the cause is spiritual and will be solved spiritually. So one can be infected with this disease and he will attribute it to the cause of gods, spirits or evil people and will be looking for solution spiritually. So such a thing can affect the control of the disease.[Male, Farmer, Aged 46, Ebonyi State].

Table 3.

Distributions of respondents by cultural factors affecting control of onchocerciasis among rural dwellers in Southeast Nigeria

Response	Frequency	Percentage (%)
Tingling of nodules increases sexual libido and excitement	34	3.5
Women with nodules are favoured in marriage selection	127	13.1
It is caused by the gods	431	44.6
It is punishment from the gods for disobedience	159	16.4
It can only be treated spiritually	217	22.4
Total	969	100.0

Another respondent who is a youth leader expanded the scope by including other factors. He said.

Onchocerciasis can be attributed to spiritual cause because we are very superstitious. Healthcare is very poor here in Nigeria especially in rural areas…so if you don’t go for test, how will you know exactly what that is wrong with you? Somebody have symptom of river-blindness like emm….visual impairment or itching, the person might not even think that it is river-blindness. He may think that it is spiritual attack. In fact, that might be the first cause that will come to his/her mind. The person might even die without realizing the problem. I think our cultural aspersions in terms of superstitions and lack of access to medical care can prevent people from understanding what that is wrong with them and seeking for solutions.[Male, Farmer, Aged 38, Enugu State].

To determine cultural factors that influence participation in onchocerciasis preventive and control programmes, multinomial logistic regression was conducted. The findings are presented in Table 4.

Table 4.

Multinomial logistic regression predicting the effect of cultural factors on participation in onchocerciasis control programmes in rural Southeast Nigeria

Model	Model fitting criteria	Likelihood ratio tests	Df	Sig
	2 log likelihood	Chi-square
Model fitting information
Intercept only	656.658
Final	555.857	100.801	18	.000

Effect	Model fitting criteria	Likelihood ratio tests	Df	Sig
	-2 Log Likelihood of Reduced Model	Chi-square
Likelihood ratio tests
Intercept	555.857a	.000	0
Belief in traditional medicine	564.967	9.110	3	.028
Belief in gods	576.398	20.540	3	.000
Belief that tingling of the nodules increases sexual libido	556.970	1.112	3	.774
Belief that the disease is hereditary	566.286	10.429	3	.015
Belief that it is punishment from the gods	596.398	40.540	3	.000
Belief that the disease can only be treated spiritually	575.975	20.117	3	.000

Table 4 shows a multinomial logistic regression analysis of effects of cultural factors on decision to participate in onchocerciasis prevention and control programmes. The Model Fitting Information shows that the independent variables statistically significantly (P-value = 0.000) predicts (or are likely to predict) the dependent variable. The table further indicates that out of the 6 independent variables tested, only 1: Belief that tingling of the nodules increases sexual libido (P-value = 0.774) is not statistically significant. In the IDI data, “religious/spiritual beliefs” and “belief in traditional medicine” were also identified as major cultural beliefs about onchocerciasis that affect the disease prevalence and control. The belief in efficacy of traditional medicine was aptly captured by one of the respondents who is a civil servant in the IDI data:

In truth, where there are many people, understanding and faith is different. Some people believe that traditional medicine is more potent but there are other people that believe that orthodox medicine is more potent. So those people that believe that traditional medicine is more potent may not frequently go to collect orthodox medicine because the person believes that traditional medicine can cure every sickness [Male, Retired Civil Servant, Aged 73, Imo State].

Similarly notion was shared by another respondent who described the belief and its consequence as follows:

Belief in traditional medicine or that the disease is sent spiritually can also affect participation in the disease preventive programmes. I told you that some people think that they are suffering from what other people sent to them so they will be going to native doctor to seek for solution. So this can make the disease instead of going it will continue [Female, Farmer, Aged 73, Ebonyi State].

Religious/spiritual beliefs in some rural communities may affect the control of onchocerciasis in the community. This was described by one of the respondents with these words: “…most people here believe that they were given poison or someone spiritually inflicted them with the disease. So you will see them looking for solution traditionally [Female, Student, Aged 27, Imo State]. Similarly notion was presented by another respondent who is a farmer and a trader. He noted that:

Some people may due to traditional belief think that it is their sin or that someone projected the disease spiritually to him and this may make them to begin to seek spiritual help and at the end the issue may be complicated. People that have this belief are many [Male, farmer/trader, Aged 68, Enugu State].

Test of research hypothesis

1. There is a statistical significant positive relationship between religious beliefs and participation in the control of onchocerciasis in rural South-East Nigeria.

To determine the relationship between religious beliefs and participation in onchocerciasis control, Spearman's rho Correlation test analysis was conducted and presented in Table 5.

Table 5.

Spearman's rho correlation test of religious belief and participation in onchocerciasis prevention and control programmes

			Participation in onchocerciasis control programme	To what extent do belief that the disease can only be treated spiritually affect onchocerciasis control
Spearman's rho	Participation in onchocerciasis control programme	Correlation coefficient	1.000	− 0.124**
		Sig. (2-tailed)		0.000
		N	0.969	854
	To what extent do belief that the disease can only be treated spiritually affect onchocerciasis control	Correlation coefficient	− 0.124**	1.000
		Sig. (2-tailed)	0.000
		N	854	854

The Spearman's rho Correlation test analysis in Table 5 shows a statistical significant negative correlation (P-value = 0.000, r = − 0.124) relationship between religious beliefs and participation in onchocerciasis control in rural southeast Nigeria. This means that the more people perceive onchocerciasis from religious point of view, the likelihood that participation in onchocerciasis control will continue to decline.

Discussion of findings

This study investigated socio-cultural factors affecting the control of onchocerciasis in rural southeast Nigeria. It was found that the traditional belief that onchorcerciasis is caused by the gods and the belief it is punishment from the gods for disobedience were major socio-cultural factors affecting control of onchocerciasis in endemic communities of South-east Nigeria. When people that are infected by onchocerciasis attribute the cause of the disease to supernatural factors, they tend to look for the solution of the problem spiritually. This line of thought may exacerbate the problem and affect the speed of the disease control in southeast Nigeria. This is in line with a study conducted by Okereke and Amadi (2016). The authors asserted that due to belief that onchocerciasis is caused by the gods or spiritually manipulated by evil people in the society; infected people also seek spiritual help to cure the disease and thereby worsen the situation.

The result of a Spearman's rho Correlation test conducted shows a statistical significant negative correlation between religious beliefs and participation in onchocerciasis control in rural southeast Nigeria. This means that as long as people define onchocerciasis from religious point of view, the likelihood their participation in onchocerciasis prevention and control programmes will continue to decline. Therefore for you to understand why fewer people participate in onchocerciasis prevention and control programmes, there is need to first understand those factors (beliefs) that influence their perception of the disease. People do not participate in onchocerciasis prevention and control programmes because they belief that the source of the illness is spiritual and requires spiritual attack. This is in line with the study IDI findings which identified “religious/spiritual beliefs” and “belief in traditional medicine” as major socio-cultural factors that affect onchocerciasis prevention and control programmes. Also, this is supported by the result of a study conducted by Adeoye (2012) where locals did not comply with the treatment of onchocerciasis using ivermectin because they belief that the disease has spiritual cause and should be treated spiritually.

Conclusion

Onchocerciasis control and the decision to participate in the disease control programmes are influenced by socio-cultural characteristics of the people. Consequently, to prevent and control onchocerciasis in rural South-east Nigeria, there is need to address those socio-cultural factors that negatively affect the disease control in rural southeast Nigeria.

Funding

The research work contained in the manuscript was supported by Imo State University 2016 PhD TETFUND research funding program.

Code availability

Yes.

Compliance with ethical standards

Conflict of interest

The author declare that there is no conflict of interest.

Ethics approval

School of Postgraduate Studies Nnamdi Azikiwe University, Awka, Anambra State (NAU/SPGS/14).

Availability of data and material

Yes.

Consent to participants

Individual participant consent was gotten.