Several studies have suggested investigation of health beliefs in children to be an important pre-condition for primary prevention of disease. However, little effort has been made to understand these in the context of podoconiosis. This study therefore aimed to explore the health beliefs of school-age rural children in podoconiosis-affected families. A cross sectional qualitative study was conducted in March 2016 in Wolaita Zone, Southern Ethiopia. Data were collected through in-depth individual interviews (IDIs) and focus group discussions (FGDs), with a total of one hundred seventeen 9 to15-year-old children recruited from podoconiosis affected families. The study revealed various misconceptions regarding risk factors for podoconiosis. Most children believed barefoot exposure to dew, worms, snake bite, frog urine, other forms of poison, and contact with affected people to be major causes of the disease. Their knowledge about the role of heredity and that of long term barefoot exposure to irritant mineral particles was also weak. Though most participants correctly appraised their susceptibility to podoconiosis in relation to regular use of footwear and foot hygiene, others based their risk perceptions on factors they think beyond their control. They described several barriers to preventive behaviour, including uncomfortable footwear, shortage and poor adaptability of footwear for farm activities and sports, and shortage of soap for washing. Children also perceived low self-efficacy to practice preventive behaviour in spite of the barriers. Health education interventions may enhance school-age children’s health literacy and be translated to preventive action. Overcoming practical challenges such as shortage of footwear and other hygiene facilities requires other forms of interventions such as livelihood strengthening activities. Linking podoconiosis-affected families with local governmental or non-governmental organizations providing socio-economic support for households may assist school-age children in those families to sustainably engage in preventive behaviours.
Podoconiosis is an example of a lifestyle-related disease that develops later in life and affects millions of people with little experience of preventive behaviour. It is non-infectious (and thus also termed ‘non-filarial elephantiasis’) and is characterized by bilateral swelling of the lower legs, commonly affecting people in the economically productive age groups [1,2]. In Ethiopia, over 1. 5 million people are believed to live with podoconiosis [3]. Evidence to date indicates that the combination of inherited genetic susceptibility and barefoot exposure to soil rich in irritant mineral particles contributes to the cause of podoconiosis [2,4]. An estimate of heritability of podoconiosis is 63% while the risk ratio of siblings in affected families is 5 times higher than their counterparts in the general population [2]. Luckily, genetically susceptible individuals can entirely prevent the disease if they consistently protect their feet from exposure to irritant particles by wearing shoes starting at young age [5]. However, few children in podoconiosis-affected families engage in preventive behaviours such as regular use of footwear and foot hygiene in spite of their higher susceptibility to the disease. In the most recent study in an endemic setting in Ethiopia, the proportion of preschool children reported to have “all day, every day” use of footwear was only 31% [6]. Another study also reported poor hygiene among children [7]. Previous studies among adults in communities endemic for podoconiosis have reported higher level of misconceptions regarding the cause and prevention of podoconiosis [6–11], and discussed the implications of the misconceptions to disease prevention behaviour and interpersonal interactions [6]. The beliefs that podoconiosis is contagious, caused by worms in the soil, indiscriminately inherited among relatives, caused by evil eye, curse, witch, or cold weather [8,9] were found to have negative consequences on preventive behavioural choices and interpersonal interactions [10]. The perceptions of adults regarding their own and children’s susceptibility to the disease were also reported to be inaccurate [6,11]. The perceptions that footwear does not permit farm activities and other duties, is uncomfortable for walking in the mud, smells bad in the hot season, wears out too quickly, softens the feet, and should be preserved for special events have all been identified as factors discouraging optimum use of footwear among people at high risk for the disease [11,12]. However, most of these studies focused only on adults. The studies that have investigated preventive behaviour among children [6,7, 13] have explained it based on the parents’ health beliefs. Children are perceived as “active, purposeful beings who make sense of their world and contribute substantially to their own development” [14], and whose cognitive developments occur intensively within the age of 7–15 years [15–17]. Researchers have acknowledged increasing levels of social autonomy of school-age children as they spend more time away from home with less parental supervision. This gives them the chance to develop independent beliefs about health [18]. Several studies have underscored the importance of investigating the dimensions of health beliefs in school-age children, particularly for control and prevention of diseases that arise from behaviour and habits established in childhood and continue to adult life [18,19–23]. The formation of values and behaviour in early childhood necessitates understanding of health beliefs of children [19]. This is supported by other studies which argue for the establishment of accurate beliefs about health in early childhood as habits in childhood are predictive of habits in adulthood [20–22]. Investigating health beliefs in children is also thought to enable better understanding of the impact of health education on the modification of health beliefs and encouragement of preventive behaviour [18,19]. Knowledge of the health beliefs of school-age children can be used to engage them as health messengers to their families and peers. A growing body of thought supports the belief that school-age children are not just passive recipients of health information. Rather, they can act as change agents who positively influence the behaviour of others in their communities through communicating health messages [24,25]. Investigating the health beliefs of school-age children may not only help promotion of footwear use for preventing podoconiosis, but also prevention of other neglected tropical diseases contracted through the feet. To our knowledge, no studies have actively involved children of this age group in the study of their health beliefs in the context of podoconiosis. The main purpose of the present study is therefore to explore various forms of health beliefs in school-age children.
Ethical approval was obtained from the ethics committee of the Armauer Hansen Research Institute (AHRI) (Project reg. No. P035/15) and College of Health Sciences, Addis Ababa University (Protocol number 047/15/Ext). The Wolaita Zone Administrative Bureau gave written permission to work in the community. The Mossy Foot International also allowed their outreach clinic site staff to help in the identification of study participants. Individual participation of children and group interviews was guided by the international guidelines for involving children in research [26–28]. A developmental psychologist helped during the recruitment and interviews to make sure that the content and format of questions was appropriate to the age and cognitive level of the child. Informed consent was obtained from caregivers and children also gave their assent to participate in the study. Taking into account likely difficulties understanding written consent forms due to low literacy [29], a conversational style oral presentation of consent information was made in the local language to caregivers and children. Caregivers confirmed their permission for a child to participate in the study by signing or thumb-printing on the consent forms. Children expressed their assent verbally in the presence of their caregivers as a witness, to ensure the assent process is without any coercion. The use of verbal assent to children was approved by the ethics committee. The study was conducted in Wolaita Zone, one of the thirteen zones in Southern Nation Nationalities and Peoples Regional State (SNNPRS). Wolaita Zone is located in the south-west of Ethiopia roughly between 6. 30–7. 10 N and 37. 10–38. 10 E, latitude and longitude respectively (Fig 1). According to the 2007 census report, the total population of the area was around 1. 7 million; of whom 83. 2% resided in rural areas. The dominant means of living is subsistence agriculture [30]. In this Zone, the point prevalence of podoconiosis has been calculated at 5. 46% [31]. Since 1998, Mossy Foot International (MFI) (formerly, the Mossy Foot Treatment and Prevention Association), an international non-governmental organization, has been offering community-based prevention and control activities against podoconiosis in 15 outreach sites located at 15 to 65 km from the head office in Wolaita Sodo. Clinics in all outreach sites are run by community podoconiosis agents (CPAs) who are themselves patients, and social workers recruited from the local community. The MFI reaches the wider community through a group of network members who provide voluntary services of awareness and demand creation in collaboration with site workers. The organization has been serving over 30,000 registered patients for over a decade [32]. A cross sectional qualitative study was conducted in March, 2016 using in-depth individual interviews (IDIs) and focus group discussion (FGDs) methods. A purposive sampling technique was used to select three study sites with large numbers of registered patients and a relatively long history of establishment. The selected sites were Damot Pulasa Woreda (district), Boloso Sore Woreda and Ofa Woreda. Study site staff members helped identify affected families and children eligible for interviews in those families. A theoretical sampling technique was used to determine the number of participants in the study, i. e. the process of sampling that continues until theoretical saturation is reached [33]. The major inclusion criteria for children were being part of a podoconiosis-affected family and age 9–15 years. Podoconiosis-affected families having at least one child between the age of 9–15 years were identified through the MFI site workers. One child per household was selected either for IDI or for FGD. None of the selected child participated in both activities. Children affected by podoconiosis or other forms of physical impairment were excluded from the study. Focus group discussions were disaggregated by gender: three with boys and three with girls. Twelve children participated in each FGD, giving a total of 72 participants. A total of 45 IDIs were held with children: 15 in each of the three sites. Together, 117 children participated in individual and group interviews. Semi-structured questions were developed in English and translated into the local language, Wolaitatto (AT is the native speaker). Children were interviewed individually during home visits while FGDs were held in a place proximate for children coming from surrounding villages. All interviews were digitally recorded. Before assessing the beliefs of children about podoconiosis in both IDIs and FGDs, the mental image of children regarding their recognition of podoconiosis as a disease and its manifestations was assessed through drawings and their verbal description of the pictures they drew. Drawing exercises have been suggested as a tool to understand children’s imagery of disease and to assess their knowledge and conceptions [34,35]. To prompt recalling, the interviewer used the local term “na’u gediya kitisiya hargiya”, literally “disease that causes bilateral swelling of feet”. This term was used instead of common local terms such as “Kita”, “Inchricha” [8], which were reported as derogatory and entailing demeaning connotation against affected persons [29]. Participant children were asked about their thoughts regarding the cause of podoconiosis, their perceptions of severity of disease, their appraisal of susceptibility to the disease, the advantages and disadvantages of various types of footwear, their perceptions of barriers to regular use of footwear and their self-efficacy beliefs to use footwear regularly in spite of these barriers. In the middle or at the end of FGDs, role plays were performed by children, which boosted their confidence to talk openly what goes on within the family and in the community. Whenever children found a given question difficult to understand, guidance and repeated clarifications were used to facilitate responses. While individual interviews lasted a maximum of 30 minutes, it took 1 hour to complete each FGD. At the end of the interviews, participants were provided brief information about the causes of podoconiosis and the role of consistent use of footwear in preventing the disease. After every interview, children received a piece of soap, a pen and a note book as compensation for their time, and this was suggested in a previous study as ethically appropriate if made in consultation with community members in the study setting [29]. Data were transcribed and translated into English and imported to NVivo software version 11 for analysis. Both deductive and inductive approaches were used to analyse the data. Deductive coding of themes in the data was based on Health Belief model constructs such as knowledge, perceived severity, perceived susceptibility, perceived benefits and barriers, and perceived self-efficacy. The Health Belief Model (HBM) provides a useful framework to understand and explain health beliefs in association with disease preventive behaviour [36–40]. A number of studies have used the health belief model to explain health beliefs of young and adolescent children [18,19,41,42]. A grounded theory approach was used to inductively identify newly emergent themes and subthemes as coding process proceeded. Grounded theory refers to a set of integrated and inductively generated concepts, categories, and themes that are formulated into a logical, systematic and explanatory scheme [33].
Children were asked if they thought they might or might not be at risk. Some provided logical reasons for considering themselves at risk considering exposure to risk factors in the environment and lack of preventive actions taken to reduce their exposure to these risk factors. They believed that they would be at risk if they went barefoot and were aware that their exposure could be reversed through preventive actions. If I walk barefoot and simply step on harmful things, I think my feet may also swell like that of my father. As a result, whatever they complain about poverty, I urge them to buy shoes for me. (FGD participant, boy, 13 years, grade 4) On the other hand, misperceptions around personal susceptibility to podoconiosis were also common. Some children thought that they were at risk based on exposure to factors that are not recognized to cause podoconiosis such as exposure to snake bite and sharing of contaminated water. Some children never thought about the risk of getting podoconiosis. This is mainly because they related occurrence of disease to ‘God’s plan’. Some children thought that they were not at risk and not worried of getting the disease because their feet were healthy at the time of interview. When a boy was asked whether he had ever thought about getting podoconiosis, he replied “no, I have never thought about getting foot swelling as my feet are healthy now. (IDI participant, boy, 12 years, grade 2) Participants in all individual and group interviews were aware of the negative consequences of the disease on affected individuals and their families. They noted that podoconiosis “causes illness and results in unexpected medical expenses”, “limits capacity to work”, “embarrassing”, “exposes family of affected person to starvation”, “causes illness and makes them bedridden due to swelling in groins”, “limits their ability to walk or run fast”, and “dissociates them from other people because of the bad smell and flies collected on wounds of their feet”. More importantly, they also revealed the impact of their parents’ condition on their own life, citing stress and starvation because of their parents’ illness. The participants held a positive outlook towards using footwear. They stated that using footwear protects the feet from dust, snakes, poison, dew, chilly weather, injuries by sharp things. Children also clearly stated the importance of foot hygiene in preventing podoconiosis. As a FGD participant states, “if people wash feet regularly, before and after wearing shoes, they cannot get the disease” (FGD participant, boy, 12 years, grade 4). The perceived discomfort of footwear, particularly in hot weather, was commonly thought to be a barrier to regular use. Children associated closed rather than open shoes with discomfort in hot weather. They repeatedly stated that using closed footwear in hot weather caused nail dystrophy and ‘mich’. On the other hand, girls tended to perceive the disadvantages of both open and closed footwear. They thought that the regular use of sandals caused heel fissures while the regular use of closed plastic boots damaged the toenails. They recommended changing between different types of footwear for better foot health. Most children also said that they felt uncomfortable using any type of footwear when they engaged in farming activities. Children also said it was difficult to do sport wearing shoes. While some were worried about shortening of the shoes’ life, others were more concerned about injuring themselves. Another problem was the limited number of pairs of footwear they owned. Those who had a single pair of shoes kept them for special occasions such as school or church. Some children were concerned about the economic situation of their parents and refrained from wearing shoes regularly so as to preserve the ones they had. The poor quality of shoes purchased for children was also reported to negatively influence the motivation of children to use them regularly. Regarding foot washing, most children indicated that they washed their feet before putting on shoes, before going to bed in the evening and after performing certain activities barefoot. Almost all of the children reported that they washed their feet at least once a day. They did not perceive barriers to washing their feet regularly, except discipline or consistency. The availability of water nearby and the encouragement of parents were reported to be enabling factors. However, when observed, the participant children’s feet were not as clean as expected since they rarely used soap. As discussed earlier, because of the discomfort of wearing closed shoes for farm activities and hot weather, children tended to instead wear either open (less protective) types of footwear or to walk barefoot. They were asked if they thought they could use closed footwear for all conditions regardless of the perceived challenges. Most said they could not wear closed shoes while farming because they were too heavy and cause bad smell. On the other hand, for some participants, self-efficacy depended on the type of closed footwear. For instance, most children thought that they could use canvas or ‘sieve’ plastic boots (with ventilation holes) in all seasons or times of day. They thought that these boots let air circulate around the feet in hot weather and are comfortable for cold weather since they cover the whole foot. Canvas shoes were also thought to be good under all conditions.
To our knowledge, this study is the first to address health beliefs of school-age rural children in podoconiosis-affected families. We have explored dimensions of health beliefs that are important to public health intervention in relation to this condition and other Neglected Tropical Diseases. However, the findings of this study may not be generalizable to other settings as the participants belong to a homogenous cultural background. In addition, the present study emphasized exploration of the school-age children’s health beliefs. Further study is required to examine the interplay between school-age children’s health beliefs and the socioeconomic circumstances of their families. In conclusion, children held misconceptions regarding behavioral, environmental and genetic risk factors. They also perceived obstacles that threaten their ability to engage in preventive behaviors. Health education interventions may enhance school-age children’s health literacy and be translated into preventive action. Overcoming practical challenges such as shortage of footwear and other hygiene facilities requires other forms of interventions such as livelihood-strengthening activities. Linking podoconiosis-affected families with local governmental or non-governmental organizations providing socio-economic support for households may assist school-age children in those families to sustainably engage in preventive behaviors.
Podoconiosis is an example of a lifestyle-related disease that develops after childhood and affects millions of people with little experience of preventive behaviour. It is caused by prolonged barefoot exposure to irritant mineral particles, accompanied by inherited susceptibility. Children with a family history of podoconiosis are highly vulnerable to the disease. Several studies have underscored the importance of studying health beliefs in children for the early control of diseases that arise from risky behaviour and habits established in childhood, which continue into adulthood. This study attempted to explore the health beliefs of school-age children in podoconiosis affected families. The forms of health beliefs addressed in the present study were knowledge of podoconiosis risk factors and perceptions of severity of and susceptibility to the disease, benefits of and barriers to engaging in preventive actions such as footwear use and feet hygiene, and self-efficacy to perform preventive actions regardless of perceived barriers. Various forms of misconceptions and inaccurate risk perceptions were recorded. Participant children also reported several barriers that limited their engagement in preventive actions and low confidence to overcome them. These findings imply that school-age children at high risk of podoconiosis might benefit from an intervention that improves their knowledge about podoconiosis and enhances their self-efficacy to sustainably perform preventive behaviours.
children
medicine and health sciences
sociology
tropical diseases
social sciences
parasitic diseases
biological locomotion
pediatrics
age groups
human families
neglected tropical diseases
families
public and occupational health
elephantiasis
podoconiosis
behavior
hygiene
child health
walking
people and places
heredity
physiology
genetics
population groupings
biology and life sciences
Health beliefs of school-age rural children in podoconiosis-affected families: A qualitative study in Southern Ethiopia