Abstract

Objectives To assess cholera-related knowledge, attitudes and practices (KAP) and identify associated factors in a cholera endemic health zone in the Democratic Republic of the Congo (DRC).

Design A community-based cross-sectional study.

Setting The study was conducted in Kalemie health zone, which is located in the Tanganyika province in eastern DRC.

Participants A total of 455 participants were enrolled in this study using a three-stage random sampling procedure.

Main outcome measures Sociodemographic characteristics, cholera and water, sanitation and hygiene (WASH)-related KAP, and their associated factors.

Results The study revealed that the population demonstrated a good knowledge (64%), a positive attitude (73.6%) and good WASH practices (73.8%) regarding cholera. The identification of cholera symptoms, modes of transmission and means of prevention ranged from 79.6% to 94.3%, 38.2% to 41.5% and 32.5% to 56.3%, respectively. It was also noted a high prevalence of tap water use (93.4%) and limited access to water treatment (43.1% to 57.1%), as well as a significant proportion of latrine access (70.8%) with the presence of open defecation (16.3%). In multivariable logistic regression, poor knowledge about cholera was associated with being aged 18 years or younger, having limited education and practising poor WASH habits. No significant factors influenced participants’ attitudes. Poor WASH practices were associated with being from households with daily expenditures of less than 1 USD and 5 USD, as well as having poor knowledge about cholera. In addition, believers from Catholic and Muslim backgrounds were less likely to have poor WASH practices.

Conclusions Our findings indicate that health education initiatives targeting younger demographics should be intensified to enhance awareness of cholera prevention and household water treatment. Furthermore, there is a need for targeted interventions to provide public standpipes and community boreholes, as well as to improve the coverage of covered pit latrines, especially for poorer households.

Data availability statement

Data are available upon reasonable request. The data that support the findings of this study are available from the corresponding author upon reasonable request.

http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

STRENGTHS AND LIMITATIONS OF THIS STUDY

• The recruitment of participants residing in the community enabled the identification of genuine deficiencies in comprehension and conduct with regard to cholera prevention.

• Due to the cross-sectional nature of the study, it was not possible to draw any conclusions regarding causality.

• The study design may also limit the generalisability of the findings beyond the Kalemie health zone.

• The lack of observation did not allow for minimising the gaps that may exist between people’s knowledge and actual practices regarding handwashing, drinking water treatment and latrine use.

Introduction

Cholera is a longstanding disease that remains a major public health threat in resource-limited settings.1 2 It is an epidemic diarrhoeal disease caused by ingestion of food or water contaminated with pathogenic strains of Vibrio cholerae, a bacterium belonging to the family Vibrionaceae and the species cholerae.3 V. cholerae serogroups O1 and O139 cause cholera epidemics.4

After a short incubation period ranging from a few hours to a maximum of 5 days, the expression of the disease is variable. It may range from mild symptoms to life-threatening dehydration.5 6 The treatment of cholera relies on oral or intravenous rehydration to replace digestive losses of water and electrolytes.6 Prompt and appropriate treatment can reduce the mortality rate from over 50% to less than 1%.7 In severe cases, antibiotics are used. However, an increasing number of strains are multi-resistant to antibiotics,8 9 making rehydration and especially prevention all the more important. Improving access to clean, potable water and adequate sanitation, as well as promoting good water, sanitation and hygiene (WASH) practices, remains the mainstay of preventing both endemic cholera and cholera outbreaks, especially in areas with limited access to healthcare.6

Since the beginning of the current seventh cholera pandemic, Africa has been the continent hardest hit by the disease. More than 40 years after its reappearance in Africa in 1970, the highest burden of disease has been particularly concentrated in the Great Lakes region.10–12 The Democratic Republic of the Congo (DRC), located in the Great Lakes region, has reported cholera cases and deaths every year since the 1990s.13 Based on the results of research projects aimed at understanding the epidemiology and ecology of cholera in the DRC, a national cholera elimination plan has been launched since 2008, with the main strategy of targeting endemic lake areas as priorities for cholera control interventions.14 Despite the implementation of this plan, the cholera epidemiological situation does not appear to be improving in most of these endemic lake areas, in this case Tanganyika Province.15–17

From 2008 to 2021, the Tanganyika Province reported 40 866 suspected cholera cases, of which 32 863 were recorded in areas bordering Lake Tanganyika, representing 80% of all cases reported in Tanganyika Province. Specifically, the Kalemie health zone accounted for more than one-third (36%) of the cases reported in this province.18 However, it is notable that approximately 80% of the population living in Kalemie had access to water supplied by the national water agency (REGIDESO).19 Furthermore, the area had been the beneficiary of a number of anti-cholera interventions, including mass cholera vaccination campaigns and drinking water supplies.20 21

While environmental and epidemiological studies have been conducted,22 23 the socioeconomic and behavioural drivers of cholera persistence in Kalemie remain unexplored. However, extant research conducted elsewhere has demonstrated that factors such as absolute poverty, adult illiteracy, utilisation of unimproved water sources, inadequate water treatment methods, open defecation, suboptimal food preservation techniques and participation in social or commercial mass gatherings can play a pivotal role in the persistence of cholera.24–27 Thus, this study aimed to assess knowledge, attitudes and practices (KAP) related to cholera among residents of the cholera-endemic health zone of Kalemie and to identify factors associated with KAP. This will inform the development and refinement of control interventions to strengthen prevention of recurrent cholera epidemics.

Methods

Results

Discussion

The objective of the present study was to assess cholera-related KAP and to identify the associated risk factors in the Kalemie health zone, where cholera is endemic. Our research revealed that a considerable proportion of the population exhibited inadequate knowledge about cholera, an unfavourable attitude towards the disease, and substandard WASH practices in the context of cholera. The lack of knowledge regarding the disease was particularly pronounced among individuals aged 18 and under, as well as those with low educational levels. Regarding WASH practices, it was observed that a high prevalence of tap water use was associated with limited access to water treatment, such as chlorination or purification, and consistent access to latrines did not guarantee the absence or disappearance of open defecation in the community.

Six out of ten respondents demonstrated a satisfactory level of knowledge regarding cholera. The majority of respondents from the community were able to identify symptoms with relative ease. However, there was a notable lack of awareness regarding modes of transmission and means of prevention of cholera. This inadequate level of knowledge regarding cholera, which can be influenced by the socio-cultural backgrounds of people in the affected area,34 is comparable to other studies on the KAP of communities conducted in the same region,35 as well as in other parts of the world, including Saudi Arabia,34 Yemen36 and Bangladesh.37 Research has demonstrated that the public’s limited knowledge and awareness regarding the disease, particularly the modes of transmission of the pathogen, contributes to an elevated risk of the spread of cholera.34 38 Furthermore, our findings suggest that the correlation between the experience of multiple recurrent cholera epidemics and an increased awareness of the disease may not always be readily apparent.

The study revealed a notable lack of knowledge about cholera among individuals with younger age groups and limited educational attainment. Despite the absence of a significant correlation between age and the level of knowledge regarding cholera in other studies,37 39 40 it is postulated that young individuals tend to have a lower perception of risk associated with the disease in comparison to their older counterparts. Consequently, they demonstrate a reduced propensity to seek information regarding preventive measures. As posited by Albitar and Almasri,41 older individuals may be more compliant due to the accumulation of maturity and a pronounced sense of responsibility. Furthermore, our observation provides a potential explanation for the higher incidence of cholera among younger populations compared with older populations in cholera-endemic zones of the DRC.42 Frequent mass educational campaigns through on-the-ground communications, community gatherings, school-based programmes and public announcements, leveraging all communication channels, particularly social media platforms, would help deliver accurate cholera awareness messages to the target population to inform them on contamination routes and prevention means and practices. The involvement of a renowned celebrity as a champion for the cause would be instrumental in this effort.43

In our study, poor knowledge about cholera was also likely to be more prevalent among participants with poor WASH practices than among those with good WASH practices. Conversely, respondents with limited knowledge about cholera were more likely to exhibit poor WASH practices than those with adequate knowledge about the disease. It can be reasonably assumed that a low level of knowledge can be translated into a low level of practices related to cholera40 44 and vice versa. However, while a high level of knowledge is a prerequisite for effective practice, it is not a guarantee of it.36 It is possible that respondents with a comprehensive understanding of cholera and its prevention strategies may not accurately reflect their actual practices.

It is noteworthy that a high level of attitudes towards cholera was observed according to the severity, concern, curability and seeking of treatment if suspecting cholera. However, it is worrisome that only 25% of the participants in this study agreed with the recommendation to notify the nearest health centre of a suspected cholera case. This underscores the crucial role of policymakers, health professionals and the media in mobilising society to disseminate tailored information, thereby facilitating collaborative efforts to enhance community engagement in the control of the disease.45

In terms of WASH practices, seven out of ten respondents demonstrated satisfactory performance. The primary source of drinking water was tap water (93%), and covered containers were the most common method of storing collected water (92%). Nevertheless, approximately 45% of respondents indicated that they also used lake water, which can be attributed to the frequent interruptions in the water supply system. A previous study conducted in Uvira, a cholera-endemic area in eastern DRC comparable to Kalemie, demonstrated that neighbourhoods with higher tap water consumption exhibited a greater susceptibility to water supply disruptions. A 1 day interruption was followed by a substantial increase in the incidence rate of suspected cholera cases within 12 days,46 particularly given the association between exposure to lake water and the occurrence of epidemics.47 48 Furthermore, this study revealed that a low percentage of participants reported treating their water with chlorine or purifiers and boiling. In accordance with the high utilisation of tap water observed in this study, it is likely that this situation is due to the belief that the water source is safe, thereby negating the necessity for treatment.36 49 However, microbiological testing of untreated piped water sources conducted in numerous urban and peri-urban areas of developing countries revealed that water samples continued to show evidence of faecal contamination.50 51 It is, therefore, recommended that policymakers and relevant stakeholders collaborate to implement community workshop initiatives that enhance public participation in the prioritisation of water treatment techniques at the household level. This should be done on the one hand to ensure that the most appropriate techniques are selected for the treatment of drinking water and, on the other, to promote practices that ensure the provision and maintenance of safe, high-quality drinking water from drinking water sources.

Although the current study demonstrated that the majority of respondents have access to latrines, a low percentage of them continue to engage in open defecation in these communities. This finding is consistent with evidence indicating that open defecation persists even in areas with high latrine coverage.36 52 53 In accordance with Dureab et al,36 a qualitative survey is the optimal method for elucidating the socio-cultural factors influencing the practice of open defecation. This understanding is essential for the success of any efforts to mitigate the risk of cholera.

Our findings indicate that individuals from households with low and lower daily expenditures were more likely to engage in poor WASH practices than those from households with high daily expenditures. It is not surprising that those who are poorer are less likely to have access to improved water sources and sanitation facilities. In comparison to households of a higher socioeconomic status, poor households are less able to afford household tap water connections or pay for water from safe sources, even when they are closer to facilities or services. Moreover, they frequently lack the financial resources to procure improved toilet facilities.54–56 Additionally, a correlation was identified between WASH practices and religious beliefs. Individuals who adhere to the Catholic and Muslim religions demonstrated a reduced probability of engaging in suboptimal WASH practices in comparison to those who belong to other religious groups. The utilisation of clean water is regarded as a fundamental aspect of ritual purity and blessing in numerous religious traditions. For example, the practice of hand washing is perceived as an obligatory practice prior to prayer within Islamic tradition.57 Similarly, within the Catholic Church, the ceremony of foot-washing represents a significant and highly intimate rite that is performed during the Holy Thursday Mandatum.58 Therefore, there is evidence that suggests a link between access to clean water and religious adherence. However, further research is needed to explore thoroughly the specific cultural behaviours within religious groups that contribute to adherence to WASH practices.

This study is subject to certain limitations. First, the cross-sectional nature of the study precludes the ability to draw conclusions regarding causality. Additionally, the study design may restrict the generalisability of the findings beyond the Kalemie health zone or analogous high-risk settings within the same geographical area. Second, the potential for social desirability bias should be considered, as the participants with a high level of knowledge about cholera might have overreported their actual prevention practices, thus giving the appearance of a causal relationship where none exists. Further studies employing direct observation are required to highlight the plausible gaps between individuals’ knowledge and actual practices regarding handwashing with soap or ash after defecation or before eating, the treatment of drinking water and the use of latrines. Nevertheless, the present study offers an update on the limited number of studies that have previously explored the KAP of communities regarding cholera in the context of the DRC’s cholera endemic. It also helped to identify deficiencies in the community’s comprehension and conduct with regard to cholera prevention, thereby enabling the development of targeted intervention plans designed to encourage the adoption of health-promoting behaviours. In the future, we propose a community intervention trial with two arms. The intervention arm will address the key findings, while the control arm will remain as is. The trial will be conducted over time to assess the impact of the interventions.

Conclusion

The present study revealed that a substantial proportion of the population in a high-risk cholera setting, such as Kalemie, remains at heightened risk due to limited knowledge about cholera and suboptimal WASH practices. Individuals in the younger age group and with limited educational attainment, as well as those with poor WASH practices, demonstrated a greater prevalence of poor knowledge about cholera. In addition, WASH practices were influenced by the level of knowledge about cholera, socioeconomic status and religious beliefs. From an operational perspective, there is an evident necessity for targeted health education initiatives that are tailored to enhance risk perception and compliance with preventive measures among young people, as well as to improve household water treatment. Targeted interventions should also be implemented to provide public standpipes and community boreholes and to improve coverage of covered pit latrines, especially for poorer households. To this end, the establishment of long-term coalitions comprising policymakers and strategic partners is imperative to address cost and affordability issues, which are potential barriers to implementing WASH interventions.

Data availability statement

Data are available upon reasonable request. The data that support the findings of this study are available from the corresponding author upon reasonable request.

Ethics statements

Acknowledgments

The authors would like to thank all those who participated in this study voluntarily.