Onchocerciasis, also known as River blindness is a parasitic disease caused by the filarial worm Onchocerca volvulus. It is transmitted through the repeated bites of female infective blackfly species of the genus Simuliumduring a bloodmeal. The subcutaneous nodules located underneath the skin of infected humans are active sites for the adult worms. The female adult worms hatches millions of immature microscopic larval forms; the microfilariae which normally last for an active lifespan of 9-14 years[1]. These Microfilariae are picked up from the skin during a blood meal and transmitted to another person by femaleSimulium flies[1, 2].The disease is known to be associated with dreadful clinical and pathological conditions as onchocercal skin disease (OSD) (onchodermatitis), lymphadenitis (resulting in hanging groin), ocular lesions (impaired vision and blindness) and systemic manifestations. Blindness and severe skin manifestations are the commonest symptoms of the disease [2].The disease often leads to severe itching, skin diseases and disfiguration, which frequently leads to stigmatization[3]. According to estimates, onchocerciasis is the second most common infectious cause of blindness, right after trachoma[4,2].

Sibling species within the S. damnosum complex namely S. damnosums.s., S. sirbanum, S. squamosum, S. yahense, S. sanctipauliandS. soubrenseare known to transmit Onchocerciasis in Nigeria. These flies are known to breed in fast-flowing, highly oxygenated water with nutrients[2]. These flies are known to exhibit habitat preference which limits them mainly to communities around these breeding sites and this preference in turndetermines the distribution of Onchocerciasis within a given region [2].

Africa, most especially the Sub-saharan region and among all the continents of the world,has been established to record the greatest burden of the disease, with over 96% of the its burden[5, 2].Nigeria is the most endemic country in the world and accounts for about 40% of the global prevalence[6, 7]. About 32 million Nigerians living in 36,000 communities in 413 LGAs of 32 States and FCT were estimated to be at risk of the disease [7]. An estimated 15% of this population were children less than 5 years, while 26.3% were between the ages of 5 and 15 years. By 2002, all States except Lagos, Sokoto, Bayelsa and Rivers were endemic for Onchocerciasis [7].

In a bid to control Onchocerciasis in West Africa since 1974, vector control was employed as the main strategy during the Onchocerciasis Control Program (OCP).This was achieved by regular spray of aerial herbicides overall simulium larval breeding sites and this was maintained for at least 14 years until the infection was ascertained completely eliminated from human populations [5].This strategy was used in combination with annual mass drug administration of Invermectin[5] and the two strategies had provedeffective in Onchocerciasis control which eventually led to the elimination of the disease in seven OCP countries and the end of the OCP in 2002.With the shift of control programme focus from disease morbidity reduction to complete elimination, the World Health Organisation had set an elimination timeline by 2030[5].Considerable progress had beenmade inthe control of the disease because of the over two decades of intervention majorly through the annual mass administration of Mectizan in endemic communities[5].Despite progress made over time, disease elimination within these endemic foci is yet to be achieved inKogi State and Nigeria at large.

Kogi state beenmesoendemic for Onchocerciasis based on the Rapid Epidemiological Mapping of Onchocerciasis (REMO) mapping surveys conducted from 1995–1996 [9], have been on mass administration withivermectin treatment 2000[10]. The state is also considered to be on track for disease elimination still with existence of endemic foci within the communities[9]. However, there is paucity of evidence-based information on the infectivity status of both humans and blackflies breeding within these endemic communities in Kogi West in the state.The absence of data on Onchocerciasis prevalence in these selected study regions, despite the observed blackfly activity, raises concerns about potential transmission dynamics, given the vector’s role in the epidemiology of the disease. This study was designed as an epidemiological survey to evaluate community knowledge, attitudes, practices, beliefs and determine level of participation in ivermectin mass drug administration (MDA) to assess the Onchocerciasis transmission risk in the region. As Nigeria transitions from control to elimination of Onchocerciasis, this data will be a vital too for the Federal, State Ministries of Health, the National Onchocerciasis Elimination Committee (NOEC), non-governmental organizations and treatment implementing partners in developing targeted strategies to ensure optimal therapeutic coverage and achieve disease elimination.

Materials and Methods

Study Areas

Selected communities within Kabba, Ijumu, Mopa-muro and Yagba-east LGA of Kogi west senatorial districts were selected. These LGAs are known to share border with certain south west states that constitutes endemic foci for Onchocerciasis and study areas were selected based on the availability of fast flowing rivers typical of Simuliumspecies and an ambient climatic conditions with crowded shady forest distribution supportive of Simulimvectors. The available aquatic environment within the LGAs which includes marshes, vast bodies of water including creeks, rivers, dams and lagoons, as well as forests, shaped its significance.Four villages from Kabba LGA namely Ohe (7.8222222, 6.057222222), Akefe (7.8254827, 6.0727886), Otowo (7.8491767, 6.0821343) and River side (7.8257068, 6.0788653), three from Yagba-east: Illafin (8.326, 5.831), IsanluItedo(8.302033, 5.842098), Isanluijowa (8.261613, 5.856425), two villages from Ijumu LGA: Iyara (7.8437792, 5.9679932), Ogidi (7.7772, 6.019)and two villages from Mopa-muro LGA; Orekere (8.1730, 5.968), Okagi (8.1340, 5.942) were specifically selected for the study. These communities were specifically selected based on certain epidemiological and hydrological factors. They were selected based on information obtained from local NTD coordinators, local health officials and populace as these communities had been previously classified as endemic for Onchocerciasis. The major occupation of the populace is trade, agriculture and fishing, although a sizeable fraction also works as artisans in industries like carpentry, clothing manufacturing, and hair styling. Males and females between the ages of 18 and 60 who had lived in the study communities for at least a year and provided their consent to participate in the study were the inclusion criteria for the research.

Study design

A community-based cross-sectional questionnaire survey was conducted from March, 2025 to September, 2025 in selected communities of Kabba,Ijumu, Mopa-muro and Yagba-east Local Government Area (LGA) to assess the knowledge, attitude and practices of the local residents toward Onchocerciasis.

Variables

Outcome: knowledge, attitude, preventive practice, beliefs, MDA compliance

Exposure: age, gender, education, occupation, marital status, length of residence

Predictors: age, occupation, good knowledge, positive attitude

Potential confounders: age

Sample size determination and sampling technique

The sample size was calculated using Cochran’s formula for studying proportions:

n= Z²pq/d²[12].

 Since there was no prior data on Onchocerciasis in these study sites, a conservative prevalence of p=50% was assumed. Using this formula and considering z=1.96 and d=0.05, n=385 participants were recruited into the study. Considering a 20% non-response rate, the final minimal sample size was 462 per LGA. Therefore, the overall required minimal sample size was calculated as: N=462×4=1848. Hence 462 participants were randomly selected from each LGA [12].Local neglected tropical disease coordinators (LNTDs), facility health workers from the community primary health centers (PHCs) and local mobilizers facilitated community sensitization and mobilization efforts. A total of 1399 questionaires were retrieved, as 449 were unaccounted for by the local mobilisers and health workers used as assistants for the survey; automatically 1399 became the sample size.

Ethics statement

The ethical approval for this study was granted by the Ethics Review Committees of the Kogi State Ministry of Health (reference number KSMoH/PRS/334).The research adhered to international ethical standards, including the 1964 Helsinki Declaration and its subsequent amendments. Written informed consent was first obtained from community leaders and religious heads of the communities. For participants aged 10 and below 18 years, recruitment was conducted with the written consent of their parents or guardians after explaining the study’s objectives in English and in the local language (Yoruba). Written informed consent was also obtained from participants above 18 years. All participants were informed that participation was voluntary and that they could withdraw at any point without any negative consequences to them.

Data Collection and Statistical Analysis

Study participants were interviewed using a standardized questionnaire adapted from a study by [12]. The questionnaire included questions about socio-demographic characteristics and structured close-ended questions relating to knowledgeincluding causes, symptoms, modes of transmission, prevention and management, and knowledge of Community Mass drug Administration with Ivermectin; respondents’ attitudes and preventive practices regarding onchocerciasis; and self-report on the disease.Data were entered into Microsoft Excel and analyzed using the 2021 version of the Statistical Package for the Social Sciences (SPSS). Frequency tables, percentages, charts were performed and relationships between variables were assessed using logistic regression analysis with proportions analyzed at a 95% confidence interval.

Results and Discussion

Socio-demographic characteristics of respondents

The demographic profile of the study population showed similar presentation across the selected study areas and spans a broad spectrum of age, occupation, education, marital status, and community residency

Age and Gender Distribution

The age of the respondents ranged from 18 to 84 years(Figure 1). The most heavily represented age group was the 35–44year age group, accounting for 34.5% (n = 482) of the total sample. Conversely, the advanced age bracket of 75–84 years constituted the smallest proportion of participants at 0.1% (n = 2). In terms of gender distribution(Figure 2), male respondents comprised the majority of the study population at 62.0% (n = 868), while female respondents accounted for 36.7% (n = 513).The high representation of male respondents (62.0%, n = 868) compared to females (36.7%, n = 513) may reflect localized socio-cultural divisions of labor, where men are predominantly tasked with clearing dense vegetation or farming closer to riverbanks during peak blackfly biting hours.

Occupational Profile

The study population engaged in a wide array of livelihoods, including farming, trading, artisanal crafts, teaching, civil service, tailoring, mechanical work, healthcare, and driving(Table 2). farming constitutes the dominant occupation at 53.3% (n = 745), followed by trading at 21.9% (n = 306). Occupations in the banking sector and professional art represented the lowest engagement, with each accounting for just 0.1% (n = 2) of the sample.A defining characteristic of this study population is its overwhelming engagement in agrarian labor, with farming emerging as the predominant occupation at 53.3% (n = 745), complemented by trading at 21.9% (n = 306). This high concentration of agrarian workers is in agreement with classic epidemiological profiles of onchocerciasis-endemic foci across sub-Saharan Africa. Studies within Nigeria according to [14, 13]have consistently documented that subsistence farming places individuals in direct, prolonged contact with the breeding sites of the Simuliumdamnosum vector,specifically fast-flowing river systems.This occupational exposure establishes farming communities as structural hyper-endemic reservoirs, making their specific behavioral choices critical to breaking the transmission cycle.

Educational Attainment and Marital Status

Analysis of educational backgrounds revealed the largest segment of the population had achieved a secondary school level of education (46.0%, n = 644)(Table 3). Notably, a high proportion of respondents had no formal education (38.9%, n = 544), while those with only a primary education formed the smallest formal schooling tier at 5.8% (n = 81).The educational profile of the cohort reveals a stark polarity. While a substantial segment achieved a secondary education (46.0%, n = 644), a major proportion of the sample had no formal education whatsoever (38.9%, n = 544). This substantial illiteracy barrier (nearly 40%) mirrors findings by[17] in South-Western Nigeria, who identified a direct correlation between lack of formal schooling and the persistent subscription to superstitious or non-scientific etiologies of river blindness (such as attributing the disease to witchcraft or ancestral curses). Conversely, the presence of an educated secondary-school tier provides a vital community asset. As noted by standard community-directed treatment with ivermectin (CDTI) frameworks, individuals with basic literacy are crucial for serving as Community-Directed Distributors (CDDs), executing accurate dosing metrics, keeping records, and translating health-education messages for their non-formal counterparts.Regarding marital status, a substantial majority of the participants were married (70.4%, n = 985), 26.4% (n = 369) were separated, and 0.3% (n = 4)were divorced(Table 3).

Length of Residency

The duration of community residency varied across the cohort (Table 4). The largest single group consisted of individuals who had lived in their respective communities for 20–30 years (22.9%, n = 320), followed closely by shorter-term residents with 0–10 years of residency (20.8%, n = 291). Long-term multi-generational residency spanning 70–80 years was rare, observed in only 0.1% (n = 2) of the sample population. The length of residency data demonstrates a deeply rooted, stable population, with the largest segment having inhabited these specific communities for 20 to 40 years (42.8% combined).

Binary logistic regression was conducted to identify independent predictors of onchocerciasis infection(Table 5). The regression model was statistically significant (χ² = 34.042, df = 7, p< 0.001), indicating that the included predictors collectively explained variation in the Knowledge, attitudes and practices (KAP) survey. The Nagelkerke R² value of 0.360 suggests that approximately 36.0% of the variability in the KAP was explained by the model, which is considered substantial for epidemiological studies involving behavioural and environmental variables. Age group emerged as a strong predictor (B = 1.139, p = 0.001). The odds ratio (Exp(B) = 3.125) indicates that individuals in higher age categories were over three times more likely to be infected compared to younger respondents. This reinforces the test findings and underscores the role of cumulative exposure. Length of residence in the community was also statistically significant (B = −1.030, p = 0.002). The odds ratio (Exp(B) = 0.357) suggests a protective effect of longer residence, possibly reflecting greater familiarity with local health interventions, better adaptation to preventive measures or a higher likelihood of prior ivermectin exposure.

LGA, sex, occupation, education, and marital status did not retain statistical significance in the multivariate model(Table 5). This indicates that while some of these factors were associated with the KAP at the bivariate level, their effects were attenuated after controlling for age and length of residence, highlighting the importance of these two variables as primary drivers of infection risk

REGRESSION

3.2 Knowledge, Attitudes and Practices of Study Participants across Selected Endemic Areas of Kogi West.

The study evaluated the knowledge, attitudes, practices and MDA compliance of an indigenous population across communities of Kabba, Ijumu, Mopa-muro and Yagba-east of Kogi west district, Kogi State. The assessment of these parameters revealed a similiarity in the response of the study participants without variations as observed in their responses. This could be traceable to their close proximity, shares similar culture, traditions, beliefs and speaks the same language/dialect. Also the similiarity in the environmental settings cannot be left out.

3.2.1 Knowledge and Awareness of Onchocerciasis

The distribution of respondents’ knowledge regarding the awareness, etiology, transmission pathways, clinical manifestations and preventive strategies of Onchocerciasis reveals significant gaps across the study population (Table 6). A substantial majority of the survey population had low baseline awareness of the disease; 76.1% (n = 1064) of respondents reported that they had never heard of Onchocerciasis. Conversely, less than a fifth of the cohort (19.7%, n = 275) indicated prior awareness of the condition, while 4.3% (n = 60) did not provide a response. This trend was mirrored in the assessments of etiological knowledge. The majority of participants (76.5%, n = 1070) possessed no knowledge regarding the causative agent of Onchocerciasis. Among the remaining respondents who attempted to identify the etiology, 20.6% (n = 288) correctly recognized a parasite as the causative agent. Misconceptions were present, with 1.6% (n = 22) and 1.2% (n = 17) attributing the disease to viral and bacterial origins, respectively, while 0.1% (n = 2) declined to respond. The mechanisms dictating disease transmission were poorly understood across the communities; 69.7% (n = 975) of respondents stated that they did not know how transmission occurs. Only 21.8% (n = 305) accurately identified the bites of blackflies (Simulium spp.) as the vector pathway. Erroneous modes of transmission were identified by some participants, including person-to-person contact (4.5%, n = 63) and the consumption of contaminated water (3.5%, n = 49), while 0.5% (n = 7)did not respond. Assessments of the clinical manifestations of onchocerciasis revealed that 76.5% (n = 1070) had no knowledge of the symptoms and 1.9% (n = 26) did not respond. Among those aware of the clinical signs, the specific symptoms reported included: Blindness: 9.4% (n = 132), Pruritus/Itching: 4.4% (n = 62), Skin nodules combined with itching: 2.9% (n = 40), Cutaneous bumps or rashes: 2.1% (n = 30), Limb swelling (lymphedema): 1.4% (n = 19), General visual impairment: 0.6% (n = 8), Systemic constitutional symptoms (cold, fever, or headache): 0.6% (n = 8), Other unspecified clinical symptoms: 0.3% (n = 4). When asked specifically about ocular complications, 76.1% (n = 1065) of the total sample could not link the disease to blindness. Meanwhile, 20.2% (n = 282) recognized it as a major cause of vision loss, and 3.7% lacked prior knowledge to form an association. Perceptions regarding the preventability of onchocerciasis varied widely. More than half of the sample population (55.4%, n = 775) were unsure whether the disease could be prevented. Furthermore, 23.4% (n = 328) reported no knowledge of prevention, 17.1% (n = 239) affirmed that the disease is preventable and 4.1% (n = 57) provided no response. When evaluating specific preventive measures among those who believed the disease could be mitigated, the responses were distributed as follows: General medication/chemotherapy: 11.4% (n = 160), environmental and personal cleanliness: 2.6% (n = 36), avoidance of blackfly vector bites: 1.6% (n = 22), combined use of chemotherapeutic drugs and protective clothing: 0.5% (n = 7), vaccination or sole use of protective clothing: 0.3% (n = 4). Finally, a large majority of the sample (83.0%, n = 1161) yielded no response regarding specific preventive interventions and 0.6% (n = 9) explicitly stated they lacked any functional knowledge concerning preventive measures.

A striking 76.1% (n = 1064) of respondents reported that they had never even heard of the term “onchocerciasis.” This baseline deficit directly corresponds with the 76.5% of the population who possessed no functional knowledge regarding its causative agent. This profound information vacuum is in sharp consonance with findings by[13] in deep forest-savannah mosaic communities of Nigeria, where structural gaps in localized health sensitization left over 70% of rural workforces unaware of the formal scientific nomenclature and parasitic nature of river blindness.The mechanisms dictating how Onchocerca volvulus spreads were poorly understood across the surveyed districts. Nearly 70% of participants stated they did not know how transmission occurs and only a small minority (21.8%, n = 305) accurately identified the bites of blackflies (Simulium spp.) as the vector pathway. Instead, erroneous transmission beliefs persisted, including person-to-person contact (4.5%) and the consumption of contaminated water (3.5%).This biological ignorance is deeply anchored in local cultural frameworks

 3.3.2 Perceived Severity and Personal Risk

The majority of participants viewed the disease as a significant public health threat with 62.7% (n = 877) classification onchocerciasis as a “very serious” condition. Conversely, 24.4% (n = 342) considered it “somewhat serious,” 12.5% (n = 175) viewed it as “not serious,” and 0.4% (n = 5) declined to respond (Table 7). Despite recognizing its clinical severity, a substantial portion of the population demonstrated a low sense of personal vulnerability. Specifically, 69.6% (n = 974) of respondents believed that they and their family members were not at risk of contracting the disease. In contrast, 24.7% (n = 345) acknowledged being at risk, while 5.4% (n = 76) lacked functional knowledge of their risk status and 0.3% (n = 4)did not respond. Public acceptance of intervention initiatives was remarkably high. A substantial majority of respondents (83.1%, n = 1163) expressed explicit willingness to participate in mass treatment programs. However, 12.0% (n = 168) indicated an unwillingness to engage in available treatment options, while 4.4% (n = 61) remained unsure and 0.5% (n = 7) gave no response. Social stigmatization emerged as a near-universal concern within the surveyed communities. An overwhelming 92.4% (n = 1293) of respondents believed that individuals suffering from onchocerciasis face social stigma. Only a minor fraction (3.1%, n = 43) stated that victims do not experience stigmatization, while 4.1% (n = 58) were unsure and 0.4% (n = 5) did not provide a response.Crucially, social stigmatization remains a near-universal burden within these communities, with 92.4% (n = 1293) of respondents affirming that individuals suffering from visible onchocerciasis manifestations face severe social exclusion. The intense dread of being stigmatized, isolated from communal markets, or deemed unfit for marriage forces individuals to hide their symptoms. This fear of exclusion likely explains why 73.1% of the wider population refused to provide a specific response when asked about their active symptom experiences, retreating into defensive silence to evade community labeling. The evaluation of personal protective behaviors against blackfly bites reveals a complete absence of defensive practices across the districts.

A profound cognitive dissonance emerged when analyzing how communities perceive personal risk versus public health severity. On one hand, 62.7% (n = 877) of the population correctly classified onchocerciasis as a “very serious” condition, showing an understanding of its historical capacity to cause blindness and permanent skin damage. On the other hand, a substantial 69.6% (n = 974) of these exact same individuals believed that they and their immediate family members were at zero personal risk of contracting the disease. This dangerous “vulnerability paradox” can be explained using the Health Belief Model (HBM). Because decades of ivermectin distribution have successfully collapsed microfilarial loadspreventing the highly visible, catastrophic ocular blindness valleys of the past,the community visually perceives that the danger has vanished. Consequently, their perceived susceptibility has dropped to near zero, even though their daily occupational exposures as farmers (53.3%) keep them in constant contact with active Simulium vector biting zones.

3.3.3 Behavioral Practices Regarding Vector Control and Mass Drug Administration

The evaluation of community-level preventive practices against blackfly (Simulium spp.) bites, historical participation in screening or treatment and household advocacy for Mass Drug Administration (MDA) programs reveals a distinct gap between personal protective behaviors and community intervention support (Table 8). An overwhelming majority of the study population reported a total lack of personal behavioral interventions against the primary vector; 84.9% (n = 1188) of respondents indicated they did not engage in any preventive measures against blackfly bites. Conversely, only a minor fraction (11.8%, n = 165) actively employed protective strategies, while 0.4% (n = 6) did not provide a response. Among the small cohort utilizing personal protective measures, specific practices reported across the total sample population included: Insecticide-treated nets and protective clothing: 2.0% (n = 28), Chemotherapeutic drugs combined with protective clothing: 0.6% (n = 8), Sole reliance on medications/drugs: 0.1% (n = 2), Perceived or reported regular vaccination: 0.1% (n = 2).An overwhelming 84.9% (n = 1188) of respondents explicitly stated that they engaged in absolutely no preventive measures against Simulium bites. Only a negligible 2.0% utilized a combination of insecticide-treated nets (ITNs) and protective clothing. This passive behavioral stance agrees with[14], who noted that standard vector control measures like ITNs are structurally ineffective against Simulium species because blackflies are diurnal, outdoor-biting vectors that strike while farmers are actively clearing land, far away from evening bed nets. Because 53.3% of the population are farmers who spend their peak hours outdoors without long-sleeved thick clothing or topical repellents, they remain entirely defenseless hosts to residual vector populations. The final, and perhaps most critical, threat to the verification of elimination in these districts lies in the documented ivermectin ingestion patterns.

 Adherence to personal clinical surveillance and therapeutic options was remarkably low. A substantial majority of participants (80.0%, n = 1119) declared that they had never participated in any onchocerciasis screening or treatment programs. In contrast, less than a fifth of the population (18.2%, n = 254) reported prior participation in these clinical interventions. The remaining segments of the sample were either unsure of their historical participation (0.6%, n = 9) or declined to respond (1.2%, n = 17). Despite low personal participation in vector prevention and clinical screening, a strong positive trend emerged regarding public health advocacy within domestic units. A substantial majority of respondents (87.8%, n = 1229) actively encouraged other members of their household to participate in MDA campaigns. Conversely, only 9.6% (n = 135) stated that they did not promote household participation, while 2.5% (n = 35) provided no response on the matter.

3.3.4 Sociocultural and Communal Beliefs Surrounding Onchocerciasis

The evaluation of communal perceptions, traditional belief frameworks, and the utilization of indigenous healing systems reveals the cultural context influencing health-seeking behaviors within the study areas (Table 9). A significant proportion of the study population identified deeply entrenched sociocultural frameworks as the primary drivers of local disease understanding. Specifically, 66.9% (n = 936) of respondents stated that superstitious beliefs were viewed as the primary cause of onchocerciasis within their respective communities. Conversely, 10.8% (n = 151) of participants were unaware of their community’s localized beliefs regarding the disease and 2.7% (n = 38) provided no response. When respondents outlined the specific communal or traditional etiologies recognized by their communities, the responses were distributed as follows: Blackfly bites: 8.5% (n = 119) (representing an accurate epidemiological alignment), Hereditary transmission: 7.9% (n = 110), General cultural beliefs: 1.0% (n = 14), Community influence: 0.8% (n = 11), Poor personal hygiene: 0.4% (n = 5), Agrarian labor / Farming: 0.3% (n = 4), General active infection: 0.3% (n = 4), Demonic or diabolical forces (“the devil”): 0.2% (n = 3),Inadequate vaccination or awareness campaigns: 0.1% (n = 2), Mosquito bites: 0.1% (n = 2). The interaction between traditional practices and modern healthcare systems varied across the cohort. The majority of participants, 59.7% (n = 835), stated that their communities did not harbor traditional beliefs that discouraged individuals from seeking modern medical interventions, while 1.6% (n = 22) held no opinion on the matter. However, a notable segment comprising 38.7% (n = 542) of respondents affirmed that traditional beliefs actively competed with or affected the acceptance of modern orthodox medicine. Within this group, the primary cultural barriers identified were a distinct preference for traditional medicine over orthodox healthcare (34.5%) and the communal practice of indirect family planning (0.2%, n = 3). The structural availability and community reliance on traditional healers for managing onchocerciasis symptoms were also evaluated. Less than half of the respondents (44.1%, n = 617) reported a total absence of traditional healers specializing in onchocerciasis within their localities. Only a small minority (6.4%, n = 90) confirmed that such traditional healers were actively available. Notably, a substantial proportion of the population lacked clear insights into this therapeutic sector, with 48.5% (n = 678) reporting no information regarding traditional healer availability and 1.0% (n = 14) declining to respond. Regarding actual therapeutic choices, the data indicates high trust in modern programs over indigenous remedies. An overwhelming majority of participants, 89.6% (n = 1254), stated that they did not use traditional medicine to manage or treat the symptoms of onchocerciasis. In contrast, only 6.8% (n = 95) admitted to using traditional remedies for symptom management, while 3.6% (n = 50)did not respond to the subject.

An overwhelming 66.9% (n = 936) of respondents stated that superstitious beliefs were viewed as the primary cause of onchocerciasis within their communities, with some explicitly attributing it to hereditary causes or diabolical forces (“the devil”).This heavy subscription to metaphysical etiologies aligns closely with behavioral studies by[17] in South-Western Nigeria and [18]in similar sub-Saharan contexts. These researchers observed that when a parasitic infection causes highly distressing, invisible cutaneous symptoms (like intense, unyielding pruritus), rural populations frequently bypass rational germ theories in favor of spiritual explanations. This is not merely an academic concern; it directly warps health-seeking behaviors. While 59.7% of the cohort denied that traditional beliefs actively stopped them from accessing orthodox care, a notable 38.7% (n = 542) affirmed that traditional belief systems actively competed with modern medical interventions. This competition manifested primarily as a distinct behavioral preference for traditional herbalists and indigenous healers over formal primary healthcare centers.

3.3.5 Ivermectin Coverage and Longitudinal Compliance Patterns

More than half of the participants, 57.3% (n = 801), reported that they had never taken the medication. Conversely, 32.5% (n = 455) affirmed a history of drug utilization, while 7.8% (n = 109) were unsure of their usage history and 2.4% (n = 34) provided no response (Table 10). When evaluating the specific timeline of the last received dose, the data shows that: 1–2 years ago: 18.6% (n = 260) of respondents received treatment, more than 2 years ago: 17.0% (n = 238) of respondents received treatment, never ingested: 60.3% (n = 843) of the sample pool reaffirmed a complete lack of therapeutic history. Data regarding the tolerability profile of the drug indicates that 37.2% (n = 521) of the participants experienced no side effects during treatment. However, an active group comprising 10.6% (n = 148) of the population documented post-treatment complications. The specific manifestations reported among the cohort included: Swellings (edema): 2.0% (n = 28), Pruritus (itching): 1.5% (n = 21), Cutaneous rashes: 0.1% (n = 2). Uncertainty regarding physical reactions to the drug was common, with 52.2% (n = 730) reporting they were unsure of their symptoms. Additionally, 96.4% (n = 1348) of the wider sample did not offer a specific response within the detailed side-effect categories. An analysis of the behavioral and structural factors influencing community integration into Mass Drug Administration (MDA) frameworks identified several key variables driving compliance or non-compliance: Programmatic Trust: Identified as a primary motivator by 29.4% (n = 411) of participants, information deficits: 22.1% (n = 309) reported that a lack of adequate program communication hindered engagement, fear of adverse effects 17.3% (n = 242) avoided participation due to concerns over side effects, Social and Communal Pressure: 11.7% (n = 163) indicated that community influence shaped their involvement, alternative Factors; 1.2% (n = 170) linked their choices to unspecified reasons, while 17.0% (n = 238) declined to provide feedback. Public perceptions regarding the credibility of frontline distribution personnel were heavily skewed toward programmatic acceptance. Exactly half of the sample pool, 50.0% (n = 700), expressed explicit trust in the community drug distributors. In contrast, 11.2% (n = 157) reported a distinct lack of trust, 30.7% (n = 429) remained undecided on the matter, and 8.1% (n = 113) gave no response regarding distributor credibility.

According to the WHO guidelines for verifying the elimination of human onchocerciasis, a minimum therapeutic coverage of 80% must be sustained annually across all endemic communities for at least 10–12 years to successfully interrupt transmission. These findings revealed a substantial failure to meet this standard: 60.3% (n = 843) of the total sample pool reaffirmed a complete lack of therapeutic history with ivermectin, while more than half (57.3%) stated they had never taken the medication under any programmatic layout. Only 18.6% had taken a dose within the past 1–2 years. This finding stands in sharp, dramatic contrast to the high community ivermectin compliance rates routinely claimed in administrative supervisor reports. It also directly contrasts with contemporary micro-level studies, such as the[15], assessment inUbanlu, Olamaboro LGA of Kogi East, Kogi State, Nigeria, which reported localized compliance hitting 90.8%. This massive discrepancy indicates a major operational gap: while macro-level drug delivery metrics may show high distribution numbers, the actual ingestion of the tablet at the household level is heavily compromised. The results of this findings provides clear insights into the behavioral and structural mechanics driving this non-compliance; this was attributed to Information deficits, fear of adverse effects, distributor trust split. Information Deficits (22.1%, n = 309); Nearly a quarter of the population avoided the drug simply because of poor communication and a lack of programmatic information from community distributors, Fear of adverse effects (17.3%, n = 242); Apprehension regarding post-treatment systemic complications was a powerful barrier. This fear is somewhat grounded in clinical reality; 10.6% (n = 148) of the study cohort documented active post-treatment complications, including localized edema (2.0%) and intense reactive pruritus (1.5%). As microfilariae die under ivermectin pressure, they trigger severe localized inflammatory cascades. Without proper community counseling to explain that this itching is a positive sign of the drug actively killing the parasite, loops of fear quickly spread, driving mass non-compliance, Distributor Trust Split: While 50.0% (n = 700) expressed explicit trust in their frontline Community-Directed Distributors (CDDs), a large combined fraction was either openly distrustful (11.2%) or completely undecided (30.7%). This trust deficit undermines the core philosophy of the CDTI strategy, which relies on absolute communal ownership to achieve high treatment coverage.

3.3.6 Clinical Manifestations and Health-Seeking Behaviors

The distribution of self-reported symptoms, chronicity of clinical manifestations, and subsequent health-seeking pathways outlines the morbidity burden and therapeutic choices within the surveyed communities (Table 11). A notable segment of the study population reported experiencing classical clinical signs associated with onchocerciasis. Pruritus emerged as the most widely recognized manifestation, with 20.9% (n = 292) of respondents experiencing intense itching. Other dermatological and ocular pathologies identified across the cohort included: Vision-related problems or blindness: 3.6% (n = 50), skin discoloration: 1.5% (n = 21), subcutaneous nodules: 0.6% (n = 9), skin thickening or roughness: 0.3% (n = 4), a substantial majority of the participants (73.1%, n = 1023) did not provide a specific response regarding active symptom experiences. Regarding the duration of these reported symptoms, the data show that the onset was primarily recent for most affected individuals. Specifically, 20.1% (n = 281) of respondents had experienced these symptoms for less than one year. In terms of more prolonged morbidity, 3.1% (n = 43) reported symptom persistence for more than two years, while 2.4% (n = 34) had experienced them for a period of one to two years. Notably, 74.4% (n = 1041) of the total sample population lacked awareness regarding the precise duration of their symptoms. The analysis of health-seeking dynamics indicated that 20.7% (n = 289) of the total respondents actively sought intervention to manage their symptoms. Conversely, 4.0% (n = 56) did not seek any form of therapeutic remedy, and 75.3% (n = 1054) provided no response regarding their treatment-seeking actions. Among the participants who accessed healthcare options, formal and informal treatment channels were utilized in the following proportions: Local Health Clinics: 12.4% (n = 173), traditional Healers: 4.4% (n = 61), pharmacies or Patent Medicine vendors: 2.4% (n = 33), general or Tertiary Hospitals: 0.5% (n = 7). Finally, 80.4% (n = 1125) of the total study population did not provide a response specifying their utilized healthcare facility or treatment provider.

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