Mixed methods analysis of pig associated zoonoses in Lao PDR

Abstract

Southeast Asia carries a large burden of endemic zoonotic diseases, in livestock and humans, especially in countries where livestock production is increasing among rural households for income generation and poverty reduction. This thesis explores the risk factors for transmission of pig-associated zoonoses – particularly Q fever, brucellosis, hepatitis E, and Japanese encephalitis – in northern Lao PDR, with a view to development of recommendations for “catch-all” control measures to impact on multiple diseases, improving biosecurity and preventing disease transmission to the human population. Research included (i) a qualitative assessment of the knowledge, attitudes, and practices of villagers related to pig-associated zoonoses and their risk factors using focus group methodology; (ii) an assessment of health seeking behaviour at hospital/health centre and village level to examine factors that influence choice of health care provider and determine the impact of health seeking behaviour on illness and treatment costs, and an examination of non-conventional health care sources to understand the complexity of health seeking behaviour and influences on choice of health care provider and, lastly, (iii) health care provider and service delivery assessments to determine healthcare facility routine service delivery procedures and assess capability in diagnosing and treating illness. In terms of disease, the most common illnesses reportedly seen by all those interviewed were respiratory illness, acute febrile illness and diarrhoea, confirming them as the leading causes of morbidity. Knowledge and awareness of the etiological agent of pig-associated zoonoses among villagers, patients, and health care providers was very poor for brucellosis and Q fever, with limited awareness of hepatitis E. Most were aware of Japanese encephalitis. Clinical diagnosis and symptomatic treatment of illness is the normal practice and identification of causative agents in human illness does not often occur. All three empirical assessments identified poor diagnostic capability as a major concern. Focus group discussions revealed that knowledge and awareness of disease risk factors, and of zoonoses in general, was low among villagers. Practices related to food consumption, latrine usage, hand hygiene and sanitation, which are known disease risk factors, were found to be a concern in study villages. Attitudes and practices adopted by villagers in relation to human and animal health and health seeking behaviours were strongly influenced by financial circumstances, access to appropriate healthcare facilities, spiritual beliefs, and a lack of knowledge and resources to maintain the health of both animals and humans. The first point of care when experiencing illness was often the health centre or a local traditional healer or spiritual healer or pharmacist/drug seller, depending on location. This was followed by the district hospital, if nearby. Many villagers described going back and forth between traditional medicine and modern medicine service providers, with 76% (19/25) of participants reportedly seeing more than one type of healthcare provider for a given episode of illness. Self-medication was the most common practice (84% of all participants) irrespective of the care provider consulted. Attendance at a healthcare facility was dependent on available funds and the perceived severity of illness. Overall household costs ranged between no cost, because of the “poor patient” policy that exempts vulnerable groups from paying for care, and $2500 USD for medical treatment, hospital stay, transportation and sometimes food. Healthcare workers at all facility levels (from health centre to provincial hospital) expressed a lack of confidence in making an accurate diagnosis for these pig associated zoonoses due to poor diagnostic capability in their respective facilities. A One Health approach to zoonotic disease surveillance that incorporates transdisciplinary methods and partnerships will lead to improved understanding of the underlining social determinants of health and their impact on health-seeking behaviours, disease transmission and ultimately disease reporting.