CHAPTER ONE

INTRODUCTION

1.1 Background of Study

Cholera remains one of the public health problems today particularly in the under-developed and
less industrialized countries of the world. In industrialized countries, functional modern sewage,
improved sanitation practice and water treatment technologies have eliminated the disease but
the reverse is the case in developing countries. In low and middle income countries, there are 1.3
to 4.0 million cases per year, with 21,000 to 143,000 deaths. (LaRocque & Harris,2022; Ali,
Nelson, Lopez, & Sack, 2015).

In sub-Saharan African countries, 999 suspected cholera outbreaks were identified in 744 regions
between January 2010 to January 2020 (Zheng, Luquero, Ciglenecki et al, 2022). The outbreak
periods accounted for 1.8 billion persons which is 2% of the total during these periods. While in
Nigeria, the 2021 outbreak that started in Delta State affected 89% of states in the country.
Other affected states were Benue, Zamfara, Gombe, Bayelsa, Kogi, Sokoto, Bauchi, Kano,
Kaduna, Plateau, Kebbi, Cross River, Niger, Nasarawa, Jigawa, Yobe, Kwara, Enugu, Adamawa,
Katsina, Borno and FCT (NCDC, 2021)

During the different outbreak periods, people above 15 years of age were the most affected
(59%) while the under-five accounted for 26% of cases (Ehisianya, Ezeruwa, Okore, & Ukpa,
2020; Takarinda, Nyadundu, Govha, Gombe, Chadambuka, Juru, & Tshimanga, 2021). The
magnitude of the 2021 outbreak was unprecedented as reported by Zheng, Luquero, Ciglenecki
et al, (2022). In the South-East with Abia State in perspective, the outbreak of the disease
became a public knowledge by the 28th of September 2021. Ugwunagbo Local Government Area
was one of the local government areas affected in Abia State. Other affected LGA’s are Ohafia,
Aba North and South.

Cholera is an acute diarrheal infection caused by ingestion of food or water contaminated with
the bacterium Vibrio cholera either by type O1 or type O139. The bacterium is usually found in
inadequately treated water or in foods that have been contaminated by feces from a person
infected with cholera bacteria. It is a very serious infection involving the lower part of the small
bowel of which both adults and children can be infected with this disease that mostly spread in

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places with poor hygiene and sanitation practices (Centers for Disease Control and Prevention,
2021; Anderson, 1975).

Nigeria is reported to be one of the three major current cholera foci countries in the world
(LaRocque & Harris,2022; Zheng, Luquero, Ciglenecki et al, 2022). In 2021, Nigeria reported
31,425 suspected cases with 311 confirmed cases and 816 deaths from 22 states and the Federal
Capital territory between 1st of January and 1st of August 2021 while in 2022, between 28th
March to 1st May, 1,861 suspected cases were reported. The suspected death cases which were
54 and case fatality ratio of 2.9% was reported from sixteen states namely - Abia, Adamawa,
Akwa Ibom, Bauchi, Bayelsa, Borno, CrossRiver, Katsina, kebbi, Kwara, Lagos, Nasarawa,
Ondo, Rivers, Taraba and Zamfara (NCDC, 2021; NCDC, 2022). All these outbreaks are
attributed mainly to the contamination of water supplies with diarrhea discharge of untreated
cholera patients during the rainy season, which therefore brings to the focus the vulnerability of
Nigerian rural communities as previously opined by Adagbada, Adesida, Nwaokorie, Niemogha,
and Coker, (2012).

As evidenced from several literatures, the risk of cholera disease is highest when poverty, war, or
natural disasters make people to live in crowded conditions without access to clean-safe water,
improved sanitation facilities and modern sewage disposal system. Thus, Cholera outbreak is a
result of socio-economic deprivation, absence of basic social amenities, inequality and social
advancement (Ali, Nelson, Lopez, & Sack, 2015;s Ayenigbara, Ayenigbara, and Adeleke, 2019;
Bennington-Castro, 2020; LaRocque & Harris, 2022; Zheng, Luquero, Ciglenecki et al, 2022).

Furthermore, untreated or poor management of human wastes, lack of access to safe drinking
water, poor hygiene or sanitation practices, lack of knowledge of the subject matter, attitude,
perception, preventive practices amongst others, which are common characteristics of rural
settings in Nigeria, are plausible causes of repeated cholera outbreak (Ali, Mohamed and
Tawhari, 2021; NCDC, 2021; NCDC, 2022).

Knowledge is the process of absorbing and storing new information in memory (Zlotnik &
Vansintjan, 2019). It refers to the fact or condition of knowing something with familiarity gained
through experience or association. It is simply the fact or condition of being aware of someone or
something such as objects, skills, or facts. The knowledge of any situation is very important
because it shapes ones’ personality, behavior and dealings with people. However, knowledge is

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closely related to awareness which is defined as [the process that seeks to inform and educate
people about a topic or issue with intention of influencing their attitudes, behaviors and beliefs
towards the achievement of defined purpose or goal (Sayers, 2006).

When individuals acquire knowledge and awareness of any situation, they become more
confident and surer of what to do when confronted in life with such situations. In other words,
knowledge and awareness contributes to an individual’s understanding of any situation.
Researchers like Aminrad, Zakariya, Hadi, and Sakari, (2013) believed that the knowledge and
attitude are linked to each other where attitude is further connected to the behavior. To them,
when people become more knowledgeable about something and its associated issues, they will,
in turn, become more aware of it, its problems and thus, be more motivated to act toward it in
more responsible ways. Thus, adequate knowledge can lead to positive attitude resulting in good
practices.

Mothers play a huge role in their children’s lives, caring for them, loving them, teaching them
and so much more. Mothers are the primary care givers in most home and their knowledge as
well as awareness of the health dangers of Cholera will help them imbibe healthy and safety
health practices at home. However, mothers especially those in the rural communities are not
aware of the various factors that put them, their unborn babies and the entire family at the risk of
Cholera (Ali, Mohamed and Tawhari, 2021; Wahed, Kaukab, Saha, Khan, Khanam, Chowdhury,
Saha, Khan, Siddik, Cravioto, Qadri, and Uddin, 2013).

A study by Ali, Mohamed and Tawhari, (2021) showed that most people are unaware that street
vended water, not washing hands with soap before eating, and water supply from hand dug wells
are all potential sources of major transmission during outbreaks. Other plausible channels
reported in the literature are contaminated ponds, on which most Northern States rely as their
primary source of drinking water.

In addition, Tran, Taylor, Antierens and Staderini (2015) as well as Chan and Smith (2018)
found out that some mothers do not know that Cholera infections during pregnancy can lead to
sudden loss of the fetus, premature delivery, stillbirth, increased mortality and morbidity both for
the baby and the mother.

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Attitude is another factor that affects how individuals respond to any life situation. Attitude is
simply a feeling, a settled way of thinking or acting towards a thing, situation or person that
affects an individuals’ behavior at any given point in time. Thus, a mothers’ knowledge about
Cholera will either create a positive or negative attitude towards the diseases as well as
determine preventive practices carried out as documented in the studies by Ali, Mohamed and
Tawhari, (2021) as well as Wahed, Kaukab, Saha, Khan, Khanam, Chowdhury, Saha, Khan,
Siddik, Craviota, Oadri, and Uddin, (2013).

With respect to Cholera, preventive measures are actions or activities that will eliminate or
reduce the frequently experienced outbreaks, promote desired behavioral outcomes and ensure a
state of general well-being. In this regard, Okeke, Badung, Ajani, Gidado, Nguku, Fawole,
(2012) found that lack of adequate knowledge on the cause and preventive measures of cholera
such as a proper disposal of waste generated from the house, open defecation or use of pit toilets
contributes to Cholera outbreak. Therefore, in this project work, the researcher will focus on
knowledge, attitude, and prevention measures of Mothers towards Cholera in Ugwunagbo Local
Government Area in Abia State.

1.2 Statement of Problem

In the 2021 and 2022 monthly epidemiological report by the Nigeria Centre for Disease Control
(NCDC), Abia State was listed alongside sixteen other states as a cholera endemic region in the
country. Other states mentioned are Adamawa, Akwa Ibom, Bauchi, Bayelsa, Borno, Cross
River, Katsina, kebbi, Kwara, Lagos, Nasarawa, Ondo, Rivers, Taraba and Zamfara. In the
situation report for Epi week 1 to 52 of 2021, the state had a total of 99 cholera cases with 3
deaths and a Case Fatality Rate (CFR) of 3.0%. In the 2022 situation report for Epi week 1 to 17,
the state recorded 25 cases with 1 death and a CFR of 4.0% (NCDC, 2021).

Furthermore, in a related report on the 2021 outbreak in Abia State by a combined team of the
World Health Organization and the State Ministry of Health, 40 suspected cases with 2 deaths
and a CFR of 5.0% was recorded (WHO, 2021). Of the suspected cases, the less than 5 years’
age group were the most affected while in terms of gender, 47% of those affected were males
and 53% were females as reported in the weekly bulletin on outbreak and other emergences of
WHO Africa Regional Office (2022). Umule Osamadi village in Nkpukpuevule ward of
Ugwunagbo local government area was the most affected (WHO, 2021).

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Currently, for the 2022 outbreak in Abia State, the local government areas affected are Ohafia,
Aba North and Aba South, with obvious global advancement in general hygiene and living
conditions, this recent outbreak in the state is a threat to public health and an indicator of several
underlying factors such as poor sewage systems, weak sanitation practices, inequality in the
provision of basic social amenities such as potable water, poor hygiene, lack of knowledge,
attitudes, among others. Beyond these listed factors, the outbreak in general points to clear
deficiency in overall public health and living conditions since many Nigerians are living in
extreme poverty and dehumanizing conditions as reported by Eneh (2009). Therefore, this study
is an investigation carried out to find out the knowledge, attitude and preventive measures of
mothers towards Cholera in Ugwunagbo Local Government Area, Abia State.

1.3 Research Questions

1. What is the mother’s level of knowledge on Cholera in Uguwunagbo LGA, Abia State?
2. What is mother’s attitudinal disposition towards Cholera in Ugwunagbo LGA, Abia
State?
3. What are the preventive measures put in place towards Cholera disease by mothers in
Ugwunagbo LGA, Abia State?
4. How does knowledge correlate with attitudinal disposition towards Cholera disease of
mothers in Ugwunagbo LGA, Abia State?
5. How does Knowledge correlate with the preventive measures put in place by mothers
against Cholera in Ugwunagbo LGA, Abia State?

1.4 General Objective

The general objective of this study is to assess the knowledge, attitude and preventive measures
of mothers towards Cholera in Ugwunagbo Local Government Area, Abia State.

1.5 Specific Objectives

1. To determine the level of knowledge on Cholera disease of mothers in Ugwunagbo LGA,

Abia State.
2. To determine the attitudinal disposition towards Cholera disease of mothers in
Ugwunagbo LGA, Abia State.

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 3. To find out the preventive measures put in place towards Cholera disease by mothers in
Ugwunagbo LGA, Abia State.
4. To assess the relationship between knowledge and attitudinal disposition towards Cholera
disease of mothers in Ugwunagbo LGA, Abia State.
5. To determine the association amongst knowledge, attitudinal disposition and preventive
measures of mothers towards Cholera disease with reference to designation in
Ugwunagbo LGA, Abia State.

1.6 Research Hypotheses

Ha 1: There is significant association between the knowledge and attitudinal disposition of

mothers towards Cholera in Ugwunagbo LGA, Abia State.

Ha2: There is significant association between the knowledge and the preventive measures of
mothers towards Cholera in Ugwunagbo LGA, Abia State.

1.7 Justification of Study

Cholera is said to be one of the oldest known infectious diseases that have great impact on
morbidity and mortality among all age groups in both developed and developing countries.
Developing countries like Nigeria are currently suffering from the threat of Cholera outbreak.
The Nigeria Centre for Disease Control (NCDC) in August 2021 made a public outcry stating
that there was Cholera in Nigeria; as such, there was urgent need to strengthen, sanitation and
hygiene (WaSH).

As at 28th of September 2021, Abia State was listed among the states suffering from cholera
outbreak with Ugwunagbo Local Government Area as one of the local government areas
affected. Other affected LGA are Ohafia, Aba North and South. Ehisianya, Ezeruwa, Okore, and
Ukpa, (2020) found that the predominance of houseflies and mosquitoes in refuse dump sites is
one of the reasons for high prevalence of vector borne diseases in the metropolis.

More so, the study by Okpasuo, Aguzie, Joy, and Okafor (2020) conducted in a neighboring state
revealed that most household water choices are vulnerable to contamination at many points along
their journey from source to mouth and advocated for adequate provision of safe water "point of

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use," household water treatment, and good storage methods to effectively curb Water Borne
Infections.

In addition, from available literatures, several studies have been done in Nigeria on Cholera but
none in Ugwunagbo LGA in Umuahia, Abia State where the disease occurred for the first time in
2021. Consequently, this study is an attempt to bridge this gap.

Therefore, it is expedient for this research on knowledge, attitude and preventive measures of
cholera amongst mothers in Ugwunagbo Local Government Area, Abia State to be carried out.

1.8 Significance of the Study

The results of this study on knowledge, attitude and preventive measures towards cholera of
mothers in Ugwunagbo Local Government Area, Abia State will be of immense benefit to
mothers, health agencies, community leaders and the government at large.

Furthermore, community leaders will equally benefit from the results of this study because the
findings will make them become more aware of cholera preventive measures to put in place so
that community drinking water source channels will not be contaminated. The findings will be
used to prompt the leaders to put in place measures that will enhance proper use of water sources
in their communities so as to help to prevent cholera infection and transmission.

As it pertains to health agencies, the findings of the study will help them emphasize to mothers
the need for personal hygiene and to effectively participate in the monthly clean up exercise
carried out in most states of the country which is critical to preventing and controlling the
transmission of cholera and other waterborne diseases.

The government will see the need to put in place more measures to curb inequity and lack of
social development in the area of study. In addition, measures will be put in place to avoid the
premature deaths of young adults and children so that economic loss of the working population
will be averted.

Findings on the knowledge gaps of mothers in the study area will help in the proper planning of
public health interventions programmes that will bring in the needed expertise, skills and know-
how of how to prevent and manage any future Cholera outbreak.

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In addition, understanding the attitude and preventive measures of the public especially
vulnerable groups such as mothers and pregnant women will help public health agencies, health
care centers and other health agencies in taking decisions in an objective manner in order to
prevent or tackle any future outbreak successfully.

1.9 Limitations
1 Language was one of the limitations to this study. Although the researcher made
available the translated Igbo version of the questionnaire, some respondents who speak
the Igbo language fluently could not read Igbo fluently. As such, the researcher and the
research assistants tried to do verbal interpretation of some items.
2. The characteristics of the study participants is also considered as a limitation that may
affect the generalizability of this study because the researcher only used mothers of child
bearing age but cholera disease affects both gender and cuts across all age limits.
3. The Local Government Area – Ugwunagbo where this study was carried out is one Local
Government Area out of the 17 in Abia State and may not effectively represent all the
others in this situation because of some peculiarities.

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 CHAPTER TWO

LITERATURE REVIEW

This chapter will be discussed under the following sub-headings:

2.1 Introduction and background studies related to the emergency of the problem (other issues
related to the study including variables).

2.2 Theoretical framework.

2.3 Conceptual review for the study.

2.4 Empirical review for the study.

2.1 Introduction and background studies related to the emergency of the problem
Cholera is an acute secretory diarrheal illness caused by toxin-producing strains of the gram-
negative bacterium Vibrio cholerae of serogroup O1 or O139. (LaRocque & Harris, 2022). This
infectious disease is a waterborne life-threatening form of dehydrating diarrheal disease which
remains a public health threat as evidenced by its substantial contribution to morbidity and
mortality in low-income countries over the years (Waheed et al, 2013).

More than 40 years ago, the cholera case fatality rate among children of 1-5 years was reported
to be more than 10 times that of adults. Thus, cholera transmission by ingestion of feces(poop)
contaminated water or food remains an ever-present risk in many countries since a person can
get cholera by drinking water contaminated by the feces of an infected person especially in areas
where human wastes are untreated or eating food contaminated with the cholera bacteria
(Centers for Disease Control and Prevention, 2021).

Furthermore, according to the World Health Organization (WHO), cholera occurs in both
endemic and epidemic patterns. It is said to be endemic in Africa, parts of Asia, the Middle East,
South and Central America because confirmed cases were detected during the last 3 years with
evidence of local transmission (meaning the cases are not imported from elsewhere). On the
other hand, epidemic outbreaks usually occur when natural disasters like earthquake, tsunami,
volcanic eruptions, landslides, floods, war or civil unrest disrupt the normal balance of nature
and essential system services such as water, sewage or public sanitation as the case may be
(Qudri, 2005).

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An outbreak is defined as a higher-than-expected number of occurrences of a disease in a
specific location and time which can occur in both endemic countries and in countries where a
disease does not regularly occur. In recent areas where cholera infection has occurred, it occurred
irrespective of the season and affected individuals of all ages since once infected, they excrete
the bacteria in stool. While in times of natural disasters, developing countries are
disproportionately affected because of their lack of resources, infrastructure and disaster
management preparedness systems (Sur, Dutta, Nair, & Bhattacharya, 2000).

2.1.1 Signs and Symptoms

Cholera is a dangerous and destructive disease that causes extreme and intense water loss. This
disease takes between 12 hours and 5 days for an individual to exhibit symptoms after ingesting
contaminated food or water (Azman, Rudolph, Cummings, & Lessler, 2013). Cholera affects
both the young and old and it can kill within hours if left untreated. Among the major symptoms
of cholera, one of them is diarrhea which is often described as “rice water” which may also have
a fishy smell (Sack, Sack, Nair & Siddique, 2004).

An untreated person with cholera may eliminate 10 to 20 liters of diarrhea daily (Sack et.al,
2004) and serious cholera that has not undergone treatment could result in life- threatening
dehydration as well at electrolyte imbalances which can kill about half of affected individuals.
Furthermore, it is also important to note that when infected with cholera, a person’s skin may
turn bluish-gray from extreme loss of fluids. Cholera patients are usually fatigued and lethargic
with sunken eyes, dry mouth, cold clammy skin or wrinkled hands and feet most of the times.

Other symptoms are vomiting, leg cramps, rapid loss of body fluids that leads to dehydration and
shock which if not treated can lead to death within hours (LaRocque & Harris, 2022; Centers for
Disease Control and Prevention, 2021; Tran, Taylor, Antierens, & Staderini, 2015; Waheed et al
2013).

More so, persons suffering from cholera disease may have Kussmaul breathing which is
characterized by a deep and labored breathing pattern due to acidosis from stool bicarbonate
losses and lactic acidosis associated with poor perfusion (Ayenigbara, Ayenigbara, &Adeleke,
2019). In addition, blood pressure may drop because of dehydration, peripheral pulse is rapid,
and urine output diminishes with time. Also, muscle cramping and weakness, altered

10
consciousness, seizures or coma might occur due to electrolyte imbalances. These symptoms are
common especially in children (Sack et.al, 2004).

Noteworthy of mentioning in terms of signs and symptoms is the fact that in some cases, many
people infected with Vibrio cholerae do not develop any symptoms even though the bacteria are
already present in their feces for 1-10 days after infection. Thus, the bacteria are shed back into
the environment potentially infecting other people (WHO, 2018).

2.1.2 Global and National Perspective on Cholera

Cholera has been found to be a substantial burden in the developing countries of the world for
decades. According to LaRocque and Harris (2022), it is endemic in approximately 50 countries
(defined as having reported cholera cases in at least three of the five past years) but mostly in
Africa and Asia. More specifically, extensive epidemics outbreak due to V. cholerae have
occurred throughout Africa, Asia, the Middle East, South and Central America, and the
Caribbean (LaRocque & Harris, 2022).

Severe outbreaks of cholera mostly occurred in under-developing areas with inadequate

sanitation, poor hygiene and limited access to safe water supplies, while in some countries a
seasonal relation for cholera epidemics has been observed. Several decisions which concern
cholera prevention and control are based on surveillance reports. However, due to the limitations
in the current surveillance systems, differences in reporting procedures and failure to report
cholera cases to WHO, official figures are more likely to underestimate the true prevalence of the
disease resulting to uncertainty in the exact scale of the problem (LaRocque and Harris, 2022).

Researchers have estimated that each year there is 1.3 to 4.0 million cases of cholera and 21,000
to 143,000 deaths worldwide due to cholera (Ali, Nelson, Lopez, & Sack, 2015).However, more
current reports indicate that there is an estimated 3 million cases of diarrheal illness and
approximately 100,000 deaths worldwide caused by V. cholerae annually (LaRocque & Harris,
2022) ; As such, the number of cholera cases reported to WHO has continued to be at a high rate
over the last few years. During 2020 outbreak, 323, 369 cases, 857 deaths were reported from 24
countries (WHO). The discrepancy between these figures and the estimated burden of the
diseases is due to many cases not being recorded due to limitations in surveillance systems.

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2.1.3 Cholera in Africa

Cholera has largely been eliminated from industrialized countries because of improved water and
sewage treatment over a century ago but it still remains a significant cause of illness and death in
many African countries. From the late 1990’s through the first decade of the 21 st century, sub-
Saharan Africa has reported more cholera cases and more deaths than any other region. Though
with some exceptions, this trend has continued through most years of the second decade of this
century. The proportion of people who die from reported cholera remains higher in Africa than
elsewhere (CDC, 2020)

2.1.4 Cholera in Nigeria

The first series of cholera outbreaks in Nigeria were reported between 1970 to 1990 after which
subsequently recurrent outbreaks followed (Lawoyin, Ogunbodede, Olumide, & Onadeko, 1999).

In Nigeria, as reported by the World Health Organization (WHO) and Nigeria Center for Disease
control (NCDC) cholera outbreaks was obvious in 1970 and in 1991. Three other major
outbreaks occurred 1992, 1995–1996 and 1997. Epidemiological information from the Public
Health Department and the Kano State Ministry of Health, revealed intermittent outbreaks in
Kano State from the year 1995 to 2001 with 2,630 cases in 1995/1996, 847 cases in 1997, and
2,347 cases in 1999. Furthermore, as documented by the Nigeria Centre for Disease Control
(2018) and cited by LaRocque and Harris, (2022) as well as some other researchers earlier
mentioned in this work, the World Health Organization (WHO) was informed of major cholera
outbreak in Kwara State, Nigeria on June 7th 2017.

Other suspected cases were reported between May 1st and June 30th from five local government
areas namely Asa (18), Ilorin East (450), Ilorin South (215), Ilorin West (780), and Moro (50) in
the same State that same year. And as at June 2017, an aggregate of 1,558 associated cases with
cholera have been documented with 11 deaths cases (causality rate: 0.7%) The disease affected
all age groups with 50% of the presumed cases been males and 49% females. Since 2018, over
5,607 presumed cases of cholera have been reported from nine states (6). The general case
fatality rate (CFR) for all cases was 1.05% and the most affected age groups are 5–14 years
(24.8%) and 1–4 years (23.4%), while the male: female ratio is 1.2:1 (Nigeria Centre for Disease
Control, 2018; LaRocque & Harris, 2022).

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Importantly, as at 21st of September 2021, the Nigeria Centre for Disease and Control (NCDC)
reported a total of 73,055 suspected cases with 2,407 deaths (CFR 3.3%) from 27 states out of
the 36 states and in Abuja - the Federal Capital Territory (FCT). The affected states were Benue,
Delta, Zamfara, Gombe, Bayelsa, Kogi, Sokoto, Bauchi, Ekiti, Osun, Kano, Kaduna, Plateau,
Kebbi, Cross River, Nasarawa, Ogun, Niger, Jigawa, Yobe, Kwara, Adamawa, Enugu, Katsina,
Borno, Taraba, Abia, and the FCT. In Abia State, the affected Local Government Areas include
Aba North and South, Ohafia and Ugwunagbo.

2. 1.5 Epidemiological Review

2.1.5.1 Epidemiology

The incidence of Cholera is exceedingly underreported, and there is no accurate statistics on the
morbidity and mortality linked to V. cholera infection. However, V. cholera is thought to be
responsible for about 100,000 annual deaths and 3 million episodes of diarrheal disease
worldwide (Ali et al., 2015).

2.1.5.2 Mode of Transmission

Transmission of cholera is primarily through the fecal-oral route of contaminated food or water
caused by poor sanitation (WHO, 2010). Most cholera cases in developed countries are caused
by the consumption of contaminated food while in the developing countries; it is caused by
drinking contaminated water (Sack et.al, 2004). Occasionally, food transmission of Vibrio
cholerae can occur when individuals collect shellfish. For example, in waters contaminated with
sewage, Vibrio cholerae accumulates in planktonic crustaceans, which are eaten by oysters and
other shellfish (Ayenigbara, &Adeleke, 2019).

Furthermore, individuals infected with cholera frequently have diarrhea, and infection
transmission may occur if the liquid stool, conversationally alluded to as “rice-water”
contaminates water used by others (Ryan & Ray, 2004). In other words, when the diarrhea stool
of an infected individual enters public waterways, groundwater or drinking water supplies,
contamination and transmission of cholera will occur. As such, drinking any contaminated water,
eating any food washed in the contaminated water or eating shellfish living in the contaminated
conduit all predispose to becoming infected with cholera ( Ayenigbara &Adeleke , 2019 ;

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Bonner et al, 1983; Centers for Disease Control and Prevention, 2021; Janda et al., 1988 ; Tran,
Taylor, Antierens, & Staderini, 2015; Waheed et al., 2013 ; West, 1989).

2.1.5.3 Risk Factors for Increased Transmission

Cholera generally is associated with poverty and lack of access to safe food, water, and adequate
sanitation while large cholera epidemics occur in populations impacted by natural disaster or
human conflict. Cholera is transmitted through fecal-oral route via contaminated water or food,
carriers of the infection and inadequate sanitary conditions of the environment but the ingestion
of contaminated water or food still remains the principal mode of transmission (D’Mello-Guyett,
Gallandat, Van den Bergh, Taylor, Bulit, Legros, et al. 2020).

From previous research works, two conditions have to be met for a cholera outbreak to occur.
The first condition is that there must be significant breaches in the water, sanitation and hygiene
infrastructure used by the group of people which gives rise to food or water contamination with
Vibrio cholera organisms and cholera must be present in the population. In Nigeria, the 1996
cholera outbreak in Ibadan (Southwest) was attributed to contaminated potable water sources
(Lawoyin et.al, 1999). Street vended water and not washing of hands with soap before eating
food are said to be the possible reasons for the 1995-1996 cholera outbreaks in Kano state (Lipp,
Huq, & Colwell, 2002).

Other risk factor routes are by drinking water sold by water vendors, the hand dug wells and
contaminated ponds being relied on by most of the Northern States. The study by Idoga, Toycan
and Zayyad, (2019) equally found that floods, improper sewage disposal, and lack of
environmental hygiene were the main causes of the spread of cholera. The outbreak in 2010 was
speculated to be directly linked with water sanitation and water supply.

Furthermore, population movement which enhances the spread of infectious agent to others and
to different sites is another factor that may greatly contribute to the risk of cholera transmission.
An instance was when all the surviving residents that fled a two-month outbreak in Kebbi State
(North-North) became indices for subsequent infection in the north and southern part of a
neighboring state. This is so because an increase in overcrowding increases the risk of contact
with vomitus, excreta and contaminated water or food.

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All these factors have contributed greatly to cholera infections in Nigeria however, lack of safe
water and poor sanitation are important risk factors. Since early detection and containment of
cases (isolation facilities) are paramount in reducing transmission, poor access to health services
and poor diagnosis are in some cases major barrier to controlling the infection.

2.1.5.4 Host Genetic Factors, Demographic and Socioeconomic Factors

Susceptibility to cholera infection and factors enhancing its spread is multi-factorial. The host
immune system is the critical defense mechanism against cholera. However, infection with
cholera can result in a range of responses, from severe and life-threatening diarrhea to mild or
unapparent infections. Another factor is differences in gastric acidity. It has been stated that low
acid production can lead to cholera. People who produce less stomach acid such as young
children, older people and those taking drugs that reduce stomach acid, including proton
pumping inhibitors are likely to contact the infection (Sack et.al, 2004).

A number of demographic and socioeconomic factors including age, gender, nutritional status,
social status, economic status as well as travelling also play crucial roles in susceptibility to
cholera genic V. cholera. Sanitation and nutrition are particularly important factors and it has
become clear that good sanitation and hygienic practices largely prevent the disease.
Researchers have proven that Vibrio cholera infection is known to be more severe in individuals
suffering from malnutrition. Also, studies have shown that women of reproductive age who fall
within the age bracket of 15-49 years and pregnant women are vulnerable to complications of
cholera (Khan, A. I., Ali, M., Chowdhury, F., Saha, A., et al 2017, Bolarinwa, 2021).

As regards to host susceptibility factor, epidemiological research suggests that there is

association between cholera and blood group. Researchers postulated that the incidence of
cholera in patients with blood group A was lower than those in the general population, while
incidence in those with blood type O was significantly higher.

2.1.5.5 People Most Affected

According to the Centre for Disease Control (CDC), individuals living in places with unsafe
drinking water, poor sanitation, and inadequate hygiene are at the highest risk of cholera. These
conditions are more prevalent in developing countries due to lack of proper treatment and
maintenance of their sewage systems (Centers for Disease Control and Prevention, 2021; Tran,

15
Taylor, Antierens, Staderini, 2015; Ayenigbara, Ayenigbara, and Adeleke, 2019; Bonner et al,
1983; Janda et al., 1988; Waheed et al., 2013; West, 1989.

2.1.5.6 Preventions and Control Measures

In Nigeria, existing prevention and control strategies are multi-sectoral. Epidemic Preparedness
and Response (EPR) approaches including registration of cases, case management and public
health measures targeting personal hygiene and water treatment as well as emergency responses
from both governmental and non-governmental agencies have contributed to the reduction in
cases fatality rates over the years (Adagbada, Adesida, Nwaokorie, Niemogha, & Coker, (2012).

Researchers have deemed it necessary to introduce intervention measures that address the root
problems of poor sanitation and unsafe water supplies in order to prevent future cholera
epidemics. Simple methods such as boiling water for drinking, washing and cooking, treatment
of infected facilities, sewage and drainage systems, proper disposal of infected materials such as
waste products, clothing and beddings, treatment of infected fecal waste water produced by
Cholera victims. Studies have indicated that use of soap and hand washing promotion can
achieve a 26% to 62% decrease in the incidence of diarrhea in developing countries (Ejemot-
Nwadiaro, Ehiri, Arikpo, Meremikwu, & Critchley, 2021).
2.1.5.7 Basic Cholera Prevention Steps

 Make sure to drink and use safe water to brush your teeth, wash and prepare food, and
make ice.
 Wash your hands often with soap and safe water
 Use latrines or bury your poop; do not poop in any body of water.
 Cook food well (especially seafood), keep it covered, and eat it hot.

2.2 Theoretical Framework

Knowledge, Attitude and Practices model is a model used widely for cross-sectional
surveys. It was developed as a tool to investigate what is known, believed and done by
participants in a specific topic. This is a quantitative method (predefined questions that
are formatted in standardized questionnaires) which provides access to quantitative and
qualitative information. KAP is a rational model used in health education. It was created

16
 based on the notion that increasing personal knowledge will influence behavior change
(WHO, 2012). KAP survey reveals misconceptions or misunderstandings that may
represent obstacles to the activities that can lead to behavior change. This model also
establishes the baseline (reference value) for use in future assessments and help measure
the effectiveness of health education activities.

ATTITUDE

PRACTICE KNOWLEDGE

The Knowledge-Attitude-Practice Model (Bano et al., 2013)

2.3 Conceptual Review

This review is carried out to help readers understand the connection amongst major concepts in
this study. In other words, the conceptual review will help readers to understand how knowledge
of a particular disease can influence an individual’s belief about the disease which also
influences their attitude towards the disease thereby enabling the individuals to take preventive
measures towards the particular disease.

2.3.1 Community Knowledge

Knowledge is the primary factor that clearly distinguishes the human race from the animals. It
has contributed to all the advancements made in science and technology. By definition,
knowledge refers to the fact or condition of being aware of someone or something such as facts,
skills, or objects. It contributes to ones understanding of any situation through equipping
individuals with facts and information necessary for proactive decision making in life. In the
study by Orimbo, Oyugi, Dulacha, Obonyo, Hussein, Githuku, Owiny, and and Gura, (2020) on
knowledge, attitude and practices on cholera in an arid county – Kenya, it was found that the

17
people who participated had a high knowledge score on cholera with gaps in preventive
practices. This study which was a cross-sectional study that used a mixed-methods approach
which included a questionnaire survey and focus group discussions (FGDs) was carried out using
428 participants of which 372 (86.9%) were females.

More so, using multistage sampling with household as the secondary sampling unit, interviewers
administered structured questionnaires to one respondent per household with age ≥18 years.
Results of data analysis in more specific details revealed that of the 425/428 (99.3%) who had
heard about cholera, 311/425 (73.2%) knew that it is communicable. Although 273/428 (63.8%)
respondents knew the importance of treating drinking water, only 216/421 (51.3%) treated
drinking water. Those with good defecation practice were 209/428 (48.8%). Respondents with
high knowledge score were 227/428 (53.0%). Positive attitude (aOR = 2.88, 95% C.I = 1.34–
6.20), treating drinking water (aOR = 2.21, 95% C.I = 1.47–3.33), age <36 years (aOR = 1.75,
95% C.I = 1.11–2.74) and formal education (aOR = 1.71, 95% C.I = 1.08–2.68) were
independently associated with high knowledge score. FGDs showed poor latrine coverage,
inadequate water treatment and socio-cultural beliefs as barriers to cholera prevention and
control.

Furthermore, in the study by Ali, Mohamed, and Tawhari, (2021) on knowledge, attitude, and
practice of people in Jazan, Saudi Arbaia toward cholera infections, it was found that the level of
knowledge is poor. This study which used a self-administered structured questionnaire
distributed via online link was carried out using 400 participants. The mean score for knowledge
section was 1.86 ± 0.990, for practice section was 5.07 ± 1.353, and for attitude section was 6.14
± 2.346, that were all below average rating. In addition, there was statistically significant
difference (P-value = 0.003) between different educational levels, with a positive correlation
between educational level and level of knowledge about cholera. There was a statistically
significant difference (P-value = 0.034) between different genders. Females showed a
significantly improved practice towards cholera infection.

A strong knowledge base of something helps the brain to function smoothly and more
effectively. It sharpens reasoning and problem-solving skills in any subject matter. Thus,
knowledgeable individuals are smarter and solve problems more easily. Mothers play very

18
important roles in the family cycle and as such, should be well equipped with relevant
knowledge on current health issues that may affect the lives of every individual in the home.

2.3.2 Community Attitude

Attitude as earlier defined is a feeling, a settled way of thinking or acting towards a thing,
situation or person that affects an individuals’ behavior at any given point in time. This settled
way of thinking helps organize and structure our experience and ultimately influences all our
actions. More so, an individual’s attitude gives direct insight into his or her thoughts, beliefs, and
emotions in each moment while the quality of our perception is determined by our attitude.
Ayenigbara, Ayenigbara and Adeleke, (2019) carried out a study on contemporary Nigerian
public health problem with emphasis on prevention and surveillance as key to combating
cholera. The review which focused on cholera outbreak in Nigeria in 2017/2018 found that the
lethality of cholera is up to 70% a recommended a multifaceted approach such as public policy,
surveillance, water purification and hygiene, community sensitization, and the use of oral cholera
vaccination (OVC) as vital measures to prevent, control, and reduce the cholera mortality rate.

Cholera is a deadly disease and a multifaceted approach of political will on the part of the
government, surveillance, water purification and hygiene, community sensitization, and oral
cholera vaccination are vital to prevent, control, and to reduce the rate of deaths from cholera.
Furthermore, Attitudes provide meaning (knowledge) for life, as such, public health education
and adherence to appropriate and basic sanitation practices, for example hand washing, are of
primary importance to help prevent and control transmission of cholera and other diseases. The
study by Ali, Mohamed, and Tawhari, (2021) on knowledge, attitude, and practice of people in
Jazan, Saudi Arabia toward cholera infections found that prevention of cholera is highly
dependent on the knowledge and attitude of the general population toward the symptoms and
preventive measures of the diseases.

2.3.3 Community Preventive measures

In contrast to disease treatment, preventive measures are actions intended to ward off illness. The
primary, secondary and tertiary prevention levels are the usual categories used to define
preventive care practices. Preventive health measures include a range of actions that can be
performed to stop or halt the spread of disease, as well as to lessen future exposure to it. The

19
identification and treatment of potential health issues before their emergence is made possible in
many cases, by preventive health measures, which are a significant component of efforts to
promote good health. Cholera affects communities already burdened with a lack of
infrastructure, poor health systems and affected by crises.

Any global map of poor water and sanitation services, and high levels of poverty and insecurity,
is essentially similar to the map of cholera burden (Legros, Lessler, Moore, Luquero, McKay et
al, 2018). The cornerstones of cholera prevention are access to clean water and proper
sanitation. However, in environments or communities with little resources. These can be
challenging to implement. More than 2 billion people do not have access to clean water or
adequate sanitation, putting them at risk for cholera and other water-borne illnesses (WHO,
2017). Breast feeding of young infants in endemic settings protects against cholera and other
enteric infections).

2.3.4 Mothers or Women and Infectious Diseases

A mother is the female parent of a child who provides care and plays the role of a teacher in
every aspect of a child's developmental growth and as such, the mother-child relationship is vital
for the healthy development of children. In most homes, apart from the skills and abilities which
the women bring to bear in the day to day running of the home; she equally creates awareness on
most burning issues in the society. In the study by Gerberding, (2004) on women and infectious
diseases, it was found that, women are at higher risk for many infectious diseases and have more
severe course of illness than men. Some of the reasons postulated for the increase risk of women
to diseases are biologic differences, social inequities, and restrictive cultural norms. As such, the
researcher opined that measures be put in place to recognize and reduce health disparities among
women as it has particular relevance for global health.

In another study by Periago, Fescina, and Ramón-Pardo, (2004) on steps for preventing
infectious diseases in women, it was found that poor women in rural areas are mainly affected by
communicable diseases. The researchers stated that for prevention of infectious diseases in
women, a gender perspective must be incorporated into infectious disease analysis and research
should target policies and programs. More so, models must be developed and implemented that
address gender inequities while outreach activities must be supported using information,

20
education, advocacy and training as well as other communication strategies. In addition, health
policies must be changed, social restrictions that circumscribe women eliminated, and active
participation of civil society groups.

A good approach to approach to getting individuals involved in effective disease prevention,

control and transmission is imparting requisite knowledge, attitude and creating awareness. This
present study is a step in this direction.

2.3.5 Conceptual Framework

Knowledge Attitude Practice

Familiarity Feasibility- how convenient
is the preventive measures?
And
Agreement
Awareness

What is cholera? Motivation

Symptoms of cholera?

Causes of cholera? Perceived Self- Efficacy

Appropriate treatments

For cholera? Outcome Expectancy

21
2.4 Empirical Review

Cholera still remains a public health threat worldwide particularly in countries where access to
safe water, modern waste management facilities and good sanitation practice is poor. In the study
by Zheng, Luquero, Ciglenecki et al (2022) on Cholera outbreaks in sub-Saharan Africa during
2010-2019 using a descriptive analysis, it was found that within the study time frame there were
999 suspected cholera outbreaks in 744 regions across 25 sub-Saharan African countries. The
outbreak periods accounted for 1.8 billion person-months (2% of the total during this period)
from January 2010 to January 2020 and among the 692 outbreaks reported from second-level
administrative units (e.g., districts), the median attack rate was 0.8 per 1000 people (interquartile
range (IQR), 0.3-2.4 per 1000), the median epidemic duration was 13 weeks (IQR, 8-19), and the
median early outbreak reproductive number was 1.8 (range, 1.1-3.5). Larger attack rates were
associated with longer times to outbreak peak, longer epidemic durations, and lower case fatality
risks. The researchers concluded that the result is a good baseline from which the progress
toward cholera control and essential statistics to inform outbreak management in sub-Saharan
Africa can be monitored.

In terms of knowledge, attitude and prevention of cholera, a cross-sectional study in Dhaka,

Bangladesh by Wahed, Kaukab, Saha, et al (2013) on Knowledge of, attitudes toward, and
preventive practices relating to cholera and oral cholera vaccine among urban high-risk groups,
the results of data analysis showed that out of 2,830 families included in the final analysis, 23%
could recognize cholera as acute watery diarrhea and 16% had never heard of oral cholera
vaccine. About 54% of the respondents had poor knowledge about cholera-related issues while
97% had a positive attitude toward cholera and oral cholera vaccine. One-third showed poor
practice relating to the prevention of cholera. The findings showed a significant (p < 0.05)
association between the respondents’ knowledge and sex, education, occupation, monthly overall
household expenditure, attitudes and practice. In the adjusted model, lower monthly overall
household expenditure and less positive attitude by the male gender were significant predictors
to having poor knowledge toward cholera. As such the researchers suggested the strengthening
of health education activities to improve knowledge on cholera, its prevention and treatment as
well as adequate dissemination of information on cholera vaccination among high-risk
populations.

22
In a similar study by Ali, Mohamed and Tawhari (2021) designed to explore the level of
knowledge as well as attitude and practice of people in Jazan, Saudi Arbaia toward cholera
infections which used a self-administered structured questionnaire distributed via online to 400
participants showed poor level of knowledge of the subject matter. In the results of data analysis,
the mean score for knowledge section was 1.86 ± 0.990, for practice section was 5.07 ± 1.353,
and for attitude section was 6.14 ± 2.346, all of which were below average rating. There was
statistically significant difference (P-value = 0.003) between different educational levels, with a
positive correlation between educational level and level of knowledge about cholera. There was a
statistically significant difference (P-value = 0.034) between different genders. Females showed
a significantly improved practice towards cholera infection.

Furthermore, looking at the Nigerian perspective, the study by Idoga, Toycan and Zayyad,
(2019) on analysis of factors contributing to the spread of cholera in developing countries carried
out in Benue State which examined the various factors that contribute to the infection and spread
of cholera from 2008 to 2017 showed that terrorism, floods, improper sewage disposal, and lack
of environmental hygiene were the main causes of the spread of cholera in that region.
Therefore, researchers recommended that donor agencies and the government should channel
their focus and prepare ahead in view of any other emergency outbreak.

Cholera from most of the literature discussed in the background to this study and reviewed thus
far is endemic in Africa and major parts of Nigeria, as such a multifaceted approach is necessary
to preventing, controlling, and reducing the mortality rate during outbreak periods. In the South-
Eastern part of Nigeria, the study by Eyisi, Nwodo and Iroegbu (2013) on distribution of vibrio
species in shellfish and water samples collected from the Atlantic coastline of South-East of
Nigeria showed that the shellfish (crayfish and lobster) harvested from waters of the Atlantic
coast were heavily contaminated with Vibrio species; Vibrio counts were estimated to be as high
as 104 -109 cfu/g. Samples of the water habitat from where the shellfish was harvested were
equally heavily contaminated with Vibrio counts reaching 107 –109 cfu/ mL in some places.

The outbreak of suspected cholera cases reported in Nkpukpuevule ward in Ugwunagbo LGA,
Abia State on the 11th of September 2021 and some other neighbouring communities suggest that
more still need to be done. The investigation carried out by WHO staff and SMoH reviled 40
suspected cases of Cholera with two deaths. The suspected cases presented with frequent rice,

23
white and watery stool, vomiting, cramp, weakness, and black stool with slight blood. Therefore,
this study aims to investigate on knowledge, attitude and preventive measures towards cholera of
mothers in Ugwunagbo Local Government Area; Abia State will be of immense benefit to
mothers with a view of proffering more sustainable approach to cubing the problem.

24
 CHAPTER THREE

METHODOLOGY

3.1 Research Design

This study adopted a cross-sectional research design. A cross-sectional research study is one in
which data is collected from many different individuals at a single point in time so as to observe
certain variables without influencing them. It involves looking at data from a population at one
specific point in time and the participants are selected based on particular variables of interest
(Simkus, 2021) – an approach which was taken in this study.

3.2 Description of the Study Area

This research work was carried out in Ugwunagbo Local Government Area of Abia State.
Abia is a state in the South Eastern part of Nigeria with the capital at Umuahia, and Aba as one
of the major commercial city. It is located on latitude 5.4527° N and longitude 7.5248° E and
bordered by Enugu and Ebonyi States to the North, Akwa Ibom to the East and
Southeast, Rivers to the South and Southwest, and Imo and Anambra to the West.

The State has one Federal University of Agriculture by the name Michael Okpara Univiersity of
Agriculture located at Umudike and one State University by the name Abia State University at
Uturu. There is also a College of Education at Arochukwu. Abia State has a lot of oil-palm bush
and tropical rain forest in its Southern part and woodland savanna in its hilly North. Mineral
resources available in the state includes Lead and Zinc and this geographical space is mainly
inhabited by the Igbo (Ibo) people. Abia State is one of Nigeria's most densely populated areas
with a rich culture and history.

Ugwunagbo is one of the 17 local government areas located in the Southern part of the state. It is
a suburb of Aba on the coordinates of 4°59′4.1053″N 7°19′32.82″E. Towns and villages that
make up Ugwunagbo LGA includes Ihie, Obuzo, Ngwayiekwe, Obegu, Asa-Umunka, Amaokpu
Umuitiri, and Amapu-uke. It has an area of 108 km2 and a population of 97,710 according to the
2011 national census. However current information available online indicates that the area has

25
163,732 inhabitants. The Igbo language is commonly spoken and Christian religion is
extensively practiced in the area.

Some health and environmental agencies in the State includes - Abia State Environmental and
Protection Agency (ASEPA), Abia State Ministry of Health and Ministry of Environment.

3.3 Study Population

The estimated population of Ugwunagbo LGA is put at 126,569 inhabitants (WHO Umuahia,
2022) made up of men, women and children. However, the target population will consist of all
women of reproductive age (18-49) who are pregnant or have given birth within the study time
frame. According to the data obtained from WHO Umuahia, the women of reproductive age
within the stipulated age bracket or have given birth as at December, 2022 are 6,326. (WHO
Umuahia, 2022).

Inclusion Criteria:

 Should be within the age bracket of 18-49

 Must be resident in any of the stratified communities/towns in Ugwunagbo LGA
 Must have had at least a child

Exclusion Criteria:

 Women within the age of 18-49 but without a child

 Women that are visiting – not resident in the LGA

3.4 Sample Size

The sample size for this study is 381 women of reproductive age (18-49) who have given birth to
at least one child or are pregnant. This figure was determined using the Cochran’s formula for
sample size determination as stated below:

Formula for calculating a sample for proportions: n 0= Z2 pq/e2

Where,

26
P = 0.5, Z= 1.96, q = 1-p (1-0.5= 0.5), e = 95% i.e., 0.05

n 0 = (1.96)2 * 0.5 * 0.5 / (0.05)2 = 385

Formula for calculating sample size for finite population correction for proportions:

n0
n=
(n0−1)
1+
N

Where,

n = Sample size, n o= 385, N (Total population of the wards chosen randomly): 39,988

385
n= 1+ (385−1) = 381.33
39988

Approximately = 381.

3.5 Sample Technique/Sample Procedure

This study adopted multi-stage sampling techniques.

 In the first stage, simple random sampling technique was used to select 4 wards out of the
15 wards in Ugwunagbo LGA, Umuahia, Abia State. The wards were selected without
bias using the random number generator function in Google using the population data
obtained from a WHO Local Government Area Facilitator in Umuahia, Abia State. The
wards selected through the random number generator after 8 trials are - Asa Amauhi, Asa
Umunka, Ihie Obuaku and Ihie Ukwu.
 In the second stage, after selecting the wards, household sampling technique was used to
select the houses in each ward. The selection process began at the center of each ward
where a pen or pencil was spun in a clockwise direction to determine which direction to
start the house-to-house sampling process based on the calculated number of women to
sample in each ward with regards to the sample size in order to achieve good coverage.
To achieve proper coverage of the 4 wards selected, the number of women to access in
each ward for the house-to-house sampling was determined using the sum total

27
 population of the 4 wards selected randomly, the population of each ward and the sample
size determined. Population data on the residents of Ugwunagbo Local Government
Area was obtained from the WHO_LGAF of Ugwunagbo Local Government Area.
Formula used for calculation:
Total population ∈the ward
∗Sample ¿ ¿
∑ total population of the 4 wards selected randomly
Where,
Sum total population of the 4 wards to be accessed: 39988
Sample size: 381
Total population in Asa Amauhi: 7771
Total population in Asa Umunka: 12381
Total population in Ihie Obuaku: 6185
Total population in Ihie Ukwu: 13650
7771
Number of women to access in Asa Amauhi: ∗381=74
39988
12381
Number of women to access in Asa Umunka: ∗381=118
39988
6185
Number of women to access in Ihie Obuaku: ∗381=¿ 59
39988
13650
Number of women to access in Ihie Ukwu: ∗381=¿ 130
39988
 In the third stage, purposive sampling technique was used to select in line with the
inclusion criteria all the women within the age bracket of 18-49 who have at least one
child or are pregnant within the 4 wards to participate in the study during the house-to-
house sampling. Any household without women who met these inclusion criteria and or
declined to participate where an eligible woman resides was skipped and a move to the
next household was made.

3.6 Data Collection Method/Instrument for Data Collection

The instrument for data collection was a questionnaire titled “Knowledge, Attitude and
Preventive Measures of Mothers towards Cholera (KAPMTC)” adapted from Ali, Mohammed
and Tawhari, 2021. The questionnaire has 4 sections; Section A- Socio-demographic variable -

28
Age, marital status, religion, and ethnicity; Section B- Knowledge on Cholera with 23 items,
Section C- Attitude towards Cholera with 16 items and Section D- Preventive measures towards
Cholera with 7 items.

Section B was scored using dichotomous scale with the response options of True =1 and False =
0; Section C was scored according to a 4-point Likert Scale of strongly agree = 4, agree =3,
strongly disagree=2 and disagree= 1; while Section D was scored using the response options of
always= o, most times= 1, commonly= 2, rarely= 3 and never=4, which is a 5-point Likert scale.

3.7 Validity

In order to find out the extent to which the research instrument measures what it is designed to
measure, face validity which is a type of content validity was carried out (Alen & Yen, 1979;
Thatcher, 2010; Pallant, 2011; Mohajan, 2017). Content validation of the questionnaire for this
study is necessary because the researcher needs to establish that the items under each sub-section
of the research instrument correctly measure the problem under study.

Therefore, the validation was carried out by the researcher’s supervisor, two randomly selected
lecturers in the Public Health Department of Babcock University and a staff of WHO office in
Umuahia, Abia State in line with the objectives of the research. More so, the validators equally
checked for ambiguity and indicated items that were irrelevant to the study. Any irrelevant or
extraneous items was removed or revised where necessary.

3.8 Reliability

To determine the degree to which the research instrument will produce stable and consistent
results, the researcher calculated the internal consistency of the items in the questionnaire using
Cronbach Alpha statistic. According to De vellis (2006), internal consistency is a measure of
reliability used to evaluate the degree to which different test items that probe the same construct
produce similar results.

Put differently, internal consistency examines whether or not the items within a scale or measure
are homogeneous (Mohajan, 2017). Thus, using Cronbach Alpha test statistics, the reliability
index of 0.78 was obtained for the section on knowledge of cholera, 0.92 for attitude towards
cholera and 0.84 for preventive practices of mothers towards cholera. The overall reliability

29
index of the instrument was calculated as 0.88. These values which are greater than the pre-set
acceptable limit of >=0.70 were obtained after the trial test of the instrument using 10% of the
sample size. Therefore, the research instrument was adjudged to be reliable.

3.9 Data Collection Procedure

The researcher gathered data from the field with the help of two research assistants. These
research assistants were recruited from the WHO office of which one of them is the Disease
Surveillance Officer (DSNO) of Ugwunagbo Local Government Area where the study was
carried out and the second person is the Office Assistant (OS) in WHO office, Umuahia, Abia
State. To achieve this, a letter introducing the researcher and seeking for permission to carry out
the study in the selected wards was taken to the Head of the Primary HealthCare Centre, the
Ward Focal Person and the Community Head of Ugwunagbo Local Government Area.

Furthermore, the researcher and the two research assistants worked closely with the Ward Focal
Person and the Community Mobilizers/ Volunteers organized by the Community Head. The
structured questionnaires were administered with adequate guidance on how the questionnaires
should be filled. In addition, eighty –one (81) translated Igbo version of the research instrument
was administered to sampled respondents who were more literates in the Igbo language than the
English language. The final response rate after data collection and cleaning of eligible
respondents was 99.7% (380 respondents).

3.10 Data Management and Data Analysis

All questionnaires were checked for complete filling of the different sections during the process
of administration while in terms of data analysis; data was analyzed using appropriate test
statistic in line with the stated research questions and hypotheses, particularly descriptive
statistics such as mean and standard deviation. Frequency counts/graphs and percentages were
equally used. The IBM SPSS Statistics version 25 was applied after data have been coded and
inputted into the statistical package.

For each research questions, simple descriptive statistics such as mean, frequency count and
percentages was used to provide answers to them while the hypotheses were tested using Person
Product Moment Correlation and Chi-Square Statistic as shown in Table4.1 to 4.5.

30
Table 3.10.1: Test statistic per research questions and hypothesis

S/n Objectives Research questions Hypothesis Test statistics

1 To determine the level of What is the mother’s N/A Mean, frequency
knowledge on Cholera level of knowledge on counts and
disease of mothers in Cholera in percentage
Ugwunagbo LGA, Abia Uguwunagbo LGA,
State. Abia State?
2 To determine the attitudinal What is mother’s N/A Mean, frequency
disposition towards Cholera attitudinal disposition counts and
disease of mothers in towards Cholera in percentage
Ugwunagbo LGA, Abia Ugwunagbo LGA,
State. Abia State?
3 To outline the preventive What are the N/A Mean,
measures put in place preventive measures frequency counts
towards Cholera disease by put in place towards and percentage
mothers in Ugwunagbo Cholera disease by
LGA, Abia State. mothers in Ugwunagbo
LGA, Abia State?
4 To assess the relationship How does knowledge There is significant Pearson’s
between knowledge and correlate with association between Product Moment
attitudinal disposition attitudinal disposition the knowledge and Correlation
towards Cholera disease of towards Cholera attitudinal disposition
mothers in Ugwunagbo disease of mothers in towards Cholera by
LGA, Abia State. Ugwunagbo LGA, mothers in
Abia State? Ugwunagbo LGA,
Abia State.
5 To determine the association How does Knowledge There is significant Pearson’s
amongst knowledge, correlate with the association between Product Moment
attitudinal disposition and preventive measures the knowledge and Correlation
preventive measures of put in place by mothers the preventive
mothers towards Cholera against Cholera in measures of mothers
disease with reference to Ugwunagbo LGA, towards Cholera in
designation in Ugwunagbo Abia State? Ugwunagbo LGA,
LGA, Abia State Abia State.

31
32
Measures of Data collected

Knowledge on Cholera

The level of knowledge of mothers on cholera disease in the study area was investigated using a
3-point scale questionnaire with 23-items and the response options of “True, False and I Do Not
Know”. The correct response was coded 2 and incorrect response coded 1. However, lack of
knowledge of the statements was coded 0. Thus, under this measure, the maximum score for
each respondent was 46 while the minimum was 0. And using a mean point range of 31 – 46
(Positive Knowledge), 15.5 – 30.5 (Fair Knowledge) and 0 – 15 (Poor Knowledge); a decision
was taken.

The decision rule applied was that if the mean value computed using IBM SPSS version 25 was
within the range of 31 – 46, then the mothers have good knowledge, 15.5 – 30.5 implies that the
mothers have fair knowledge while 0 – 15 means that the mothers have poor knowledge of the
disease - cholera. Data gathered from the field were analyzed using frequency count, simple
percentages, mean and standard deviation.

Attitudinal Disposition

Attitudinal disposition of mothers towards cholera was investigated using a 4-point Likert Scale
questionnaire with 17-items and the response options of “Strongly Agree, Agree, Disagree, or
Strongly Disagree coded 4, 3, 2, 1 respectively. In this measure, the maximum score for each
respondent is 68 while the minimum is 1. Using a mean point range of 46 – 68 (Positive
Attitude), 23.5 – 45.5 (Fair Attitude) and 1 – 23 (Poor Attitude); a decision was taken.

The decision rule applied was that if the mean value computed using IBM SPSS version 25 was
within the range of 46 – 68, then the mothers have positive attitude, 23.5 – 45.5 implies that the
mothers have fair attitude while 1 – 23 means that the mothers have poor attitude of the disease -
cholera. Data gathered from the field were analyzed using frequency count, simple percentages,
mean and standard deviation.

33
Preventive measures

The variable preventive measures put in place towards cholera disease by mothers in the study
area was investigated using a 5-point Likert Scale questionnaire with 7-items and the response
options of “Always, Most Times, Commonly, Rarely and Never” coded as 4, 3, 2, 1, and 0
respectively. The maximum score for each respondent in this section is 28 while the minimum is
0. Using a mean point range of 19 – 28 (Satisfactory), 9.5 – 18.5 (Fair) and 0 – 9
(Unsatisfactory); a decision was taken.

The decision rule applied was that if the mean value computed using IBM SPSS version 25 was
within the range of 19 – 28, then the mothers have satisfactory preventive measures put in place,
9.5 – 18.5 implies that the mothers have fair preventive measures put in place while 0 – 9
means that the mothers have poor preventive measures put in place towards cholera disease. Data
gathered from the field were analyzed using frequency count, simple percentages, mean and
standard deviation.

3.11 Ethical Considerations

Ethical approval of the research proposal was obtained from the Babcock University Health
Research Ethics Committee (BUHREC) upon review of the study protocol to permit the conduct
of this research and ensure the safety of participants’ autonomy, informed consent,
confidentiality, information, etc. thereby ensuring regulation of the research procedure and the
protection of rights of participants.

In addition, each participant was required to sign and submit a dully completed consent form
before the questionnaire was administered to them. The Consent form which was dully
completed by the participants served as an official permission for the sampled individuals to
participate in the study. Find attached a copy of the consent form in the appendix (sample of
consent form used for health survey).

34
35
 CHAPTER FOUR

RESULTS

4.0 Introduction

In this chapter, the results of data analysis and findings are presented. The presentations were
done under the following sub-headings - socio-demographic profile of respondents, knowledge
of mothers on cholera, mother’s attitudinal disposition towards cholera, preventive measures put
in place towards cholera disease by mothers and test of hypotheses. In all, three research
questions were answered and two alternate hypotheses tested for significance at 0.05 level. A
total of three hundred and eighty (380) questionnaires correctly completed were used for data
analysis. This yielded 99.74% response rate

4.1. Socio-demographic Profile of Respondents

This study was carried out using women who have given birth to at least a child and are within
the age bracket of 18 – 49 years. Using a class size of 7, the women within the ages of 18 – 24
were 59 (15.5%), 25 – 31 were 114 (30%), 32 – 38 were 71 (18.7%) and 39 – 45 were 94
(24.7%). Respondent who were 46 years and above were 42 (11.1%). A closer look at the age
distribution of the respondents showed that they were mostly within the age bracket of 25 to 31
(30%) which is in line with the mean age requirement for the study (18 + 49 = 33.5 ± 5).

In terms of religion, Christianity was the most represented religion while the most represented
ethnic group was Igbo (93.2%). However, 13 (3.4%) were of the Ibibio – Akwa Ibom State
origin. Akwa Ibom State is a neighboring State to Abia State sharing boundary with her to the
East. The demographics in terms of marital status revealed that 82 (21.6%) are single mothers,
244 (64.2%) are married, 33 (8.7%) are divorced and 21 (5.5%) are widowed. Finally, their
designation (i.e. their source of daily income or livelihood) showed that 245 (64.5%) were
employed and 135 (35.5%) were not employed (full time house wives). The full details of their
socio-demographics profiles are as presented in Table 4.1

36
Table 4.1: Socio-demographic profile of respondents

S/n Variables Frequency(n) Percentage%

1 Age
18 - 24 years 59 15.5
25 - 31 years 114 30
32 - 38 years 71 18.7
39 - 45 years 94 24.7
46 – 49 years 42 11.1
2 Ethnicity
Igbo 354 93.2
Hausa 8 2.1
Yoruba 5 1.3
Others(Ibibio) 13 3.4
3 Religion
Christianity 378 99.5
Islam 2 0.5
Traditional 0 0
Other 0 0
4 Marital Status
Single Mother 82 21.6
Married 244 64.2
Divorced 33 8.7
Widow 21 5.5

4.2: DESCRIPTIVE STATISTICS OF INDEPENDENT AND DEPENDENT VARIABLES

4.2.1: Descriptive Statistic of Mothers Knowledge on Cholera

A global look at the item-to-item analysis of the questionnaire statements measuring mothers’
knowledge on cholera showed that 326 (85.8%) respondents affirmed that cholera spread

37
 through contaminated water. This questionnaire item which is serial number 2 on the knowledge
section agreed with the responses given to item number 9 which state that unsafe water sources
are the causes of cholera. The item which states that vomiting is a symptom manifestation of
cholera was equally highly affirmed by 326 (85.8%) respondents. Other question statements
which received high positive affirmation are cholera spreads through poor hygiene - 310
(81.6%), diarrhea is a symptom manifestation of cholera - 312 (82.1%), poor sanitation leads to
the spread of cholera - 307 (80.8%). However, the question statement that cholera is a
punishment from God received the least affirmation as shown in Table 4.2.1.

Table 4.2.1: Results of item-to-item percentage analysis of mothers’ knowledge on cholera

S/n Statements True False I Do Not
Know
1 Cholera spreads from one person to another. 146 (38.4%) 91(23.9%) 143 (37.6%)
2 Cholera spreads through drinking contaminated 326 (85.8%) 28 (7.4%) 26 (6.8%)
water.
3 Cholera spreads through flies and mosquitoes’ bites. 148 (38.9%) 125 (32.9%) 107 (28.2%)
4 Cholera spreads by having poor hygiene. 310 (81.6%) 36 (9.5%) 34 (8.9%)
5 Poor sanitation leads to the spread of cholera. 307 (80.8%) 41 (10.8%) 32 (8.4%)
6 Diarrhea is a symptom manifestation of cholera. 312 (82.1%) 23 (6.1%) 45 (11.8%)
7 Vomiting is a symptom manifestation of cholera. 326 (85.8%) 33 (8.7%) 21 (5.5%)
8 Cholera causes death through dehydration. 267 (70.3%) 58 (15.3%) 55 (14.5%)
9 Unsafe water sources are a cause of cholera. 329 (86.6%) 27 (7.1%) 24 (6.3%)
10 Antibiotics are an effective treatment for cholera. 195 (51.3%) 67 (17.6%) 118 (31.1%)
11 Oral rehydration solution (ORS) is used to treat 222 (58.4%) 58 (15.3%) 100 (26.3%)
cholera.
12 Cholera is common in Nigeria. 269 (70.8%) 46 (12.1%) 65 (17.1%)
13 Cholera can spread through the air. 106 (27.9%) 141 (37.1%) 133 (35.0%)
14 Cholera is a poison released by the wealthy to the 48 (12.6%) 251 (66.1%) 81 (21.3%)
poor.
15 Cholera is spread through bacteria. 180 (47.4%) 107 (28.2%) 93 (24.5%)
16 Cholera affects only children. 60 (15.8%) 250 (65.8%) 70 (18.4%)
17 Cholera is spread through viruses. 95 (25.0%) 138 (36.3%) 147 (38.7%)
18 Cholera is a punishment from God. 34 (8.9%) 270 (71.1%) 76 (20.0%)
19 Cholera has been completely eliminated. 63 (16.6%) 222 (58.4%) 95 (25.0%)
20 Cholera affects all age groups. 274 (72.1%) 63 (16.6%) 43 (11.3%)
21 Cholera affects only older persons or adults. 66 (17.4%) 245 (64.5%) 69 (18.2%)
22 Cholera can be contracted from persons in a single 166 (43.7%) 153 (50.3%) 61 (16.1%)
household.
23 Consumption of fishery products increases risk of 76 (20.0%) 166 (43.7%) 138 (36.3%)
cholera.

38
4.2.2: Descriptive Statistic of Mothers’ Attitudinal Disposition towards Cholera

Generally, the results of item-to-item analysis of the questionnaire section measuring mothers’
attitudinal disposition towards cholera showed that 230 (60.5%) respondents affirmed that hands
should be washed before taking any food. In the same perspective, 226 (59.5%) respondents
agreed that poor washing habits at home will promote the spread of cholera which equally
correlates with the item statement in serial number 2 that says- poor hand washing habits in
public places will promote the spread of cholera as 224 (58.9%) affirmed this statement. The
least positively rated item was serial number 8 which state that the presence of animal feces will
encourage the spread of cholera - 132 (34.7%). The comprehensive responses of the respondents
are as presented in Table 4.2.2.

39
 Table 4.2.2: Results of item-to-item percentage analysis of mothers’ attitudinal disposition
towards cholera
S/n Statements Agree Strongly Disagree Strongly
agree disagree
1 Drinking water from the community river can 185 39 64 92
make a person to contract cholera disease. (48.7%) (10.3%) (16.8%) (24.2%)
2 Poor hand washing habits in public places will 224 89 39 28 (7.4%)
promote the spread of cholera. (58.9%) (23.4%) (10.3%)
3 Poor washing habits at home will promote the 226 88 54 12 (3.2%)
spread of cholera. (59.5%) (23.2%) (14.2%)
4 Inappropriate use of latrines will encourage the 175 134 55 16 (4.2%)
spread of cholera. (46.1%) (35.3%) (14.5%)
5 Staying in an unhygienic environment makes a 190 135 40 15 (3.9%)
person vulnerable to cholera. (50.0%) (35.5%) (10.5%)
6 Vaccination can keep a person safe from 162 111 85 22 (5.8%)
cholera disease. (42.6%) (29.2%) (22.4%)
7 To me, the burying of feces (Poop) of babies in 119 60 107 94
the sand will encourage the spread of cholera. (31.3%) (15.8%) (28.2%) (24.7%)
8 The presence of animal feces will encourage 132 42 117 89
the spread of cholera. (34.7%) (11.1%) (30.8%) (23.4%)
9 Drinking from local wells will encourage the 151 67 76 86
spread of cholera. (39.7%) (17.6%) (20.0%) (22.6%)
10 Funeral cultural practices like drinking water 165 93 96 26 (6.8%)
washed from the corpse promote the spread of (43.4%) (24.5%) (25.3%)
cholera.
11 Immunizations are effective in the prevention 205 116 50 9 (2.4%)
of disease. (53.9%) (30.5%) (13.2%)
12 Cholera vaccination may have side-effects. 129 82 138 31 (8.2%)
(33.9%) (21.6%) (36.3%)
13 I believe that our hands should be washed with 171 157 35 (9.2%) 17 (4.5%)
soap and or ash after defecation. (45.0%) (41.3%)
14 Hands should be washed before taking any 230 136 10 (2.6%) 4 (1.1%)
food. (60.5%) (35.8%)
15 Cholera is a very serious disease for children. 171 166 37 (9.7%) 6 (1.6%)
(45.0%) (43.7%)
16 Cholera is a very serious disease for adults. 179 127 60 14 (3.7%)
(47.1%) (33.4%) (15.8%)
17 Good sanitation practices are effective against 155 190 23 (6.1%) 12 (3.2%)
cholera. (40.8%) (50.0%)

4.2.3: Descriptive Statistic of Preventive Measures put in Place towards Cholera Disease by
Mothers

40
The descriptive analysis of the questionnaire section measuring preventive measures put in place
towards Cholera disease by mothers showed that 279(73.4%) respondents agreed that to
thoroughly clean our house environment regularly is a preventive measure towards cholera in the
family. Mores so, 269 (70.8%) respondents opined that garbage generated should be collected in
bags and thrown away in approved places to prevent the outbreak of cholera. Furthermore,
enforcing flushing of the toilets after use by every member of the household was also rated
highly - 263(69.2%) as a good preventive measure against cholera disease. However, the use of
traditional medicine on members of household by mothers to keep cholera away was poorly rated
- 105(27.6%) as shown in Table 4.2.3.

41
 Table 4.2.3: Results of item-to-item percentage analysis of preventive measures put in place
towards Cholera disease by mothers

S/n Statements Always Most times Commonly Rarely Never

1 Traditional medicine is 107(28.2%) 71(18.7%) 32 (8.4%) 65(17.1%) 105(27.6%)

administered to members of
my household to keep cholera
away.

2 Washing hands with soap and 238(62.6%) 84(22.1%) 31(8.2%) 13(3.2%) 143(3.7%)
clean water before doing
anything is a regular practice
in my house.

3 We thoroughly clean our 279(73.4%) 54(14.2%) 29(7.6%) 7(1.8%) 11(2.9%)

house environment regularly
in my family.

4 Water is stored in clean and 249(65.5%) 76(20.0%) 34(8.9%) 13(3.4%) 8(2.1%)

airtight bottle to avoid
contamination.

5 In my house, garbage 269(70.8%) 50(13.2%) 32(8.4%) 20(5.3%) 9(2.4%)

generated is collected in bags
and thrown away in approved
places.

6 I enforce the flushing of the 263(69.2%) 60(15.8%) 39(10.3%) 9(2.4%) 9(2.4%)

toilets after use by every
member of my household.

7 Buying of food from public 148(38.9%) 116(30.5%) 59(15.5%) 31(8.2%) 26(6.8%)

vendors is discouraged in my
house.

42
4.3: Research Questions

4.3.1: Respondents Knowledge on Cholera

Research Question 1: What is the mother’s level of knowledge on Cholera in Ugwunagbo

LGA, Abia State?

The level of knowledge of mothers on cholera disease in Ugwunagbo LGA was investigated
using a 3-point scale questionnaire with the response options of “True, False and I Do Not
Know”. Under this section, the maximum score for each respondent was 46 while the minimum
was 0. Thus using a mean point range of 31 – 46 (Positive Knowledge), 15.5 – 30.5 (Fair
Knowledge) and 0 – 15 (Poor Knowledge); a decision was taken.

The decision rule applied was that if the mean value computed using IBM SPSS version 25 was
within the range of 31 – 46, then the mothers have good knowledge, 15.5 – 30.5 implies that the
mothers have fair knowledge while 0 – 15 means that the mothers have poor knowledge of the
disease - cholera. Data gathered from the field were analyzed using frequency count, simple
percentages, mean and standard deviation as presented in Table 4.3.1.

Table 4.3.1: Results of percentage and mean analysis of mothers’ knowledge on cholera

Categorie Points Frequency (n) Percentage Mean SD

s (%)

Good 31 – 46 181 47.6 29.71 4.884

Fair 15.5-30.5 195 51.3

Poor 0 – 15 4 1.1

Total 380 100

From the results of data analysis presented in Tables 4.3.1, the computed mean value of 29.71
which is approximately 30.00 is within the mean range of 15.5 - 30.5 (Fair Knowledge). Thus,
the mothers used as respondents in this study have fair knowledge of cholera disease as the

43
computed mean value for the three categories (Good, Fair and Poor) is within the mean range of
15.5-30.5 (Fair Knowledge).

4.3.2: Mother’s Attitudinal Disposition towards Cholera

Research Question 2: What is mother’s attitudinal disposition towards Cholera in Ugwunagbo

LGA, Abia State?

Data on mothers’ attitudinal disposition towards cholera in Ugwunagbo LGA was investigated
using a 4-point Likert Scale questionnaire with the response options of “Agree, Strongly Agree,
Disagree, or Strongly Disagree. In this section, the maximum score for each respondent is 68
while the minimum is 1. Using a mean point range of 46 – 68 (Positive Attitude), 23.5 – 45.5
(Fair Attitude) and 1 – 23 (Poor Attitude); a decision was taken.

The decision rule applied was that if the mean value computed using IBM SPSS version 25 was
within the range of 46 – 68, then the mothers have positive attitude, 23.5 – 45.5 implies that the
mothers have fair attitude while 1 – 23 means that the mothers have poor attitude of the disease -
cholera. Data gathered from the field were analyzed using frequency count, simple percentages,
mean and standard deviation as presented in Table 4.3.2.

44
Table 4.3.2: Results of percentage and mean analysis of mothers’ attitudinal disposition towards

Cholera

Categorie Points Frequency (n) Percentage Mean SD

s (%)

Positive 46 – 68 335 88.2 49.95 4.258

Fair 23.5-45.5 45 11.8

Negative 1 – 23 0 0

Total 380 100

From the results of data analysis presented in Table 4.3.2, the computed mean value of 49.95
which is approximately 50.00 is within the mean range of 46 - 68 (Positive Attitude). Thus, the
mothers used as respondents in this study have positive attitudinal disposition towards cholera
disease as the computed mean value for the three categories (Positive, Fair and Negative) is
within the mean range of 46 – 68 (Positive Attitude).

4.3.3: Preventive Measures Put in Place towards Cholera Disease by Mothers

Research Question 3: What are the preventive measures put in place towards Cholera disease
by mothers in Ugwunagbo LGA, Abia State?

Data on preventive measures put in place towards cholera disease by mothers in the study area
was investigated using a 4-point Likert Scale questionnaire with the response options of
“Always, Most Times, Commonly, Rarely and Never”. The maximum score for each respondent
in this section is 28 while the minimum is 0. Using a mean point range of 19 – 28 (Satisfactory),
9.5 – 18.5 (Fair) and 0 – 9 (Unsatisfactory); a decision was taken.

The decision rule applied was that if the mean value computed using IBM SPSS version 25 was
within the range of 19 – 28, then the mothers have satisfactory preventive measures put in place,

45
9.5 – 18.5 implies that the mothers have fair preventive measures put in place while 0 – 9
means that the mothers have poor preventive measures put in place towards cholera disease. Data
gathered from the field were analyzed using frequency count, simple percentages, mean and
standard deviation as presented in Table 4.3.3.

Table 4.3.3: Results of percentage and mean analysis of preventive measures put in place
towards Cholera disease by mothers

Categories Points Frequency (n) Percentage Mean SD

(%)

Satisfactory 19 – 28 298 78.4 22.09 4.557

Fair 9.5-18.5 76 20.0

Unsatisfactory 0–9 6 1.6

Total 380 100

From the results of data analysis presented in Table 4.3.3, mothers in the study area have
satisfactory preventive measures put in place towards Cholera disease. More specifically, the
computed mean value of 22.09 for the three categories (Satisfactory, Fair and Unsatisfactory) is
within the mean range of 19 – 28 (Satisfactory).

46
4.4: Test of Hypotheses

Using Pearson Product Moment Correlation test statistic, two null hypotheses were tested at 0.05
significant levels in this study. The decision rule applied was that if the p-value computed is less
or equal to the cut-off significance level of 0.05 (p ≤ 0.05), then the null hypothesis will be
rejected and the alternate accepted. But if it is greater, (p > 0.05), then the null hypothesis will be
accepted and the alternate rejected.

Hypothesis 1

H01: There is no significant association between the knowledge and attitudinal disposition of
mothers towards Cholera in Ugwunagbo LGA, Abia State.

This hypothesis was tested using Pearson Product Moment Correlation formula and the results
are as presented in Table 4.4.1.

Table 4.4.1: Results of correlation between knowledge and attitudinal disposition of mothers

Variables n r df p-value

Knowledge vs Attitudinal Disposition of

Mothers 380 .23 378 .000

** Correlation is significant at the 0.01 level (2-tailed)

A Pearson correlation coefficient was performed to determine the relationship between the
knowledge of mothers and their attitudinal disposition towards cholera in Ugwunagbo LGA,
Umuahia, Abia State. From the results of data analysis presented in Table 4.4.1, the p-value
of .000 is positive but less than 0.05 level of significance; as such, there is a significant weak
positive relationship between the knowledge of mothers and their attitudinal disposition towards
cholera, r ([378]) = [.23], p = [< .001]. Therefore, the null hypothesis is rejected and the
alternative hypothesis is accepted.

Hypothesis 2

H02: There is no significant association between the knowledge and the preventive measures of
mothers towards Cholera in Ugwunagbo LGA, Abia State.

47
This hypothesis was tested using Pearson Product Moment Correlation formula and the results
are as presented in Table 4.4.2.

Table 4.4.2 : Results of correlation between knowledge and preventive measures of mothers
towards cholera.

Variables n r df p-value

Knowledge vs Preventive measures

Mothers 380 .13 378 .012

* Correlation is significant at the 0.05 level (2-tailed)

A Pearson correlation coefficient was performed to determine the relationship between the
knowledge of mothers and their preventive measures against cholera in Ugwunagbo LGA,
Umuahia, Abia State. Looking at the results presented in Table 4.4.2, the p-value of .012 is
positive but less than 0.05 level of significance; as such, there is a significant weak positive
relationship between the knowledge of mothers and their preventive measures towards cholera, r
([378]) = [.13], p = [.012]. Therefore, the null hypothesis is rejected and the alternative
hypothesis is accepted.

48
 CHAPTER FIVE

DISCUSSION, CONCLUSION AND RECOMMENDATIONS

This chapter is presented under the following sub-headings - discussion, conclusion and
recommendations.

5.1 Discussion of Findings

5.1.1 Socio-demographic Profile of the Respondents

The socio-demographic profile of respondents with reference to age showed that they were
mostly within the age bracket of 25 to 31 (30%), 32 to 38 (18.7%) and 18 to 24 (15.5%). In other
words, they were mostly within the high child bearing age which agreed with the findings by
Bolarinwa (2021) whose study showed that prevalence of 59% home deliveries in Nigeria is
among women of reproductive-aged 15-49. It equally agreed with earlier study by Khan, Ali,
Chowdhury, Saha, et al (2017) who opined that women of reproductive age fall within the age
bracket of 15-49 years and pregnant women are vulnerable to complications of cholera.

In terms of ethnic origin, majority of the respondent were Igbo (93.2%). The remaining 3.4%
were of the Ibibio origin - Akwa Ibom State. Akwa Ibom State is a neighboring State to Abia
State sharing boundary with her to the East. All the respondents indicated Christianity as their
religion. This was expected as Christianity is the most represented local religion in the study
area.

5.2 Respondents level of Knowledge on Cholera

This study showed that the respondents had fair knowledge of cholera as evidenced from the
results of mean and percentage analysis presented as the computed mean value was within the
mean range for fair knowledge. In addition, the results of Pearson Product Moment Correlation
statistics presented that tested the relationship between level of knowledge and attitudinal
disposition towards Cholera by mothers showed that there exists a weak positive relationship.

49
This finding is in line with some works reviewed in the literature such as Idoga, Toycan and
Zayyad, (2019); D’Mello-Guyett, Gallandat, Van den Bergh, Taylor, Bulit, Legros, et al (2020)
and Ali, Mohamed and Tawhari, (2021) who found that majority of the respondents had poor
knowledge of the causes of cholera disease and the ingestion of contaminated water or food
remains the principal mode of transmission of cholera.

Other contributing factors are floods, improper sewage disposal and lack of environmental
hygiene. However, the result of this present study is at variance with the study carried out by
Ejike, Ohaeri, Amaechi, Ejike, Oleka, Irole-eze and Belonwu in (2016) in the same study area
which found that majority of the respondents have good knowledge of different causes of
diseases. It also contradicted the study by Orimbo, Oyugi, Dulacha, Obonyo, Hussein, Githuku,
Owiny, and Gura, (2020) who reported that the participants in their study had high knowledge
score on cholera with gaps in preventive practices.

5.3 Mother’s Attitudinal Disposition towards Cholera

Mothers have positive attitudinal disposition towards cholera from the results of data analysis
presented since the computed mean value was within the mean range for positive attitude. More
so, there is a significant association between knowledge and attitudinal disposition of mothers
towards Cholera as shown by the results of Pearson correlation performed to determine the
relationship between the two variables.

This finding agreed with the study conducted by Akel, Sakr, Haddad, Hajj, Sacre, Zeenny,
Safwan, and Salameh, (2023) which revealed that the knowledge of the public toward the
symptoms of a disease correlates with their attitudes to the diseases. In their study, the
researchers found that poor knowledge due to reluctance to seek information about the outbreak
and negative attitudes despite obtaining information from official sources and social media were
responsible for the spread of the disease.

More so, a previous study by Ali, Mohamed, and Tawhari (2021) found that the attitude of the
general population toward the symptoms of a disease plays vital role in the management of that
disease. Attitude which is a settled way of thinking that helps to organize and structure our
experiences and ultimately influence all our actions is correlated with our level of knowledge on
the subject matter. Thus, deliberately planned health education activities for public awareness of

50
certain diseases in order to tackle misinformation and disinformation in our communities is
inevitable.

5.4 Preventive Measures Put in Place towards Cholera Disease by Mothers

In terms of preventive measures, mothers who were sampled and used for this study have
satisfactory preventive measures put in place towards cholera disease since the computed mean
value from the three categories - satisfactory, fair and unsatisfactory fell within the mean range
of satisfactory. This finding contradicts the study by Orimbo, Oyugi, Dulacha, Obonyo, Hussein,
Githuku, Owiny, and Gura, (2020) who found that the participants in their study showed gaps in
preventive practices but have good knowledge of cholera. It equally contradicts the study by
Akpo, Dougnon, Klotoe, Agbankpe, and Bankole, (2021) which found that low levels of hygiene
were the main cause of this disease in their study area.

Furthermore, in the study by Akpo, Dougnon, Klotoe, Agbankpe, and Bankole, (2021), most
household have waste bins but do not subscribe to refuse collection structures. As such, some
respondents throw garbage in unofficial places such as landfills, street, gutters and bushes. In
addition, hand washing was hardly ever done after using the toilet and as a result, members of
the household are not protected from diseases. This aligns with the study by Ejemot-Nwadiaro,
Ehiri, Arikpo, Meremikwu and Critchley (2021) which indicated that promoting the use of soap
and regular hand washing can achieve a 26% to 62% decrease in the incidence of diarrhea in
developing countries.

5.5 Relationship Between Knowledge and Attitude as well as Relationship Between

Attitude and Preventive Measures

From the results of Pearson Correlation performed to determine the relationship between the
variables – knowledge and attitude as well as attitude and preventive measures of mothers
towards cholera in the study area, the outcomes showed that there exists a significant weak
positive relationship. This outcome agreed with the findings by D’Mello-Guyett, Gallandat, Van
den Bergh, Taylor, Bulit, Legros, et al (2020) and Ali, Mohamed and Tawhari, (2021) whose
study found that lack of adequate knowledge and poor preventive practices such as the ingestion
of contaminated water remains the principal mode of transmission of cholera.

51
More so, in the views of Ali, Mohamed and Tawhari, (2021) attitude of the general population
toward the symptoms of a disease plays a vital role to preventive measures of the diseases.
However, this study in terms of knowledge contradicted the study by Orimbo, Oyugi, Dulacha,
Obonyo, Hussein, Githuku, Owiny, and Gura, (2020) who reported that the participants in their
study had high knowledge score on cholera with gaps in preventive practices. From the observed
variation in the outcome of this present study when compared with some in the literature, the
researcher is of the view that the regular health sensitization seminar organized by WHO and
other health agencies on hygiene practices within communities since the initial outbreak of the
disease in 2021 could have contributed to the observed changes in attitude and preventive
practices. However, a lot still needs to be done particularly in the aspect of knowledge.

Therefore, more health sensitization need to be carried out to increase community dwellers level
of knowledge on cholera in particular and epidemic disease outbreaks in general. Such
sensitization activities or community health education programs should equally reiterate on
simple preventive measures such as practicing good sanitation, using water from safe water
supply sources, boiling water for drinking, constructing proper sewage and drainage systems,
early treatment of infected persons and facilities, proper disposal of infected materials such as
waste products, clothing and beddings.

5.5. Conclusion
The findings of this study strongly suggest that mothers who reside in Ugwunagbo Local
Government Area of Abia State and participated in the study have fair knowledge of cholera
disease, positive attitudinal dispositions and satisfactory preventive measures put in place to
forestall the outbreak of Cholera. As such, the fair knowledge of the disease possibly accounted
for why the community was among the communities affected during the 2021 and 2022
outbreak.
Therefore, there is still a need to increase community health education programs or activities in
the area so as to create more awareness of the danger of the disease, increase level of knowledge,
enshrine better attitudinal dispositions and preventive measures towards general disease outbreak
in the South East. In addition, more information on the importance of vaccination against the
disease is needed as most respondents displayed poor knowledge on this item. When members

52
of a community put in place preventive measures that addresses possible root cause of the
problem, epidemic outbreaks are averted.
5.6 Recommendations

Based on the findings of this study, the following recommendations were made:

1. Fair knowledge (in adequate knowledge) is not enough to prevent the outbreak of a
diseases such as cholera; as such more health education programs should be organized to
increase knowledge of community members residents in local communities across the
country.
2. Community dwellers in the study area should be encouraged to continue and improve on
the adopted good attitudinal practices as well as get more persons around them to do
same.
3. The community dwellers in the study area and neighboring communities should equally
maintain the preventive measures discussed in this study to forestall reoccurrence of the
disease since good preventive practices address possible root causes of epidemic
outbreaks.
4. In response to the repeat 2022 cholera outbreak, it is necessary to deploy control
measures involving treatment, improvement of the present health situation, and more
health education activities.
5. Other variables should be investigated to in the study area since level of knowledge,
attitudinal disposition and preventive measures may not be the only variable that can lead
to Cholera disease outbreak.
6. The demographic variables should be investigated to determine their possible influence
on knowledge, attitude and preventive measures of mothers towards Cholera disease.

5.7 Suggestion for Further Study

1. This research topic should be replicated using the same variables in the remaining wards
of the Local Government Area using the same variables to find out if the results will be
the same.

53
2. The study should be replicated using the same variables in the other three Local
Government Areas - Ohafia, Aba North and Aba South which also experienced the
outbreak during the period.
3. This study should be replicated considering other variables because with the outbreak of
cholera in the study area one would have expected that level of knowledge, attitudinal
disposition and preventive measures would have been significantly low.

54
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 APPENDIX I
INFORMED CONSENT FORM
Please take your time to read the information below carefully before you decide to
participate in the study.
My name is Eluwa, Amarachukwu Akubuike, from the Department of Public Health, Babcock
University, Ilishan-Remo, Ogun State, Nigeria
Research Title: KNOWLEDGE, ATTITUDE AND PREVENTIVE MEASURES
TOWARDS CHOLERA OF MOTHERS IN UGWUNAGBO LOCAL GOVERNMENT
AREA, ABIA STATE. Category of Research: B. Sc Project
You are invited to take part in the study titled “Knowledge, Attitude and Preventive Measures
towards Cholera of Mothers. The purpose of this study is to find out the knowledge, attitude and
preventive measures towards Cholera of mothers in Ugwunagbo Local Government Area in Abia
State, Nigeria.
A questionnaire will be given to you and you are expected to give the correct answers to the
questions. Your answers to each question under the different sections of the questionnaire will
help the researcher ascertain your level of knowledge, attitude and preventive measure towards
the cholera disease currently affecting resident of the State.
Participating in this study will not take more than 60 minutes of your time and there are no risks
in participating in this study. More so, your responses to the questionnaire items are to be used
strictly for the purpose of this research work; as such, your anonymity is guaranteed as your
name will not be mentioned. The data will be analyzed as a whole group and no individual will
be identified. Please note that your participation in this study is voluntary and you are required
to sign the consent form if you have decided to participate. However, you will not be sanctioned
if you choose not to participate or choose to discontinue your participation after you have started
at any time without giving any reason. This will not affect the relationship you have with the
researcher.
More so, your participation will not cost you any money as no form of payment is needed from
you. But accurate data generated from your honest responses will provide a good data base to the
Ministry of Health, WHO, and other health agencies in solving the current cholera outbreak in
Abia State and other neighboring State in the South East as well as in advancing the frontiers of
knowledge. In addition, data from this research work will also have impact on educational health
policies and health professionals since it will ascertain preventive health measures that will help
forestall future outbreak of the cholera disease and equally constitute baseline information for
future research to scholars.
Finally, there is no conflict of interest as this research work is intended to contribute to the body
of knowledge and it is not funded by any organization. Ethical Approval have been obtained
from the Babcock University Health Research Ethical Committee (BUHEREC). In case you
have any questions(s), please contact the researchers:
Name: Eluwa Amarachukwu Akubuike Phone No: 09033140032
Email: aaamarachukwu003@gmail.com
You can also contact Eluwa, Amarachukwu Akubuike’s Supervisor:
Name: Dr. Ajike Saratu .O. Phone No: 09077452449 Email: ajikes@babcock.edu.ng
Consent: By signing this consent form, I confirm that I have read and understood the
information and that I have had the opportunity to ask questions. I hereby voluntarily agree to
participate in this study.
Participant’s Name: …………………………. Signature: ………………………….

62
 QUESTIONNAIRE
Dear Respondent,

I am a student in the Department of Public Health in Babcock University, Ilishan-Remo Ogun

State. The purpose of this questionnaire is to assess your knowledge, attitude and preventive
measures adopted as a mother towards cholera who resides in Ugwunagbo Local Government
Area, Abia State.
I am kindly requesting your voluntary participation in this exercise and seek your honest
response to the questions posed below. Please, the data collected is strictly for academic
purposes and all information provided will be treated with utmost confidentiality. Do not write
your name(s) on any part of this questionnaire. Thank you.

Section A: Socio- Demographic Profile of Respondent

Kindly complete the blank spaces provided or tick (√) the appropriate response which concern
you in the boxes provided below.
1. Age:___________years
2. Religion: a. Christianity b. Islam c. Traditional d. Others
3. Ethnicity a. Igbo b. Hausa c. Yoruba d. Others (please specify)
_________________
4. Marital Status a. Single b. Married c. Divorced d. Widow
5. Designation (occupation, what you do for a living?) _________________________

Section B: Knowledge of Cholera

Instructions: Table 1 contains statements related to your knowledge on cholera. For each
statement, tick (√) either in the true, false or do not know column.
Table 1
S/N Statements True False Do not
know
1 Cholera spreads from one person to another
2 Cholera spreads through drinking contaminated water
3 Cholera spreads through flies and mosquitoes’ bites
4 Cholera spreads by having poor hygiene
5 Poor sanitation leads to the spread of cholera
6 Diarrhea is a symptom manifestation of cholera

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7 Vomiting is a symptom manifestation of cholera
8 Cholera causes death through dehydration
9 Unsafe water sources are a cause of cholera
10 Antibiotics are an effective treatment for cholera.
11 Oral rehydration solution (ORS) is used to treat cholera.
12 Cholera is common in Nigeria.
13 Cholera can through the air
14 Cholera is a poison released by the wealthy to the poor
15 Cholera is spread through bacteria
16 Cholera affects only children
17 Cholera is spread through viruses
18 Cholera is a punishment from God
19 Cholera has been completely eliminated
20 Cholera affects all age groups
21 Cholera affects only older persons or adults
22 Cholera can be contracted from persons in a single
household
23 Consumption of fishery products increases risk of
cholera

Section C: Attitude towards Cholera

Instructions: Table 2 contains statements that represent your various attitudes toward cholera.
For each statement, please tick (√) whether you agree, strongly agree, disagree, or strongly
disagree.
Table 2
S/N Statements Agree Strongly Disagree Strongly
agree disagree
1 Drinking water from the community river can make a
person to contract cholera disease
2 Poor hand washing habits in public places will
promote the spread of cholera

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3 Poor washing habits at home will promote the spread
of cholera
3 Inappropriate use of latrines will encourage the
spread of cholera
4 Staying in an unhygienic environment makes a
person vulnerable to cholera
5 Vaccination can keep a person safe from cholera
disease
6 To me, the burying of feces (Poop) of babies in the
sand will encourage the spread of cholera
7 The presence of animal feces will encourage the
spread of cholera
8 Drinking from local wells will encourage the spread
of cholera
9 Funeral cultural practices like drinking water washed
from the corpse promote the spread of cholera.
10 Immunization are effective in the prevention of
disease
11 Cholera vaccination may have side-effects
12 I believe that our hands should be washed with soap
and or ash after defecation
13 Hands should be washed before taking any food
14 Cholera is a very serious disease for children
15 Cholera is a very serious disease for adults
16 Good sanitation practices are effective against
cholera

Section D: Preventive Practices towards Cholera

Instructions: Table 3 contains statements that represent actions you regularly take to keep
cholera infection away from your family. For each statement, please tick (√) whether you
always, most times, commonly, rarely and never.
Table 3

65
S/N Statements Always Most Commonl Rarely Never
times y
1 Traditional medicine is administered
to members of my household to
keep cholera away.
2 Washing hands with soap and clean
water before doing anything is a
regular practice in my house.
3 We thoroughly clean our house
environment regularly in my family.
4 Water is stored in clean and airtight
bottle to avoid contamination.
5 In my house, garbage generated is
collected in bags and thrown away
in approved places.
6 I enforce the flushing of the toilets
after use by every member of my
household.
7 Buying of food from public vendors
is discouraged in my house.

Thank you.
Amarachukwu Akubuike Eluwa

QUESTIONNAIRE CONSENT FORM

I (respondent’s name) ____________________________ hereby give my permission to
ELUWA AMARACHUKWU AKUBUIKE (researcher) to allow me to respond to a

66
questionnaire and quote my response in a scholarly research paper. I understand that their work
is for academic purposes.
I also understand that I waive any claim for copyright to this material should the researchers ever
publish it in a scholarly journal or in electronic format online.
I understand that the Research Title is Knowledge, Attitude and Preventive measures of
Mothers towards Cholera.
I also understand that the researcher, hereby named ELUWA AMARACHUKWU
AKUBUIKE, will maintain anonymity with regard to my response to Questionnaire items.

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