Knowledge, Attitude, and Practices of Population towards Brucellosis in Ethiopia: A Systemic Review and
Meta-Analysis

Kasse GE; Alemayehu YD; Aynew DW; Yimam TM

Research Article

Austin J Public Health Epidemiol. 2023; 10(2): 1143.

Knowledge, Attitude, and Practices of Population towards Brucellosis in Ethiopia: A Systemic Review and Meta-Analysis

Kasse GE¹*, Alemayehu YD², Aynew DW³ and Yimam TM⁴

College of Veterinary Medicine and Animal Sciences, University of Gondar, Ethiopia

*Corresponding author: Gashaw Enbiyale Kasse College of Veterinary Medicine and Animal Sciences, University of Gondar, Ethiopia

Received: December 12, 2022; Accepted: February 06, 2023; Published: February 13, 2023

Abstract

Background: Brucellosis is one of the zoonotic pathogen in the world which is a challenging issues for health and responsible for enormous economic losses in many developing countries such as/like Ethiopia. Considering the high prevalence and economic importance of brucellosis, the aim of this study was systematically review published data to explore the distributions of the pooled knowledge, the awareness, attitude and practice of level of the disease in Ethiopia.

Methodology: A comprehensive literature search was conducted through search engine includes Web of Science, Google Scholar, Scopus, Scirus, Science Direct, HINARI databases, PubMed and reference lists of previous studies. Published articles were included based on inclusion and exclusion criteria. Overall knowledge, awareness levels, attitude and practices of study participants regarding the mode of brucellosis transmission, zoonotic nature, and symptoms of brucellosis in animals and humans. Results were presented in funnel plot, the forest plot, figures, and tables with a 95% Confidence Interval (CI). To assess heterogeneity we used inconsistency index (I2) test statistics. And also we used random effect model and R studio (4.2.0) statistical software to compute the analysis of the data. The analysis was conducted and reported in accordance with Meta-analyses guidelines and the Preferred Reporting Items for Systematic Review.

Results: After excluded articles which did not fulfill the inclusion criteria, a total of 28 original articles that reporting the brucellosis awareness levels of communities in Ethiopia were included in the analysis. 16.98% of the studies population had overall knowledge of brucellosis, and the pooled awareness levels regarding the zoonotic nature and mode of transmission of brucellosis were 22.75% with 95% CL (0.1337; 0.3373). And also 18.5% of study participants had awareness about clinical sign of signs of human and animal brucellosis. From the study participants, 74.3% of them had poor practice regarding transmission of brucellosis includes consumption of raw milk and meat, unsafely contact their animals. Sub-group analyses showed that there were differences in brucellosis awareness levels among regions. In Oromia region 20.4% of respondents had knowledge with 95% CL (0.0999; 0.2524), I2 = 94.8%, p-value < 0.0001 where as in Amhara region 69.8% of respondents had knowledge about brucellosis. Regarding attitudes in Amhara region the studies participants had lowest attitudes (22%) towards brucellosis as compared with others region.

Conclusion: In general, the result of the present study showed that the population had less clear understanding about brucellosis as it affects their animals, cause abortion and its zoonotic importance. This result implies that it is necessary to create awareness of the zoonotic and its economic effect of brucellosis through a various methods, including the public media, veterinary professionals, community health extension, and local leaders.

Keywords: Knowledge; Attitude; Practices; Brucellosis; Meta-analysis; Ethiopia

Introduction

The life of human being is closely associated with livestock products in the different livestock production systems particularly in pastoral communities [1]. Because of this interaction the threat of zoonotic diseases for human is high. Brucellosis is one of the most important neglected zoonotic bacterial disease in the world which is caused by Brucella and more than 500,000 human cases occurring globally per year [1,2]. Some important Brucella strains including B. melitensis and B. abortus can affect both livestock and human [3]. World Health Organization (WHO) [4] and World Organization for Animal Health (OIE) [5] reports indicated that brucellosis is rarely prioritized by health systems and is considered a neglected zoonosis. In both agro-pastoral and pastoral livestock production systems, people live closely with livestock making contact with different animal discharge and consumption of raw animal product lead to have a high incidence of brucellosis and thus, are at higher risk of acquiring the infection [4,5]. Brucellosis is the major reproductive problems causes abortions, and infertility in livesock [3,6].

Human brucellosis is characterized by muscular pain, lumbar pain, weight loss, fatigue, fever, sweating, joint pain, headache, and arthritis [7,8]. Humans become infected through ingestion of raw milk or milk products, handling of infected animals, contact with animal discharges such as vaginal fluids, placenta especially during parturition [9]. Veterinary health workers, farmers, pastoral communities, abattoir workers and laboratory personnel are highly exposed for brucellosis and are considered the highest occupational risk- groups [10-12]. Generally, due to prevalence of the disease in animals and poor hygiene practices of humans that expose to infected animals or their products can significantly increase the risk of the occurrence of the disease in humans. As its clinical manifestation resembles other febrile illnesses such as tularaemia, malaria, typhoid fever and tuberculosis, and lacking resources and laboratory diagnostics, the disease is difficult to accurately diagnose based solely on clinical sign [13-15]. The prevalence of brucellosis in Ethiopia is ranging between 1.3% and 22.8% with depending on husbandry systems and livestock species [2,16]. Dairy cattle owners, consumers, institutions promoting dairy industry, public health professionals, veterinarians and policy makers require baseline information about the health of dairy cattle, the public health implication and the safety of dairy products. Control and eradication of brucellosis cannot be achieved through test-and-slaughter, vaccination and treatment only; the cooperation of relevant occupational groups is an important component in achieving this goal [17]. Knowledge and attitude are promotes people to take protective measures at work and actively participate in disease control programs, thus greatly assisting the development of brucellosis control strategies. So far, in Ethiopia, different studies have been done on the prevalence, knowledge, attitude, and practice about brucellosis among the public. However, the findings of these different studies show that there is a high variability in the level of the knowledge, attitude, and practice across the regions of the country and unclear. The aim of this systemic and meta-analysis was to explore the knowledge, attitude and practice of peoples towards brucellosis in Ethiopia.

Materials and Methods

Data Bases, Literature Search and Selection

Typically, the published papers were reported based on the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guideline [18]. The published papers and abstracts were identified by a computerized literature search of electronic databases include PubMed (www.ncbi.nlm.nih.gov./entrez/), Science Direct (www.sciencedirect.com), Scirus (www.scirus.com/srsapp), ISI Web of Knowledge (http://www.isiwebofknowledge.com), Google Scholar (http://scholar.google.com) and HINARI databases. The search was performed from May to July 2022. The search queries were set based on Medical Subject Headlines (MESH) and Boolean logic. Relevant MeSH terms and keywords were used to retrieve all relevant articles from the databases listed above. The keywords and MeSH terms used were “brucellosis AND knowledge OR awareness AND perception OR KAP) OR attitude AND Ethiopia:” [Publication Date]). (“Knowledge” [Mesh] OR “Knowledge, Attitudes, Practice” [Mesh])OR(“Attitude”[Mesh] OR “Attitude” [Mesh] OR“ Attitude to brucellosis ”[Mesh ] )) OR “Awareness” [Mesh]) AND (“Ethiopia”[Mesh].To identify additional relevant citations search was conducted on the previous studies of reference lists as well as “cited by” and “related information” tools in PubMed and Google scholars were searched. Only those articles which fulfill the selection criteria and written by English language were used to analyses the information.

Inclusion and Exclusion Criteria

Studies were chosen for this systemic review and meta-analysis based on inclusion criteria includes randomized subjects in all studies, trial procedures, provide complete data, the study design, method of assessing the outcome, and handling of protocol deviations whereas, secondary reports, no original research, comments, editorials and reviews were directly excluded. Research conducted on knowledge, attitude and practices towards brucellosis in Ethiopia and full-length published articles in the English language were included in the analysis. The papers that were conducted to assess only the prevalence of brucellosis in Ethiopia not included. The studies were included cross-sectional observational studies and conducted in Ethiopia only.

Selection of the Identified Publications

All the retrieved studies were imported and duplicates were removed by using the software of EndNote version 8. The two investigators (GEK and YD) independently selected the research titles and abstracts which were followed by a full-text review to determine the eligibility of each study. If there was any disagreement between the two investigators the gap was solved by consensus with the presence of the third investigator (DW). The screening and selection of studies were promoted by the creation of appropriately labeled sub-groups in EndNote.

Data Extraction

The selected articles were coded and the data were extracted from selected articles using a format prepared in Microsoft Excel. The format consist of the following basic information: author name, study period, publication year, geographic region, study design, study population, sampling method, number of participants (sampling size), sample type, gender distribution and the number of participants for the assessment of brucellosis awareness, knowledge, and acceptance, or the rate percentage proportions for these studied factors. The number of studied cases (n) and sample size (N) were the two necessary parameters for the calculation of the pooled level of awareness, knowledge, and practices of brucellosis in the meta-analysis. In particular, the number of participants who answered positively (n) was obtained directly from these studies or by multiplying the sample sizes (N) with the proportions (%) associated with the investigated items reported in the studies.

Quality Control

The quality of each search study was evaluated by using different criteria based on Joanna Briggs Institute (JBI) [19]. Quality appraisal criteria adapted for studies including appropriateness of the research design to address the target population, quality of paper, completeness of the information, adequate sample size and appropriateness of methods for isolation of the bacteria and appropriate statistical analysis [20]. The eligibility of selected research articles was also assessed and approved by experts in the discipline.

Publication Bias and Heterogeneity

Part of the strategy in conducting a meta-analysis is to identify factors that may be significant determinants of sub-population analysis or covariates that may be appropriate to explore in all studies. Variation among different trials is usually assessed using Cochran’s Q statistic, a chi-squared (Χ2) test of heterogeneity with k-1 degrees of freedom. Variability in the participants, interventions, and outcomes studied has been described. Meta-analysis was conducted sufficiently homogeneous studies in terms of subjects involved, interventions, and outcomes. To check publication bias we used funnel plot and asymmetry detected using Egger’s linear regression test, and Begg’s rank correlation test [21]. Heterogeneity of results among trials was quantified using the inconsistency index I 2, which describes the percentage of total variation across studies [22]. Therefore, the value of I2, 25%, 50%, and 75% represented low, moderate, and high heterogeneity, respectively. Negative values of I 2 are put equal to zero, consequently I 2 lies between 0 and 100%. In the same way, a p-value less than 0.05 were used to declare heterogeneity. A random effect model was used to reduce the heterogeneity of studies [23].

Data Analyses

The data were compiled in Microsoft Excel 2016 spreadsheet and summarized by descriptive statistics. A random-effect model was used to estimate the overall status of knowledge, attitude, and practice with the 95% Confidence Interval (CI). All statistical analysis was done by using R statistical software (Version 4.2.0). The presence of publication bias was assessed by funnel plot; in addition the Begg and Egger’s weighted regression method was used to detect evidence of publication bias. Hence, a p-value of < 0.05 was considered as indicating the presence of significant publication bias. All available data were pooled in the present meta-analysis [24]. The sub-groups and categories considered included region, study population, education, and occupation. The data were described using forest plots, figures, and tables. Statistical heterogeneity was evaluated by Cochran’s chi-square (Q-test) and the inconsistency index (I2). A funnel plot was constructed to visually examine the publication bias [21].

Results

Characteristics of the Included Studies

The selection process of different studies for this systematic review was presented through a flow diagram shown in (Figure 1). Of 3886 identified studies, 3086 articles were removed due to duplication then after 725 articles were excluded upon reviewing the titles, abstracts and full articles because they were irrelevant (were not focusing on KAP of brucellosis) or were done outside Ethiopia and review, sero-prevalence and meta-analysis articles. 75 studies were screened and from these screened studies 60 studies were assessed for eligibility, of these 60 studies, 32 articles were excluded because they were not meeting the inclusion criteria. Finally, 28 studies meeting the inclusion criteria were included in the qualitative synthesis and quantitative synthesis (meta-analysis) as presented (Table 1).

Figure 1: Flow diagram of study selection for systematic review and meta-analysis of KAP towards brucellosis in Ethiopia, 2022.

    
    
    Figure 1: Flow diagram of study selection for systematic review and meta-analysis of KAP towards brucellosis in Ethiopia, 2022.

Table 1: Characteristics of the included studies regarding brucellosis awareness, attitude and practice in the meta-analysis.




  
    Reference
    publication year
    Stud.period
    region(study area)
    Study population
    Gender distribution
    Age catagories
    Occupation
    Sample type(data collection methods)
    Study design
    sampling method
    Sample size
  
  
    [25] 
    2017
    Nov,2016 and May, 2017
    Amhara(north shewa)
    smallholder dairy farmer, milk collectors,    retailers
    all
    young, adult
    dairy farmers, retailers
    full stractutred quetinarie
    cross sectional
    random
    230
  
  
    [1] 
    2020
    Dec, 2017 to May, 2018
    Oromia (adama town)
    dairy farmers
    all
    adult
    farmers
    semistructured questionnair
    cross sectional
    random
    384
  
  
    [26] 
    2018
    Dec ,2015 to April ,2016
    oromia (bishoftu)
    dairy farmers
    all
    adult
    farmers
    full stractutred 

      quetinarie
    cross sectional
    random
    400
  
  
    [27] 
    2017
    March to April, 2017
    Amhara(laygayint)
    Rural communities
    all
    adult
    farmer, merchant, embloyer
    semistructured

      questionnair
    cross sectional
    random
    579
  
  
    [28] 
    2022
    Nov, 2020 to April ,2021
    Oromia(borana zone)
    pastural comunity
    all
    _
    pasturalist
    semistructured

      questionnair
    cross sectional
    random
    45
  
  
    [29] 
    2021
    Nov, 2018 to Nov, 2019
    Oromia(Bale Zone)
    small ruminant owners and attendants
    All
    _
    farmers
    full stractutred quetinarie
    cross sectional
    random
    80
  
  
    [30] 
    2015
    Nov, 2013 to May, 2014
    Afar(Mille, Dubti and Chifra)
    pastural comunity,animal and human health    profetionals
    all
    _
    pasturalist, employers
    semis and full tructured

      questionnair
    cross sectional
    Stratified sampling method
    168
  
  
    [31] 
    2020
    Oct, 2017 to Feb, 2018
    Oromia(borena zone)
    Animal owers and attendants
    all
    young, adult
    pasturalist
    structured quetinarie and interview
    cross sectional
    multistage and conveniet sampling
    341
  
  
    [32] 
    2018
    Oct to Dec, 2016,
    Afar(amibara district)
    pastoral community
    All
    adult
    pasturalist, agro-pasturalist
    structured and open-ended questions,    interivew
    cross sectional
    multistage ( simple random and stratified)
    475
  
  
    [33] 
    2021
    Nov ,2017 and June, 2018
    Afar(awash,afambo, chifra,mille) and Somali    afdem, erer,aysha,mieso,hadegale)
    all community( pasturalist,atendant,    keeping animals for their livelihood)
    all
    adult
    pasturilist, employer
    A semi-structured questionnaire
    cross sectional
    random (multistage cluster sampling)
    647
  
  
    [34] 
    2021
    _
    Centeral highland of ethiopia
    farm owners, farm managers
    all
    adult
    farmers, employers
    interview
    cross sectional
    random
    284
  
  
    [35] 
    2021
    Oct , 2016 and Oct, 2017
    Oromia(Jimma zone)
    livestock owners
    all
    adult
    farmers and others
    structured and semi-structured questinarie
    cross sectional
    random
    180
  
  
    [2] 
    2011
    Oct, 2007 to March, 2008
    Southern and Eastern Ethiopia
    livestock owners
    All
    adult
    farmers
    
    cross sectional
    random
    90
  
  
    [36] 
    2005
    Oct, 2003 to April , 2004.
    Oromia (Jimma zone)
    abattoir workers, 

      butchers, farmers and animal health workers
    ALL
    young, adult
    abattoir workers, 

      butchers, farmers and animal health workers
    structured quetinarie and interview
    cross sectional
    Multi stage sampling
    126
  
  
    [37] 
    2008
    Sep, 2005 and March,2006
    Oromia (walmara district, lume and adamitulu)
    households which keep cattle,
    all
    
    not specify
    structured questionnaire
    cross sectional
    rundom (one-stage, cluster sampling method)
    176
  
  
    [38] 
    2021
    Feb, 2017 to Jan, 2019
    Afar (Dubti, Asaita, and Chifra.)
    pastoral community
    all
    young, adult
    pasturalist
    Semistructured questionnaire
    cross sectional
    randomized and purposive sampling techniques
    384
  
  
    [39] 
    2019
    Nov, 2016 to April, 2017.
    Somali (Fafan Zone)
    pastural community
    all
    young, adult
    livestock owners and tendants
    Questionnaire interview
    cross sectional
    random
    211
  
  
    [40] 
    2016
    Nov , 2013 to April, 2014
    Afar Region(Chifra and Ewa)
    livestock owners/herders
    all
    adult
    farmers
    structured questionnaire and interview
    cross sectional
    random
    45
  
  
    [41] 
    2013
    Oct, 2011 and April, 2012
    tigray(Southern Zone)
    livestock owner
    all
    adult
    farmer
    semi-structured questionnaire
    cross sectional
    Multistage random sampling
    100
  
  
    [42] 
    2012
    Nov, 2010 and April, 2011
    Diredewa region estern ethiopia
    small ruminant owners and attendants
    all
    adult
    farmers
    questionnaire and interview
    cross sectional
    random
    49
  
  
    [27] 
    2017
    Feb to Sep, 2010
    Harari region
    semi-intensive and intensive farms owners
    all
    adult
    farmers
    semi-structured questionnaire
    cross sectional
    random
    307
  
  
    [43] 
    2018
    May to June, 2013
    SNNP (Nechisar National

      Park)
    all community who have contact with animals
    all
    young, adult
    livestock owners and tendants
    structured questionnaire and interview
    cross sectional
    random and systematic
    50
  
  
    [44] 
    2022
    _
    Oromia (Borena zone)
    pastural comunities
    all
    young, adult
    pasturalist
    interview and questionarie
    cross sectional
    random 

      sampling methods.
    60
  
  
    [45] 
    2016
    Nov 2013 to May 2014
    Oromia (in and around Asella)
    all comunities
    all
    
    _
    interview and questionarie
    cross sectional
    random
    500
  
  
    [46] 
    2018
    Oct 2016 and April 2017
    Oromia (Yabello districts)
    pastural community
    all
    young, adult
    pasturalist
    questionarie
    cross sectional
    random
    120
  
  
    [47] 
    2013
    Nov, 2011 to April,2012
    Oromia (jimma zone)
    public
    all
    
    farmers
    semi-structured questionnaire
    cross sectional
    simple random sampling method
    175
  
  
    [48] 
    2013
    Oct 2011 and Mar 12
    Oromia (Arsi zone)
    livestock owners
    all
    adult
    farmers
    open and closed end question
    cross sectional
    stratified cluster sampling
    130
  
  
    [49] 
    2020
    Feb 2019 to Nov 2019
    Gambella (Gambella and Itang districts)
    livestock owners
    all
    adult
    farmers
    interview and

      questionnaire
    cross sectional
    random
    80



Table 1: Characteristics of the included studies regarding brucellosis awareness, attitude and practice in the meta-analysis.

Among the included Publications, 3 (10.7%) studies from Amhara, 13 (46.4%) studies from Oromia, 5 (17.9%) studies from Afar, 2 (7%) studies from South Nation and Nationalities People (SNNP), 1 (3.6%) studies from Harari region, 1 (3.6%) Tigray, 1 (3.6%) studies from Diredewa administration, 1 (3.6%) studies from Somali region and 1 (3.6%) studies from Gambella region. However, we did not found published articles in Benishangul Gumuz regions of the country) (Figure 1). All selected studies were published in English and all the studies enrolled in this systematic review were cross-sectional studies. The study populations of the studies included pastoral community, animal and human health professionals, farmers, animal owners, abattoir workers, butchers, and farm managers. A questionnaire survey was conducted for all the studies included in the analysis, which were interview-administered and self-administered questionnaires. The main animals reared by the respondents were cattle, sheep and goats and camels.

All cross-sectional studies were conducted from 2003 to 2021 and published online from 2005 to 2022. The knowledge was assessed based on the overall knowledge of the respondents includes mode of transmission, clinical signs, symptoms, treatment and vaccine availability and mechanisms of prevention. Knowledge was defined as good if the respondents scored above the mean level. Attitude was assessed the way the community views and behaves on brucellosis preventive measures, fear of acquiring the disease and interest. Practice was assessed about protective measures for brucellosis during assisting abortion, including the use of gloves when handling an aborted fetus, washing after contact with animals and animal products, and methods of disposing of aborted fetuses and placenta and the respondent was categorized as good and poor practice based on the mean score of practice.

The sample size of all studies which were included ranged from 45 to 647 and all studies were used random sampling methods. The highest level of good knowledge (56.3%) was recorded in a study from Oromia region and the lowest (19%) was recorded in a study. A conducted in Tigray. There was a high level of poor practice recorded in a study done in Tigray region which was 93.2%.

As the (Figure 2) showed below, currently the country has 11 regions and two city administrations. Reports were from 9 of them which are indicated in the figure. Reports were not found from Sidama, South-west Ethiopia and Benishangul Gumuz regions during the period of data. The results of the meta-analysis were presented separately for over all knowledge, awareness on zoonoticity and means of transmission, awareness of respondents on clinical signs of brucellosis, awareness on the source of information, awareness on disease control and prevention strategies, over all attitudes respondents for brucellosis and over all practices of respondents on brucellosis.

Figure 2: Percent of published studies in different regions of Ethiopia.

    
    
    Figure 2: Percent of published studies in different regions of Ethiopia.

Publication Bias

The presence of publication bias for knowledge, attitude, and practice towards brucellosis was assessed using Egger regression test at P<0.05 and funnel plot. There was statistical evidence that there was no publication bias for a good level of knowledge of respondents with P-values = 0.663. For knowledge, each article's effective size was visual inspection of the funnel plot suggests asymmetry and allocated against the standard error. Since eight studies lay on the right side and fifteen studies on the left side of the line representing the estimated status (Figure 3).

Figure 3: Funnel plot for awareness and knowledge of brucellosis.

    
    
    Figure 3: Funnel plot for awareness and knowledge of brucellosis.

The Overall Knowledge of Study Participants toward Brucellosis

The overall awareness about brucellosis was reported in 28 studies, with a pooled awareness level of 22% with 95% CI (0.1021; 0.2683) by using random-effects model. These result shows significant heterogeneity among studies (I²=96.7%, p≤0.0001). Participants' knowledge and perceptions further demonstrated that brucellosis might be passed from animals to people by ingesting raw milk. The estimated overall level of good knowledge, practice in Ethiopiais presented in a forest plot (Figure 4).

Figure 4: Show forest plots of meta-analysis for brucellosis awareness and knowledge of population in Ethiopia. At the bottom of the plot, a diamond shape represents the average effect. The length of the diamond symbolizes the confidence interval of the pooled result on the x-axis.

    
    
    Figure 4: Show forest plots of meta-analysis for brucellosis awareness and knowledge of population in Ethiopia. At the bottom of the plot, a diamond shape represents the average effect. The length of the diamond symbolizes the confidence interval of the pooled result on the x-axis.

Awareness of Study Participants on Zoonoticity and Means of Transmission

From included studies fifteen studies were explored the awareness of the respondents about the zoonotic importance and the means of transmission of brucellosis from infected animals to humans. Pooled awareness level of respondent which have awareness on zoonoticity and transmission of brucellosis was 22.75% with 95% CL (0.1337; 0.3373) as presented in a forest plot (Figure 5). These result shows significant heterogeneity among studies (I²=98.1%%, p≤0.0001). The pooled awareness levels of raw milk consumption and the consumption of infected meat as risk factors for brucellosis were 5% and 6%, respectively.

Figure 5: Show forest plots of meta-analysis for awareness population about zoonoticity and transmission towards brucellosis in Ethiopia. At the bottom of the plot, a diamond shape represents the average effect. The length of the diamond symbolizes the confidence interval of the pooled result on the x-axis.

    
    
    Figure 5: Show forest plots of meta-analysis for awareness population about zoonoticity and transmission towards brucellosis in Ethiopia. At the bottom of the plot, a diamond shape represents the average effect. The length of the diamond symbolizes the confidence interval of the pooled result on the x-axis.

Awareness of Study Participants on Clinical Signs of Brucellosis

From included studies nine studies were explored the awareness of the respondents about clinical signs of brucellosis. Pooled awareness level of respondent which have awareness on clinical signs of brucellosis was 18.5% with 95% CL (0.0639; 0.34930) as presented in a forest plot (Figure 6). We explored the distribution of brucellosis symptoms in human that were mentioned in the included studies. Fever, fatigue, joint pain, sweating and abortion were the most commonly mentioned symptom of animal brucellosis.

Figure 6: Show forest plots of meta-analysis for awareness population about clinical signs of brucellosis in Ethiopia. The black dot at the center of the grey box represents the pooled proportion of each study and the horizontal line indicates the 95% confidence interval of the estimates. The grey box indicated that the weight of each study which contributing to the pooled proportion estimate.

    
    
    Figure 6: Show forest plots of meta-analysis for awareness population about clinical signs of brucellosis in Ethiopia. The black dot at the center of the grey box represents the pooled proportion of each study and the horizontal line indicates the 95% confidence interval of the estimates. The grey box indicated that the weight of each study which contributing to the pooled proportion estimate.

Source of Information about Brucellosis in the Study Participants

Six studies were explored the awareness regarding the source of information about brucellosis. The pooled awareness level of respondent which have awareness on source of information about brucellosis was 17.83% with 95% CI (0.0476; 0.3657). These six studies were analyzed the information sources of those respondents who had heard about brucellosis. The respondents mainly acquired knowledge of brucellosis from neighbors, friends, mass media, and health workers and from different training. The estimated overall level of good knowledge, practice in Ethiopia is presented in a forest plot (Figure 7).

Figure 7: Show forest plots of meta-analysis for awareness population about the source of information of brucellosis in Ethiopia. The black dot at the center of the grey box represents the pooled proportion of each study and the horizontal line indicates the 95% confidence interval of the estimates. The grey box indicated that the weight of each studies which contributing to the pooled proportion estimate.

    
    
    Figure 7: Show forest plots of meta-analysis for awareness population about the source of information of brucellosis in Ethiopia. The black dot at the center of the grey box represents the pooled proportion of each study and the horizontal line indicates the 95% confidence interval of the estimates. The grey box indicated that the weight of each studies which contributing to the pooled proportion estimate.

Awareness of Study Participants on Disease Control and Prevention Strategies

The overall awareness of respondent about control and prevention strategies of brucellosis was reported in 11 studies, with a pooled awareness level of 20% with 95% CI (0.1300; 0.2915) by using random-effects model as presented in a forest plot (Figure 8). The others 79.51% of the respondent have not awareness about control and prevention of the brucellosis. These result shows significant heterogeneity among studies (I2= 91.1%, p ≤0.0001).

Figure 8: Show forest plots of meta-analysis for awareness of population about brucellosis control and prevention strategies in Ethiopia. At the bottom of the plot, a diamond shape represents the average effect. The length of the diamond symbolizes the confidence interval of the pooled result on the x-axis.

    
    
    Figure 8: Show forest plots of meta-analysis for awareness of population about brucellosis control and prevention strategies in Ethiopia. At the bottom of the plot, a diamond shape represents the average effect. The length of the diamond symbolizes the confidence interval of the pooled result on the x-axis.

Figure 9: Show forest plots of meta-analysis for overall practice of population about Brucellosis control and prevention strategies in Ethiopia. The black dot at the center of the grey box represents the pooled proportion of each study and the horizontal line indicates the 95% confidence interval of the estimates. The grey box indicated that the weight of each studies which contributing to the pooled proportion estimate.

    
    
    Figure 9: Show forest plots of meta-analysis for overall practice of population about Brucellosis control and prevention strategies in Ethiopia. The black dot at the center of the grey box represents the pooled proportion of each study and the horizontal line indicates the 95% confidence interval of the estimates. The grey box indicated that the weight of each studies which contributing to the pooled proportion estimate.

Practices of Study Participants toward Brucellosis

From included studies 25 articles were explored the overall practice of respondents on Brucellosis. The overall poor practices of the respondents were 74.3%, with 95%-CI (0.6411; 0.8333) while the remaining 26% of the respondents had good practice about Brucellosisas presented in a forest plot (Figure 6). These result shows significant heterogeneity among studies (I²=98.5%, p ≤0.0001). Most of the respondents practiced unsafely contact with their animals; used meat slaughtered from backyard slaughter system, consumed raw milk and had a habit of eating raw meat.

Sub-Group Analysis for Knowledge Based on Occupation and Region

Sub-group analysis was done for overall knowledge of respondent based on region, occupation, sampling method, and animal species and we checked the possible heterogeneity among studies. In Oromia region, 20.4% of respondents have knowledge with 95% CL (0.0999; 0.2524), I2=94.8%, p-value < 0.0001 where as in Amhara region 69.8% of respondents had knowledge about brucellosis. Furthermore, we have done a sub-group analysis by way of occupation, since there is heterogeneity. Hence, three was the highest estimated status of the knowledge for pastoralist, and agro-pastoralist sub-group which was 20% (0.0314; 0.4574) while dairy farmers and retailers had 22.6% (0.1425; 0.3217) (Table 2). Again, the heterogeneity still existed. So, for the last, we performed sub-group analysis based on the study area but there is no evidence of heterogeneity.

Table 2: Sub-group analysis of knowledge of brucellosis.




  
    Subgroups
    Categories
    Numbers of studies
    Pooled Proportion
    Level (95%CI)
    I2
    P-Value
  
  
    Region
    Oromia
    14
    20.4%
    0.0999; 0.2524
    95% 
    < 0.0001 
  
  
    Amhara
    1
    69.8%
    0.2941; 0.9730
    _
    _
  
  
    Afar
    5
    21.4%
    0.0077; 0.5784
    99.1% 
    < 0.0001
  
  
    Tigray
    1
    51%
    0.1174; 0.8957
    _
    _
  
  
    Somali
    1
    8.9%
    0.0000; 0.4677
     
     
  
  
    Occupation
    Livestock owners    (farmers)
    14
    22.6%
    (0.1425; 0.3217)
    95.5%
    <0.0001
  
  
    Pastoralist and    agro-pastoralist
    7
    20%
    0.0314; 0.4574 
    98.8%
    <0.0001
  
  
    Employers
    2
    26.5%
    0.0001; 1.0000
    98.7%
    <0.0001
  
  
    Others
    2
    10.4%
    0.0000; 0.4694
    51.2%
    <0.0001



Table 2: Sub-group analysis of knowledge of brucellosis.

Sub-group analysis also done for practices respondents towards brucellosis based on occupation and region. Of the 25 studies, the highest estimated status of poor practice respondents towards brucellosis was 98% (0.6650; 1.0000) in Dire dawa city administration. While Amhara region respondents had the lowest poor practice with 22.11% 95% CI (0.0027; 0.6343). Finally, we have carried out a sub-group analysis based on occupation. Hence, the highest estimated prevalence of the poor practice among pastoralist and, agro-pastoralist with 85.9% 95% CI (0.4062; 1.0000) but farmers and employers had less poor practice with 59% 95% CI (0.1369; 0.9631).

Sub-group analysis for attitude towards brucellosis using methods of a region, and occupation was done. Of the 12 studies, the highest estimated status of attitude towards brucellosis studied in Harari region, 98% the respondents had positive attitudes with (0.6650; 1.0000) whereas, the lowest one was in Amhara region which was 22% of the respondents had positive attitudes towards brucellosis with 95% CI (0.0027; 0.6343). Furthermore, we have done a sub-group analysis based on occupation since heterogeneity existed. Hence, 90% of employer and agro-pastoralist had positive attitudes towards about brucellosis with 95% CI (0.4062; 1.0000) but, 50% dairy farmers and retailers had less attitudes towards brucellosis with 95% CI (0.0839; 0.9256).

The pooled awareness level of the zoonotic nature of brucellosis had higher in pastoralist (16%) than farmer (14%). The Livestock owners (farmers) (24%) showed relatively higher awareness of the zoonotic nature of brucellosis than dairy farmers (11%), pastoralist (15.8%) and abattoir workers,\butchers (12.5%). Regarding the mode of transmission from infected animal to human, a low awareness level was found in the occupationally exposed population, whereas a relatively higher awareness level was found in human health care providers and animal health workers. However, abattoir workers and dairy farmers had extremely low awareness levels. With regards to awareness of the symptoms of brucellosis in human and animals, higher awareness levels were found in employers and pastoralists.

Discussion

Occupation based training regarding raising of the awareness of brucellosis is an important for the effective control of brucellosis [19]. Raising the awareness of brucellosis and brucellosis-related knowledge in occupation-related groups is an important aspect for the effective control of brucellosis [50]. The overall result of this study revealed that from the total study participants 16.96% had awareness and knowledge about brucellosis, while the remaining 83% had no awareness about brucellosis. This finding is nearly similar with study in India (region of Puducherry) revealed 16.4% in brucellosis [51]. But, it is lower than another study (30.8 %) which was done in Punjab region of India [52]. Brucellosis is neglected zoonotic disease that causes a considerable animal and human morbidity in many areas of the world especially poor countries like Africa [53,54]. However, the results of this study revealed that the study participants had no information on the zoonotic importance of brucellosis with 22.75%. The result is also in agreement with the study reports from Tajikistan in which the majority (85%) of the study participants had no awareness about brucellosis [55].

The awareness of the participants in this study about the zoonotic importance of brucellosis was lower than others studies which have done at Jimma in Oromia region with reported 46.0% [56]. On the other hand, similar studies done in Jimma reported 22.1%, while 0% in another case for brucellosis respectively [57,58]. There were similar findings in Afar Region in which only (7.7%) study participants had knowledge about a disease called brucellosis. This variation could be due in the variation of socio-economic, socio-demographic, training access and residence factors.

This study revealed that study participants were consumed raw milk (54%), raw meat (50%) and contact of sick animal product without protective. This study in agreement with other studies in Jimma and 66.8% responded by consumption of both raw milk and meat [47], while in Cape Town which is reported 67% and 56% of raw milk and meat, respectively [59]. The result of this study indicated that the study respondents had poor level of knowledge on transmission of brucellosis through milk and meat. This could be due to the respondent had not training access about means of transmission of brucellosis.

Only 20% the pastoral and agro-pastoralist community had concern about brucellosis which causes abortion in their animals. This is similar to the findings of a study by Kothalawala et al. [60] in Sri Lanka where farmers identified this disease as a cause of abortion in their cattle, but they had no adequate information regarding brucellosis as a cause of abortion in animals.

On the other hand, 28.5% of the present study participants mentioned brucellosis (hahayita) as a disease which causes abortion in animals. However, the finding of this study contrasts the findings of studies which showed that most of the study participants mentioned abortion as the major clinical sign of brucellosis in animals from elsewhere [61]. The present study indicated that in Ethiopia there was lack of well-organized extension system communities to create awareness to the community members about diseases which cause abortion in their animals like elsewhere [62].

In contrast to present studies, studies done in other countries such as Kenya [61,58,63] indicated that a large proportion of the study participants knew the disease by the name brucellosis. 74.3% of present study participants not wearing protective glove when assisting of animal during abortion, calving, and removing retention placenta. 80% of respondent in study area was had no about prevention and control method of brucellosis in animal and human. The main practices for management of aborted material and fetus in the present studies were giving to dogs, and throw on the ground without disposing properly.

17.83% of study participants mentioned they had information about brucellosis from different sources includes mass media (radio/TV), friends and training; this fact may suggest that dissemination of knowledge about brucellosis by using of television or radio was the main way to reach the communities. This should be considered in the development of education programs regarding brucellosis control. And also the study participants heard information about the zoonoticity of brucellosis was from health education, training, and families. Generally, most of present study participants had not information sources [27].

The results of 14 studies in Oromia region showed that the estimated practice towards brucellosis (poor practice) was 68% (95% CI (0.5453; 0.8018)) as well as Amhara region had less poor practice as compared to other regions as shown in (Table 3). Based on the occupation of study participants, 85.9% of pastoralist and agro-pastoralists had poor practice as compared to different occupation.

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Citation: Kasse GE, Alemayehu YD, Aynew DW, Yimam TM. Knowledge, Attitude, and ractices of Population towards Brucellosis in Ethiopia: A Systemic Review and Meta-Analysis. Austin J Public Health Epidemiol. 2023; 10(2): 1143.

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Subgroups	Categories	Numbers of studies	Pooled Proportion	Level (95%CI)	I2	P-Value
Region	Oromia	14	68%	0.5453;0.8018	96.5%	< 0.0001
	Amhara	1	22.11%	0.0027; 0.6343		-
	Afar	5	87.71%	0.7052; 0.9809	95.7%	< 0.0001
	Tigray	1	48.98%	0.0936; 0.8938	-	-
	Somali	1	84.44%	0.4155; 1.000	-	-
	Harari	1	98%	0.6650; 1.0000	-	-
	SNNP	1	86.67%	0.4551; 1.0000	-	-
Occupation	Livestock owners (farmers)	15	70.7%	0.5461; 0.8452	98.6%	<0.0001
	Pastoralist and agro-pastoralist	6	85.9%	0.7051; 0.9246	91.2%	<0.0001
	Employers	2	64.95%	0.4018; 0.8608		_
	Others	2	81.97%	0.0001; 1.0000	99.4%	<0.0001

Subgroups	Categories	Numbers of studies	Pooled Proportion	Level (95%CI)	I2	P-Value
Region	Oromia	11	29.93%	0.1910; 0.4202	96.5%	< 0.0001
Region	Afar	3	67.3%	0.0000; 0.3841	92.6%	< 0.0001
	Harari	1	80%	0.0000; 0.3905	-	-
Occupation	Livestock owners (farmers)	8	29.34%	0.1776; 0.4244	95.3%	<0.0001
	Pastoralist and agro-pastoralist	4	17.45%	0.0004; 0.5242	97.6%	<0.0001
	Employers	2	23.42%	0.0000; 1.0000	98.9%	<0.0001
	Others	1	19%	0.0000; 0.2770	_	_