Assessing the knowledge, attitudes, practices, and perspectives of stakeholders of the deworming program in rural Rwanda

Background Worm infections are among the most prevalent neglected tropical diseases worldwide. Schistosomiasis and soil-transmitted helminths infections, most common worm infections affecting Rwandan school-aged children, are addressed by the national deworming program since 2014. To date, no published studies have assessed the knowledge, attitudes, and practices of the key implementers of the national deworming program conducted at village and school level in Rwanda. This study aimed to assess key stakeholders’ knowledge, attitudes, practices, and perspectives about the decentralized national deworming program. Methods/Principal findings We carried out a quantitative, cross-sectional study with complementary in-depth interviews in two districts of Rwanda in June 2021. From the 852 surveyed community health workers and teachers, 54.1% had a knowledge score considered good (≥80%). The mean knowledge score was 78.04%. From the multivariate analysis, lack of training was shown to increase the odds of having poor knowledge (OR 0.487, 95% CI: 0.328–0.722, p <0.001). The in-depths interviews revealed poor water access and hesitance from caregivers as perceived challenges to the success of the deworming program. Conclusion Our findings demonstrate the importance of training community health workers and schoolteachers on worm infections as they are the key implementers of the deworming program. This would enhance their capacity to provide health education and sensitization on misconceptions and misinformation towards deworming. Moreover, research is needed to assess the impact of poor access to water, sanitation and hygiene facilities on the prevalence of worm infections in Rwanda.


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• * typeset Additional data availability information: school level. This study aimed to assess key stakeholders' knowledge, attitudes, practices, and 23 perspectives about the decentralized national deworming program. 24 Methods/ Principal Findings: We carried out a quantitative, cross-sectional study with comple-25 mentary in-depth interviews in two districts of Rwanda in June 2021. From the 852 surveyed com-26 munity health workers and teachers, 54.1% had a knowledge score considered good (≥80%). The 27 mean knowledge score was 78.04%. From the multivariate analysis, lack of training was shown to 28 increase the odds of having poor knowledge (OR 0.487, 95% CI: 0.328 -0.722, p <0.001). The 29 in-depths interviews revealed poor water access and hesitance from caregivers as perceived chal-30 lenges to the success of the deworming program. 31 Conclusion: Our findings demonstrate the importance of training community health workers and 32 schoolteachers on worm infections as they are the key implementers of the deworming program. 33 This would enhance their capacity to provide health education and sensitization on misconceptions 34 and misinformation towards deworming. Moreover, research is needed to assess the impact of poor 35 access to water, sanitation and hygiene facilities on the prevalence of worm infections in Rwanda. 36 .

AUTHOR SUMMARY 37
Worm infections affect over 2 billion people worldwide, and the most common are schistosomiasis 38 and soil-transmitted helminth infections. In Rwanda, the prevalence of soil-transmitted helminth 39 infections can be as high as 45%, while the prevalence of schistosomiasis is 2.7% among school-40 aged children. 41 The government of Rwanda continues to develop initiatives to eradicate worm infection, among 42 which, the national decentralized deworming program, implemented at village and school level. 43 In this program, community health workers collaborate with teachers and local leaders to admin-44 ister deworming tablets, community sensitization and health education. To date, no published stud-45 ies have been conducted to understand the experiences and perspectives of key stakeholders in the 46 national deworming program in Rwanda. We conducted a quantitative analysis of the Knowledge, 47 Attitudes and Practices (KAP) of teachers and community health workers, and a qualitative as-48 sessment of the perspectives of local leaders in two of the most food insecure districts of Rwanda. 49 The results show a gap in the knowledge of community health workers and teachers on worm 50 infections. The study also revealed that there were some misconceptions about deworming tablets, 51 which highlights the need to train key implementers of the program for them to transfer their 52 knowledge to the broader community. 53

INTRODUCTION 54
Worm infections affect more than 2 billion people worldwide, with soil-transmitted helminth in-55 fections (STH) and schistosomiasis being the two most common types [1]. In 2022, about 1.5 56 billion people were affected by STH, and 200 million by Schistosomiasis [2, 3]. The infections 57 disproportionally affect impoverished populations in low and middle income countries (LMIC) 58 [4], with over 90% of Schistosomiasis cases being recorded in sub-Saharan Africa [2, 3]. 59 STH and Schistosomiasis are transmitted through contaminated water or soil, either orally or 60 through punctured skin [4,5,6]. Impoverished populations are at higher risk due to lack of ade-61 quate access to clean water, basic sanitation and hygiene facilities, and footwear [4,7]. People 62 living in rural communities where agriculture and fishing are commonly practiced are at high risk. 63 The infections can affect people from all age groups, but children were found to be more affected 64 by numerous long-term effects. Worm infections cause numerous intestinal symptoms and chronic 65 illness, which frequently lead to decreased growth, and cognitive impairment resulting in long 66 term diminished productivity [8, 9, 10, 11] 67 In Rwanda, Schistosomiasis and STH are the most common neglected tropical diseases [12]. Oc-68 cupational exposure through agriculture and water bodies is a common risk factor as 74% of house-69 holds (primarily rural) are engaged in agriculture and live around Lake Kivu -the largest body of 70 water in Rwanda. Moreover, with insufficient sewage water treatment, they are exposed to urban 71 and household waste [13]. A nationwide study conducted in 2008 showed that 65.8% of school-72 aged children had STH, with a higher prevalence in rural districts compared to Kigali

In-depth Interview 162
Local community leaders were contacted through the district health coordinators. They 163 were first contacted through phone calls and data collectors met with them at the agreed 164 appointment time and locations. 165 Informed consents and permission to record were obtained after detailed explanation of the 166 study was provided. The interviews were conducted in a private office in Kinyarwanda; 167 only the researcher and participant were in the room during the interview. 168

Data collection tools 169
Survey 170 A questionnaire (S1 appendix) was developed based on previous similar KAP studies [23]. 171 The questionnaire had four parts. Part 1 collected some basic demographic information. 172 to schistosomiasis and seven related to STH. Part 3 contained ten 4-point Likert scale state-174 ments, with five related to the respondents' attitude on Schistosomiasis and five on STH. 175 The options for these statements were: "strongly agree", "agree", "disagree" and "strongly 176 disagree". Part 4 contained six 4-point Likert scale statements related to their practices. 177 The options for these statements were: "never", "rarely", "often" and "always". 178

Data management and analysis
Descriptive analyses were conducted for demographic information and the KAP results. The 194 knowledge score was calculated as the percentage of correct answers divided by questions 195 answered. The overall knowledge was categorized as "good" if the score was between 80 and 196 100%, and poor if less than 80% [24]. The attitude statements were presented as the percentage 197 of choosing "agree" and "strongly agree" versus the percentage of choosing "disagree" and 198 "strongly disagree". The practices statements were presented as the percentage of choosing 199 "never" and "rarely" versus the percentage of choosing "often" and "always". 200 Fisher's exact test was used to analyze the association between knowledge level and 201 demographics, between knowledge level and attitude category, and between knowledge level and 202 practice category. 203 All demographic variables with P<0.10 in the bivariate analysis were then included in the logistic 204 regression model for analyzing factors contributing to knowledge level, attitude and practices. 205 All the statistical tests were performed using SPSS v.27.0.1, with a p-value < 0.05. 206 The IDIs were transcribed and translated. The codebook was developed based on the interview 207 responses inductively and iteratively by three investigators. All transcripts were coded based on 208 the final codebook first individually then together as a team. Thematic analysis was used to identify 209 emerging themes. Qualitative analyses were conducted using Dedoose software. 210

Ethical Consideration 211
This study was approved by the University of Global Health Equity institutional review board. 212

Assessment of attitudes 238
The three statements which most participants strongly agreed/ agreed with were 1) "I am an 239 important contributor to the prevention of schistosomiasis in my community" (97.2%); 2) "I am 240 an important contributor to the prevention of STH in my community" (97.8%) and 3) 241 "Deworming is helpful in treating schistosomiasis" (96.5%). The two statements which most 242 participants strongly disagreed/disagreed with were 1) "STH can be best treated by traditional 243 healers" (98.9%) and 2) "Schistosomiasis can be best treated by traditional healers" (98.5%) 244 (Table 3). 245

Assessment of practices 247
Most respondents reported that they often or always wash hands before eating (n=845, 99.2%) and 248 often or always encourage children/people to wash their hands before eating (n=844, 99.1%). The 249 survey also showed 298 (35%) respondents reporting that they often or always drink untreated 250 water, 790 (92.7%) never or rarely swim in rivers/lakes, and 771 (90.5%) never or rarely wash 251 clothes or utensils in open water source (Table 4). 252

Association of demographic characteristics and knowledge 259
Five demographic factors (occupation, age, district, years of experience and training) in bivariate 260 analysis had P<0.1. Only training in the deworming program was found to have a statistically 261 significant association with knowledge using multivariate analysis. Participants who were trained 262 were 2.04 more likely to have good knowledge on worm infections compared to those who were 263 not trained (95% CI: 1.39 -3.03, p <0.001) ( Table 6). 264

Association of knowledge and attitudes 268
Knowledge level was found to have significant association with one attitude statement. Respond-269 ents with good knowledge level were found to be 4.66 times more likely to agree with the attitude 270 statement "I am an important contributor to the prevention of schistosomiasis in my community" 271 than those with poor knowledge, with a P<0.001 (Table 7). 272

Association of knowledge and practices 274
Knowledge level was found to be significantly associated with one practice statement. 275 Respondents with good knowledge were 2.19 times more likely to "often/always" swim in 276 rivers/lakes compared to those who had poor knowledge, with P=0.006 (Table 8).

Community mobilization and sensitization by local leaders and CHWs contributed 286
to the outreach of the deworming program 287 In the national decentralized deworming program, local leaders are responsible for informing 288 community members about the program and encouraging them to have their children dewormed. 289 In addition, local leaders oversee and supervise the distribution of deworming tablets done by 290

CHWs. 291
"I work hand in hand with community health workers daily to make sure that every child 292 of our Village receives the medicine that the government provided. I am present from the 293 start till the end of the program. I have to make sure that all tablets are distributed, that 294 they are over… yes, I have to be there." (IDI 3) 295 In case children are missing at the time of distribution, local leaders would conduct follow-up visits 296 to the households to make sure that children receive their tablet. 297 "At the sites, we checked out if parents brought children to get tablets as encouraged dur-298 ing household mobilization; and we could re-visit the ones we noticed did not come so that 299 s/he brings the child the following day." (IDI 8)

Community members reportedly appreciate the value of the decentralized 301
deworming program and express the desire to expand it. 302 All 17 local leaders stressed that the community members appreciate the introduction of the de-303 worming program at village level since it makes it easier for them to access the service without 304 travelling long distances to health centers. 305 "They are very receptive because they do not walk miles to access the program. They are 306 very receptive and happy with the program." (IDI 1) 307 According to the local leaders interviewed, community members are asking for adult deworming 308 tablets so that they too can benefit from the program. In addition, the local leaders express the need 309 to increase the frequency of MDA in order to improve child health. Five local leaders observed that some caregivers do not adhere to the deworming program. Instead 349 of bringing the children to the deworming sites, they would choose to go out to their farms. 350 "When the community health workers come on time, they may also not find parents… that 351 is the challenge. The parents come whenever they want, after farming activities." (IDI 6) 352 According to one local leader, some caregivers are resistant to deworming because they think it 353 increases food consumption by the children, which they cannot afford. 354 "The main reason they say is that those deworming tablets have adverse effects to their 355 children. Another reason they say is that when a child has taken that tablet, s/he eats a lot 356 and "I will not be able to find that food." (IDI 10) 357 According to some respondents, some caregivers perceive their children to be healthy, and they do 358 not see the importance of deworming them. Overall, the qualitative analysis led to the identification of key challenges based on the experiences 376 and perspectives of local leaders, as well as their perspectives of the needs of the community. The CHWs took on the responsibilities in the distribution of deworming tablets. They widely 404 agreed they were important contributors in the prevention of worm infections, and the deworming 405 was important. On this continent, the use of traditional medicine is widely accepted in many coun-406 tries [25]. However, most of our study respondents did not believe traditional healers could effec-407 tively treat worm infections. The receptive attitudes showed the success of the program in enhanc-408 ing buy-in from stakeholders. 409 Overall, our study shows that the deworming program was appreciated by the local community 410 leaders. Local leaders could identify the benefits of the decentralization of the MDA program, 411 contributing to the ease of access to the tablets, and the numerous positive health outcomes. Similar 412 appreciation of the decentralization of health services were seen in similar countries such as Kenya 413 [30]. However, local leaders expressed a need to increase the frequency of MDA. Currently the 414 WHO recommends frequency for MDA to be twice a year [29]. However, respondents perceived 415 that some communities only had MDA once a year. Additionally, they expressed the need for adult 416 deworming, as worm infections also affect adults. Studies have shown that adult who were en-417 gaged in farming activities could have higher risk than children of getting hookworm infections 418 [30]. Policy makers should consider expanding the scope of the deworming program to include 419 adults. 420 Local leaders reported that some misconceptions and resistance from the community members 421 pose a challenge to the implementation of the deworming program. One of the misconceptions is 422 that their children are healthy and do not need medication. Resistance to deworming is also found 423 in other countries like Kenya, where misconceptions about the tablets was found to cause reluctance [28]. Additionally, according to local leaders, one of the reasons why community 425 members exhibit resistance to the deworming program is their inability to provide enough food to 426 their children, as they believe that deworming contributes to increasing children's appetite. This 427 was highlighted in a similar study conducted in Kenya where food insecurity posed a major 428 challenge to MDA compliance [28]. Misconceptions and resistance may become bottlenecks to 429 the deworming program as they may hinder timely control and elimination of worm infections. 430 Therefore, there is a need to strengthen community sensitization programs, with an emphasis on 431 these misconceptions and on the impact of deworming on child health. 432 The study results showed that most of the respondents consumed water from taps and boreholes. 433 However, due to geographical and financial limitations to water access, many people had to walk 434 long distances to reach these water sources, and some were required to pay to access water in 435 certain areas. Lack of access to safe water could increase the prevalence as well as the intensity of 436 infection and re-infection [31]. Regardless, similar to many other neighboring countries, a signif-437 icant portion of our respondents (35%) reported drinking untreated water [32]. Literature has sug-438 gested that effective deworming program must be complemented with water, sanitation and hy-439 giene (WASH) interventions [33,34]. 440 One unexpected finding in our study was that respondents with good knowledge on worm infec-441 tions were more likely to swim in rivers/lakes. A study in Tanzania