In this study, we evaluated knowledge, attitudes and practices towards TSCT in rural Tanzania, by a combined assessment through a questionnaire survey and households inspection. Interestingly, almost all the participants had heard about PCC, half of the participants knew about the pork tapeworm (T. solium taeniasis), but almost nobody had heard anything about HCC. The questionnaire also revealed that knowledge of the means of transmission and the various aspects of pork tapeworm and HCC prevention was particularly poor, although the latter is not surprising as no one had ever heard anything about HCC. The knowledge on the transmission and prevention of PCC was fair in the aforementioned areas. The effects of T. solium on human health (taeniasis and NCC) were not well known, although knowledge of signs/symptoms of taeniasis was fair, compared to knowledge of the effects on pig health which were mainly known among pig keepers. The general good knowledge about PCC may be attributable to epidemiological studies on PCC conducted previously in the districts (25,26) and information obtained through village meetings/gatherings, household visits by Extension Officers or leaflets. Not only was the knowledge on the impact of T. solium on human health and HCC in general limited, but also many participants did not consider themselves at risk of T. solium infection, despite living in areas with high T. solium endemicity and having heard about the parasite before, at least in the context of T. solium taeniasis. This was surprising because several studies on T. solium, with different research questions, had previously been conducted in some of the study districts [6, 18, 20, 22,23,24, 29, 30]; among these studies were also studies that assessed appropriate T. solium health education packages which proved successful. This means that health education packages may not have had sustained effects on knowledge and practices regarding TSCT and that new health education packages not only need to deliver information on T. solium but also need to include the risk perception of participants. Health education packages, therefore, have to be perceived as an iterative process including not only the researchers and the local authorities but also and foremost the local communities from the beginning and throughout the entire process in a co-creative design.
To the best of our knowledge, to date, no studies regarding TSCT have been conducted in the Rungwe district. Nonetheless, participants from Rungwe showed similar results to those shown by participants in other districts in all KAP domains. This may be a result of good extension services and other interventions on sanitation and hygiene in this district. This could also be attributable to knowledge spill over from the adjacent districts that are known to be PCC endemic thus representing a desirable effect. In addition, the district is popular for intensive dairy cattle management which may further explain their pig management system and pig feeding practices. Thus, knowledge transfer from one knowledge domain to another should not be underestimated, instead, it should be explored in health education programmes.
On average, pig keepers knew that free-roaming of pigs and exposure to human faeces and contaminated feeds were central to the transmission of T. solium infection. This finding is comparable to the findings from several other studies conducted in Tanzania [8, 9, 24, 25]. On the contrary, most respondents had never heard of HCC, possibly due to a lack of knowledge among medical staff and/or lack of appropriate diagnostic tools. It seems that people are hardly ever diagnosed with HCC (especially NCC) outside research projects in sub-Saharan Africa as access to neuroimaging facilities is mandatory for the correct diagnosis of NCC but very costly. However, our findings are not unusual. Also, other studies conducted in areas highly endemic to T. solium showed low awareness of HCC/NCC [18, 31, 32]. Interestingly, knowledge about epilepsy was high, but not many people knew that T. solium cysticercosis is one of the causes of epilepsy.
In general, the level of knowledge on PCC was good. This may be because almost three-quarters of the respondents were pig farmers who might have acquired their knowledge from Livestock Field Officers (LFO) and other extension agents allocated to their respective villages. In the present study, most participants, especially pig farmers were aware of the predilection sites of T. solium cysticerci in the infected pig; under the tongue being the most commonly mentioned site. This may be because when selling pigs to traders, they usually check for the presence of cysticerci under the tongue. Regarding the aetiology of PCC, some interesting misconceptions persist. Pawpaw seeds and jiggers (sand fleas) were reported by a few farmers as causes of PCC, all of the farmers were from Rungwe District where feeding fruits to pigs is a very common practice (results not presented). This is probably because of the similarity in the morphology of T. solium cysticerci to pawpaw seeds and jiggers (sand fleas). This confusion implies that although general knowledge of PCC was good, there is still a need for health education to consolidate knowledge even among pig farmers.
In our study, most of the pig farmers visited had access to veterinary services and were frequently visited by LFO. This is likely the reason, why pig farmers had often higher knowledge about T. sodium related health questions. This may indicate access to some education interventions that had already been conducted before. Information for farmers is mostly provided by LFO through village meetings, and sometimes through household visits during the treatment of pigs, usually focusing on PCC and other animal-related diseases. LFOs usually encourage farmers to confine their pigs without including proper information on feeding and/or TSCT control/elimination, in general. Likewise, it is customary for medical practitioners in health facilities to provide education on environmental sanitation, personal hygiene, and human health-related matters. In most cases, only patients and expectant mothers visiting health facilities for other medical services benefit from such education, while the rest of the community members remain uninformed. This rather siloed approach calls for a One Health perspective, that is, the close collaboration of medical doctors and nurses, veterinarians, and LFO together with environmental and sanitation officers in addressing the matter. There is a need for joint training and information campaigns in the communities to provide cross-sectoral information on TSCT. Ultimately, the One Health collaboration should not only concern communities at the grassroots level but also relevant policymakers at the district, regional and national levels.
Practices reported by the respondents during our questionnaire survey often differed from those observed during direct household observations. While the majority of the respondents reported always using the toilet, household observations found many households without toilets. One of the striking observations was that in some of the visited households, children’s faeces was disposed of directly into pigpens, which enhances the completion of the T. solium life cycle. Three-quarters of the respondents reported washing their hands with water and soap after using the toilet, but household observations found that less than half of all toilets had installed handwashing facilities, commonly known as tippy taps; but most of them were without water or soap on grounds that the tippy taps were emptied to safeguard the health of children who used to play with them and drink the water from the handwashing facilities. Furthermore, while the majority of the respondents reported confining their pigs, nearly half of the households had either no pigpens or pigpens with spaces for pigs, especially piglets, to escape and roam freely. The discrepancy between questionnaire responses and household observations shows the importance of direct observation in assessing KAP as many questions may be given socially desired responses.
Our findings are not only relevant for local stakeholders but also for the overall target of control/elimination of TSCT as outlined in the WHO roadmap for neglected tropical diseases 2021–2030 . The roadmap also mentions four cross-cutting targets for 2030 which include (1) integrated approaches, (2) multisectoral coordination, (3) universal health coverage and (4) country ownership. Other important points made include the involvement of local communities by social mobilisation at the very basis of every health intervention, knowledge sharing, and prevention strategies targeted at local situations. The current project is following those principles, and in a second step, a contextualised and co-created health education intervention will be developed. The WHO roadmap for neglected tropical diseases also emphasizes the integrated approaches and multisectoral coordination which calls for a One Health approach to the plan. Our study demonstrated that knowledge was rather different between PCC and HCC/NCC which shows clear potential for the engagement of the humans, animals and environmental sectors beyond their boundaries, that is, medical officers informing about the relevant animal diseases and LFO informing about human diseases. In addition, environmental services need to be promoted and brought into the big picture as most transmission happens because of a lack of hygiene and within various environmental compartments. However, this also requires adopting a “whole of the system” approach, where the human, animal and environmental sectors need to be strengthened in an equitable manner, which, in turn, requires good One Health governance at different levels. The objectives and results of our study contribute to the educational One Health approach of TSCT in the control/elimination and prevention. Although community-based TSCT health education has shown to have an impact on HCC and PCC [34, 35], the integration of different TSCT One Health approaches, including treatment of PCC and taeniasis, the prevention of PCC by vaccination and health education, seem to be able to fully eliminate active PCC .