Quantitative.

A total of 1,127 household heads were interviewed using a structured questionnaire with mostly close-ended questions. All twenty-one (21) veterinary camps in the four districts were included in the study. A veterinary camp is the smallest administrative unit of a district. It is managed by a veterinary assistant and holds a maximum number of about five thousand herds of cattle. There were 836 respondents from Western province and 291 from Muchinga province. The questionnaire was translated into local languages, Lozi for Western Province and Tumbuka for Chama district. A pilot study was conducted in Mongu of Western province (not reported in this survey study). Before collecting data in each district, two to three veterinary camp officers were oriented to the questionnaire by the Principal Investigator in order to ensure consistency in data collection. Data was collected through face to face interviews. Questions asked involved whether respondents had ever heard of anthrax disease, knowledge of mode of transmission and who gets infected, their attitudes towards cattle vaccination, risk factors for anthrax and local veterinary services. Respondents were also asked about how they handled carcasses of moribund animals and whether any of their cattle or family members ever suffered or died from anthrax disease in the last twelve months.

Qualitative.

In order to get an in-depth understanding of the context in which the disease occurs, qualitative data was also collected. Six (6) focus group discussions (FGDs)were held as follows: Chama (n = 1), Nalolo (n = 2), Mongu (n = 2) and Limulunga (n = 1).Mongu had two FGDs because it had twice the number of Veterinary Camps compared to other districts. Each focus group discussion (FGD) had an average of eight participants. Two (2) FGDs were held with female respondents only while the rest had mixed sex. Focus group participants were purposefully sampled from among survey respondents. Respondents who were willing to participate in the discussions were invited regardless of whether they owned cattle or not. FGDs were conducted using interview guides with open ended questions to allow respondents elaborate responses in their own words. Questions asked concerned what respondents knew about anthrax transmission, signs and symptoms of the disease in humans and animals, mode of transmission of anthrax, prevention measures and challenges that they face in controlling the disease, meat consumption practices, cattle rearing practices, cultural beliefs concerning anthrax disease and perceptions about local veterinary services. Respondents were also asked about how they handled carcasses and how they dealt with moribund animals. Discussions were held in local languages and were recorded on a digital recorder after getting verbal consent from the participants.

In addition key informant interviews with staff involved in anthrax control (n = 7) were conducted. Informants included veterinary officers (n = 3), health officers (n = 2), officers from the wildlife authority (n = 1) and from the agriculture sector (n = 1). Informants were asked what experiences they had with the local communities while implementing anthrax control programs, how they collaborated with other sectors, the challenges faced in controlling anthrax and how veterinary services were organized in their districts. Information from their experiences was cross checked with that of the FGD participants and quantitative data. Respondents’ confidentiality was observed by avoiding identifiers on the questionnaires and transcripts. Informed verbal consent was obtained from respondents before collecting information from them and before recording the discussions or interviews.

Quantitative.

Descriptive statistics on socio-demographic characteristics, awareness of anthrax, attitudes towards cattle vaccination and risk factors for anthrax and vaccination practices were run using STATA 12 for analysis. Comparisons of socio-demographic characteristics, awareness, attitudes and vaccination practices between the two provinces were done using chi-square tests. Comparison of results was done between Western province and Muchinga provinces. This was because there were no significant differences noted between the three districts of Western province.

Qualitative.

Audio files for focus group discussions were translated into English after which they were transcribed into computer files. After reading and re-reading the narratives, the data was transferred into Nvivo 12 for coding. Initially, broad coding was done using major themes that were derived from the topic guides. This was followed by further coding from the major themes into sub-themes. Framework matrices were then formulated by identifying key quotes under each sub-theme and summarising the narratives under each major theme. Framework matrices were used to cross check narratives from key informants with those of focus group participants in order to identify divergent or supporting views. Illustrative quotations that clearly represented the themes were used in the data results.

Socio-demographic characteristics.

The age range of respondents was 18–99 years, with a median age of 43.5 years. For educational level, the majority of respondents (85.9%) had never been to school while only 4.6% attained secondary education. Most of the respondents (89.3%) were self-employed. Significant differences in socio-demographic characteristics were noted between the two provinces as shown in Table 1.

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Table 1. Comparison of socio-demographic characteristics of respondents between Western and Muchinga provinces.

https://doi.org/10.1371/journal.pntd.0005580.t001

As shown in Table 2, a majority (88%) of respondents had heard of anthrax across the two provinces. Most of respondents (64.2%) were also aware that both animals and human beings can be infected with anthrax. Although most of the respondents (83.5%) acknowledged that animal vaccination is an effective control measure for anthrax in Western province, the majority (63.3%) in Muchinga province did not know. A majority of respondents (86.4% in Western and 83.9% in Muchinga) knew that anthrax can be transmitted by eating infected meat.

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Table 2. Comparison of awareness of anthrax among respondents in 2 provinces, given as numbers (%).

https://doi.org/10.1371/journal.pntd.0005580.t002

However, there was no significant difference in awareness about eating infected meat as a common mode of transmission for anthrax between the two provinces. The most common source of information about anthrax in Western province was from radio and friends (45.6%) while in Muchinga province it was mostly from friends (39.7%).

Although majority of respondents were positive that animals can transmit diseases to humans, only 26.3% believed that eating infected beef was risky. These attitudes were significantly different between the two provinces, most notably the attitude towards local veterinary services. While most of respondents in Western province were positive about local veterinary services (89.7%), only 22.1% in Muchinga province showed a good attitude.

A majority (82.3%) of respondents in Western province reported that they vaccinate their cattle against anthrax. However, provincial vaccination records indicated that the majority of cattle farmers in Western province did not actually vaccinate their animals. Although most (34.5%) of the respondents across the provinces indicated that they reported cattle mortalities to the local veterinary authorities, only 13.5% burnt or buried the meat carcasses. Most (68.3%) of respondents participated in gutting of carcasses when an animal died in the community and (36%) shared the meat among their communities. Results are illustrated in Table 3.

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Table 3. Community practices of relevance for anthrax in the two provinces, reported as numbers (%) in each province.

https://doi.org/10.1371/journal.pntd.0005580.t003

Awareness of anthrax disease.

The names by which anthrax disease is addressed suggest that respondents understood the common signs of disease and transmission route. In Western province, anthrax is called “Lubete”, which is the English translation for spleen. According to the respondents, the disease is called as such because one of the classical signs of anthrax in cattle is swelling of the spleen. In Muchinga province anthrax is called “Chigwere”, which is the English translation for hippo (Hippopotamus amphibious). The disease is called as such because the communities understand that it is transmitted by eating infected hippo meat. Participants were mostly able to identify signs of disease in animals.

When the cattle die that is when we realize that it was suffering from anthrax. You will notice that the blood is coming out from the nose and at the back and at the tail (referring to the anal orifice). The disease spreads in the kraal fast, you see cattle just dying even 3 at once (male participant, Mongu).

The majority of respondents were able to identify signs of cutaneous and gastro-intestinal anthrax.

The disease of anthrax, what I have observed is that in humans there is a boil-sore which has no pus, even when you open it, it is just a swelling (female participant, Limulunga).

None of the respondents identified or discussed inhalational anthrax. Generally, awareness of anthrax was poor among some communities, notably among female participants and villages where anthrax outbreaks had never occurred.

Participants mentioned that eating infected meat was the commonest route of transmission. One male participant described how he thought anthrax was transmitted from animals to humans, he said: This disease of anthrax when our cattle died we did not bury, we ate

Qualitative findings seemed to suggest two different origins of anthrax in the two provinces. A Wildlife officer working in Muchinga province explained that outbreaks of human anthrax commonly occurred following death of hippos in the Luangwa valley.

What normally happens is when the hippos start dying, we have some fishermen and also in the human habitations people are mobile. So sometimes rather than our officers that go for patrols, these mortalities are discovered by nearby communities. So once they have discovered sometimes they by-pass the law, they would just start cutting the meat and start eating. Then the meat becomes too much for the communities living around those areas to consume so what they would do is to dry the meat and rush to where they could find the market (Wildlife Officer, Chama).

For Western province, anthrax seems to originate from eating infected beef from moribund cattle as mentioned by a veterinary officer:

… l mean human beings would get infected then we would follow and find that there are cattle that had died and people had eaten it and eeh got infected. That is the situation in Western Province. (Veterinary Officer, Mongu)

Attitudes of community towards anthrax disease.

Professional workers involved in anthrax control indicated that most community members had negative attitudes towards not eating meat from moribund animals. Professional workers narrated that one of the challenges they faced in anthrax control was failure to convince community members against eating infected meat as indicated below.

I think according to my own view, l think one of the things that makes them not to comply, it’s just the mind-set. Yes, the mind-set, so for us to convince them that meat can actually kill, we need to work very hard, yes. (Veterinary Officer, Limulunga)

In addition, interviews showed that most cattle farmers had a negative attitude towards cattle vaccination against anthrax. One veterinary officer narrated that in his veterinary camp, farmers would usually avoid taking their animals for vaccinations for fear that the disease was going to be introduced into the animals and cause them to die.

They hindered the progress of vaccinations, others would even hide their animals they didn’t bring it to the crash pane for fearing that they might die after vaccination. …so they think by putting a vaccine in an animal would make it die, get an infection of that disease and die, yes. Those are the hindering points we are facing, for fear of the animal dying after vaccination….(Veterinary Officer, Nalolo)

The above quotation seems to be supported by what focus group participants felt about animal vaccinations. One male participant in Western province said:

the veterinary have vaccinated them though there has been no change observed …. that may be the vaccines do not work on the disease.

Veterinary staff indicated that traditional beliefs and practices seemed to have an influence on community attitudes as indicated below.

l mean, this is meat that we have been eating for years and years, our ancestors have been eating and now you say it’s infected, it’s making us sick, me l refuse because as far as we are concerned, there are no graves for cattle. (Veterinary Officer, Mongu)

Such beliefs and attitudes clearly influenced how people received and interpreted health education messages that they received from professional workers.

Community practices.

Apart from cultural beliefs, there are traditional practices that have been implicated in anthrax transmission. One such practice is the ‘Mafisa’ traditional practice. In this practice, cattle owners give their cattle to other people to herd in order to spread the risk of dying. Such animals are used for manuring, and draught power. Using the same practice, cattle herders are paid an agreed number of cattle as payment. This practice in turn empowers those families without cattle to eventually own some. However, in the event that cattle dies while under the care of the herder, there is need to produce evidence. Therefore, meat and the animal skin are dried and taken to the owner as evidence for the dead cattle. So if cattle died from anthrax, it meant that along with the meat, the disease was transferred to a new area. One respondent explained what happens when cattle on ‘Mafisa’ dies:

If the owner of cattle is far away, the meat is cut into threads and dried. The skin is also dried so that the owner can find it. The skin is stored because it is evidence for the dead cattle. (Female respondent, Mongu)

Another practice is associated with the Lozi traditional ceremony called ‘kuomboka ceremony’. The ceremony takes place at the end of the rainy season when the upper Zambezi river floods the plains of the Western province. Due to flooding, the ‘Litunga’, the king of the Lozi’s and his subjects move upland along with their livestock and belongings. They stay upland until the waters have subsided. Therefore, cattle stays upland for manuring the fields. This movement of cattle between the areas facilitates the spread of anthrax. In case, cattle dies while on the upland, meat has to be dried and taken to the owner in the plains as evidence, therefore spreading the disease. This was illustrated by one veterinary officer who said:

… the owners of the cattle stay in the plain, so when the animals go in the upland, they stay with other people there for manuring the fields, so you find that an animal got affected in the upland, the meat has to be transported to the plain. So you have an outbreak from different place from where it died.

Meat consumption practices.

Respondents discussed a number of meat consumption practices that they thought could be implicated in the transmission of anthrax in the community. One such practice was where community members who helped in skinning and gutting dead cattle each received a share of meat. The practice was called ‘Maleu’. This practice exposes more people to the disease other than the owner of the cattle. A female respondent explained what happened when an animal died in her community:

Yes, what we do is that if the veterinary officers do not come at that time we skin after skinning just there where the cattle died from, we start to share among ourselves, there is meat that they give the skinners.

Sometimes meat was shared among community members, sold, or exchanged with other items

Dead cattle, we help ourselves by eating it, some meat we sell and keep the money so that may be able to buy another animal. Sometimes we burn it.

Other practices discussed included boiling the meat for the whole day to render it safe for eating, or cutting out and throwing away parts of the meat which were believed to be infected by anthrax and eating the rest of it.

Us (village) we are of the belief that, meat when it is cooked then the disease is killed, it cannot be transmitted (female FGD participant)

Reasons for consuming infected meat.

Reasons cited for consuming meat included, lack of education, cultural beliefs, poverty and economic reasons. Poverty and lack of health education were cited as the most common causes of eating infected meat in all the six FGDs. A female respondent elaborated how hunger and lack of health education affected their meat consumption behaviour.

Those who eat meat is due to misery caused by hunger, there is draught in Lozi land, rains do not fall, crops are not doing well, thus there is no food, so due to lack of enlightenment and hunger, they eat dead cattle’s meat.

Other than lacking awareness and hunger, geographical location also seem to influence consumption behaviours of these communities. The remote location of the communities make it difficult for them to access certain facilities such as butcheries where they can buy safe meat. Chama district is one such area.

…. We do not have butcheries here, we suffer because we do not have butchery facilities here, that is why whenever we hear of information on meat, even for small animals you go and get it to eat.

Chama district is a game management area (GMA) and therefore rearing of domestic animals is a challenge because of wild carnivores. The communities therefore have problems accessing meat protein.

Both professional workers and community respondents pointed out that cattle was the main source of wealth and livelihood [15]. Respondents showed that most people consume or sell meat from infected carcasses due to economic reasons. Therefore, when cattle die, most families are forced to salvage some losses by eating or selling the meat. This was explained by a female participant during discussions on the impact of anthrax on the livelihoods of people:

It does not feel good because that is where you had put all your hopes and thoughts altogether. Now that it dies, that is why you see that many people fail to bury so that they can sell some meat as something to get comfort from. That is what causes that they sell meat from cattle which died on its own.

Dependence on cattle for livelihood means that families have to put up some cost recovery measures whenever they lose cattle

A number of expressions indicating the economic impact of loss of cattle were made by respondents in most focus group discussions in Western province. One male participant said:

Cattle here in Lozi land is our mine because we do not work, it is our copper (copper mining is the major source of the country’s economy).

Another female respondent said:

It feels bad because it is an asset that helps us, when you sell it, it helps you but when it dies, it feels bad, it is the same as losing a child.

These study findings indicate the economic importance of cattle, especially in Western province and the emotional stress that cattle losses cause in the communities.

Apart from poverty and lack of education, it was found that entrenched cultural beliefs and practices were contributing to resistance in behaviour change. In describing challenges that they face in anthrax control, most key informants indicated that most communities had certain beliefs and practices that contributed to the transmission of anthrax disease. Below is an example of some of the responses that veterinary officers in Western province commonly received from community members:

l mean, this is meat that we have been eating for years and years, our ancestors have been eating and now you say it’s infected, it’s making us sick, me l refuse because as far as we are concerned, there are no graves for cattle.

Such beliefs and attitudes clearly influence how people receive and interpret health education messages that they may receive from professional workers.

This is clearly demonstrated by what by one participant said during a focus group discussion.

Us Lozis we don’t slaughter cattle for relish unless it dies on its own. Dead cattle, we help ourselves by eating it, some we sell and keep the money so that may be able to buy another animal, sometimes we burn it.

It is shown here that meat consumption patterns are equally shaped by cultural beliefs. In Western province, cattle are mainly kept for draught power, manure and for wealth and prestige.

Other reasons for consuming meat is that people do not perceive eating meat as risky because they did not observe obvious signs of disease in those who ate the meat. One participant said:

…what causes that we eat …there is nothing that happens on our bodies when we eat all of the meat …

Animal vaccination is an effective preventive measure for anthrax. Animals should receive vaccinations every year in order to avoid infections. However, animal vaccination levels have been low in Western province due to various reasons. One of the reasons described by one informant in Western province was lack of knowledge and poor attitude by cattle farmers. However, a senior veterinary officer pointed out that most farmers do not understand what diseases their animals are vaccinated against. In Zambia, it is the responsibility of the farmer to buy their own vaccine and have their animals vaccinated against anthrax. However, other vaccinations like Foot and Mouth Disease, Black leg and Contagious Bovine Pleural Pneumonia (CBPP) are given freely. But because most farmers are of low education or are not well informed, they think that the free vaccinations also cover anthrax disease. The other reasons for the low vaccination were failure to afford the cost of the vaccine and poor access to the vaccine and logistics. A senior veterinary officer explained a practical scenario in Western province and said:

It is up to the farmer to vaccinate his animals but to start with even if they know, they cannot afford. Sometimes they may want to protect their animals but now the vaccine might not… is not readily available, what is involved to get your animals vaccinated it’s not easier. (Veterinary Officer, Mongu)

Similar concerns were raised by all key informants from the veterinary sector that they faced challenges of poor funding, inadequate transport, and lack of cold chain facilities in remote areas, poor staffing and lack of accommodation and office space for them to work effectively. Because of this, they are not able to vaccinate cattle as recommended. They mentioned that government does not fund anthrax vaccinations unless there is an outbreak. Therefore, free vaccinations are only conducted when there are outbreaks. This scenario seemed to create frustration among cattle farmers and has contributed to certain misconceptions. One misconception is that the vaccine makes cattle to get infected with anthrax and die; therefore farmers avoid taking their animals for vaccination.

There were several challenges faced by both control officers and the community in getting animals vaccinated. Most community participants also mentioned poor extension services, lack of funds to pay for vaccination and lack of government support. They also kept their animals from being vaccinated for fear of their animals dying because veterinary officers mostly conducted vaccinations when there was an outbreak. They also indicated that most of their communities had no resident veterinary officers within their localities due to lack of accommodation.