An integrated approach to assess Knowledge, Attitude and Practices (KAP) regarding major Neglected Tropical Diseases endemic in the Mbengwi health district (North West Region, Cameroon)

Background Preventive chemotherapy (PCT) is the main strategy currently used to control and/or eliminate onchocerciasis (Oncho), lymphatic filariasis (LF) and Soil Transmitted Helminthiasis (STH), and community participation (through implementation of MDA or adherence to PCT) is critical to achieve this goal. However, these Neglected Tropical Diseases (NTDs) are still persisting in most endemic areas as a consequence of sub-optimal treatment coverage, the presence of systematic non-compliers in communities … This study aimed at investigating whether the knowledge, attitudes and practices of populations about these NTDs can explain the poor trends towards elimination. Methodology A cross-sectional survey was carried out in the Mbengwi Health District (North West Region, Cameroon) using the cluster sampling technique. Clusters were selected using the Probability Proportionate to Estimate Size strategy. In each cluster, the random walk technique was used for the selection of households, and a structure questionnaire was administered to 2-3 of its members. Principal Findings A total of 254 households from 26 clusters were visited, and 514 individuals were interviewed. The sex ratio of interviewees (1.08) was unbiased, and their ages ranged between 10 and 99 years old. Though most of the respondents declared having already heard of these NTDs (41.2%, 73.7% and 89.9% for Oncho, LF and STH respectively), only a minority of them were aware of correct response of how they are acquired/transmitted (3.7%, 6.8% and 12.5% for Oncho, LF and STH respectively), and prevented (23.1%, 18.9% and 47.2% for Oncho, LF and STH respectively). Even when respondents were aware that medicines were useful to prevent and/or treat these NTDs, almost none of them knew the drug used or the treatment frequency. Conclusion/Significance This study reveals that interviewees exhibit poor knowledge, attitudes and practices as regards to these NTDs, although they are endemic in the study area and PCTs given yearly since a while. These misconceptions can seriously affect the adherence and contribution of populations to the success of PCTs, and it appears compulsory to improve individual knowledge, with a focus on the importance and rationale behind MDA, to optimize their attitudes and practices, especially community participation to PCTs. Author summary The control and/or elimination of Neglected Tropical Diseases (NTDs) are currently on top of the agenda of endemic countries’ control programs and stakeholders. Ivermectin- and Albendazole/Mebendazole-based mass distribution is currently the main strategy to control/interrupt transmission of onchocerciasis, lymphatic filariasis and soil-transmitted helminthiasis, and adherence of communities is compulsory for the success of this approach. Despite the success registered in the fight against these diseases, the trend towards elimination remains unsatisfactory in many endemic areas. This study was carried out to assess whether the perceptions, attitudes, and practices of the Mbengwi health district (North West Region, Cameroon) populations regarding these three parasitic diseases can explain the poor trend towards elimination. A cross-sectional study revealed important misconceptions about these NTDs amongst most of the respondents, which can clearly affect their adherence and contribution to the success of preventive chemotherapies, and seriously slower the momentum towards elimination.

The objective of this study was to assess knowledge and perceptions of populations, in 5 relation to their attitudes and practices, regarding the most prevalent NTDs in the 6 Mbengwi Health District (North West Region, Cameroon). obtained from those who agree to participate. The approval of parents or legal guardians 16 of minors was necessary before any procedure. An individual code was attributed to 17 each participant for anonymous data analysis.  Table S1). The overall score for a given study participant was the sum of all responses 15 for a specific disease. Respondents whose scores were equal and above the mean (over a 16 total of 10) were considered as having 'good knowledge, attitude and practice' (coded as 17 1), while those below the mean were considered as having 'poor knowledge, attitude 18 and practice' (coded as 0). Associations between a KAP score and different respondents' 19 socio-demographic and socio-economic characteristics were tested using the Chi-Square 20 and Fisher exact probability tests.

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The Classification and Regression Tree (CART) was used to assess the association 23 between socio-demographic characteristics and respondents' knowledge, attitude and 24 practice scores for each of the targeted diseases. Indeed, CART is a non-parametric 25 multiple regression approach that both avoids multicollinearity issues and explains a

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Socio-demographic and socio-economic status of study participants 16

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More than half of respondents (58.4%) indicated that they have never heard about 4 onchocerciasis ( Table 2). For those who were aware of this debilitating disease, the most 5 common information sources were community members (42.2%) and health personnel 6 (41.1%). Regarding LF, 379 (73.7%) respondents indicated that they had already heard 7 about this filarial infection, the most common source of information being community 8 members (Table 2). STH infections were well known to the respondents (89.9%), mostly 9 from health personnel (61.5%) ( Table 2). Among those who were aware of these diseases, only few of them (16.0%) identified 13 black flies as the river blindness transmission agent (Table 2). A similar situation was 14 observed for LF, less than quarter (10%) of the respondents indicating that mosquito act 15 as vector (Table 2). Likewise awareness, respondents' knowledge of STH transmission 16 was higher as compared to onchocerciasis and LF, though remaining low (Table 2).   participants' attitudes and practices scores were similar among the different socio-10 demographic and socio-economic variables for onchocerciasis and lymphatic filariasis, 11 but significantly increased with age (p = 0.031) and were associated with occupation (p 12 < 0.001) for STH.

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The multivariate analysis was performed using the CART approach to better identify the  Table S3).

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As for lymphatic filariasis, CART enable to organize socio-demographic and socio-  Table S4). For STH infections, CART led to the organization of socio-12 demographic and socio-economic determinants into three main classes (Figure 3).  The purpose of this study was to assess, through an integrated approach, the attitudes 9 and practices of the Mbengwi health district populations, in relation to their level of 10 knowledge regarding three of the five major NTDs endemic in this area.

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The awareness of study participants was quite variable from one NTD to another.

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Indeed, more than half of the study participants declared that they had never heard The majority of study participants (69.1%) was not aware of onchocerciasis prevention 17 means, and almost half of them (53.0%) ignored how to treat this filarial disease. This 18 was quite surprising, especially because the fight against this disease through the CDTI 19 is implemented in this health district since more than 15 years, with acceptable 20 therapeutic coverage. It is worth to however mention that CDTI is critically deviating 21 from its initial pathway, with absence of health education at the community level, 75.6% of them knew that to control STH they should take drugs.
14 15 Multivariate logistic regression revealed that knowledge of these three group of diseases This study revealed that study participants exhibit poor knowledge, attitudes and 7 practices as regards to these three PCT-based highly prevalent diseases, although they 8 are endemic in the study area and MDA administered yearly since decades.