Social and cultural features of cholera and shigellosis in peri-urban and rural communities of Zanzibar

ABSTRACT: BACKGROUND: Responding to the high burden of cholera in developing countries, the WHO now considers vaccination as a supplement to the provision of safe drinking water and improved sanitation in the strategy for cholera control in endemic settings. Cultural concepts of illness affect many aspects of public health. In the first step of a two-step strategy to examine determinants of cholera vaccine acceptance, this study identified social and cultural features of diarrhoeal illness for cholera control in endemic communities. METHODS: A cultural epidemiological study with locally adapted vignette-based interviews was conducted in two cholera-endemic communities of Zanzibar. A random sample of unaffected peri-urban (n=179) and rural (n=177) adults was interviewed to study community ideas of cholera and shigellosis, considering categories of distress, perceived causes, and help-seeking behaviour. RESULTS: Cholera was recognised by 88%. Symptoms of dehydration were most prominent in reports at the peri-urban site. Interference with work leading to strain on household finances was frequently emphasised. Dirty environment was the most prominent perceived cause, followed by unsafe drinking water and germ-carrying flies. Causes unrelated to the biomedical basis of cholera were reported more often by rural respondents. Rural women had more difficulty (20%) to identify a cause than men (7.1%, p=0.016). Peri-urban self treatment emphasised rehydration; the rural community preferred herbal treatment and antibiotics. Shigellosis was recognised by 70%. Fewer regarded it as very serious compared with cholera (76% vs. 97%, p>0.001) and regarded it as less likely to be fatal (48% vs. 78%, p>0.001). More respondents could not explain causes of shigellosis (23%) compared with cholera (7.3%, p>0.001). Community respondents less frequently identified dehydration and contagiousness for shigellosis. Government facilities were preferred healthcare providers for both conditions. CONCLUSIONS: This study clarified local views of cholera and shigellosis relevant for diarrhoeal disease control in Zanzibar. The finding that rural women were less likely than men to specify causes of cholera suggests more attention to them is required. Better health education is needed for cholera in rural areas and for shigellosis in general. This study also identified variables for subsequent analysis of social and cultural determinants of cholera vaccine acceptance