Study design and period
This is a mixed methods study involving both quantitative and qualitative study methods. The study was conducted in January and February 2020 among mothers of children aged 2–5 years in Abakpa-Nike, Enugu East Local Government Area (LGA), Enugu State, Nigeria.
The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guideline was used to ensure appropriate reporting of our study’s design, conduct and findings [21], while the FGD sessions are reported according to the consolidated criteria for reporting qualitative research framework [22, 23].
Study setting
Abakpa-Nike – the urban extension of the Nike community, is a densely populated slum in Enugu East LGA. The 2016 projected population of Enugu East LGA is 374,100, with most of the population living in Abakpa-Nike [24]. Abakpa-Nike is composed of five neighborhoods: Ugboghe, Ogwuago, Ugbene I, Ugbene II, and Ugboezeji [25]. The main religion in the community is Christianity and the major occupations are farming, trading, civil service, artisans of different trades, e.g. carpentry, mechanics, electricians, and daily-paid labour [26]. Abakpa-Nike has inadequate infrastructures for safe drinking water, sanitation, and hygiene [27, 28].
Quantitative study / community-based cross-sectional survey
Study participants
All consenting mothers of PSAC aged 2–5 years who were available during the survey period were eligible to participate.
Sample size
The sample size for the survey was calculated based on a single proportion formula by assuming 50% coverage to obtain the maximum sample size [29]. Based on a design effect (DEFF) of 1.05 obtained by pretesting the questionnaire, significance of 5.0%, precision (margin of error) of 5.0%, and an inflation of 5.0% (to account for non-response), the estimated minimum sample was 426. This was then increased to 440 to boost the power of the study.
Sampling procedure
Multistage sampling was used to identify the mothers to be interviewed. Each neighborhood in Abakpa-Nike was divided into four clusters. Twenty-two households were identified from each cluster using a 1 in 5 systematic sampling method after an initial random sampling to interview the fifth household. Mothers in the selected households who met the inclusion criteria were recruited. The inclusion criteria were every available consenting mother with a child aged 2 to 5 years. Exclusion criteria were mothers who did not live for 1 year in the study area and mothers who refused consent. Where the mother had more than one child in this age group, we asked her to give answers based on the youngest child in that age bracket.
Data collection
Questionnaires were paper-based and administered in either English or Igbo languages depending on the language preference of the mother. Questions were directed at the mothers and only her responses were collected. The questionnaires were interviewer-administered by five teams of paired female social workers (each pair had at least one mother) who had basic medical experience, suitable communication skills, competent in both English and Igbo languages, and were trained for a full day prior to data collection. Study questionnaires were piloted on 25 mothers to ensure internal validity. The validity and reliability of the instrument were ascertained prior to final administration. The Cronbach alpha correlation was 0.80. Data collection was directly supervised by three of the authors with technical support from the other authors.
Study variables
Demographic information: This information included mothers’ age in years, marital status, educational level, and occupation. Other demographic information collected were the fathers’ occupation, household income and religion, sex of the index child, and the number of children aged 2–5 years in the family.
Mothers’ knowledge of STH: we first assessed mothers’ general familiarity with STH and the source of their knowledge of STH. This was followed by 20 questions on the knowledge of the different STH, modes of transmission of STH infection, symptoms of STH infection, and main complications of STH infections in PSAC to assess mothers’ knowledge of STH infections. The response options were “Yes” or “No”. A response of Yes was scored 1 and No was scored 0. Total scores ranged from 0 to 20.
Mothers’ knowledge of deworming: we assessed mothers’ general familiarity with deworming for STH infections in preschool children, how they got to know about periodic deworming, knowledge of common drugs for deworming for STH (albendazole, mebendazole, and pyrantel), and frequency of periodic deworming.
Mothers’ attitude to periodic deworming: we assessed mothers’ attitude to periodic deworming with a five-point Likert type scale – strongly disagree, disagree, indifferent, agree and strongly agree, and nine statements: “STH infection is a serious health infection in preschool children”, “Deworming is good for the health of preschool children”, “Deworming helps to prevent malnutrition in preschool children”, “Deworming helps to prevent growth retardation in preschool children”, “Deworming prevents shortage of blood in preschool children”, “Periodic deworming of preschool children is very difficult”, “Deworming of preschool children is quite expensive to do”, “Deworming is NOT necessary for the health of preschool children”, and “Deworming makes preschool children sick and should NOT be encouraged”.
Mothers’ preventative measures against STH infection: We then assessed preventative measures mothers take at home, source of household drinking water, toilet care for index child, care of fingernails, and frequency of wearing footwear. For mothers who have never dewormed their child, we asked for the reasons why they never dewormed their PSAC.
The outcome variable was periodic deworming of the index child aged 2–5 years in the last 12 months. Periodic deworming for this study was defined as the mother’s reported deworming of the index child at least twice in the past 12 months (January to December 2019) and the last deworming treatment was given within the 6 months prior to the interview (July to December 2019).
Data management and statistical analysis
Data were entered into Microsoft Excel® (Microsoft, Redmond, WA, USA), cleaned and transferred to IBM SPSS® version 25.0 (IBM, Armonk, NY, USA) for statistical analyses. 100% stacked bars were prepared using Microsoft Excel. Frequency and percentage were used to describe the data and Chi-square test was used to test for statistical significance. Scores for each knowledge domain were summed up to obtain an aggregate score for these knowledge domains. T-test was used to assess for statistical difference in the mean scores for knowledge scores. Mothers’ attitude to deworming were dichotomized; strongly disagree, disagree, and neither agree nor disagree responses were aggregated into one group while agree and strongly agree responses were aggregated into another group. Chi-Square analysis was used to assess the attitudinal difference between the two groups of mothers. Finally, multivariable logistics regression analyses were performed to assess for difference in the general familiarity with, specific knowledge of STH, transmission, symptoms, complications, and frequency of deworming while adjusting for potential confounders such as socio-demographic characteristics (mothers age, marital status, mothers educational status, mothers occupation, fathers occupation, religion, family monthly income, number of children < 5 years in the family, and sex of the index child), and source of information on STH infections and deworming. P < 0.05 was used to define statistical significance, and all tests were two-tailed.
Qualitative study / focus group discussions (FGD)
Sample size and sampling strategy
Forty-three mothers participated in five FGD sessions, averaging at least 8 mothers per session. Mothers were purposely selected during the community-based survey, particularly inviting mothers who indicated that they had never dewormed their PSAC (four sessions) and mothers who do not periodically deworm their PSAC (one session).
Data collection instrument and data collection technique
Different semi-structured guides were developed and applied for focus group discussions. A moderator and a note-taker conducted each session using an FGD guide and a tape recorder. The FGD sessions were guided by themes with discourse analysis which evaluated mothers’ perception and attitude to deworming of their PSAC. FGD sessions were held after work hours at the Abakpa-Nike primary healthcare center, were led by two of the authors (both females) and the average duration of FGD sessions was about 40 min. The discussions were conducted in Igbo language as all the mothers preferred this language. Confidentiality was assured and mothers were encouraged to be frank with their contributions.
Data management and analysis
Audio records of the FGD were transcribed verbatim into Igbo by an external research assistant and was checked by two authors (UJA and CLA) who listened to the recording while checking the accuracy of the transcripts. A thematic analysis approach was adopted, and three authors (UJA, CLA, and PE) independently analyzed transcripts using comparative analysis from which themes were developed until data saturation [30]. Themes were discussed among the authors to clarify biases. The transcript of the audio records and the major findings from the analysis of these transcripts were cross-checked with a few FGD participants for corrections and validation. Selected texts were then translated into English when drafting this paper.
