KNOWLEDGE, PERCEPTIONS AND PRACTICES ON CHOLERA TRANSMISSION AND PREVENTION MEASURES AMONG HEADS OF HOUSEHOLD MEMBERS IN KIGAMBONI MUNICIPALITY, DAR ES SALAAM, TANZANIA

Background: The Kigamboni Municipality has been experiencing recurrences of Cholera outbreaks. Objectives: The objective of this study was to evaluate knowledge, attitude and practices associated with Cholera transmission and prevention measures. Method: A cross section descriptive study was adopted. A multistage sampling was used to select 410 respondents. An Interview schedule was used to obtain respondents opinions. Statistical Package for Social Sciences software version 20.0 was used to generate descriptive statistics which were further summarized into contingency tables. Results: Results indicate that the most study population (70.2%) had knowledge on causes, symptoms and the modes of transmission of Cholera. It was also found out that communities treat drinking water to make it safe (76.8%) and are regular in hand washing with soap (80.9%). The result also indicates that the community is willing to vaccination (90%) and to adopting the Cholera prevention measures (92.7%). Conclusions and recommendations: The supply of pure water and adequate sanitation may serve as the prevention measures against the Cholera outbreak recurrences at Kigamboni Municipality.


Introduction
Since the early 1800s, pandemics of cholera have affected millions (Harris et al., 2012). It is estimated that 1.3 to 4.0 million cases of cholera and 21 000 to 143 000 deaths occurs each year due to cholera worldwide (Ali et al., 2015). Cholera is one among the global public health and an indicator of underdevelopment (Adeneye et al., 2016). It is an acute enteric infection of the small intestines, caused by bacterium ingestion of Vibrio cholera and is transmitted through ingestion of contaminated food or water (Kadaleka, S., 2011). The signs and symptoms of cholera can vary from mild to severe such as severe watery diarrhea, vomiting and others, the promotion of improved hygiene practices and better access to safe water and sanitation facilities are the methods of preventing cholera due to being fecal-oral disease and rapid in its onset and spread (UNICEF., 2004). The control of cholera outbreak often requires changes to hygienic behavior (Phiri et al., 2015). Cholera can be endemic or epidemic. A cholera endemic area is an area where confirmed cholera cases were detected during 3 out of the last 5 years with evidence of local transmission. A cholera outbreak or epidemic is an occurrence of at least 1 confirmed case of cholera with evidence of local transmission in an area where there is not usually cholera. (WHO., 2019).The risk factors associated with cholera outbreak includes little knowledge on the causes, modes of transmission, symptoms, prevention and control of the disease, attitudes towards the disease outbreak, low level of hygiene and environmental sanitation, poor hand washing behavior after visiting latrines, before and after eating food, during food preparation and during milking of the infants, poor tendency of using latrines, defecation behavior near sources of rivers, lack of treatment facilities and general treatment of drinking water such as water chlorination, low income and the socio economic status, use of street vended foods, bathing in the river, short distance to water sources and residents or the proximity to surface water, use of untreated water, low educational level, poor housing, unhygienic food handling, processing and preservation practices, poor sources of water for various domestic uses and improper and inadequate sewage disposal systems ( In Tanzania, the first 10 cholera cases were reported in 1974. Since1977 then, an outbreak were reported each year with a case fatality rate (CFR) averaging 10.5% (between 1977 and 1992). The first major outbreak occurred in 1992 when 18'526 cases including 2173 deaths were recorded with a case fatality rate of (CFR= 11.7%). The outbreak of 1997 resulted in 40'249 cases and 2'231 deaths (CFR 5.54%) (WHO., 2008 The control and prevention of the disease outbreak has been linked to the access of safe water and improved sanitation. Tanzanian government with stakeholders tried to prevent and control an outbreak by providing health education and training with regards to cholera causes, signs and symptoms, its transmission and modes of control and preventions of the disease as well as purchasing supplies and equipment. However, the outbreak have been recurring every year despite the efforts above hence necessitates further studies on the critical factors behind the recurrence of the outbreak. Therefore, the present study aims at underlying the reasons behind the epidemics focusing on behaviours of the population and individuals members in Kigamboni Municipal, Dar es Salaaam, Tanzania.

Statement of the Problem
Cholera outbreak is still a public health problem in Tanzania. It has been in recurrence since 1977. Knowledge level, perceptions and hygiene practices contributes to the Cholera preventive measures that are implemented. Despite the vast body of knowledge on cholera, treatments and prevention measures, Cholera remains a challenge in Kigamboni municipality. The study conducted in Dar es Salaam revealed that the hygiene practices of the community members reflected a lack of knowledge and a negative attitude towards cholera with some misconceptions about the Cholera (Mpazi and Mnyika., 2005). As the levels of knowledge, perceptions and hygiene practices determine the preventive measures needed to combat the recurrence of Cholera; this study assessed the knowledge, perceptions and practices of the heads of households in the Kigamboni community regarding cholera transmission and prevention measures. The study seeks to contribute necessary information for developing effective and efficient policies, strategies and interventions that are easily implementable in the resource scarce areas like Kigamboni municipality in combating the Cholera outbreak.

Research Objectives and Rationale of the Study
The main objective of this study was to assess the Knowledge, Perceptions and Practices on Cholera transmission and prevention measures among heads of household members in Kigamboni Municipality.
The present research study provides the information towards Knowledge, Perceptions and Practices on Cholera transmission and prevention measures among heads of household members in Kigamboni Municipality. The information will be utilized by the policy makers and health management teams in developing efficient and effective policies, strategies and interventions against Cholera in Kigamboni Municipality. Kigamboni Municipal is located in the eastern part of Dar es Salaam city and shares its border with Indian Ocean on its northern and eastern parts while the south is bordered with Mkuranga district and on the west with Temeke municipal. There is one tarmac road from Kigamboni Ferry to Kimbiji and Mbagala (kigambonimc.blogspot.com).

Sample Size Selection and Determination
The heads of households' members were randomly selected from parts of Kigamboni Municipality. Sample size was estimated by using single proportion formula (Wayne, 1987) and the sample size for this study was adjusted to 410. Http://www.granthaalayah.com ©International Journal of Research -GRANTHAALAYAH [32] Sampling Procedure A multistage sampling method was used to select the study participants. The sampling frame of all 9 wards in Kigamboni Municipal was randomly made and 3 wards were randomly selected. From the selected ward the sampling frame of all villages was randomly made and only 5 villages were randomly selected. From the selected 5 villages the sampling frame was randomly made to randomly select 10 hamlets with ten households each in 4 villages and 1 hamlet with ten households in 1 village was used for the study, from each household, the heads of the households were interviewed.

Variables
The dependent variables are Knowledge, perception and practice and independent variables are age, sex, marital status, poverty, unemployment, street food vending, poor water and sewage systems and infrastructures, Drinking water treatment, toileting and latrine use, poor cultural practices, hand washing with soap and clean water, poor general sanitation and eating cold leftover food. Generally the practice was measured as good practice or poor practice, the knowledge was assessed as good, moderate or poor depending on the respondent's responses and perception was measured as positive or negative both depending on the responses provided by the respondent in attempting the questions and the number of questions attempted and the correctness of the responses.

Data Collection Instruments and Pre Testing
The interview schedule was used to collect information. Principal researcher and the two research assistants trained on this study were involved in data collection. Data collection instruments were pre-tested in Mji Mwema ward in Kigamboni Municipality to check the clarity of the questions. The review of questions was made following the outcomes of the pre testing before embarking upon the data collection of the study.

Data Processing and Analysis
All filled interview schedules were checked daily for completeness after the interview. At the end of interviews, open-ended questions were coded for computer entry. Once data entry was completed, data was cleaned, validated and analyzed using the Statistical Packages for the Social Sciences (SPSS) version 20.0. Chi-squared statistics for contingency tables was used to assess the association between knowledge of cholera, perceptions, practices and influencing factors on cholera transmission and prevention. Statistical significance was assessed using P values and all results were considered significant if P ≤ 0.05.

Ethical Issues
Ethics is a system of moral values that is concerned with the degree to which research procedures adhere to legal, professional and social obligations to the study participants (Polit and Beck, 2008

Socio Demographic Characteristics of The Respondents
The socio demographic characteristics of the respondents are presented in

Knowledge of Cholera in Relation to Age Groups
The majority of respondents with high knowledge regarding cholera were found between the age groups of 25-44 (66.7%), 18-24 (69.2%) and 45 and above (83.9%). The difference is statistically significant (P<0.05).  In this study it has been revealed that the most 369 (90%) residents of Kigamboni are willing to vaccinate themselves and their families while few 20 (4.9%) are not willing probably due to lack of knowledge on vaccination and 21 (5.1%) don't understand the same falls under the lack of knowledge. is statistically significant (P<0.007). Table 5, presents a cross tabulation of perception concerning food sharing among the age groups.

Practices regarding Cholera Transmission and Prevention
World health organization advocates that the long term solution for cholera control lies in economic development and universal access to safe drinking water and adequate sanitation. That is to ensure use of safe water, basic sanitation and good hygiene practices in cholera hotspots (WHO, 2019).

Practices on Boiling Drinking Water Among the Age Groups
Among the respondents age groups majority 140 (91.5%), 145 (78.8%) and 50 (76.9%) of them boil their drinking water to make it safe among the age groups 18-24, 25-44 and 45 years and above respectively. The difference is statistically significant (P<0.05).

Knowledge on Cholera Transmission and Prevention Measures
This study aimed at assessing the knowledge, perceptions and practices regarding Cholera transmission and prevention. Results showed that among 410 respondents, 70.2% had knowledge about Cholera; respondents identified germs as the causative agent of cholera, severe diarrhea and vomiting as signs and symptoms of cholera and identified that Cholera is transmitted through contaminated food and water. Similar study where conducted in Dar es Salaam, Tanzania where by 85% of the respondents possessed knowledge of cholera (Mpazi et al., 2005). However, this study also revealed a negative belief on the mode of transmission of cholera, that it is transmitted through air and tears. Studies conducted in Dar es Salaam and Haiti reported negative belief among the community members studied (Mpazi et al., 2005 andValery et al., 2011).
Respondents in this study revealed that the supply of pure water and adequate sanitation is a key prevention measures in controlling cholera outbreak in Kigamboni. WHO report of 2019 recommends the supply of pure water and adequate sanitation as standard control and prevention measures against Cholera (WHO., 2019). However similar study were conducted in Nigeria and revealed that the provision of safe and clean water as well as good environmental hygiene as control and prevention measures against Cholera outbreak (Adeneye et al., 2016).
According to WHO, Vaccine -Preventable Disease Surveillance Standards of 2019 recommends that treatment of Cholera should depends on severity of illness and level of dehydration and that severe cases need intravenous rehydration and antibiotics, Milder cases can be treated with an

Perceptions on Cholera Transmission and Prevention Measures
This study found out that the respondents had positive perceptions about food sharing on gatherings during the Cholera Outbreak this indicated a positive perception about Cholera, also respondents perceived that fruits should be washed before eating which is one among the methods of preventing Cholera transmission. The studies conducted in Bangladesh revealed that the majority of the respondents had positive perception about Cholera with regards to food sharing and fruits washing (Tasnuva et al., 2013). Again, in this study it has been found out that there is a relationship between perceptions of food sharing in gatherings during cholera outbreak and the age groups. The difference is statistically significant (P<0.007).
The present study suggest that the majority of the respondents are interested in preventing Cholera and are willing to vaccinate themselves and their families in prevention of Cholera. These findings are vital in planning for the vaccination program and campaign in the area in an effort to prevent Cholera Outbreaks. These findings concords to the findings of the study conducted in Haiti, where many people were found to be willing to vaccination (Louise et al., 2016).

Practices on Cholera Transmission and Prevention Measures
The outbreak of Cholera could be attributed to transmission through faecally contaminated water (Adeneye et al., 2016). This study revealed that the majority of the respondents use piped water and well water as their source of drinking water; however, water treatment, treatments of wells and covering of the wells had been a challenge to the respondent's interviewed. This may lead to the drinking of Vibrio Cholerae contaminated water and finally leads to the transmission of the Cholera. The studies conducted in Hait, Dar es Salaam and Notre dame its respondents mentioned piped water and well water as the sources of drinking water however the challenges were on the treatments of the water sources and water itself (Adeneye et al., 2016, Mpazi et al., 2005and Guzman J. C ., 2013. The findings of this study revealed that the respondents treat water to make it safe for drinking through boiling and Chlorination or bleach solution. Water treatment is one of the methods used in prevention and control of Cholera. Several studies have reported the use of choline or bleach solution, water treatment tablets and boiling as the methods of water treatments to make drinking water safe for drinking and hence preventing Cholera Outbreaks and its transmissions WHO recommends that preventive efforts should include promotion of hand-washing and safe food handling practices (WHO., 2019). The waste disposals and hand wash practices are essential practices in fighting against cholera; however, pits should be treated to avoid multiplication of cholera germs (Zohura et al., 2016). In this study the results revealed that the majority of the respondents ware regular in hand washing with soap and clean water, wash their hands after visiting toilets, poses soap and detergents at their homes for washing hands and wash fruits before eating, however there were slackness in its implementation.
These findings revealed that the practices needs to be improved towards prevention of Cholera Outbreaks and similar findings on practices has been reported by studies The study conducted in Madagascar revealed that consumption of the cold leftover food had significance in Cholera transmission (Megan et al., 2001). In this study it has been found out that the majority of the respondents covers and refrigerate the leftover food and most of the respondents heat the leftover food before eating in an effort of preventing Cholera Transmission.
Practices when a family member develops a Cholera has been revealed in this study that majority of respondents will give ORS (Oral Rehydration Solution) and rush the cholera patient to the nearest Cholera Treatment Center (CTC). Study conducted in Nigeria, Haiti and Dar es Salaam, recommended on the provision of a documented guidance to the Cholera Treatment Centers and the supply of Oral Rehydration Salt (ORS) packets so as to improve Cholera patient management and treatment. Among the respondents age groups majority 91.5%, 78.8% and 76.9% of them boil their drinking water to make it safe among the age groups 18-24, 25-44 and 45 years and above respectively. The difference is statistically significant (P<0.05).

Conclusion
The study was carried out to seek the Knowledge, Attitude and Practice on Cholera transmission and prevention measures at Kigamboni Municipal. The study revealed that the majority of the respondents had good knowledge on cholera; the majority had average Practices and positive Perceptions towards the transmission and prevention of cholera. The study has revealed that 70.2% of the respondents had knowledge on cholera regarding its causes, symptoms and signs, transmission, treatments and its prevention measures. It was also found out that the respondents had positive perceptions in Cholera transmissions and prevention measures as most 92.7% were interested in Cholera prevention and willing to vaccination.
Furthermore the results indicated that the respondents had an average practices with regards to Cholera transmission and prevention measures as 63.5% use the pipe water as their source of drinking water and among them only 76.8% treat water to make it safe for drinking and 80% are regular in washing their hands with soap after and before food, visiting toilets and preparations of foods.

Recommendations
The study had revealed that majority of the respondents agreed on the supply of Oral Rehydration Solution (ORS) sachets, pure water, adequate sanitations and vaccination as the control and prevention measures against Cholera Outbreak in Kigamboni Municipality.
The following are the recommendations made based on the findings of this study, awareness creations among the residents of Kigamboni Municipality regarding practices which facilitate the spread of Cholera, removal of misconception with regards to the causes of Cholera and its modes of transmissions, well water used as the sources of drinking water should be treated regularly and protected all the time and the supply of Oral Rehydration Solution (ORS) sachets, pure water, vaccination, adequate and proper sanitations to the Kigamboni Municipality by the Government. However, future studies should be planned to investigate on the effectiveness and efficiency of knowledge, health policies and health related in addressing the Cholera Outbreak Challenge.