Scabies Among High School Students in Accra, Ghana: Risk Factors and Health Literacy

AUTHORS

Masood Maleki Birjandi 1 , Mahbobeh Oroei 2 , * , Seyed Naser Emadi 3 , ** , Ali Asghar Peyvandi 4 , Abraham Kwabena Anang 5

1 Iran Clinic, Iranian Red Crescent Society, Accra, Ghana

2 Hearing Disorders Research Center, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran

3 Skin Research Center, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran

4 Hearing Disorders Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran

5 Department of Parasitology, Noguchi Memorial Institute for Medical Research, University of Ghana, Accra, Ghana

Corresponding Authors:

How to Cite: Maleki Birjandi M , Oroei M, Emadi S N , Peyvandi A A, Kwabena Anang A . Scabies Among High School Students in Accra, Ghana: Risk Factors and Health Literacy, Iran Red Crescent Med J. 2019 ; 21(8):e92510. doi: 10.5812/ircmj.92510.

ARTICLE INFORMATION

Iranian Red Crescent Medical Journal: 21 (8); e92510
Published Online: August 25, 2019
Article Type: Research Article
Received: April 22, 2019
Revised: June 24, 2019
Accepted: July 28, 2019
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Abstract

Background: Scabies is one of the most common itchy dermatoses in school students. The scabies incidence is dependent on personal hygiene and social factors.

Objectives: This study aimed to determine the scabies prevalence and health literacy among high school students.

Methods: This cross-sectional study was performed in 22 high schools of Accra, Ghana, from March to July 2018. School students voluntarily participated in the study. After obtaining the agreement of the relevant authorities, we gathered information regarding demographic characteristics and knowledge, attitude, and hygiene habits of 2,766 students.

Results: Overall, 2,766 students consisting of 1,171 from urban areas and 1,595 from suburban areas of Accra were enrolled in this study. The scabies prevalence was 10.3% in the high school students, ranging from 3.7% in suburban students to 19.4% in urban students. The risk of scabies was higher in females than in males (OR = 1.57; 95%CI = 1.18 - 2.07; P = 0.002) and in urban students than in suburban students (OR = 6.90; 95%CI = 5.05 - 9.43; P < 0.001). The knowledge level was good in 53.4% of the students and moderate in 44.1%. Almost 91.3% of the students had a positive attitude toward scabies prevention. There were significantly higher knowledge and attitude scores in urban areas than in suburban areas (all P < 0.001).

Conclusions: According to the high prevalence of scabies in urban students in, it is necessary to perform more educational efforts and governmental/ non-governmental supports to limit the cases. It seems that high social class and urban residence do not guarantee the occurrence of scabies; thus, comprehensive prevention programs are required for all social classes.

Keywords

Attitude Scabies Ghana Habit Health Hygiene Knowledge Literacy Schools Social Class Students Pruritus

Copyright © 2019, Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited

1. Background

Scabies is one of the most common itchy dermatoses worldwide. The World Health Organization recognizes scabies as one of the neglected tropical diseases. The cause of scabies is the mite Sarcoptes scabiei. This ectoparasite burrows into the epidermal layer of the host skin and induces debilitating itching and scratching due to allergic reactions to proteins and faces exerted by the mite. This mite can transfer from the patient’s skin to other persons’ skins by direct contact (1). The scabies infestation occurs mostly in young children and rarely in adults; however, it can affect anyone regardless of age, gender, and personal hygiene (1, 2). Scabies can induce complications such as local bacterial skin infection, septicemia, rheumatic fever, and post-streptococcal glomerulonephritis (3).

The scabies occurrence has been attributed to low socioeconomic level, overcrowding, poor water resource management, and poor sanitation (4). The most cases of scabies are reported from low-income countries, the majority of which are attributed to lack of knowledge of scabies and preventive health behaviors, besides other reasons such as poor facilities and resources (2, 5). Most studies report different prevalence rates of scabies in various sub-populations (6-9); for example, Nigeria and Mali as sub-Saharan countries have reported the rates of 10.5% and 4%, respectively (7, 10). However, based on our knowledge, there was no evidence of the scabies prevalence and health literacy among high school students from Ghana. Therefore, we decided to fill this gap.

2. Objectives

The study aimed to investigate the scabies prevalence and determine the knowledge, attitude, and hygiene practice concerning scabies among high school students in Accra, Ghana.

3. Methods

3.1. Study Design and Participants

A cross-sectional study was conducted in 22 high schools in Accra from March to July 2018. According to the collaboration of high school officials, 11 high schools from each of urban and suburban regions were selected. Accra is the capital of Ghana with an area of 225.67 km2. The population size was estimated at 131,482 high school students studying in public high schools in 2010. We calculated 384 students as the minimum sample size required for the accurate estimation of the proportion by considering the disease percentage of 50% and a standard deviation at 95% confidence level and the sampling error of 5% based on the formula of sample size calculation for prevalence. Overall, 2,766 students consisting of 1,171 from urban areas and 1,595 from suburban areas of Accra were enrolled in this study. The students were junior or senior high school students that were conveniently selected for the study.

The inclusion criterion included the students of the given high schools (junior and senior) who were willing to participate in this study. The exclusion criteria included the students who were unwilling to participate and those who were absent at the time of visiting.

3.2. Data Collection

We used a predesigned questionnaire developed based on a comprehensive literature review for data collection. This questionnaire was assessed by two authors for content validity. In order to check the reliability, we administered the questionnaire to 30 school students and calculated Cronbach’s alpha. We found a reliability coefficient of 0.64 for the whole questionnaire. The questionnaire was modified and then checked for content validity. Finally, we found a reliability coefficient of 0.72. Cronbach’s alpha is a value ranging from zero to one, and an alpha (α) value equal to or greater than 0.7 indicates acceptable reliability (11). We considered this value for our questionnaire; thus, we had to change some questions for achieving the acceptable value. Finally, we developed a questionnaire with 19 yes/no questions for knowledge. Moreover, ten questions focused on attitude. The hygiene habits of students were assessed by 19 questions that six questions were related to personal hygiene. All questions are listed in Table 1. In the knowledge section of the questionnaire, a correct answer scored one, and a wrong answer scored zero. The knowledge level was categorized into three categories: good (mean score ≥ 70%), moderate (40% - 69%), and poor (< 40%). The attitude scores ranged from zero to 10, categorized into two classes of positive attitude (score ≥ 6) and negative attitude (score < 6).

Clinical examinations were carried out by two experienced physicians in a private room in each school. Female students were visited by a female physician. The suspected cases were referred to the Iran clinic to be visited by a dermatologist and to confirm the diagnosis using skin scraping smear. The topical treatment of scabies was provided for scabies patients and related families. All prescribed drugs were free of charge on behalf of the Iran clinic. Moreover, required orders about how to use drugs, need for repeating after a week, and treatment of household contacts were explained by our physician team.

We used the household crowding index as an alternative measure of crowding that was calculated by the number of usual residents in a house divided by the number of rooms in the house.

During the study period, one of the authors supervised the process of interviewing and data collection. Besides, another author conducted a primary analysis of at least 5% of the data to recheck data entry.

3.3. Statistical Methods

The data were recorded in an excel spreadsheet and imported to the SPSS Statistics for Windows, version 18.0 (SPSS Inc. Chicago, IL., USA). We had no missing data. The qualitative data were expressed as the frequency and percentages and the quantitative data as mean ± SD. The chi-square test and independent t-test were applied to determine the associations between variables and the differences between subgroups. In addition, we conducted univariate and multivariate logistic regression to find risk factors predisposing to scabies. The significance level of statistical tests was set at below 0.05 and 95% confidence intervals were calculated for all odds ratios.

3.4. Ethical Statement

Before beginning the study, institutional authorizations were obtained from the administrative authorities of the high schools, the ministry of education, and the ministry of health of Ghana. The procedures of the study and questionnaires were explained to school managers and participants. Based on the Declaration of Helsinki, we considered medical ethics in this study and reassured the participants that their individual information would be kept confidentially. Informed consent was obtained from all participants. This study was based on the humanitarian services of the Iranian Red Crescent Society as a health promotion project in Ghana. The project was confirmed by the Health and Rehabilitation Deputy of Iranian Red Crescent Society in December 2017 and then ran in the Iran clinic in Ghana.

4. Results

In this study, the overall scabies prevalence was 10.3% (286/2,766). It was 19.4% and 3.7% in urban and suburban students, respectively (P < 0.001). Female students with scabies were more frequent than male students with scabies (12.2% vs.7.9%, P < 0.001). The overall mean age of the students was 15.6 ± 3.7 years; it was 15.6 ± 1.8 in scabies patients and 15.5 ± 3.9 in healthy students (P = 0.465). Table 2 shows the demographic information of the students.

The risk of scabies was significantly associated with gender (female), urban residence, father’s and mother’s job. The family size of more than four persons increased the odds of scabies as 1.8 folds. In univariate analysis, having animals in the house and sharing clothes with others were significantly related to scabies incidence (OR = 1.69, 95%CI = 1.32 - 2.16 and OR = 1.49, 95%CI = 1.14 - 1.96, respectively); however, in multiple logistic regression, the effect of sharing of clothes was not significant.

The most common site of lesions was the wrist or the web of fingers (22.7%), followed by genitals or buttock (22.0%), armpits or upper arms (19.2%), and the breast (15.7%) (Figure 1).

The site of lesions in scabies disease. Data labels are numbers (%).
Figure 1. The site of lesions in scabies disease. Data labels are numbers (%).

Some students had other infectious skin diseases. The rates of fungal skin infection was 59.6% (n = 53), folliculitis 25.8% (n = 23), impetigo 11.2% (n = 10), and wart 3.4% (n = 3). Among the scabies patients, 46 had infectious skin diseases consisting of 22 cases with fungal infection (47.8%), 20 cases with folliculitis (43.5%), and 4 cases with impetigo (8.7%).

4.1. The Status of Knowledge, Attitude, Healthy Behaviors in High School Students

Table 2 shows the demographic specifications of the students, and Table 1 shows the rate of correct answers to the questions of knowledge and attitude. Almost 23.1% of the students recognized an insect as the cause of scabies, and 64.1% mentioned that the main route of transmission is close skin contact with patients. The mean knowledge score was 12.5 (± 2.4); 53.4% had good knowledge, 44.1% had moderate knowledge, and 2.5% had poor knowledge. The knowledge score was significantly higher in urban students than in suburban students (13.3 ± 2.1 vs. 12.0 ± 2.4, P < 0.001).

Table 1. Knowledge and Attitude of High School Students About Scabies
VariablesCorrect (%)
Items of knowledge
The cause of scabies disease639 (23.1)
Easy transmission of scabies disease 2264 (81.9)
The main route of transmission1773 (64.1)
The transmission through wearing the patient’s clothing2263 (81.8)
The transmission through handshaking and hugging with the patient1839 (66.5)
The transmission through sleeping beside the patient1830 (66.2)
Playing with animals can cause skin disease2292 (82.9)
Children are more vulnerable to scabies disease2153 (77.8)
No difference in scabies infestation between boys and girls1465 (53.0)
If anyone of your family members is affected by scabies disease, it is necessary to maintain personal hygiene2354 (85.1)
The spraying of your living area decreases the scabies disease1496 (54.1)
The scabies disease is harmful to the body2146 (77.6)
There is no need to isolate scabies patients1041 (37.6)
Disinfecting clothes and bed linen and treatment of the patient are the most important preventive measures1377 (49.8)
Using drugs for the treatment of scabies disease2094 (75.7)
Itching at night and feeling of the heat are the symptoms of scabies1805 (65.3)
The sites of involvement include the web of fingers, armpits, waist, genitals, elbows, and wrists1630 (58.9)
All age groups, especially teenagers, may suffer from scabies1913 (69.2)
Exchanging clothes with an infected person2352 (85.1)
Knowledge level, No. (%)
Good1478 (53.4%)
Moderate1219 (44.1%)
Poor69 (2.5%)
Items of Attitude
Scabies is a curable disease2416 (87.3)
No exchange of clothes, towels, and bedding with others389 (14.1)
Scabies patients do not need to be avoided1493 (54.0)
Personal hygiene is very necessary to keep the body free from scabies2506 (90.6)
If scabies disease is not treated, it may cause serious health problems for the infected person2479 (89.6)
Clothes of the infected person must be washed with boiled water and dried in sunlight2290 (82.8)
If any case of scabies is found in the family, treatment should be started quickly to prevent the disease transmission2597 (93.9)
For prevention of scabies, besides personal hygiene, the home environment must be sprayed2122 (76.7)
Contamination with this parasite is more in overcrowded areas2109 (76.2)
No need to quarantine scabies sufferers 937 (33.9)
Attitude level, No. (%)
Positive2526 (91.3%)
Negative240 (8.7%)
Table 2. Sociodemographic Characteristics of High School Students with and Without Scabies
Variables Total, No. (%)With Scabies, No. (%)Without Scabies, No. (%)OR (95%CI)P ValueaOR (95%CI)P Valuea
Gender
Male1191 (43.1)94 (7.9)1097 (92.1)----
Female1575 (56.9)192 (12.2)1383 (87.8)1.62 (1.25 - 2.09)< 0.0011.57 (1.18 - 2.07)0.002
Residence
Urban1171 (42.3)227 (19.4)944 (80.6)6.26 (4.65 - 8.43)< 0.0016.90 (5.05 - 9.43)< 0.001
Suburban1595 (57.6)59 (3.7)1536 (96.3)----
Paternal education
Illiterate/primary727 (26.3)50 (6.9)677 (93.1)----
Secondary or higher2039 (73.7)236 (11.6)1803 (88.4)1.77 (1.29 - 2.43)< 0.0011.28 (1.65 - 2.93)0.181
Maternal education
Illiterate/primary1058 (38.3)100 (9.5)958 (90.5)----
Secondary or higher1708 (61.7)186 (10.9)1522 (89.1)1.17 (0.90 - 1.51)0.2281.19 (0.87 - 1.62)0.259
Paternal job
Unemployed/worker704 (25.5)34 (4.8)670 (95.2)----
Employee/professional2062 (74.5)252 (12.2)1810 (87.8)2.74 (1.89 - 3.97)< 0.0012.87 (1.89 - 4.35)< 0.001
Maternal job
Housewife922 (33.3)106 (11.5)816 (88.5)1.20 (0.93 - 1.55)0.1581.73 (1.28 - 2.34)< 0.001
Employee1844 (66.7)180 (9.8)1664 (90.2)----
Crowding index
≤ 1.5660 (23.9)93 (14.1)567 (85.9)1.62 (1.25 - 2.11)< 0.0011.63 (1.21 - 2.18)0.001
> 1.52105 (76.1)193 (9.2)1912 (90.8)----
Family size
≤ 4432 (15.6)37 (8.6)395 (91.4)----
> 42334 (84.4)249 (10.7)2085 (89.3)1.27 (0.88 - 1.83)0.1881.82 (1.23 - 2.70)0.003
History of scabies
No1944 (70.3)181 (63.3)1763 (71.1) - - - -
Yes822 (29.7)105 (36.7)717 (28.9)1.43 (1.10 - 1.84)0.0062.19 (1.65 - 2.93)< 0.001
Sleeping index
Alone2058 (74.4)217 (10.5)1841 (89.5)----
With others708 (25.6)69 (9.7)639 (90.3)1.09 (0.82 - 1,45)0.5471.07 (0.78 - 1.47)0.663
Sharing clothes
No2127 (76.9)200 (9.4)1927 (90.6)----
Yes639 (23.1)86 (13.5)553 (86.5)1.49 (1.14 - 1.96)0.0031.21 (0.89 - 1.62)0.213
Having an animal in house
No994 (35.9)135 (13.6)859 (86.4)----
Yes1772 (64.1)151 (8.5)1621 (91.5)1.69 (1.32 - 2.16)< 0.0011.43 (1.09 - 1.87)0.009

Abbreviations: aOR, adjusted odds ratio; CI, Confidence interval; OR, Odds ratio

aP value < 0.05

There were no significant differences in the knowledge level between males and females and between scabies patients and students without scabies (Table 3). The majority of the students (n = 2526, 91.3%) had a positive attitude toward precautions for scabies infestation. Of the students with a positive attitude, 55.5% had good knowledge, 42.4% had moderate knowledge, and 2.1% had poor knowledge. The mean score of attitudes was 7.6 (± 1.5) that was higher in females (P < 0.001). Urban students had a more positive attitude than suburban students (P < 0.001). There was no significant difference in attitude between students with and without scabies.

Table 3. Comparison of Knowledge, Attitude, and Hygiene Habits Based on Some Variables
VariablesKnowledgeAttitudeHabit
Gender
Male12.6 ± 2.47.5 ± 1.58.9 ± 2.0
Female12.5 ± 2.47.7 ± 1.49.0 ± 2.0
P value0.071< 0.0010.130
Region of residence
Suburban12.0 ± 2.47.5 ± 1.59.0 ± 1.9
Urban13.3 ± 2.17.9 ± 1.59.0 ± 2.2
P value< 0.001< 0.0010.485
Scabies
No12.6 ± 2.47.7 ± 1.59.0 ± 2.0
Yes12.5 ± 2.27.5 ± 1.69.2 ± 2.0
P value0.7230.0770.086

The mean score of hygiene habits was 9.0 ± 2.0. There were no significant differences in hygiene habits in different groups of gender, residence place, and scabies infestation (P = 0.130, P = 0.485, and P = 0.086, respectively). We also found that 92.0% (n = 2547) of the students had bathing two times a day and 70.2% (n = 1942) were to change clothes two times daily. Almost half of them were to change bed linen and pillowcase four times or more in a month (Table 4).

Table 4. Hygiene Habits and Personal Hygiene in High School Students
VariablesCorrect (%)
Hygiene habits
Use of clean clothes after showing 2620 (94.7)
Use of soap/shampoo in body washing2519 (92.1)
Use of separate towels2188 (79.0)
Never lending the personal towel to others2327 (84.1)
Never sharing clothes with family members 2134 (77.2)
Never borrowing a friend’s/family member’s clothes1765 (67.5)
Never sleeping next to family members 708 (25.6)
Never using clothes/towel of an affected person with itching skin2585 (93.5)
Sleeping in separate bed/sleeping place 1225 (44.3)
Never sleeping on the floor1755 (63.4)
Never sleeping beside companion animals 2565 (92.7)
Never keeping animals at home 1135 (41.0)
Never playing with animals1192 (43.0)
Hygiene habits level, No. (%)
Good1769 (64.0%)
Moderate932 (33.7%)
Poor65 (2.3%)
Personal Hygiene
Bathing (times in a day)
354 (1.9)
22547 (92.2)
1165 (5.9)
Changing clothes (times in a day)
3675 (24.4)
21942 (70.2)
1149 (5.4)
Trimming/cleaning nails (times in a week)
< 2583 (21.1)
≥ 22183 (78.9)
Changing pillowcase (times in a month)
< 41264 (45.7)
≥ 41502 (54.3)
Changing bed linen (times in a month)
< 41178 (42.4)
≥ 41588 (57.6)

Overall, 64% (n = 1769) of the students had good hygiene habits while 33.7% (n = 932) and 2.3% (n = 65) had moderate and poor habits, respectively. The rate of using separate bedrooms or sleeping place was 44.3%.

5. Discussion

School students are susceptible to scabies due to close contact and high population density at schools. Based on our findings, the scabies prevalence was 10.3% in the students, which was different from the rates reported by other studies conducted in Ghana. The study by Hogewoning et al. in 2013 reported a very low prevalence in school children (12). Rosenbaum et al. in 2016 reported a prevalence rate of 5.1% in dermatology clinics (13). Kaburi et al. in 2017 reported a prevalence rate of 11.2% in primary school students and 25.1% in kindergarten children (14). Our different findings with the Kaburi study can be explained by the high education level and age of our participants, leading them to pay more attention to their personal hygiene. Research shows various prevalence rates of scabies in school students (4, 10, 15-18) ranging from 4.4% in Egypt (19) to 20% in Indonesia (5). Among African school students, there was a prevalence rate of 17.8 % in boarding school students in Cameroon (20) and 10.5% in school students in Nigeria (7). However, scabies has different prevalence rates worldwide, with more prevalence in countries with lower human development indices. The highest prevalence is in the Pacific and Latin American countries, and the lowest prevalence is in European and the Middle East countries (3).

There are contradictory findings of the role of gender in the scabies prevalence based on personal and social factors in different populations (18, 19, 21). We found more prevalence in females so that the odds of scabies was 57% higher in female students than in male students. It can be related to the following reasons found in our study: (a) females had less frequent bathing and changing clothes daily than males (33.9% vs. 66.1% bathing at least three times a day, P <0.001; 2.3% vs. 9.5% changing clothes at least three times a day, P < 0.001), (b) female students had more sleeping on the floor (60.2% vs. 39.8%; P = 0.01), and (c) female students had less sleeping alone than male students (40.5% vs. 59.5%; P < 0.001).

We observed an increased risk of scabies in students with a history of itchy rashes in their families similar to other studies (19), in urban residence, a relation with the paternal occupation and education, and the maternal job. The high prevalence of scabies among students whose fathers were from a high social class is not compatible with previous studies, and we have no justification. Housemakers were found to predispose the students to scabies, in that was in line with other studies (19, 22). Chaudhry (6) and Heukelbach et al. (23) showed that living in urban areas could increase the risk of scabies. The residents of villages and suburban areas usually live in more open spaces while people in urban areas live densely, which increases the risk of disease transmission through close skin contact. Besides, overcrowding, migration, and displacement in urban areas are the challenges that add to the reasons possibly explaining the higher prevalence of scabies in urban areas. Some studies challenge this viewpoint and suggest that living in rural societies with poor socioeconomic condition and the lack of access to health facilities can increase the scabies incidence (6, 17, 20).

There was a significant positive relationship between the risk of scabies and the number of households, but the crowding index had a negative relationship with predisposing to scabies. It can be explained by the cultural and traditional differences, making this population to use separate bedrooms less frequently. Hegab et al. (19) and Raza et al. (8) reported that the crowding index had no association with the risk of scabies. However, it seems that this index is not suitable for determining the risk of scabies in various communities.

In the present study, the overall health literacy of high school students in Accra was acceptable. Most students had good knowledge and positive attitudes toward scabies and precautions against it. Personal hygiene of the students in our study was better than that reported from some developing countries (4, 17, 24). Al-Zahrani et al. (24) showed a low-knowledge of the Saudi Arabia- Family Physicians regarding the Scabies. Binti Mohd Yusof et al. (5) in Indonesia reported a moderate to good level of knowledge, attitude, and health behaviors for scabies prevention. Dawoodzada reported that more than 50% of Afghan students had poor knowledge about scabies (4).

However, our results showed that living in urban areas, having more social and welfare facilities, and having good knowledge and attitude in health issues did not guarantee to have high personal health behaviors, but they may even lead to a false pride in preventing infectious diseases. We found a higher prevalence of scabies in urban students than in suburban students; however, the issue needs more investigation in other populations. The early diagnosis and treatment of patients have important roles in reducing scabies; thus, periodic screening in sub-populations such as students and their families can be effective to prevent scabies and poor school performance.

Our study can be representative of the prevalence of scabies in the school student population in Accra due to the large sample size. However, there were some limitations as follows. There was a possible bias in the information obtained from students about hygiene habits. The period of our study was limited from March to July, whereas the prevalence of scabies is affected by month, with a higher prevalence in the winter months. Our results are not generalizable to elementary school students and kindergarten children that are more susceptible than adolescents.

According to the high prevalence of infectious skin diseases and various dermatoses in HIV patients in Africa (25, 26), the epidemiologic studies and surveillance reports should be considered as health system priorities in this continent. The collaboration of international organizations as the WHO and Non-Governmental Organizations (NGOs) such as Red Crescent or Red Cross societies can be effective in surveillance programs and control of neglected tropical diseases for which the WHO has addressed actions to improve preventive efforts.

5.1. Conclusions

The high prevalence of scabies among high school students, especially in urban students, indicates the poor status of the community. Therefore, it is necessary to conduct more epidemiologic studies to explain these findings. Moreover, health policymakers should pay more attention to the issue and use community-based health promotion plans for the Ghanaian population.

Acknowledgements

Footnotes

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