Health-related quality of life and associated factors among Onchocerciasis patients in southeast Nigeria: A cross-sectional comparative study

INTRODUCTION

Onchocerciasis, a neglected tropical disease of public health importance, causes chronic morbidity and severe disability that may impact on health-related quality of life (HRQoL) of the infected people. This study assessed the HRQoL and associated factors among onchocerciasis patients in southeast Nigeria.

METHODS

This was a community-based cross-sectional comparative study. Using a multistage sampling technique, 340 onchocerciasis patients were selected and matched for age and gender with the healthy population in the same neighbourhood. The respondents were interviewed using the short-form-36 (SF-36) questionnaire to determine their HRQoL. WHO Disability Assessment Schedule 2.0 tool (WHODAS 2.0) was used to assess disability in persons with onchocerciasis. Means were compared with independent student t-test while Chi-square test was used to compare proportions. Also, correlation analysis and logistic regression were used in the analyses.

RESULTS

A significantly lower proportion of people living with onchocerciasis had a good quality of life when compared with the healthy subjects (69.4% vs 93.5%, p<0.001). Also, an inverse relationship was seen between disability and quality of life in the onchocerciasis group (r = -0.647, p<0.001). Predictors of poor quality of life among respondents with onchocerciasis were: respondents aged ≥48 years (AOR = 2.5, 95% CI: 1.4-5.0), those with some disability associated with onchocerciasis (AOR = 3.33, 95%CI: 1.4-5.0) and respondents who perceived themselves as a burden to people (AOR = 10, 95%CI: 2.5-20).

CONCLUSION

Onchocerciasis impacted negatively on HRQoL of persons with onchocerciasis when compared with the healthy population. The quality of life of persons affected with onchocerciasis reduces with increasing disability. There is the need to increase community awareness on onchocerciasis to ensure early diagnosis and prompt treatment as this will reduce disability among those affected with the disease thus enhancing their HRQoL.

Neglected tropical disease as a 'biographical disruption': Listening to the narratives of affected persons to develop integrated people centred care in Liberia

BACKGROUND

Integrated disease management, disability and inclusion (DMDI) for NTDs is increasingly prioritised. There is limited evidence on the effectiveness of integrated DMDI from the perspective of affected individuals and how this varies by differing axes of inequality such as age, gender, and disability. We used narrative methods to consider how individuals' unique positions of power and privilege shaped their illness experience, to elucidate what practical and feasible steps could support integrated DMDI in Liberia and beyond.

METHODS

We purposively selected 27 participants affected by the clinical manifestations of lymphatic filariasis, leprosy, Buruli Ulcer, and onchocerciasis from three counties in Liberia to take part in illness narrative interviews. Participants were selected to ensure maximum variation in age, gender and clinical manifestation. Narrative analysis was grounded within feminist intersectional theory.

FINDINGS

For all participants, chronic illness, morbidity and disability associated with NTDs represented a key moment of 'biographical disruption' triggering the commencement of a restitution narrative. Complex health seeking pathways, aetiologies and medical syncretism meant that adoption of the 'sick role' was initially acceptable, but when the reality of permanency of condition was identified, a transition to periods of chaos and significant psycho-social difficulty occurred. An intersectional lens emphasises how biographical disruption is mediated by intersecting social processes. Gender, generation, and disability were all dominant axes of social inequity shaping experience.

SIGNIFICANCE

This is one of the first studies to use narrative approaches to interrogate experience of chronic disabling conditions within LMICs and is the only study to apply such an analysis to NTDs. The emotive power of narrative should be utilised to influence the value base of policy makers to ensure that DMDI strategies respond holistically to the needs of the most marginalised, thus contributing to more equitable people-centred care.

Psychosocial effects of river blindness in a rural community in Nigeria

Onchocerciasis (river blindness) is a serious public health problem with important socioeconomic consequences. The presence of onchocercal skin lesions is unsightly and has a psychosocial effect on the affected.

This cross-sectional study was undertaken to assess the perception and social implication of onchocerciasis in the village of Apana in Nigeria. Apana is a rural community, hyper-endemic for onchocerciasis and currently receiving ivermectin treatment. The village is one of the ten communities of Uzairue district of Etsako West Local Government Area (LGA), Edo State, Nigeria. There are many water streams in the community which serve the domestic needs of the inhabitants but also provide the breeding sites for the vector flies of onchocerciasis.

Multi-stage sampling methods were used to select the 385 respondents that participated after informed consent was obtained. A structured researcher-administered questionnaire was the tool for data collection. Of the 385 respondents that participated in the survey, 240 (62.3%) were male while 145 (37.7%) were female. The awareness of the disease among the respondents was fair. They were aware of the nuisance value of blackflies (‘Uja-ini’) and associated the bite with itching. The signs and symptoms of onchocerciasis were recognised as specific diseases with specific local names. They called itching and rashes ‘Erhue’, nodules and leopard skin ‘Evbiomu-Ogui’, worm in the eye ‘Okogho-Ikpalo’ and blindness ‘Orunalo’. The attitude of the non-affected towards the affected was partially discriminatory and suspicious. The affected were socially withdrawn, probably due to the frustration of their health condition. There is a need to improve people’s attitude towards the disease and improve disease awareness through appropriate health education, which will encourage the acceptance of ivermectin as adequate treatment and compliance to the treatment regimen to reduce morbidity and promote self-esteem.

African Programme for Onchocerciasis Control (APOC): sociological study in three foci of central Africa before the implementation of treatments with ivermectin (Mectizan®)

The African Programme for Onchocerciasis Control (APOC) has put in place a study to assess the long-term impact of the community-directed treatments with ivermectin on various clinical and entomological indicators of onchocerciasis. As the results obtained would depend on community participation in the treatments, surveys were also conducted at the study sites to assess the people's knowledge, attitudes and practices regarding onchocerciasis and its treatment. This article presents the anthropological observations made before the implementation of the treatments in three sites: one in the Central African Republic, and two in the Democratic Republic of Congo. The information collected shows that the populations have a relatively poor knowledge of the manifestations and mode of transmission of onchocerciasis. The communities' attitudes towards those individuals afflicted with the disease vary from one site to another. Regarding treatment, the populations use both traditional and 'modern' treatments, but the beneficial effects of ivermectin are not well known. The differences recorded between the sites surveyed demonstrate that the messages to be delivered to the populations before the distributions should take into account the local epidemiological and socio-anthropological context.

Involvement of women in community-directed treatment with ivermectin for the control of onchocerciasis in Rukungiri district, Uganda: a knowledge, attitude and practice study

A study of knowledge, attitudes and practice was carried out in the Rukungiri district of Uganda, in order to investigate the involvement of women in community-directed treatment with ivermectin (CDTI), for the control of onchocerciasis. The data analysed came from interviews with 260 adult women (one from each of 260 randomly-selected households in 20 onchocerciasis-endemic communities), community informants, and participatory evaluation meetings (PEM) in eight communities. The women who had been treated with ivermectin in 1999 generally had more knowledge of the benefits of taking ivermectin, were more likely to have attended the relevant health-education sessions and were more involved in community decisions on the method of ivermectin distribution than the women who had not received ivermectin in that year. There were fewer female community-directed health workers (CDHW) than male CDHW in the communities investigated. The reasons for not attending health-education sessions, not participating in community meetings concerning the CDTI, and the reluctance of some women to serve as CDHW were investigated. The most common reasons given were domestic chores, a reluctance to express their views in meetings outside their own kinship group, suspicions that other women might take advantage of them, and a lack of interest. Most of the women interviewed (as well as other community members) felt that there were relatively few women CDHW. The women attributed this to a lack of interaction and trust amongst themselves, which resulted in more men than women being selected as CDHW. The rest of the community members were not against women working as CDHW. It is recommended that communities be encouraged to select women to serve as CDHW in the CDTI, and that the performances of male and female CDHW be compared.

Gender and the stigma of onchocercal skin disease in Africa

This paper reports results from a multicenter study of gender differences in the stigma associated with onchocercal skin disease (OSD) in five African sites: Cameroon, Ghana, Nigeria (Awka and Ibadan) and Uganda. The studies used a common protocol to compare affected and unaffected respondents, that is, men and women with onchodermatitis in highly endemic areas and respondents from communities with low endemicity or no onchocerciasis. The methods were both quantitative and qualitative, allowing for the comparison of stigma scores and people's verbal descriptions of their experiences and attitudes. Questions to the unaffected were asked after providing them with photographs and short descriptions (vignettes) depicting typical cases. We found that stigma was expressed more openly by the unaffected, who perceived OSD as something foreign or removed from themselves, whereas the affected tended to deny that they experienced stigma as a result of the condition. Gender differences in stigma scores were not significantly different for men and women, but qualitative data revealed that stigma was experienced differently by men and women, and that men and women were affected by it in distinctive ways. Men were more concerned about the impact of the disease on sexual performance and economic prospects, whereas women expressed more concern about physical appearance and life chances, especially marriage. Similar trends were found in the different sites in the responses of affected and unaffected respondents, and differences between them, despite geographical and cultural variations.

Stigma associated with onchocercal skin disease among those affected near the Ofiki and Oyan Rivers in western Nigeria

Skin diseases have been a major source of social stigma, whether they be infectious or not. The potential stigamtizing effect of skin disease associated with onchocerciasis is currently receiving attention because half of the 17 million victims of onchocerciasis in Africa live where the non-blinding form of the disease is prevalent. Some reports are available that onchocercal skin disease (OSD) is associated with social stigma including problems in finding a marriage partner. Previous studies have also implied positive effects of ivermectin treatment on OSD. Therefore a multi-country trial of ivermectin is underway to test the hypothesis that ivermectin treatment might affect perceptions of stigma associated with OSD. This paper presents the baseline stigma findings from the study site located in southwestern Nigeria. A total of 1032 persons living in villages near the Ofiki and Oyan Rivers were screened and interviewed and 500 (48%) were found to have an onchocercal skin lesion. A 13-item, 39-point stigma scale was used in interviews with affected persons. A mean score of 16.8 was obtained. No personal characteristics or disease factors were found to be associated with stigma score. The highest ranking items focused on issues of self-esteem such as feeling embarrassed, feelings of being pitied, thinking less of oneself, feeling that scratching annoys others, feeling that others thought less of the person and feeling that others had avoided the person. During the interviews it was discovered that only about half of those clinically diagnosed as having OSD labeled their own condition as onchocerciasis. Those who said their lesion was OSD had a lower stigma score than those who did not, conforming with previous studies wherein affected persons perceived less stigma from OSD than those without the disease. A broader community perspective on OSD was obtained through 50 interviews using paired comparisons of five skin-related local illnesses. Onchocerciasis placed midway in aversive responses between the higher end represented by leprosy and chicken pox and lower scoring papular rashes known locally as eela and ring worm. In-depth village based interviews yielded several case studies of how onchocerciasis had a negative social impact on its victims. While study on the cultural perceptions of OSD is recommended, the results indicate that with a fairly high prevalence of OSD, the community level effects of social stigma should be regarded as serious.

Evaluation of community compliance with annual ivermectin treatment of onchocerciasis in Patigi, Nigeria

A low community acceptance and compliance with annual ivermectin treatment was recorded in Patigi, Nigeria where ivermectin is being distributed centrally in designated centres for the fifth time. The average community acceptance rate (ACAR) for the treatment period was 53.48% while the community compliance rate (CCR) of 1.9% of the total subjects interviewed was recorded. Absenteeism from treatment was a major reason for non-treatment (average, 34.6%). Inadequate and poor mobilisation was identified as a major reason for the low ivermectin acceptance and compliance with treatment in this community. An intensive mobilisation with health education messages with the inclusion of religious/traditional institutions is advocated.

Onchocercal dermatitis: clinical impact

The clinical features of onchocercal dermatitis include itching, papular and papulomacular rash, skin atrophy and depigmentation. The results of a multi-country study have shown that > 30% of the population in communities where onchocerciasis is endemic have onchocercal dermatitis. The most troubling symptom suffered by those affected was itching and this was closely related to reactive onchocercal dermatitis (acute papular, chronic papular and/or lichenified lesions). Reactive onchocercal dermatitis and troublesome itching were common in all age-groups and were an important cause of stigma in most endemic communities, those affected suffering from poor self-esteem. Concern about onchocercal depigmentation varied between study sites and subjects.

Outcome of two patient education methods on recruitment and compliance with ivermectin in the treatment of onchocerciasis

Two patient education methods, Information Media (IM) and Social Network (SN), were compared to determine their relative effectiveness on recruitment and subsequent compliance behavior of people infected with onchocerciasis in respect of appointment keeping and ivermectin consumption in existing primary health care facilities in six communities in southwestern Nigeria. Two communities each were randomly assigned to the IM intervention group, two of the SN group, and two served as controls. A total of 1265 persons out of an estimated target population of 5033 infected individuals were enrolled in the study. Coverage rates were higher in the intervention communities (30.3% for SN and 29.9% for IM) than control (7.3%), but the differences between intervention groups was not significant. A drop-off was seen in attendance at the second round of ivermectin distribution. Nearly equal proportions of the intervention groups returned (43.3% for SN and 47.4% for IM), while few control patients came back for their second dose (12.3%). Factors responsible for the low turnout were thought to include the content of educational messages, mobility of community members and limited time available to collect the drugs. Cost considerations led to recommendations to maintain facility based distribution and the SN approach, with greater emphasis on mobilization to increase coverage and compliance.

Social anthropological aspects of onchocercal skin disease in Nebbi District, Uganda

In providing health care, the busy medical practitioner often lacks the "I-You" quality of the personal experience of illness. This paper reports the perceptions, beliefs and practices of persons living in a hyperendemic focus of onchocerciasis in Nebbi District, north-western Uganda. The study involved the use of focus group discussion and semi-structured interviews designed to explore the experiences, meanings, and illness-related coping strategies employed by the community. The results indicated that oncherciasis is considered to be a mysterious elusive disease which cannot be treated by local herbs. The disease is often mistaken for measles (odyer), and leprosy (dhobu). Persons who suffer from onchocerciasis believed that the cause of the disease is the small black fly (Kamacur), dirty water or rivers. However, non-affected individuals believed that the condition is caused by poor personal and environmental hygiene, and personal contact with persons affected by onchocerciasis. Affected people recommended public health education to control the disease while non-affected people, recommended the avoidance of personal contact with affected people, ensuring personal hygiene, and the improvement of environmental sanitation and the nutritional status of community. The belief systems of the community are probably responsible for the discriminatory practices of the people against those affected by the condition. The results indicate that onchocerciasis is a serious public health problem which needs to be controlled.

Social and psychological aspects of onchocercal skin disease in Nebbi district, Uganda

Onchocerciasis affects 7% of Uganda's population and 1.5 million more people are at risk of infection with Onchocerca volvulus, the nematode that causes the disease. This paper reports the results of part of a multi-centre study whose objective was to determine the prevalence of onchocercal skin disease and its associated psychosocial importance in Uganda. The study employed a standardised clinical dermatological survey method along with the use of structured questionnaires, focus group discussions and key informant interviews. Out of a total of 993 persons examined to determine the prevalence of onchocercal skin lesions 253 persons were interviewed to determine the psychosocial importance of the disease. The results indicate that onchocercal skin disease is associated with a variety of psychosocial, physical and economic effects. The disease also leads to stigmatisation of affected persons and their families. It is suggested that dermatological effects of onchocerciasis should be recognised as an important cause of morbidity in Uganda.

Dermatological problems of onchocerciasis in Nebbi District, Uganda

A cross-sectional survey of 770 subjects in onchocerciasis hyperendemic villages and 223 subjects from a control community in Nebbi District in the West Nile region of Uganda revealed a high prevalence of onchocercal skin disease of 48% in endemic villages. The most common skin problem was troublesome itching (40%); and the prevalent skin lesions were chronic papular onchodermatitis (16%), depigmentation (4%), lichenified onchodermatitis (2%) and acute papular onchodermatitis (1%). Other typical varieties of onchocercal skin diseases such as, hanging groin, lymphoedema and marked lymphadenopathy were infrequent, and considered rare. Pityriasis vergicolor was the most common non-onchocercal skin lesion in both control and endemic communities, accounting for 37% of all non-onchocercal skin lesions. These skin lesions were associated with a variety of psycho-social and economic impact; and there was a positive correlation between the prevalence of troublesome itching and the prevalence of modules (correlation coefficient r = 0.62, p = 0.00). Given the prospects of onchocerciasis control based on mass ivermectin distribution in communities where blindness is common, we recommend that treatment be extended to communities where blindness is less common, but skin disease known to be predominant.