Knowledge, Attitude, and Practices among HIV/Leishmaniasis Co-Infected Patients in Bihar, India

ABSTRACT.

Visceral leishmaniasis (VL) is a serious public health concern in the Indian state of Bihar, which has been exacerbated by an increasing HIV/AIDS incidence that has resulted in poor clinical outcomes. So far, there has been no investigation into the knowledge, attitude, and practices (KAP) of people who have been subjected to hospital-based supervision for VL or HIV/VL co-infection. This study assessed the KAP toward VL infection among 210 VL-infected patients (126 participants with VL and 84 participants with HIV/VL) using a pretested standard questionnaire. The findings are summarized descriptively and KAP scores are classified dichotomously (good/poor). Multivariable logistic regression and bivariate correlation were used in the analysis. The study showed that both VL-infected and co-infected patients exhibited similar deficits in KAP scores toward VL. The HIV/VL participants who had a personal or family history of VL were more likely to have appropriate awareness of and preventive practices toward VL. The independent predictors of attitude index in HIV/VL participants were education, VL family history, and marital status. There was a weak but significant positive correlation between knowledge and practice (r_s = 0.321, p<0.001), and attitude and practice (r_s = 0.294, p<0.001), while knowledge was strongly correlated with attitude (r_s = 0.634, p<0.001). Based on the study findings, it is recommended that treatment programs in Bihar should concentrate on strengthening KAP among VL and HIV/VL co-infected patients to prevent reinfection-related complications. Behavior change communication intervention is ideal for tackling this problem. This proposal entails building a comprehensive public health program in endemic regions.

INTRODUCTION

Leishmaniases are a group of vector-borne parasitic illnesses caused by protozoan parasites belonging to more than 20 different Leishmania species.¹ Leishmaniasis is one of the world’s most neglected tropical diseases, with a geographic distribution that stretches across nearly all continents, putting more than 1 billion people at risk and resulting in an estimated 0.7 to 1 million new cases each year.^1,2 Visceral leishmaniasis (VL) is the most serious systemic form of leishmaniasis and it is accountable for more fatalities than any other parasite illness, with the exception of malaria.^3,4 VL targets disproportionately the lowest-income sections of the population and those with poor health-care coverage, resulting in an estimated 1 million disability-adjusted life years lost each year in Southeast Asia.⁵ More than 90% of new VL cases reported to the WHO are located in just 10 countries: six in eastern Africa (Sudan, Eritrea, Somalia, South Sudan, Ethiopia, and Kenya), two in Southeast Asia (India and Nepal), one in southwestern Asia (Iraq), and one in Latin America (Brazil).¹

The protozoan parasite Leishmania donovani causes VL in the Indian subcontinent and is spread by the bite of an infected sandfly, Phlebotomus argentipes.⁶ Anthroponotic VL, which is most prevalent in India, holds humans as its only known reservoir.⁷ During sandfly blood meals, the flies introduce the infective stage (i.e., promastigotes) into the dermis, resulting in human infection. After invading the macrophages, the parasite begins to multiply and causes the infection to take hold.⁸ When the parasite enters the bloodstream, it causes various hematological and clinical manifestations, including hepatomegaly, splenomegaly, fever, weakness, pancytopenia, weight loss, and skin discoloration, which gave the disease the name “kala-azar.”^8,9 VL is estimated to be deadly in 95% of patients if it remains untreated.¹⁰

VL has been recognized as a serious public health problem by the WHO, which has set a target of eradicating the disease from the Indian subcontinent by 2020, with a case rate of fewer than 1 per 10,000 people.¹¹ For this eradication campaign, Bihar State in India, which contributes 60% to 90% of cases of VL in the Indian subcontinent, and approximately 80% to 90% of cases and 90% of fatalities in India, remains a primary target.^10,11 Although Bihar has a low prevalence of HIV, the incidence of HIV cases has been escalating, making it one of the most severe implications of HIV/VL co-infection.¹² Information on the prevalence of HIV/VL co-infection in India is limited because of a paucity of data. The fact that between 2% to 7% of people infected with VL in Bihar are also infected with HIV, according to various research studies,^12,13 suggests that HIV/VL co-infection has the potential to become a serious public health issue. VL and HIV share an immunopathological route that affects dendritic cells and macrophages, which increases the replication and promotes the development of both VL and HIV infection. HIV infection in conjunction with VL enhances the likelihood of subsequent development of active VL by 100 to 2,320 times.^14,15

When considering the worse outcomes reported in the HIV/VL co-infected group, including atypical manifestations, diagnostic failures, greater recurrence rates, mortality, and VL drug toxicity and resistance, we can deduce that VL infection is one of the most difficult clinical conditions to manage in the context of HIV infection.^12,15 It is crucial to emphasize that people with HIV/VL co-infection may be super-spreaders of VL, creating a threat to VL eradication efforts.¹⁶ Relapse occurs in nearly 5% of immunocompetent cases of VL and in 27% to 60% of HIV-positive people who initially recover, but it usually occurs within 6 to 12 months of following therapy.^17,18 In HIV-positive individuals, the duration between relapses was shorter than the time between the first episode and the first relapse, even for those on antiretroviral therapy.¹⁸ Patients with AIDS, who are more subject to opportunistic infections, should be mindful of the VL relapse/reinfection paradox.

Patients with VL who have been treated successfully should also take prophylactic steps to avoid contracting the infection in the future. Patients undergoing treatment of their first episode of VL should be educated about the dangers of reinfection and relapse, along with how to handle these circumstances, which must be addressed by health-care facilities. To achieve a parasitological cure in such individuals, combination medications and extended VL therapy are required.¹⁹ Drug resistance can be triggered by excessive drug exposure; therefore, it may be more beneficial to identify a relapse early rather than later and to provide treatment.¹⁹ However, there are no vaccines available in the market that can prevent VL. The only treatment now in use is chemotherapy; but, because of the high toxicity and antimonial resistance of these drugs, this treatment is far from ideal.¹⁷ Amid this challenging scenario, it is preferable to avoid VL infection in all possible ways to avoid further complications.

Before implementing prevention and control programs for a disease, it is necessary to examine the knowledge, attitude, and practices (KAP) of the general populace regarding the illness in question. Successful prevention and elimination of any disease require the involvement of the entire community, including the cooperation of people who are afflicted by the disease.²⁰ People’s information, attitude, and behavior regarding a disease are all important factors in the prevention, control, and elimination of that illness. Inadequate awareness might cause treatment delay or even denial of the condition. To comprehend fully the hurdles to leishmaniasis treatment and prevention in Bihar, it is important to determine the key drivers of KAP with regard to leishmaniasis. In light of the poor prognosis and frequent relapse of VL, KAP research and educational interventions in patients are necessary to identify aspects where knowledge, aptitude, and practices of VL are lacking; policymakers must strive to enhance awareness through educational intervention programs.

According to our knowledge, no research has been conducted in India that shows the KAP of patients with VL or with VL/HIV. In addition, the world has moved past the 2020 target date set out by the WHO for the elimination road map and it is thus important to review the existing state of knowledge, development, and intervention methods for VL in Bihar, especially considering that it is a severely impacted state in India.

MATERIALS AND METHODS

Study site and design.

From January 2019 to January 2020, a hospital-based single-center cross-sectional study was conducted to explore KAP toward VL among HIV/VL co-infected and VL-infected patients in Bihar. The study population was recruited from the indoor wards of the Rajendra Memorial Research Institute of Medical Sciences (RMRIMS), Patna, which provides free treatment and patient care. RMRIMS is a tropical disease research center and hospital affiliated with the Indian Council of Medical Research, which serves as a principal site for treatment and clinical research on VL in the state of Bihar. Patients with confirmed VL and HIV/VL co-infection of both genders who were older than 18 years were enrolled in this study. Patients with stated psychological problems and unwillingness to participate were excluded.

Consent and ethical clearance.

This study was approved by the Institutional Ethics Committee, RMRIMS, Patna, India. All participants were provided with an explanation of the aim and scope of the research before participation. Written informed consent was obtained from all study volunteers. Participation was voluntary and participants were free to withdraw from the study at any time.

Sample size.

Sample size was determined using OpenEpi (Open Source Epidemiologic Statistics for Public Health) software Version 3.3 (Atlanta, GA, USA). The prevalence of HIV/VL co-infected patients reported in India ranges from 2% to 5.6%.¹² With a power of 80% and a 95% CI, a 1:1 ratio of HIV/VL co-infected patients and VL-infected patients was considered; a sample size of 80 was required in each group. However, all VL-infected and HIV/VL co-infected patients admitted to the indoor ward of RMRIMS hospital throughout the study duration were enrolled as study subjects if they were mentally competent and willing to participate. This resulted in an overall sample size of 210 participants (84 HIV/VL-infected participants and 126 VL-infected participants). Previous studies in the same area of research calculated that a sample size of 120 would be significant to achieve results.^16,20 Thus, we anticipated that our sample size would be useful in providing study participants’ KAP regarding VL.

Data collection.

The data were collected using a well-structured and pretested questionnaire. The questionnaire was built based on previously published research that measured KAP concerning VL in the general population.^15–18 The KAP questionnaire that was used has been published previously.¹⁶ The questionnaire is broken into four sections that cover the following topics: 1) sociodemographic characteristics, 2) participants’ knowledge and understanding of VL, 3) participants’ attitude about VL, and 4) VL-related preventive measures. To ensure the quality of the research, research assistants are provided with detailed information about the study objectives, the method for administering the questionnaire in the local language, the scope of explanations, and confidentiality. The structured questionnaires were pretested on 25 research participants to verify that the items in the questionnaire were comprehensive, clear, precise, and consistent; the data from these participants were omitted from the final study. Last, data gathering commenced after necessary adjustments were made. The lead investigator double-checked the data-gathering procedures to verify they were thorough and accurate.

Scoring.

To score the questionnaire, we used the same approach that has been used in previously published publications to score similar questionnaires. The scoring technique used was described elsewhere.¹⁶ In summary, every right answer received a 1-point score, whereas a wrong or “I don’t know” response was assigned a score of 0 point. The KAP indices of participants were classified as good or poor using a 50% cutoff value. Participants who answered more than 50% of the KAP assessment questions correctly were deemed to have acceptable KAP about VL, whereas those who scored ≤ 50% were deemed to have inadequate KAP about VL. Participants’ knowledge of VL was assessed using a scale ranging from 0 to 8 points, where 0 point represents the least knowledge and 8 points denotes the greatest knowledge. Scores ranging from 5 to 8 points were classified as good knowledge, whereas scores ranging from 0 to 4 points were classified as poor knowledge. Likewise, participants’ attitudes and perceptions about VL were also evaluated on a scale of 0 to 8 points, with a score of 0 to 4 points indicating unfavorable attitude/perception and a score of 5 to 8 points indicating favorable attitude/perception. Last, on a scale ranging from 0 to 4 points, the effectiveness of VL preventive practices was evaluated. Participants who received a score of more than 2 points were deemed to practice good/optimal VL prevention techniques.

Data analysis.

The findings of the descriptive analyses were expressed as frequencies and percentages. Bivariate and multivariate regression models were used to investigate the relationship between sociodemographic variables and their KAP. The bivariable relationships between independent variables and KAP indices were investigated using binary logistic regression. The final multivariable logistic model included all bivariate variables with P < 0.2. Using multivariable backward logistic regression, we found the most predictive predictor among participants and KAP domain features. Multivariable backward logistic regression analysis was used to determine the strongest predictive variables among participant characteristics for KAP domains. Statistically significant relationships were determined by calculating an adjusted odds ratio with a 95% CI, with P < 0.05 regarded as statistically significant. The Spearman rank correlation coefficient (r_s) was used to estimate the correlation values between KAP indices. The data were analyzed using SPSS (version 27.0; SPSS Inc., Chicago, IL).

RESULTS

Sociodemographic characteristics.

A total of 210 patients with VL infection agreed to participate in the study; 84 of these participants were co-infected with HIV at the time of enrollment. The sociodemographic information of the study participants is presented in Supplemental Table S1. The cohort’s mean age was 43.7 ± 9.7 years. The majority of participants were men (79%), married (74.8%), and living below the poverty line (59.5%) in rural areas (84.8%). The majority of study participants (81.4%) belonged to a family with more than six members. Open-air defecation was practiced by 39% of the study participants. Except for VL history, there were no statistically significant differences in the sociodemographic variables between the two groups in our study. Co-infected patients (26.2%) have considerably greater experience with VL infection than participants with VL alone (P > 0.05). A large proportion of VL-infected and HIV/VL co-infected participants had no family history of VL (69% and 63.1%, respectively).

Knowledge about VL.

The vast majority of VL-infected and HIV/VL co-infected participants had previously heard of VL (95.2% and 90.5%, respectively); those who had not were eliminated from the remaining knowledge questions. In both patient groups, most respondents reported knowing at least one sign of visceral leishmaniasis, with fever being the major symptom of VL (90.5% VL, 85.7% HIV/VL) and anemia being the least recognized (13.4% VL, 11.9% HIV/VL). Approximately 35% of participants with VL and 32.9% of participants with HIV/VL were aware of at least one breeding habitat for the sandfly, whereas the rest were unaware. The majority of respondents identified contaminated water, unsanitary environments, and trash dumps as the most likely breeding grounds. Nonetheless, most respondents from both groups could not answer questions about vector characteristics accurately, such as vector identification, peak biting time, and the season of spread. Knowledge of VL was found to be poor in both study groups. Among the patients with VL, the level of knowledge was poor in 61.7% and good in 38.3%. Similarly in HIV/VL co-infected patients, the level of knowledge was poor in 67.1% and good in 32.9% (Table 1).

Table 1.

Knowledge of study participants about visceral leishmaniasis

Variable	Patients with VL, n (%)	Patients with HIV/VL, n (%)
Were you previously aware of VL? (n = 126)
Yes	120 (95.2)	76 (90.5)
No	6 (4.8)	8 (9.5)
Do you know the mode of transmission of VL? (n = 120)
Sandfly*	42 (35)	26 (34.2)
Housefly	4 (3.3)	3 (3.9)
Mosquito	24 (20)	33 (43.4)
Don’t know	50 (41.7)	14 (18.4)
What do you think are the signs and symptoms of VL?† (n = 120)
Fever*	114 (90.5)	72 (85.7)
Splenomegaly*	45 (35.70)	28 (33.33)
Anemia	17 (13.4)	10 (11.9)
Stomach ache	10 (7.9)	5 (5.9)
Skin pigmentation*	55 (43.5)	30 (35.7)
Don’t know	4 (3.1)	2 (2.4)
Do you know what a sandfly looks like? (n = 120)
Yes*	34 (28.3)	19 (25)
No	86 (71.7)	57 (75)
Do you know the breeding habitats of sandflies? (n = 120)
Yes*	42 (35)	25 (32.9)
No	78 (75)	51 (67.1)
Do you know the peak biting time of sandflies? (n = 120)
Dusk and dawn	24 (20)	13 (17.1)
Midnight*	42 (35.0)	25 (32.9)
Daytime	5 (4.2)	2 (2.6)
Any time	11 (9.2)	9 (11.8)
Don’t know	38 (31.7)	27 (35.5)
Do you know the season when VL is spread? (n = 120)
Rainy season*	22 (18.3)	15 (19.7)
Winter*	26 (21.7)	13 (17.1)
Summer	28 (23.3)	17 (22.4)
Don’t know	44 (36.7)	31 (40.8)
Is VL preventable? (n = 120)
Yes*	48 (40)	27 (35.5)
No	32 (26.7)	22 (28.9)
Don’t know	40 (33.3)	27 (35.5)
Overall knowledge
Good	46 (38.3)	25 (32.9)
Poor	74 (61.7)	51 (67.1)
Mean score, point	4.06 ± 2.12	3.89 ± 1.71
P value	0.571

VL = visceral leishmaniasis.

^*The correct response was assigned a score of 1 point; other responses were scored 0 point.

^†Any symptom assigned a score of 1 point. Multiple responses were received.

Attitude regarding VL.

Table 2 shows the study participants’ attitudes toward visceral leishmaniasis. Approximately 19% of VL-infected and 26.2% of HIV/VL co-infected patients had the wrong perception that VL is not completely curable. Approximately, 22.2% of VL-infected and 21.5% of HIV/VL co-infected patients held the misconception that living with a VL-infected individual could not cause VL transmission, whereas approximately 37.3% of VL-infected participants and 34.5% of HIV/VL co-infected participants were ignorant of this fact. More than 50% of the VL-infected patients were unaware that people living with HIV are at a greater risk of contracting VL. More than 50% of participants in both research groups had a positive outlook on the importance of early detection and persistent therapy, which, in the long term, improves recovery. The degree of attitude regarding VL was poor in 57.1% of the VL-infected group and favorable in 42.9%. Similarly, in the HIV/VL co-infected patients, the attitude was poor in 51.2% and good in 48.8%.

Table 2.

Preventive attitudes toward visceral leishmaniasis among study participants (N = 210)

Variable	Patients with VL, n (%)	Patients with HIV/VL, n (%)
Is VL completely curable?
Yes*	55 (42.7)	32 (38.1)
No	24 (19.0)	22 (26.2)
Don’t know	47 (37.3)	30 (35.7)
Is the outcome of VL fatal if untreated?
Yes*	72 (57.1)	54 (64.3)
No	13 (10.3)	11 (13.1)
Don’t know	41 (32.5)	19 (22.6)
Is it possible to control VL through community participation?
Yes*	50 (39.7)	34 (40.5)
No	20 (15.9)	19 (22.6)
Don’t know	56 (44.4)	31 (36.9)
Are people with HIV more vulnerable to kala-azar?
Yes*	38 (30.2)	43 (51.2)
No	23 (18.3)	11 (13.1)
Don’t know	65 (51.6)	30 (35.7)
Does living with a VL-infected person raise the risk of getting a VL infection?
Yes*	51 (40.5)	37 (44)
No	28 (22.2)	18 (21.5)
Don’t know	47 (37.3)	29 (34.5)
Does an early diagnosis help with VL treatment?
Yes*	80 (63.5)	56 (66.7)
No	10 (7.9)	7 (8.3)
Don’t know	36 (65.1)	21 (25.0)
Does inconsistent treatment affect recovery?
Yes*	69 (54.8)	50 (59.5)
No	20 (15.9)	11 (13.1)
Don’t know	37 (29.4)	23 (27.4)
Where is your preferred place of treatment?
Public sector*	82 (65.1)	58 (69.0)
Private sector	20 (15.9)	13 (15.5)
Other	24 (28.6)	13 (25)
Overall attitude
Positive	54 (42.9)	41 (48.8)
Negative	72 (57.1)	43 (51.2)
Mean score, point	3.93 ± 2.22	4.31 ± 2.12
P value	0.225

VL = visceral leishmaniasis.

^*The correct response was assigned a score of 1 point; other responses were scored 0 point.

VL prevention practices.

Table 3 shows participants’ practices toward VL prevention. We observed that the vast majority of participants from both groups had a habit of sleeping without bed nets (VL infected, 64.3%; HIV/VL co-infected, 58.3%). Of the respondents, the majority (59% of VL patients and 61% of HIV/VL patients) avoided sleeping outdoors. A significant portion of the VL-infected participants (31%) and HIV/VL co-infected participants (29%) did not use any sandfly control methods to prevent VL. In the VL-infected group, 60.3% had inadequate VL prevention practices, whereas in HIV/VL co-infected group, 57.1% had unsatisfactory practices.

Table 3.

Visceral leishmaniasis control and preventive practices among study participants (N = 210)

Variable	Patients with VL, n (%)	Patients with HIV/VL, n (%)
Sleeping outdoors
Yes	51 (40.5)	33 (39.3)
No*	75 (59.5)	51 (60.7)
Use of bed net
Yes*	45 (35.7)	35 (41.7)
No	81 (64.3)	49 (58.3)
Sandfly control†
Use of bed net	32 (25.4)	22 (26.2)
Use of mosquito repellents/coil	18 (14.3)	21 (25)
Cleanliness	9 (7.1)	9 (10.7)
No use of any prevention methods	39 (31)	22 (29)
Don’t know	28 (22.2)	10 (11.9)
Care of patient with VL
Use of bed net*	32 (25.4)	26 (31)
Cleanliness	25 (19.8)	17 (20.2)
Isolation of patients	25 (19.8)	20 (23.8)
Don’t know	44 (34.9)	21 (25)
Overall practice
Good	50 (39.7)	36 (42.9)
Poor	76 (60.3)	48 (57.1)
Mean score, point	1.67 ± 1.28	1.94 ± 1.19
Mean score, point	1.67 ± 1.28	1.94 ± 1.19
P value	0.131

VL = visceral leishmaniasis.

^*The correct response was assigned 1 point; other responses were scored 0 point.

^†Use of any preventive method was given a score of 1 point.

Predictors of KAP in VL-infected patients.

Supplemental Table S2 shows the sociodemographic factors associated with KAP of VL in VL-infected patients. On multivariate logistic regression, gender, education, occupation, VL family history, sanitation practices, and Below poverty line (BPL) status were associated with the knowledge index. A favorable attitude about VL was shown to be more prevalent among younger participants (< 40 years) who were literate, had a prior family history of VL, and did not live below the poverty line. Married participants younger than 40 years with a prior history of VL had a greater likelihood of positive practices regarding VL. Respondents who worked as daily laborers, belonged to a household with more than six family members, and practiced open-air defecation were found to be associated with poor VL practices.

Predictors of KAP in HIV/VL co-infected patients.

After bivariate analysis, multiple logistic regression models were developed separately for HIV/VL co-infected patients to find the significant predictor variable for KAP indexes (Supplemental Table S3). HIV/VL co-infected individuals with a personal or family history of VL were more knowledgeable of VL participants who did not. Patients with inadequate sanitation practices had a lower likelihood of having a thorough understanding of VL. The key determinants of the attitude index were education, VL family history, and marital status. HIV/VL co-infected participants with a personal or family history of VL were more likely to have effective VL prevention practices. Participants with HIV/VL who worked as daily laborers, however, were probably less inclined to follow robust VL practices compared with others.

Correlation among KAP indexes.

The Spearman correlation analyses showed a statistically significant positive correlation between the KAP indexes of study participants (Supplemental Table S4). There was a significant positive correlation between the knowledge and attitude (r_s = 0.634, P < 0.001)_, knowledge and practice (r_s = 0.321, P < 0.001), and attitude and practice (r_s = 0.294, P < 0.001) indexes, with the strongest correlation identified for knowledge and attitude indexes. This finding indicates that increasing knowledge can result in a more proactive attitude toward and practices of preventing VL.

DISCUSSION

This study provides the first description of KAP regarding VL along with factors associated with these variables among HIV/VL co-infected and VL-infected patients attending RMRIMS hospital in Bihar, India. Overall, we found limited KAP on VL prevention and control in both groups. The great majority of VL-infected and HIV/VL co-infected individuals had previously heard of VL (95.2% and 90.5%, respectively), which was reported similarly in other research conducted in endemic rural areas in the Muzaffarpur District in Bihar.²¹ The finding was insufficient because most study participants do not know that the sandfly is the cause of VL transmission and, to manage illness, one must first understand the causes and routes of transmission. In contrast to our findings, a survey performed in northwestern Ethiopia found that more than half the research participants were aware that the sandfly is the vector of VL.²² The findings of our study indicate that both patient groups were mainly unaware of probable breeding places, sandfly biting time, peak illness incidence periods, and sandfly vector prevention. These findings were comparable with other surveys conducted in endemic populations around the world and propose the heightening of public awareness about the VL vector.^21,23–25 In general, all of these studies emphasized the importance of community awareness about vector breeding locations and habitat as a preventive intervention for minimizing the likelihood of vector–human interaction. If people do not perceive the sandfly as the vector, they often do not take appropriate precautions to avoid sandfly bites and seek early treatment.^21,23–25 Sandflies had never been seen before by 70% of participants in both groups, which is greater than the findings of a KAP study regarding cutaneous leishmaniasis in southern Ethiopia.²⁶ To limit the spread of VL, more aggressive measures must be taken to decrease the number of vector populations and transmission of vectors.²⁷ This points out the inadequacy of consistent information education communication (IEC) programs that target specific populations to promote environmental initiatives, like sanitation and sand fly control. Our study revealed that only 38.3% of the VL-infected patients and 32.9% of the HIV/VL co-infected patients have exemplary or adequate knowledge of VL. These results are in accordance with the findings of research on cutaneous leishmaniasis done in Yemen.²⁸ However, a better degree of knowledge was reported by Berhe et al.²⁶ among inhabitants of Ethiopia. The findings support the WHO’s independent assessment of the kala-azar elimination program conclusions for India in 2019, which state that in certain areas of Bihar, no IEC materials or IEC activity in knowledge and attitude were recorded, and that ASHAs: Accredited Social Health Activists prioritized the Janani Suraksha Bal Yojana and immunization programs, with knowledge and attitudes taking a back seat.²⁹

We found that only 38.1% of the participants with HIV/VL in our study believed that VL is completely curable, which was substantially less than the findings of a similar study conducted in northwestern Ethiopia.²² In our study, most of the participants (72.3%) chose to get treatment at a public hospital. The fact that most of our responders are poor may explain this, as public health services are more accessible to them. Our findings differ from previous literature published from Bihar’s Muzaffarpur District.²³ We found that a significant number of participants from both study groups were positive about treatment, including the place of treatment, the likelihood of disease fatality in the absence of treatment, the communicability of the disease, and the benefits of early detection and consistent treatment over time, which in the long run fosters the recovery process. Participants with favorable perceptions may have drawn them from their personal and familial history. VL family history was an independent predictor for a positive attitude in both study groups. Moreover, 50% of the VL-infected participants were ignorant fo the fact that HIV patients are at a greater risk of contracting VL. This could be dangerous considering the increasing number of HIV cases in Bihar. In general, more than 50% of the individuals from both groups participating in our study had a negative attitude about VL. This might be a consequence of a lack of access to information on VL in the area where they reside. This is contrary to findings from a survey done among inhabitants of the South Gondar District in northwestern Ethiopia, which found that 87.1% of those who participated had a positive attitude about VL.²² This might be attributed to the study population being different, because the study in Addis Zemen was done among town residents, who had better access to mass media and a variety of health information than people living outside the city.³⁰ Unfortunately, a pessimistic attitude may cause a delay in obtaining therapy, which, in the case of VL, may result in consequences such as relapse or Post Kala-azar dermal leishmaniasis (PKDL) in the future.

In our study, nearly 30% of participants from both groups reported not using any techniques to prevent sandfly bites. This might be a result of participants’ ignorance about disease prevention strategies. More than half the participants from both groups did not sleep with a bed net, and approximately 40% of total participants slept outside. The proportion of people who used bed nets in our study was greater than that seen in a study conducted on HIV-positive people in Bihar,¹⁶ whereas the proportion of people who slept outside is comparable to those in a study of cutaneous leishmaniasis in southern Ethiopia.³¹ This might be connected to the participants’ poor economic standing and factors such as shortage of power; larger family size may force them to sleep outside. People who have been infected with VL should be aware that sleeping outside without adopting proper personal vector control measures increases their risk of contracting VL.

In our multivariable analysis, factors associated with a good knowledge of VL in our patients with VL included male gender, literacy, farmer as an occupation, VL family history, greater socioeconomic status (above the poverty line), and good sanitary practices. Because male members of the family are largely responsible for agricultural and animal husbandry activities, they are more likely to be familiar with the activity of sandflies and to have a thorough grasp of the infection. The findings of research conducted among rural residents of Bihar and Yemen^28,32 lend credence to this. According to our study findings, personal history of VL was not associated with good knowledge in the VL group. For this alarming finding, the most plausible reason would be insufficient information on VL given by health workers during their previous treatment period. Younger age, literacy, family history, greater socioeconomic status (above the poverty line), and excellent sanitary practices were all related with a more favorable attitude toward VL in patients with VL. Other research done in Bihar found that literate individuals had a positive attitude about VL,³² which is consistent with our findings. Younger people were more likely to have a positive attitude, which could be attributed to the fact that they are in adulthood, which allows them to be socially active and practice well. One possible explanation for the link between BPL status and knowledge and attitude is that people in better economic circumstances may have greater access to information and better health-care facilities. The findings from our multivariate analysis suggest that significant correlates of poor VL prevention practices were older age, illiteracy, daily laborer as an occupation, no VL family history, large family size (more than six members), and poor sanitary practices. These findings reflect the effect of socioeconomic status on leishmaniasis prevention practices. Our findings are similar to those by Priyamvada et al.,⁶ who noted that that being an unskilled nonagricultural laborer living in a crowded house and practicing open defecation were all enhanced risk factors for VL transmission. This corroborates the fact that variables associated with suboptimal preventive behaviors are also significant predictors of disease transmission. Open defecation is widespread in India. Subjects in our study who had poor sanitary practices were most likely uninformed of the possibility of disease spread as a result of open defecation. It is possible that humans and sandflies may come into contact in the early morning hours when vegetation stands serve as an intersection for humans and sandflies.⁶

Our study found that HIV/VL co-infected patients with a personal or family history of VL were more knowledgeable and had good preventive practices than their peers. This might be related to the fact that family members, health-care providers, and the patient themselves are all aware of the challenges associated with treating VL in HIV patients and, as a result, they place greater emphasis on VL prevention. This finding is in agreement with a study conducted in Bihar that reported that households with a history of VL had better preventive practices.³² Similarly, Gelaye et al.³⁰ reported that a history of VL was significantly associated with good knowledge, which corroborates our findings. Our study observed that literate and married participants in the HIV/VL group had a significantly better attitude. This is in line with the findings of Govil et al.,³² who found that literate participants from the endemic population of Bihar had better attitudes toward VL. HIV/VL participants who were laborers had a considerably lower probability of adhering to excellent preventative measures than those who were not. This may be a result of their work culture, which makes it difficult for them to effect good practices effectively. This outcome is consistent with prior research done in Bihar among people living with HIV.¹⁶

The Spearman correlation revealed a substantial positive correlation among KAP indices, with the greatest correlation observed for knowledge and attitude indexes. Research from Bihar’s Madhepura region support our finding, which revealed that people with a solid understanding about VL had a more optimistic perspective.³² Hospitalized VL patients and their family members were the most effective target group for instilling knowledge and a good attitude toward disease in the community, which will lead to optimal practice. Policymakers should urge health-care providers to take the opportunity to inform and educate patients and their visitors during their stay in the hospital. Health practitioners can use outreach tactics such as the “one to five” strategy to educate patients and visitors by distributing posters, brochures, and booklets to them.³³ These individuals can function as information multiplier agents when they return to their respective communities.

Because this research was carried out at a single institution, the applicability of our findings may be limited. Hospitalization, which occurred solely in patients who were enrolled in the study, might affect patients’ knowledge and attitude. In addition, because this survey was cross-sectional, the findings confirm an association rather than a temporal connection; thus, longitudinal investigations are required to explore the time-dependent changes in KAP and the variables that affect them. Most KAP studies have the problem of relying on reported practices rather than actual practices, and this study is no exception. Another factor to consider is the possibility of social desirability bias because the public health preventative measures were self-reported. When evaluating findings, it is necessary to take this into consideration. Another drawback is related to the KAP instrument used in our study. Several previously published studies served as the basis for developing the questionnaire, which had been used in another study that was published previously.¹⁶ Despite this, a more comprehensive evaluation of the instrument’s validity and reliability would have resulted in a more reliable instrument in the end.

CONCLUSION

The findings of our study reveal that VL and HIV/VL patients in Bihar have a poor level of KAP regarding VL and its prevention. There were no statistically significant differences between the two groups. However, it was found that people who had VL only, were day laborers, resided in a crowded household (more than six family members), and who practiced open-air defecation had a much lower likelihood of using effective VL prevention strategies. The HIV/VL participants who had a personal or family history of VL were more likely to have appropriate awareness and practice VL prevention. It appears that these outcomes are directly related to a lack of attention being given to educating people about the disease. Health intervention efforts to promote awareness about VL must be carried out in the community to avoid future outbreaks. In addition, tailored interventions in patients with VL and with HIV/VL that focus on KAP of VL would be extremely beneficial to avoid additional relapse/reinfection-related problems. Successfully treated and cured patients with VL could be contacted to share their KAP in health education programs.

Note: Supplemental tables appear at www.ajtmh.org.