ABSTRACT.
In disaster situations, cholera outbreaks represent a public health emergency due to their high fatality rates and high spreading risk through camps for refugees and internally displaced persons (IDPs). The aim of this study is to examine water, sanitation, and hygiene attitudes and cholera knowledge, attitude, and practice (KAP) among people living in resettlement sites in Cabo Delgado, the northernmost province of Mozambique. Between January 1 and March 31, 2022, a cross-sectional survey was conducted by administering a face-to-face interview to IDPs and residents in six relocation sites in Cabo Delgado Province. A total of 440 people were enrolled in the study. Overall, 77.8% (N = 342) were female, 61% (N = 268) were younger than 35 years old, and 60.5% (N = 266) reported primary school to be the highest education level. Seventy-five percent (N = 334) of participants lived with children under 5 years old. Thirty-one percent (N = 140) and 11.8% (N = 52) of the respondents reported, respectively, at least one cholera case and at least one diarrheal-related death among their family members in the previous 2 years. In multivariate analysis, being female, being younger than 35 years old, having attained a higher education level, owning a phone, or having soap at home were factors significantly associated with improved cholera KAP. In severely deconstructed social contexts, continuous education and community sensitization are crucial to achieve and maintain positive cholera prevention attitudes.
INTRODUCTION
Cholera is an acute diarrheal disease caused by Vibrio cholerae, a gram-negative bacillus found in contaminated food or water. Without timely fluid management and appropriate antimicrobial therapy, infection results in rapid dehydration and death in 25–50% of cases.1 In the acute phase of the disease, individuals may infect other people either by direct fecal–oral route or through environmental contamination. Since 1817, cholera has caused seven pandemics and uncountable outbreaks across the African continent, especially among vulnerable populations and in disaster situations.2,3
Since 2017, Mozambique has been facing a severe humanitarian crisis due to ongoing conflicts and natural disasters. In the northern Cabo Delgado province, the insurgency of several militant Islamist factions led to the displacement of 592,000 people, with 584,000 displaced in the course of 2020. Additionally, displacement occurred in the central provinces of Manica and Sofala, which were affected by the armed conflict between the ruling Mozambique Liberation Front and the insurgent Mozambique National resistance. By the end of 2020, these conflicts generated a total of 669,000 new internally displaced persons (IDPs).4–6
Mozambique is also vulnerable to recurring floods and cyclones. In 2019, cyclones Idai and Kenneth created, respectively, 478,000 and 24,000 new IDPs;7 this situation was further aggravated by severe flooding and led, by the end of 2020, to an estimated 93,000 people living in a situation of internal, climate-related displacement.7 Overall, as a result of both natural disasters and violence, Mozambique hosts more than 650,000 IDPs4 and 28,500 refugees and asylum seekers.
All this takes place in an already fragile health context, in which Mozambique ranks among the countries with the highest prevalence of HIV, tuberculosis (TB) (including multi–drug-resistant TB), and malaria, along with the areas with the highest prevalence of malnutrition and mortality of children younger than 5 years old.8–11
In this complex scenario, cholera outbreaks represent a public health emergency due to both their high fatality rates and spreading risk in refugees camps, where people live in conditions of inadequate water supply, poor sanitation, high population density, and a severe lack of resources.6
The aim of this study is to examine water, sanitation, and hygiene (WASH) attitudes and cholera knowledge, attitude, and practice (KAP) among people living in six resettlement sites in Cabo Delgado province.
METHODS
Study setting and design.
Between January 1 and March 31, 2022, we conducted a cross-sectional survey by administering face-to-face interviews to people living six different relocation sites supported by doctors with Africa CUAMM and UNICEF: Pemba, Metuge, Mecufi, Ancuabe, Chiure, and Montepuez (Table 1).
Table 1.
Demographic data of IDP sites target of the study
| District | IDPs, N | HCs, N | Total IDPs + HCs, N | No. of households (average Mz is 4.5 people per household) |
|---|---|---|---|---|
| Pemba | 144,794 | 261,195 | 405,989 | 90,220 |
| Metuge | 118,468 | 93,870 | 212,338 | 47,186 |
| Mecufi | 3,998 | 49,561 | 53,559 | 11,902 |
| Ancuabe | 59,138 | 124,866 | 184,004 | 40,890 |
| Chiure | 32,543 | 266,796 | 299,339 | 66,520 |
| Montepuez | 60,029 | 252,070 | 312,099 | 69,355 |
| Total | – | – | – | 326,073 |
HC = host community; IDP = internally displaced person; Mz = Mozambique.
All study sites were built during an exacerbation of the conflict in early 2020. At the time the present study was conducted, all sites were equipped with basic services in compliance with emergency contexts standards. During the study period, internal migration from northern districts peaked twice: between August and November 2020 and between February and May 2021. Thus, data collection was carried out in a context of fluid reallocations, driven mainly by family reunification and by the need for better conditions of subsistence.
Participants.
Participants were selected by random sampling. Community leaders (i.e., village health committees, midwives, healers, members of the councils of the elderly, community activists) provided counseling and support to study participants. Participant responses were reviewed during periodic meetings, where possible strategies for community engagement improvement were revised and discussed.
Questionnaire and data collection.
Study questionnaires were administered by seven interviewers who were instructed on study procedures. Interviewers were supervised by the Nucleo de Investigação e Pesquisa and project coordinators.
Written informed consent was obtained from all study participants. Before the survey, study aims were explained, and, when requested, health advice was provided.
The cross-sectional survey was composed of multiple choice questions and Likert-scale questions organized into five sections: 1) socio-demographic information; 2) knowledge of cholera signs, symptoms, and prevention; 3) attitudes toward oral cholera vaccine; 4) WASH practices; and 5) sexual abuse. Questionnaire development was informed by literature review.
Statistical analysis.
For categorical variables, percentages were calculated, and a χ2 test (with Fisher’s correction if fewer than five cases were present in a cell) was applied. A high level of knowledge on cholera was attributed to participants providing correct responses to at least three out of the five questions included in the knowledge section, and a positive attitude toward cholera prevention was defined by answering correctly to at least two-thirds of the statements included in the attitudes section.
For univariate logistic regression, a high level of cholera knowledge and attitude was considered as the dependent variable, and factors with a P value < 0.10 were included in the multivariate analysis. Multicollinearity among covariates was assessed through variance inflation factor, taking a value of 2 as cut-off to exclude a covariate. However, no variables were excluded according to this prespecified criterion. Odds ratios (OR) as adjusted ORs with 95% CIs were calculated. All statistical tests were two-tailed, and statistical significance was assumed for a P value < 0.05. Analysis was performed with GraphPad Prism v. 8.0 (GraphPad Software, Inc., San Diego, CA).
Ethical approval.
The study was reviewed and approved by the local Nucleo de Investigaçao Operacional de Pemba authorized agency, protocol no. 44/004 GDPS-CD 2021. Participation was voluntary, anonymous, and without compensation.
RESULTS
Participants.
Overall, 440 IDPs were enrolled in the study. Twenty-seven percent (N = 120) of participants came from Pemba, 13.7% (N = 60) from Metuge, 3.6% (N = 16) from Mecufi, 13.7% (N = 60) from Ancuabe, 20.9% (N = 92) from Chiure, and 20.9% (N = 92) from Montepuez. Most of the respondents were female (77.8% N = 342), were younger than 35 years old (61%, N = 169), and had attained a primary school education level (60.5%, N = 266). Seventy-five percent (N = 334) of participants reported to live with children under 5 years old. Thirty-one percent (N = 140) and 11.8% (N = 52) of the respondents reported, respectively, at least one cholera case and at least one diarrheal-related death among their family members in the previous 2 years. Sociodemographic characteristics are listed in Table 2.
Table 2.
Sociodemographic characteristics of the respondents of community KAP on cholera (N = 440)
| Characteristics | N (%) |
|---|---|
| IDPs camp | |
| Pemba | 120 (27.2) |
| Metuge | 60 (13.7) |
| Mecufi | 16 (3.6) |
| Ancuabe | 60 (13.7) |
| Chiure | 92 (20.9) |
| Montepuez | 92 (20.9) |
| Sex | |
| Male | 98 (22.2) |
| Female | 342 (77.8) |
| Age, years | |
| 18–25 | 134 (30.5) |
| 26–35 | 135 (30.5) |
| 36–45 | 85 (19.5) |
| > 45 | 86 (19.5) |
| Household members | |
| 1–2 | 19 (4.3) |
| 3–4 | 122 (28) |
| 5–6 | 135 (30.7) |
| 7–8 | 92 (21) |
| > 9 | 72 (16) |
| Family with children under 5 years (number of children) | |
| ≤ 3 | 334 (75.9) |
| > 3 | 106 (24.1) |
| Education level | |
| None | 81 (18.4) |
| Primary education | 266 (60.5) |
| Secondary and higher | 93 (21.1) |
| Cholera cases in the last years | |
| Yes | 140 (31.8) |
| No | 300 (68.2) |
| Death in the family from cholera or other diarrheal disease in the last year | |
| Yes | 52 (11.8) |
| No | 388 (88.2) |
| Socio-economic factors | |
| Live in a house with thatched roof | 178 (40.5) |
| Live in a house without any source of electricity | 200 (45) |
| Own a mobile phone | 255 (58) |
| Own a radio | 105 (23.8) |
| Own a car | 7 (1.5) |
| Have soap or detergent at home | 173 (39.3) |
| Distance to health center > 2 hours | 159 (36.1) |
| Source of drinking water | |
| At home | 26 (6) |
| Public fountain | 144 (32.7) |
| Protected borehole/well with hand pump | 135 (30.6) |
| Others | 135 (30.6) |
IDP = internally displaced persons; KAP = knowledge, attitude, and practice.
Knowledge.
Questionnaire answers on the knowledge section are shown in Table 3. Notably, 91% of respondents believed that cholera could be transmitted by mosquito bites, and, although most participants were aware that cholera transmission could be reduced by cooking food (89%, N = 392), boiling water (90%, N = 399), or proper disposal of human waste (90.8%, N = 400), 71.6% of participants agreed or strongly agreed with the sentence “Cholera cannot be prevented.”
Table 3.
Knowledge on cholera and oral cholera vaccine
| Survey statements | Strongly agree, N (%) | Agree, N (%) | Neither agree nor disagree, N (%) | Disagree, N (%) | Strongly disagree, N (%) |
|---|---|---|---|---|---|
| Cholera is caused by contaminated water | 186 (42.3) | 200 (45.5) | 31 (7) | 15 (3.4) | 8 (1.7) |
| Cholera is caused by contaminated food | 204 (46) | 193 (44) | 30 (7) | 9 (1.8) | 4 (0.8) |
| Cholera is caused by mosquitos/insects | 207 (47) | 194 (44) | 30 (7) | 7 (1.5) | 2 (0.4) |
| Overcrowding can spread cholera infection | 158 (36) | 151 (34) | 96 (22) | 26 (5.9) | 9 (1.8) |
| Cooking food can prevent cholera | 180 (41) | 212 (48) | 22 (5) | 18 (4) | 8 (1.7) |
| Proper disposal of human waste can prevent cholera | 196 (44.5) | 204 (46.3) | 14 (3.1) | 17 (4) | 9 (1.8) |
| Cholera cannot be prevented | 148 (33.6) | 166 (38) | 58 (13) | 51 (12) | 17 (4) |
| Cholera vaccination is an important tool to prevent cholera | 172 (39) | 174 (39) | 43 (10) | 41 (9.7) | 10 (2.3) |
| Boiling water before drinking can prevent cholera | 204 (46) | 195 (44) | 19 (4.3) | 14 (3.2) | 7 (1.5) |
| Washing vegetables/fruit can prevent cholera | 191 (43.4) | 209 (47.5) | 16 (3.6) | 18 (4) | 6 (1.4) |
Attitudes.
Although 42.5% (N = 187) of interviewed IDPs declared to have never heard about the cholera vaccine, 93.8% (N = 413) of them declared their willingness to get vaccinated or to vaccinate their children (93.4%, N = 441) in case of vaccine availability. Seventy-eight percent of the participants declared a positive attitude toward participation in awareness activities about cholera, and 81.5% (N = 359) showed willingness to change their habits to improve prevention. See Table 4.
Table 4.
Attitudes toward cholera vaccine and care in cholera diseases
| Questions | Yes, N (%) | No, N (%) | I don’t know, N (%) |
|---|---|---|---|
| Have you heard about the cholera vaccine? | 253 (57.5) | 187 (42.5) | 0 (0) |
| If a vaccine against cholera was available, would you agree to get vaccinated? | 413 (93.8) | 12 (2.7) | 15 (3.5) |
| If a vaccine against cholera was available, would you vaccinate your children? | 411 (93.4) | 13 (3) | 16 (3.6) |
| Would you be available to participate in awareness-raising activity about cholera? | 346 (78.6) | 51 (11.5) | 43 (9.9) |
| Are you willing to change your eating habit and water use to prevent cholera? | 359 (81.5) | 37 (8.5) | 44 (10) |
Practice.
Most of participants declared to disagree or strongly disagree with the practice of going to traditional healers (52% [N = 227] and 41% [N = 180], respectively) or taking home-made medicines (44.3% [N = 195] and 47% [N = 205], respectively) in case of cholera. Conversely, almost all participants (99.3% [N = 437]) agreed with going to the cholera center in case of disease. See Table 5.
Table 5.
Cholera-related practices
| Survey statements | Strongly agree, N (%) | Agree, N (%) | Neither agree nor disagree, N (%) | Disagree, N (%) | Strongly disagree, N (%) |
|---|---|---|---|---|---|
| If I have cholera, I will go to a traditional healer | 5 (1) | 14 (3) | 14 (3) | 227 (52) | 180 (41) |
| If I have cholera, I will use home-made medicine | 5 (1) | 16 (3.4) | 19 (4.3) | 195 (44.3) | 205 (47) |
| If I have cholera, I will go to the cholera treatment center/hospital | 371 (84.3) | 66 (15) | 1 (0.3) | 1 (0.3) | 1 (0.3) |
Hygiene and sexual abuse.
Sixty-one percent (N = 269) of respondents reported to have never heard about cases of sexual exploitation and abuse (SEA), notwithstanding that 78% (N = 343) declared to know the meaning of SEA. Eighty-five percent (N = 374) of enrolled subjects declared their willingness to report an eventual case of SEA, and 99% (N = 436) declared to know how to denounce it. See Table 6.
Table 6.
Hygiene and sexual abuse
| Questions | Yes, N (%) | No, N (%) | I don’t know, N (%) |
|---|---|---|---|
| Hygiene | |||
| When do you wash your hands? | |||
| After having used the latrine | 436 (99) | 4 (1) | 0 (0) |
| Before eating | 439 (99.8) | 1 (0.2) | 0 (0) |
| Before preparing food or cooking | 435 (99) | 5 (1) | 0 (0) |
| After changing a baby's nappy | 414 (94.1) | 26 (5.9) | 0 (0) |
| Have usually soap or detergent at home | 173 (39.3) | 267 (60.7) | 0 (0) |
| Non-flush toilet | 385 (87.5) | 55 (12.5) | 0 (0) |
| Sexual abuse | |||
| Do you know what prevention of sexual exploitation and abuse means? | 343 (78) | 97 (22) | 0 (0) |
| Have you heard of cases of sexual exploitation and abuse or attempted cases occurring in your community? | 171 (38.9) | 269 (61.1) | 0 (0) |
| If there is a case of sexual exploitation and abuse in your community, are you willing to report it? | 374 (85) | 66 (15) | 0 (0) |
| You know how to denounce it | 436 (99) | 4 (1) | 0 (0) |
Table 7 summarizes the results of the logistic regression analysis. At multivariable analysis, factors associated with good cholera knowledge and practices were being female, being younger than 35 years old, having a high education level, owning a mobile phone, and having soap or detergent at home.
Table 7.
Multivariate analysis of determinants of high knowledge and attitudes toward cholera
| Characteristics | Univariate analysis, OR (95% CI) | Multivariate analysis, adjusted OR (95% CI) |
|---|---|---|
| Female | 2.48 (1.16–3.90) | 3.63 (2.16–4.10) |
| Age < 35 years | 1.51 (1.28–2.03) | 2.23 (1.78–2.84) |
| Household members > 4 | 1.32 (0.88–1.71) | 1.55 (0.78–2.67) |
| High educational level | 1.45 (1.28–1.79) | 1.93 (1.38–2.59) |
| Family with child under 5 years (< 2 children) | 1.33 (0.28–1.63) | 1.29 (0.88–2.14) |
| Have a house with thatched roof | 1.34 (0.68–1.88) | 1.81 (0.91–3.18) |
| Time to go to health center/hospital? (> 2 hours) | 1.19 (0.59–1.39) | 0.88 (0.55–0.98) |
| Have a house without any source of electricity | 1.36 (0.85–1. 92) | 1.23 (0.90–1.90) |
| Have a mobile phone | 1.44 (0.38–1.78) | 1.64 (1.58–2.41) |
| Have soap or detergent at home | 1.35 (1.12–1.60) | 3.75 (2.45–5.24) |
| Public fountain as source of drinking water for household members | 1.59 (0.68–2.21) | 1.80 (0.83–3.21) |
OR = odds ratio.
DISCUSSION
Considering the pivotal role played by community engagement in attitude change, this survey was conducted as an operational planning tool to implement intervention. In this study, most of the respondents were female, young, and literate. However, despite this high literacy rate, at the time of survey administration, a consistent part of the population lived in conditions of extreme deprivation, such as in thatched roof habitations or with no reliable electricity source. Furthermore, most people reported living in overcrowded situations, with only 4.3% of respondents sharing their habitation with fewer than three people and about one respondent out of four reporting to live with at least four children under 5 years of age. However, 58% of interviewed people owned a mobile phone, but less than 25% had a radio. These findings suggest that mobilization campaigns should prioritize text messages. Furthermore, disease awareness was robust despite the widespread assumption that cholera may be spread by mosquito bites or other insects.
Globally, cholera remains a public health threat and is listed among the key social development indicators.12 Inadequate cooking processes, improper waste management, contaminated water sources, overcrowding, and insufficient handwashing are all well-recognized risk factors for cholera outbreaks. Consistent with the demographic characteristics of our sample, we observed that being female and young was significantly associated with good disease knowledge and WASH attitudes (OR: 3.63; 95% CI: 2.16–4.10 and OR: 2.23; 95% CI: 1.78–2.84). This finding supports the critical role of motherhood in disease attenuation because mothers’ involvement played a key role in child survival in cases of acute diarrheal infection.13
Interestingly, despite the high knowledge and attitudes toward the disease, in our survey, 75% of the interviewees declared that cholera cannot be prevented. Glossing over the possible anthropological and cultural roots of this seemingly fatalistic attitude, this observation may hide a sense of helplessness. In fact, just 6% of respondents had a private household water source, and just 40% had soap at home.
Co-administration of oral polio and cholera vaccine is an outstanding priority in the management of cholera outbreaks, and it proved to be highly effective (at least in the short-term) even when administered in emergency regimens such as single-dose administration.14 In this study, participants showed a good attitude and trust toward vaccination, even though 40% were not aware of its existence. As the Yemen experience well documented, vaccine delivery and distribution are major challenges in humanitarian emergencies.15 For this reason, in 2012, WHO suggested starting vaccine delivery in every humanitarian crisis.16
Nevertheless, vaccination is not the only weapon against cholera. Hygiene promotion, sanitation, appropriate housing, and health system empowerment play pivotal roles.17,18 In terms of WASH attitudes, we observed an unequivocal finding: more than 90% of the respondents knew how to perform proper handwashing, despite only a minority reporting to own soap or other type of cleanser at home. Yet, soap availability at home is the second most predictive determinant of good knowledge and attitudes (OR: 3.75; 95% CI: 2.45–5.24), thus supporting the idea that, in the relocation sites included in the study, a distribution campaign of hygiene products, together with hygiene promotion, could effectively promote prevention. Indeed, according to a review article conducted by Shannon et al,18 Sphere standards for water, sanitation, and hygiene in resettlement camps—that take into account precise amounts of personal soap, daily water, and limited distance to a water source—were effective in reducing the cholera case fatality rate.
In our survey, no mistrust in the health system was recorded: more than 90% of respondents disagreed with turning to traditional healers, and about 85% identified hospitals and health centers as the primary reference point. This finding is of utmost importance because, in other contexts,19 poor healthcare seeking was recognized as one of the key determinants of high morbidity and mortality amid a recent cholera outbreak. In our survey, we observed an inverse relationship between distance to the first health center (i.e., more than 2 hours away) and cholera awareness (OR: 0.88; 95% CI: 0.55–0.98), thus suggesting that geographical isolation may lead to information gaps. In line with this, in an intervention implemented by the National Rural Health Mission in India, the community-based capacity to respond to cholera outbreaks increased thanks to the institution of dedicated health officers in charge of reaching isolated areas.20 Also, although evidence is lacking about the impact of health promotion on cholera prevention and management,21 health education programs are still considered a pillar of infectious disease prevention.
Our work has some limitations. First, the survey focused on one health issue (i.e., cholera); therefore, no information was recorded about concurrent health determinants, such as malnutrition or underlying health condition management (e.g., HIV, noncommunicable diseases). Also, due to the small sample size and the possibility of selection biases, our results are not generalizable to the whole Mozambican IDPs population. Finally, as with other similar cross-sectional surveys, this study represents a single snapshot in a multifaced and extremely dynamic panorama in which evidence and perceptions may vary on a week-to-week—or even day-to-day—basis.
CONCLUSIONS
Management and prevention of cholera outbreaks is more effective when vaccine campaigns, hygiene, and sanitation promotion are simultaneously carried out. Because the IDPs camps represent a hard-to-reach context, preemptive planning for vaccine implementation can be considered on the basis of baseline risk assessment. Evaluation of knowledge and attitudes toward cholera among the target population is critical. Women and young adults may represent key contributors to community engagement due to 1) a higher level of literacy, which helps wider spread of information, and 2) the direct effect of women’s participation in childhood health. Geographical distribution and distance to health centers are also likely to influence health awareness, and those issues should be considered when planning interventions.
Furthermore, infection prevention and control require the delivery of health education because training on prevention measures and awareness-raising campaigns are likely to play a central role in improving cholera spread.
In conclusion, in severely deconstructed social contexts, promotion of prevention attitudes means active community participation. Efforts toward sensitization on communicable diseases need to include community engagement in the outcome of the prevention campaigns themselves.
Our work highlights the need to prioritize vaccination campaigns because it is likely that they will encounter widespread acceptance among persons living in the resettlement sites included in this study.
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