A Cross Sectional Assessment of Knowledge, Attitude and Practice towards Leptospirosis among Rural and Urban Population of a South Indian District

Background & Objective: Leptospirosis is one of the common zoonotic diseases, endemic among farmers in tropical countries. It has an epidemic potential during monsoon and flooding, several countries have witnessed such epidemic outbreaks. However, globally awareness of risk factors is reported to be very low. This study aims to quantitatively analyze the knowledge and attitude related to leptospirosis in Madurai district and to identify misconceptions that result in poor practice.


Material and Methods
The areas of present study were selected on the basis of addresses of leptospirosis patients who attended the hospital during and after epidemic outbreak. Study area included three

Study Instrument
Two focus group discussions were conducted on volunteers from Madurai. The primary version of the questionnaire was developed on results of focal group discussion and through literature review. These participants were aware of seasonal fever in rainy season but they were not aware of any specific cause. Hence the questions addressed initially the awareness of waterborne disease and risk factors. Later the term leptospirosis was introduced. This improved questionnaire was piloted on a sample of 100 outpatients who attended for glass prescription to assess its legibility and comprehensibility. The questions that were consistently misunderstood were corrected. Corrected questionnaire was pretested again in a second sample of 100 patients to assess for the clarity, reliability and validity. Internal consistency was assessed by using Cronbach's alpha (α = 0.7) and was found to be in acceptable or 'no'. A score of 1 was given to correct answer while 0 was given to incorrect response. Scores for individuals were calculated and summed up to give the total knowledge score. Good and poor knowledge was decided on mean values of the population. A cut off level of > 6 was considered as adequate knowledge and ≤ 6 was considered as poor. 5 attitude questions were labeled with positive or negative attitude. Its a 5 point likert scale. A score of> 20 considered as positive attitude and <=20 as negative attitude. Each practice question was labeled with good or poor practice. A score of 1 was given to good while 0 was given to bad practice. The training of the field worker lasted for four weeks which included pilot study on hospital based population by administration of standardized, validated questionnaire. Each village / ward was visited for 3-4 days and 13-15 persons were interviewed each day. For both the population, source of health-related education was the media (television 81% and 98%). (Table 1). The response of the participants towards knowledge, attitude and practices towards leptospirosis are shown in Tables 2-4 and in Figure 2. In the present study, single risky practice was sparse and seen only in 0.8% of rural and 3.7% of urban population. All four were seen in 70.2% of rural population while maximum of three were seen in 44% in urban population ( Figure 3A & 3B). This was followed by logistic regression modeling to assess the knowledge and attitude associated with the practices. Illiterates were found to be less knowledgeable and had unfavorable attitude and poor practice.
Significant differences based on education were seen in knowledge and attitude of urban population however their practice did not improve with education (Tables 5-7).  Animals living in close association with people of urban slum c.
Sewage workers working with bare foot and ungloved hands -Risk group d.
Bare footed milk man working in close association with cattle -Risk group.
Madurai city is a known endemic area for leptospirosis for several decades [3,4,23]. Infection is more common in specific group of population such as farmers, slaughter and sewer workers because of their frequent direct exposure to animal excreta or to the contaminated environment. In spite of high prevalence, globally awareness of the disease is not satisfactory [5][6][7][8][9][10][11][12][13]. This study aims to quantitatively collect the baseline data on understanding of risk factors for leptospirosis among rural and urban population of Madurai district and to reveal misconceptions that result in wrong practice.

Knowledge
Knowledge on common diseases of the society improves the attitude and health care practices of the population. Leptospirosis is a major public health problem globally however knowledge, attitude and practice towards the disease are highly variable from country to country. In Sri Lanka, outbreaks had occurred in 2008 and in 2011 [24]. Because of regular public health programs, their knowledge on this infection is very good, 97% of their study participants knew about leptospirosis. There was a high level of awareness of health risks associated with flooding as well [24]. Similarly, recent KAP study from Thailand revealed a good awareness (97.1%) which was much better than a previous study done in the same country a decade before [6,25]. 83% of slaughterhouse workers in Jamaica had fair knowledge on zoonotic disease and 78% had heard about leptospirosis [14]. Canoeists and dairy farmers from England had adequate knowledge on sources of leptospirosis (> 90%) [26,27].
Likewise, majority of respondents from Argentina had heard about this disease although their knowledge on the severity was limited [28]. Poor knowledge results in poor practice and disease transmission. Poor knowledge was common in several countries including India, Thailand, Malaysia, Peru and United Sates [5,7,29,30]. Leptospirosis was often misdiagnosed as Dengue in Trinidad because of poor awareness [31]. A study was conducted among municipal workers (garbage collector, drainage cleaner and septic tank cleaners) in Tamil Nadu [5]. In spite of very highrisk exposure, they never had any health education on risk and preventive measures. 87.2% had never heard the term leptospirosis.
In our district as well as globally, leptospirosis outbreaks are common during rainy season [1][2][3]14,16]. In our study, although very high percentage of our participants knew that fever is common in rainy season (98-100%) and that contaminated water can cause fever (96-100%), it was very surprising that both the groups did not feel it could be due to microbial illness (2.8-3.6%) rather they attributed the fever to mosquitoes (70-73%).
Although 116 (13%) of rural and 42 (4.5%) of urban participants reported having previously heard of fever spread by rats, the term leptospirosis was known only to a single person (who studied for a government exam) ( Table 2). 44 participants (4.9%) of urban and 76 (7.1%) of rural population recollected plague spread by rats but not about leptospirosis. As in other countries, the most commonly perceived disease in rural population was Dengue [31].
Notably they did not recollect any other microbial cause that can cause fever in human. Similarly, they knew that cattle also get fever in rainy season however microbes were not considered as the cause. However, when they were again challenged with a question whether microbes can cause deadly illness majority of them agreed that microbes can cause death (56-85%). This study indicates a significant gap in knowledge, they knew occurrence of rainy fever, but they were neither aware of any bacterial cause nor the risk factors of their fever (Table 2). uting factor to the presence of rodents [24]. Similarly, in our population 52% of rural and 25% of urban did not worry about rats in their premises. Significant number of rural population did not be-

Attitude
lieve that using open water reservoir is a risk factor. Nearly 50% did not believe that rats can transmit infectious disease. In our study, although the knowledge of leptospirosis was poor the attitude of urban population was better than rural population (Table 3).

Practice
Knowledge of infection and a positive attitude towards preventive measures alone do not influence the real practice.
Improper sewage and garbage disposal facilities, presence of rats and failure to use personal protective measures (PPM) were responsible for the endemicity of the disease in Indonesia [19].
In spite of good training and knowledge, Jamaican workers had several environmental risk factors in their slaughterhouse and had poor protective practice [14]. A cross-sectional study among school children in Sri Lanka showed a 'good' level of knowledge, however, this knowledge was not translated into practice of PPM when they helped their parents in agricultural work [32].
In spite of very good knowledge, the study participants at Brazil performed risk activities such as cleaning open sewers without protective boots (33%) or gloves (35%) [33]. In our study the most common failure of PPM was walking barefooted outdoors in rural population and using unboiled water for drinking in urban population (Table 4). In the present study, more than 73 % of rural and 95% of urban respondents agreed about the seriousness and possible transmission of the disease on using unprotected water, however 25% used such water for bathing and 20% for drinking (

Environmental Exposure-Rural
Infected cattle shed millions of leptospires in their urine and they can survive in moist alkaline soil for months. Study in an agricultural population of Thailand identified important risk factors which included farming for more than 6 hours and walking through stagnant water two weeks prior to illness [34].
Combination of tropical climate and need to immerse their bare foot in moisture for hours offer plenty of opportunity to Indian farmers to get infected ( Figure 2). Previous study from Madurai on seroprevalence of leptospirosis in animals confirmed field rats to be carriers [4]. 90 % of rural population had rats in their field and 54% of urban (Table1) had rats at home, however most (93%) could not name any specific rodent-borne diseases (Table2). It is noteworthy that similar to population of Peru, our population was not aware of rodent-borne diseases. Like them, our population was not worried about the presence of rats which were seen only as nuisance and not as microbial carriers [7]. Surprisingly very few could recollect about the plague but not leptospirosis (Table2).
Rural population had poor knowledge on disease transmission than urban population (Table2). Use of protective rubber boots or gloves will help in prevention however, agricultural workers were neither aware nor using them. Farmers and milk men buried the dead animal and abortion waste. However, they buried in any place in a shallow pit. As per the Indian national guideline's burial should be performed in a remote area, located a minimum of 300 feet down gradient from water sources. The bottom of the pit or trench should be minimum 4 to 6 feet above the water

Environmental Exposure-Urban
Environmental sanitation is a cornerstone of infectious disease prevention. Although Madurai city has drainage system in its corporation limit, some slum areas lack proper sanitation services. They have open sewers, posing risk for people who walk barefooted, especially in rainy season. Madurai had suffered from several incidents of sewage contamination of drinking water in rainy season due to failure of drainage infra-structure [36][37][38][39]. The microbial levels have been reported high in the tap water in the city. Direct tap water is not potable and cannot be drunk without purification. It is true concern that only a small proportion of the population is aware of this risk. Although it is highly recommended to take boiled water for drinking ,99% of the urban population were using unboiled water for drinking (Table 4).

Special Risk Groups
Slaughterhouse workers need to be very cautious in handling animal tissues, dead animals and animal excreta; study done on those workers in Jamaica had poor prevention practice in spite of very good knowledge on zoonotic disease (83%). Animal blood, gut contents and meat scraps were commonly seen in their open drains and only 12% of them used protective clothing [14]. In our study 85% of slaughter house workers admitted that they never use gloves as they feel it was very uncomfortable. On questioning about their personal hygiene only 23% used disinfectant after handling animal waste. Only 5% of milk man declared that they use disinfectants to clean their hand after coming in close contact with cow while milking because they did not believe that they will get infection from their own cow. Sewage workers, garbage collector and septic tank cleaners were interviewed in a previous study in Tamil Nadu. 57.6% had unsatisfactory practice score and they were very poor in using personal protective measures such as gloves, boots and mask. Though Madurai Corporation had provided gloves and boots to sewage workers. In our study, 79% of them felt it was difficult to use while they clean and 23% of them mentioned that they do not have any gloves as they were temporary workers. Our study identified two potential reasons for poor practice that favor risk exposure. First, appropriate personal protective gloves were not felt comfortable by sewers and they were not aware of the risks of exposure.
Sewage workers who had constant exposure to contaminated water and environment were seen using neither gloves nor proper foot wear ( Figure 2D) Venn diagram of the rural and urban populations on both environmental risk factors and poor personal hygiene are given in (Figure 3A & B). This study identified common behavioral risk factors (walking bare-foot, drinking unboiled water) and environmental risk factors (rats and cattle at paddy field and at home) for leptospirosis infection. The probable source of infection was difficult to ascertain because of the multiplicity of risk exposures and the overlapping unsafe activities. Interestingly more than 70% of the rural population had multiple risk factor exposure when compared to urban population. Awareness program on leptospirosis for animal shelter workers at UK was modestly successful in transferring short-term knowledge [30].
Similarly, Sri Lankan public health education programs greatly increased the knowledge of the population [24].