Socio-cultural aspects of lymphatic filariasis and the role of communities in its control in Ghana

Lymphatic Filariasis (LF) is one of the worlds most debilitating and disfiguring tropical diseases. The World Health Organization estimates that there are about one billion people at risk in about 80 countries worldwide. It is the world’s second leading cause of permanent long-term disability and its prevalence continues to increase. The World Bank development report indicates that the global burden for the disease was estimated at 850,000 DALY’s lost which represents only 0.23% of the global burden. In Africa, it is estimated that some 4.6million cases of lymphoedema and over 10 million cases of hydrocele occur. This represents 40% of the global burden of LF. In 1993, an independent international task force for disease eradication identified LF as one of the only six eliminable infectious diseases. LF was selected because of recent dramatic advances in treatment methods, both for controlling transmission and for managing the disease along with remarkable improvement in techniques for diagnosing filarial infections. The principal strategy for interrupting transmission then was to identify areas in which LF is endemic and implement community wide programs to treat the entire at risk population. In terms of managing the disease, the Global Program for the Elimination of Lymphatic Filariasis (GPELF) plans that individuals already suffering from elephantiasis will be taught effective hygiene measures that can easily be carried out in the home. For men with hydrocele, surgery is the treatment choice and guidelines will be developed and disseminated on good practical surgical procedures. The overall goal of the study was to determine the social and economic impact of LF and examine the role communities can play in its control in a country where till recently, the disease has been very low on the National Health Agenda. A number of studies were conducted in four districts in Northern and Southern Ghana that were found to be prevalent for Filariasis after a national Filariasis survey was conducted in the country in 1994. The overall prevalence in the North ranged between 20-40% and in the South between 10-20%. There were no prior studies on Filariasis neither was there a National control program in place before the conduct of these studies. The goal of these studies was achieved using a multi-disciplinary approach, to determine how people recognize and perceive LF and the social and economic impact of the disease. This involved extensive ethnographic work, and a morbidity and economic surveillance. The information from the ethnographic phase was then used to develop Information Education and Communication techniques with the help of community members through the training of community workers and community leaders as facilitators to guide the process. To develop effective and practical methods for sustainable mass treatment of LF, two different methods of mass treatment of lymphatic Filariasis with a single dose of Ivermectin were tried. Finally, the potential role of traditional health care providers in the management of elephantiasis was investigated. Focus group discussions, observation, key informant interviews, case studies and structured questionnaires were used to elicit information from health care providers, affected and unaffected individuals. The results indicate that, § LF is recognized as a problem in the study areas and there are specific local terms used to describe the various manifestations. § There is the need to pay more attention to the needs of men with hydrocele. § Each of the ethnic groups studied have different conceptions and health care seeking practices for the disease. This has implications for health education. § Communities are capable of developing their own IEC messages with the proper guidance and building on their perceptions about the disease. § Community directed treatment for Filariasis achieved 75% treatment coverage and can be effectively implemented through the regular health system § By building on positive existing local treatment practices, traditional healers can be a useful resource in the management of lymphoedema through effective hygiene measures. All these studies have been carried out in research settings. What is needed now is to come up with practical ways of up-scaling and implementing these studies in the other endemic districts in the country. This is the first time that in one report lymphatic Filariasis has been looked at from lay perceptions to practical implementations. The results contribute knowledge to the understanding of the disease in general and draws attention to the fact that the male gender also needs to be paid attention to in tropical disease research. It also raises the importance of including psychosocial aspects of disease burden in the calculation of DALY’s and adds to the body of knowledge the importance of traditional healers in particular and community effort in the global program for the elimination of LF as a public health problem. The contribution of anthropology in the study of the LF and the importance of the discipline in the study of emerging and re-emerging infectious diseases are discussed. There are however a number of issues that need further research and they include 1. Advocacy strategies to increase awareness about the disease and to ensure sustained demand supply and distribution of Ivermectin at the National, Regional and District level for the control of the disease 2. Stigma and the burden of filariasis especially in urban areas where LF is increasingly becoming a problem. 3. We have recommended that the ComDT approach be implemented on a large scale but there is the need to address issues on how cost effective will this kind of intervention be?