Kala-azar also known as black fever is a vector-borne parasitic disease caused by a protozoan called Leish-mania donovani. It is one of the most neglected and poverty-related diseases in the world, causing more than 50,000 deaths each year worldwide (Desjeux P, 2004). It is also seen that the majority of the people who are living in the endemic areas of Kala-azar have low levels of education, income, and poor quality of housing (Ahluwalia et al., 2003). Kala-azar is spread over a large geographical area across the globe with an estimated yearly incidence of 500000 cases, which leads to the loss of nearly 2.4 million disability-adjusted life years (DALYs) each year. The diseases are endemic in 88 countries of the world and over two hundred million persons are at risk in Africa, Latin America, South and Central Asia, the Mediterranean basin, and the Middle East (Stauch et al., 2011). It is also endemic in 115 districts spread over these four countries, namely India (52), Bangladesh (34), Nepal (12), and Bhutan (6) (Singh et al., 2011). Over sixty percent of the Kala-azar or Visceral leishmaniasis (VL) in the world is stated from India, Nepal, and Bangladesh only (Habib et al., 2014). In Bangladesh, 20 million people (18% of the population) are con-sidered to be at risk for VL, with 4000 – 9000 patients identified annually in facility-based surveillance (DGDA 2008). The disease is endemic in 34 districts of Bangladesh. Mymensingh, Tangail, Jamalpur, Gazi-pur, Sirajganj, Pabna, Nator, Naogaon, and Nawabgonj are the nine most endemic districts for kala-azar, among these districts Mymensingh bearing the hea-viest burden. In this country, at least 5 upazilas in Mymensingh district have the highest kala-azar bur-den. Here the majority of the disease-stricken popu-lation cannot afford the appropriate health care ser-vices because of lack of easy diagnostics and suitable drugs. Passive surveillance for kala-azar has been cont-inuing since 1994 by the Directorate General of Health Services (DGHSs), Bangladesh. Currently, several fac-tors have created a smooth road for achieving the goal of eliminating VL from the South East Asia Region (SEAR) (Islam et al., 2021; Mondal et al., 2008).

India, Bangladesh and Nepal have demonstrated strong political principles and commitment for the eradication of black fever by signing a memorandum of under-standing (MoU) during the World Health Assembly in Geneva in 2005 (Communicable Disease 2011). The aim of this Tripartite MoU was to co-operative up-grade the health status of susceptible groups and the risk population living in kala-azar prevalent zones of Bangladesh, India, and Nepal by the extinction of kala-azar so that diseases will no longer be a public health problem (Shah et al., 2020; DGDA 2012). 

For the elimination of Kala-Azar, the major strategies given by the world health organization (WHO) is effective disease surveillance, initial diagnosis and treatment, effective vector control, social mobilization, and clini-cal and operational research. One of the main strategic pillars of the VL elimination program is integrated vector management. It can be used indi-vidually or in combination. There are several vector control tools such as indoor residual spraying (IRS), long-lasting insecticide treated nets (LNs), and envi-ronmental vector management (EVM). To make the elimination program successful, enhancing social mobilization is essential and building capacity to span the key areas like organizational development and workforce development. Based on indoor residual spraying (IRS) large-scale control programs are cost-effective for local eradication of domestic vectors and interruption of Kala-azar transmission in different parts of the world. Nevertheless, IRS was recommended are the key vector control strategy in 2005. Under care-fully controlled conditions indoor residual spraying (IRS) programs are found to be particularly effica-cious, causing a 72.4% reduction in sand fly densities (Chowdhury et al., 2011). The success of the national VL elimination program is not possible without the dynamic contribution of the community. It also de-pends on the response of community members to early diagnosis and treatment, treatment-seeking behavior, knowledge of indoor residual spraying programs, and reduction of human vector contact. Therefore, the aim of this study was to find out the knowledge and attitude of the com-munity people about the indoor residual spraying (IRS) program in the kala-azar endemic area to make the national kala-azar elimi-nation program more effective and successful in Bangladesh.

Study design

The study was under taken for the purpose of assessing the IRS program-related knowledge and attitude of the community people in the Kala-azar endemic area. Data has been collected from the hyper and moderate endemic areas in Mymensingh and Gazipur districts, Bangladesh.

Sampling and data collection

 A multistage systematic selection method has been adopted for the participation of 240 households. Ac-cording to national guidelines in Bangladesh, high and moderate kala-azar incidences are found at the Upa-zilla level. There are 8 kala-azar hyper endemic and 10 temperately endemic districts in Bangladesh. Hyper and moderate endemic areas of Mymensing and Gazi-pur districts were selected randomly for data col-lection. From each area, 120 houses were carefully chosen through systemic random sampling from the random table on the basis of the existing Geographical Reconnaissance (GR) of those villages.

Data processing and analysis

A total of 240 respondents were interviewed from the selected houses through a semi-structured question-naire and face-to-face interview. Semi-structured questionnaires and consent forms were prepared in English and were translated into Bangla.

Table 1: Socio-demographic characteristics of the Respondents (n = 240).

The data was checked and verified daily and audited for errors and inconsistencies. All the results were calculated with the help of a computer by using the SPSS-16 program. Data was presented according to the information given by the participants. 

Ethical consideration

Ethical consideration is an integral aspect of research that needs to remain at the forefront of our work. So, it should be equally given due respect in any research. Written consent was taken from the participants and verbal approval from community leaders was taken for gathering the data. The information given by the res-pondent was used to concentrate the data of this study by maintaining the confidentiality and hoping that it would not be detrimental to their lives. The study and consent form were approved by the national ethical board and also the ethical board of the ASA Uni-versity, Dhaka, Bangladesh.

Socio-demographic characteristics of the respondents

The study selects ten demographic characteristics for exploring the demographic analysis so that the attitude about health care can be understood clearly. The selec-ted characteristics are age, sex, religion, occupation, education, expenses, house type, room number, and family members as the core demographic character-istics since the patients are living in kala-azar endemic areas (Table 1). The highest number (45%) of the respondents came from the age group of 39 – 59 years. While a considerable number (42.1%) of the respon-dents belong to the age group of 18 – 38 years, only 12.9% are over 60 years of age. A significant number (44.6%) of people who participated in this study were not educated or had no ability to read or write. About one-fourth of the respondents passed their primary education, 22.1% completed secondary education, and 8.3% completed higher education. This study has been conducted in urban areas, therefore the highest number of respondents were former having a percentage of 33.3%, while 32.9% were housewives, 22.5% were businessmen, 8.8% were service holders, and 2.5% were students. The data shows that 69.2% of the res-pondents have a monthly income of 1500 to 9600 taka, while 30.8% have 9700 to 45000 taka. According to income, their monthly expenses are also the same as the first group, although their percentage is slightly higher at 84.6%. Greater than half of the respondents belong to nuclear families. On the other hand, 71.3% of the families had family members of 1–5 people, and 28.8% of the respondents had family members of 6–15 people. In this study, it was also seen that the highest number of the participants were Muslim which were 98% and 1.4% were Hindu. 

Information about healthcare-seeking behavior

The selected information-seeking behavior before and after the kala-azar program is determined by some of the indicators such as kala-azar, IRS, sources of infor-mation, IRS program, knowledge about other pro-grams, and information source about IRS program (Table 2).  From the data, it was seen that around 99% of the respondents heard about Kala-azar and 1% had not heard about it. But interestingly all the participants (100%) hear about IRS, while 89.6% had heard about IRS from the IRS operating team, and 5.8% and 4.6% of applicants heard about IRS from neighbors and family members respectively. All of the respondents heard about the last IRS program among those 65% knew about other methods that reduce kala-azar and the rest of the respondents (35%) did not know about it. One hundred sixty-three (39%) respondents knew about mosquito coils to reduce kala-azar. One hundred fifty-four (36.8%) respondents and one hundred one (60.5%) respondents knew about environmental man-agement (EVM) and insecticide treated nets (ITN) to reduce Kala-Azar, respectively. The media (print and electronic) have a great role in announcing national programs from which people can learn about and take advantage. But data shows that a large number of respondents are known about the IRS from direct parti-cipants in the IRS program 1.3% from TV, 0.8% from radio, 0.4% from health care, 1.8% from print media, and community village meetings (0.3%).

Table 2: Respondents and sources of information about kala-azar and its control program (n = 240).

Participant responses to taking health care benefits

The study identified some indicators of facing challen-ges during healthcare facilities, such as removing or covering before IRS execution; cleaning after IRS exe-cution; suggestions for improving IRS; wanting to continue IRS suggestion; thinking IRS benefit; enter-ing house after spray; painting or plastering or cleaning after IRS; and removing or covering before IRS (Table 3). During the last program, the IRS was done in all households. Therefore, 83.3% of the respondents indi-cated that they knew about removing or covering animals from cattle sheds before IRS execution, 85.8% and 99.6% of the respondents indicated that they knew about removing and covering clothes and food before IRS execution, respectively. They also know that exclusion of children is necessary before IRS execut-ion. Approximately half of the respondents (52.9%) stated that they were aware of sprayed not over the bed and pillow, 60.4% not over the floor, 70% not over the curtain, and 100% of food containers and water jars. Interestingly a significant amount of the respondents (77.1%) know the time for waiting to enter the house after IRS execution. The least number of respondents (19.6%) revealed that they know the time for waiting to enter the house within 2 hours of IRS execution, and very few (3.3%) of the respondents revealed that they know the time for waiting to enter the house after 2 hours of IRS execution. After IRS execution cleaning is an important factor. Nevertheless, 77.1% of the participants dont know about the cleaning after IRS execution, 6.3% know about the following day, 8.8% know it will be within 2 – 6 days, 5.8% know it will be within 7 days to 1 month, and varying small percent-ages of the population 2.1% know it will be about 1 month to 6 months, respectively. Two hundred four (85%) participants agreed they did not get advice for painting, plastering, or cleaning after the IRS was executed by the IRS team, and the rest of thirty-six (15%) participants got advice. Two hundred eleven (87.9%) respondents wanted to continue the IRS pro-gram, but twenty-nine respondents (12.1%) did not want it. The majority of the respondents (91.3%) thought the IRS was beneficial for the community village, but 8.8% of the respondents did not. 

Table 3: Distribution of respondents according to use of preventive practices for control of kala-azar (n = 240).

Interestingly, when respondents are questioned about the suggestion of improving the IRS majority of them, 32.9% have no comments, 23.8% want to improve IRS-related information, and 14.6% of participants are said to announce before the IRS program, while 9.2% of respondents suggest spreading it regularly.

Kala-azar or black fever is endemic for many decades in Bangladesh and its causes a major public health problem. Recently its prevention and control are priori-ties here. But various control programs primarily rely on controlling the diagnosis and treatment of the disease have often been overlooked despite its import-ance for the target residents (Ruebush et al., 1992). In this study, we analyze peoples healthcare-seeking be-havior in the kala-azar pandemic area in Bangladesh to determine the present status of knowledge and attitude toward it to identify the gap from the standard level. In most cases of traditional Bangladeshi social context, the male member of the family plays an important role in controlling the diseases. Therefore, for obtaining household and community participation and making the disease control programs successful it is important to understand local customs and traditions. Under-standing the stage of consciousness and its related atti-tude and practices about Kala-azar in the community can be the key to the success of an elimination program launched by the government of Bangladesh. However, the findings and recommendations of this study will be helpful for improving IRS programs, practitioners, and general people to under-stand and monitor healthcare programs in the future. It was a household-based cross-sectional survey study about knowledge, attitude, and practice of kala-azar diseases that was administered to the heads of the family through a semi-structured questionnaire. The data indicated that 44.6% of participants are not educated and came from low-income families but had no know-ledge about the IRS program although heard about IRS. However, it is interesting that among the parti-cipants 99% of respondents heard about Kala-azar. Similar result has been found in a study on Kala-azar disease and preventive attitude (Siddiqui et al., 2010). It is also found that there are poor living conditions in the study village. This condition is an important rea-son for the increased burning of kala-azar in Bangla-desh. Similar observations were made by Alvar et al. (2006) in his article Leishmaniasis and Poverty. KAP (knowledge, attitude, and practice) studies on malaria revealed that the educational status of the study parti-cipant is significantly associated with the knowledge and practice of the disease (Panda et al., 2000; Sharma et al., 2003; Sharma et al., 2001). This study showed that the sources of information were mostly from the IRS team family members, and neighbors. It is also found that the role of mass media was limited. This finding is not consistent with the findings of other studies conducted on malaria and dengue (Karanja et al., 2002; Acharya et al., 2005). This result indicates that mass media, such as television, radio, magazines, and newspapers, are not very important transporter for sources of information about kala-azar in Bangladesh. However, interestingly it is found that the highest number of respondents (around 83%) had knowledge about the benefit of the IRS and around 17% had no knowledge about the benefit of the IRS. A similar re-sult has been published in a work studied by Chow-dhury (Ahluwalia et al., 2003). The present study fin-dings suggest that the IRS program is not sufficiently implemented for the control of kala-azar and aware-ness about the IRS program was poor in this area. Des-pite such poor levels of knowledge about the diseases, interestingly, a good proportion of the respondents pointed out that Kala-azar were not a contagious disease. There are several explanations for it, but one possible explanation is that most people are experi-enced with kala-azar in this area. Also, it isindicated by most of the participants that at least one member of each family had suffered from kala-azar. Other pos-sible explanations are the limited number of media from which they obtain their information, health care delivery services, absence of health care education, NGOs (non-government organizations) involvement, etc. In this study, we found a wide gap between aware-ness and related attitude and almost all of the res-pondents assume that kala-azar is a serious health condition that drains family resources but could be controlled by community effort. Similar results have been revealed in some studies (Matta et al., 2004; Abir et al., 2021; Tyagi et al., 2005; Rijal et al., 2006). These study findings suggest that respondents have a strong positive attitude towards kala-azar and its serio-usness. This attitude could come from their experi-ences in endemic areas. Economically the whole family is affected when a person in the family goes through kala-azar, reinforcing the link between kala-azar and poverty (Masayo et al., 2011). This thing may be one of the important reasons for such a strong attitude towards the effect on their family income. This strong positive attitude of respondents toward Kala-Azar may provide hope for health planners and policy-makers that proper health awareness programs for Kala-Azar will help in controlling the disease at the community level. Besides more implementation of the IRS program is urgently needed to achieve national and regional visceral leishmaniosis elimination goals.

The study findings showed that participants are aware of kala-azar, but their awareness of disease trans-mission, infection origin, and disease control is still limited. Peoples attitudes towards complete cure, treatability, and disease control through IRS programs were moderate. Most people know about diseases, but preventive behavior has not been favorable. Therefore, our investigation suggests that continuous support is essential to strengthening behavioral change through the implementation of the IRS program to progress the diseases condition in the pandemic areas in Bangla-desh.

I would like to thank Mr. GM Salauddin (Independent University, Bangladesh) and Dr. Md. Monirul Islam (BioIcon Academy) for their constrictive suggestions to prepare this manuscript.

Authors have no conflict of interest.