Public Awareness of Infectious diseases in

Mogadishu, Somalia: a cross-sectional study

Shafie Mohamed Ali1, Dr. Sakariye Abdullahi Hassan (Tuuryare), Dr. Suleyman Abdullahi
Mohamed3 Timothy Kimutai4

,
1
Founder Voiceup Health, 2Head of IPC , Kalkaal Hospital 3MD, Co-founder Kalkaal Hospital, 4Statistician,
Kalkaal Hospital

Abstract

Globally, Infectious diseases, including the Hepatitis B virus, tuberculosis, and human immunodeficiency (HIV), are a
significant cause of morbidity and mortality that contribute immensely to public health problems in many countries. In
2015, an estimated 1.8 million TB deaths were reported globally. In Somalia, there is less data on assessing public
awareness of infectious diseases. The country has had little healthcare investment, and the private sector and non-
governmental institutions largely control it. For this reason, we conducted this research to assess public awareness of
communicable diseases. This cross-sectional study was conducted between July 1 and July 23, 2022, in rural, urban, and
IDP settings of the Benadir region, Mogadishu, Somalia. The study was approved, and informed consent was obtained
from the respondents before the study was conducted. 397 participants participated in this study, while 11 were excluded
for incomplete responses; as a result, 386 respondents completed the interview successfully. The awareness of the
transmission of HBV is very low, scoring at 26.6% of correct responses.
Additionally, the study indicates that as much as many seek the modern solution for medical health, the traditional
systems are still widely viewed as part of the solution for health. While many people know that Tb is spread through
coughing and sneezing, the knowledge of the spread of HBV is deficient. A large number of respondents perceive that
HBV cannot be prevented through vaccinations. Overall, according to this study's results, the average knowledge of
communicable diseases was 50%. These results indicate a need for awareness programs to increase public awareness of
communicable diseases.

Keywords: HBV, HIV, TB, Awareness, Infectious diseases

I. INTRODUCTION
Globally, Infectious diseases, including the Hepatitis B virus, tuberculosis, and human immunodeficiency (HIV),
are a significant cause of morbidity and mortality that contribute immensely to public health problems in many
countries. Infectious diseases primarily affect developing countries because of a myriad of reasons that make those
countries vulnerable and susceptible to infectious diseases. (1,2)
One of the main reasons for infectious diseases to spread in developing countries is malnutrition which weakens
the immune systems worsening the situation as the infectious diseases progress to severe illness. (1) In developing
countries, people live in a crowded setting with poor hygiene and sanitation, thus accelerating the spread of
infectious diseases. Poor education among the people translates to a lack of awareness of infectious diseases and
ways of preventing them. When people in developing countries get infected with infectious diseases, the cost of
medications escalates an already adverse economic condition, thus deteriorating their living standards. The
infectious diseases lead to bad health outcomes as they cannot afford medication and the clinics within the country
are weak. People in this situation are economically less productive and thus promoting poverty. Furthermore,
infectious diseases have the potential to create a vicious circle by intertwining themselves with poverty. (3)
1
 In 2015, an estimated 1.8 million TB deaths were reported globally (4). The world Health organization has
indicated a reduction in the number of reported cases of TB from 7.1 million in 2021 to 5.8 million in 2020. The
death rate attributed to the disease in the same period increased as people refrained from going to the hospital for
fear of being infected with COVID 19. In 2020, Among HIV-negative individuals, a number 1.3 million HIV-
negative persons died of TB; this number was lower in 2019, numbering 1.2million. On the other hand, 214,000
HIV-positive people died of TB in 2020. (5)
In 2020, there was a marginal increase in TB incidence in Somalia, according to the 2021 Global TB Report. The
number of cases increased from 258 per 100,000 people in 2018 to 259 per 100,000 in 2020(5,6). The death rate
attributed to TB was 68 per 100,000 people in 2020.
In Somalia, viral hepatitis, mainly HBV, is a significant public health problem. A systematic review by authors
Hassan-Kadle, Osman, and Ogurtsov(2018) showed that the overall prevalence of hepatitis was 20% in 2018. (6)
The number of TB cases reported in Somalia in 2021 slightly increased from 17200 cases in 2020 to 17503 in 2021.
(5)
Public awareness is vital in preventing and controlling diseases because it increases the detection rate. Improving
the population's hospital-seeking behavior and reducing stigma, discrimination, and low treatment adherence rates
related to the disease are essential. A study by Ali MK, Karanja S, and Karama M. (2017) found that treatment of
TB was successful with different factors. The authors reported that education and knowledge of TB increased the
odds of successful treatment. Public awareness helps increase the timely reporting of the spread of infectious
diseases and stops it from progressing. According to the Federal Ministry of Health in Somalia, even though there
has been a slight increase in the reported cases of infectious diseases, there is still a need for more effort in
performing outreach activities to improve the detection rate(5).
The ministry of health has indicated that despite the high prevalence, there is still a low detection rate and timely
diagnosis of the diseases. Furthermore, the MOH indicates that the people are still unaware of the symptoms
In Somalia, there is less data on assessing public awareness of infectious diseases. The country has had little
healthcare investment, and the private sector and non-governmental institutions largely control it. For this reason,
we conducted this research to assess public awareness of communicable diseases. This study is handy in promptly
addressing infectious diseases.

II. METHODS
A. Population and sampling
This cross-sectional study was conducted between July 1 and July 23, 2022, in rural, urban, and IDP settings of
the Benadir region, Mogadishu, Somalia. The study was approved, and informed consent was obtained from the
respondents before the study was conducted.
The questionnaire was designed based on relevant literature on the subject, pretested among 30 people, and was
modified as necessary. The questionnaire comprised four sections; section one covered demographic characteristics,
including age, sex, education, and marital status. The second section covered participants' knowledge of
communicable diseases and practices when the disease is there. The third section covered participants' knowledge of
two specific infectious diseases; the questions comprised three items related to TB and two on HBV. A correct
answer for each question was awarded 1 mark, while an incorrect answer was awarded 0. The total marks scored
were calculated as follows: 75% to 100 were considered "excellent, 60%-74% were considered good, 50-59 were
considered average, while 25%-49% and 0% - 24% were considered poor and very poor, respectively.
In analyzing the relationship between demographics and disease awareness, good and excellent were regarded as
"aware," while those who scored poorly were regarded as "not aware." The responses for this study were collected
through both a self-administered questionnaire and a face-to-face interview conducted by local investigators who
had been trained before the commencement of the survey.
Informed consent was obtained from the participants before conducting the survey, and the participant was not
included in the survey in case of refused to participate in the survey.
B. Data Analysis
The management and data analysis was done using excel and SPSS version 25. The descriptive statistics were
calculated as mean, SD, and percentages.

2
 III. RESULTS
397 participants participated in this study, while 11 were excluded for incomplete responses; as a result, 386
respondents completed the interview successfully. The result of this study indicates that females and males were
56.7% and 43.3%, respectively. Classification of the participants according to the place of residence indicated that
60% of the residents were from rural while 40% were from urban areas. When grouped by age, the highest number
of the participants were above 50 years, 140(46.7%), between 30 and 40 numbered 50(16.7%), 10-20 were
40(13.3%), while 20-30 numbered 30(10%). Regarding education, 260(86.7%) had no formal education while
140(13.3% had formal education. Married 210(70%) and unmarried 190(30%).
Distribution of knowledge of two infectious diseases in a rural and urban population in Mogadishu, Somalia, May
2022- July 2022 (N = 300)
Items N %

General Information

Gender

Male 130 43.3%

Female 170 56.7%

Place of residence?

Rural 120 60%

Urban 80 40%

Age?

10 - 20 40 13.3%

20 - 30 30 10%

30 - 40 50 16.7%

40 - 50 40 13.3%

>50 140 46.7%

Educational Level?

No formal school 260 86.7%

Formal School 140 13.3%

Martial Status?

Married 210 70%

Unmarried 190 30%

A. Communicable Disease Knowledge

When asked whether any of the family had communicable disease230(76.7%) indicated that member of the
family, 70(23.3%) indicated that there was no member of their family with a communicable disease. Furthermore,
the results of the data indicate that among those whose family members had the communicable disease, the highest
percentage, 45% (30), was covid 19, followed by HBV at 30% (90) and TB at 13% (45), when asked on whether the
sick person was hospitalized 60% (180) and 40% (120).
259(83.3%) of the participants indicated that communicable diseases be treated with traditional burning, while
50(16.6%). When asked about the ever-got awareness from the local government, hospitals, or NGOs, 30(10%)
3
indicated that they received it while 270(90%) did not.
Communicable disease

Is there any member of your family with communicable diseases?

Yes 230 76.7%

No 70 23.3%

If yes, what is the name of the disease?

HBV 90 30%

TB 45 15%

Covid-19 135 45%

Others 30 10%

Has the sick person gone to the hospital to seek medical attention?

Yes 180 60%

No 120 40%

Do you seek medical attention from a traditional healer

Yes 220 73.3%

No 80 26.6%

Can communicable diseases be treated with traditional burning?

Yes 250 83.3%

No 50 16.7%

Have you ever got awareness from the local government, hospitals, or NGOs?

Yes 30 10%

No 270 90%

B. HBV KNOWLEDGE
220(73.3%) of the participants indicated that they agree that HBV infection can cause liver cancer, while
50(16.7%) indicated that it is not, and 30(10%) indicated that maybe it is. 220(73.3%) of the participants indicated
that HBV could not be spread during childbirth, while 26.6% indicated it could. 230(76.7%) indicate that HBV
cannot be prevented by vaccination, while 23.3% indicate it can.
HBV KNOWLEDGE

Do you agree that HBV infection can cause liver cancer?

Yes 220 73.3%

No 50 16.7%

May be 30 10%

4
 Can HBV be spread during childbirth?

Yes 80 26.6%

No 220 73.3%

Do you think that vaccines can prevent HBV?

Yes 70 23.3%

No 230 76.7%

C. TB KNOWLEDGE
The data results according to TB knowledge are as indicated in table IV. The results indicated that 210(70%) of
the respondents could describe symptoms of TB 90(30%) could not. 240(80%) of the study participants indicated
that TB transmission could occur through coughing and sneezing.
TB KNOWLEDGE

Can you describe the main symptoms of TB?

Yes 210 70%

No 90 30%

Can TB be transmitted by coughing and sneezing?

True 240 80%

False 60 20%

Table 4 Awareness of two infectious diseases in a rural and urban population in Mogadishu, Somalia, May - July
2022 (N = 300)
Variable Aware Unaware
n % n %
HBV transmission awareness 80/300 26.6% 220/300 73.3%
HBV Prevention 70/300 23.3% 230/300 76.7%
TB transmission awareness 240/300 80% 60/300 20%
Knowledge of symptoms of TB 210/300 70% 90/300 30%
Average=600/1200 Average=50% Average=600/1200 Average=50%

IV. DISCUSSION
There was a total of 311 participants in this study, but 11 were excluded due to incomplete responses; as a result,
300 participants completed the interview. The results of this study indicate that there were 56.7% females and 43.3%
males. The classification of participants by residence revealed that sixty% were from rural areas and forty% were
from urban areas. The largest proportion of participants, 140 (46.7%), were over the age of 50, followed by those
between 30 and 40 (16.7 per cent), 10 to 20 (13.3%), and 20-30 (30%) (10%). 260 (86.7%) had no formal education,
whereas 140 (13.3%) had formal education. Results for marital status Married 210 (70%) and Unmarried 190 (30
per cent).
When asked whether any member of the family had a communicable disease, 76.7% indicated that there was a
family member present. Moreover, the data reveal that among those whose family members had a communicable
disease, covid 19 accounted for the highest percentage (45%) (30). The percentage of those with HBV was 30%.
This result is reflected in the literature review whereby authors Hassan-Kadle, Osman, and Ogurtsov(2018), in a
systematic, indicated that the overall prevalence of hepatitis in Somalia was 20% in 2018. (6) The percentage of TB
type of infectious disease present in family members was (13%). This is higher than a National study in a previous
study by Global, where authors indicated that the number of TB patients was 259 per 100,000 in 2020(5,6).

5
 In assessing the hospital-seeking behavior of the people, 60% of respondents responded agreeably when asked if
the sick person was hospitalized. However, 73.3% of the respondents indicated that they seek medical attention from
a traditional healer. The study shows that 259 (83.3% of participants) indicated that communicable diseases should
be treated with traditional burning, while 50 (50%) did not (16.6 per cent). In Somalia, people may favor the
conventional system in some regions where the two medical systems coexist due to their beliefs and the satisfaction
they derive from it. The causes and treatments for diseases are viewed differently by the Somali people. The
ancestors are as significant in this society as in other African societies. Even now, many illnesses and natural
disasters are blamed for not appeasing the ancestors enough.
Additionally, Somalia had trade relations with Asian nations like the Arabs, Indians, and Persians through which
they imported medical practices. The "evil eye," "envy," "sin", or "mistake" committed against a member of society,
as well as supernatural causes like spirits or Jinni, are some of the causes of disease in Somalia. The pre-Islamic
concepts of illness and treatment have coexisted with those brought by the Islamic religion to Somalia.
When asked if they had ever received information from the local government, hospitals, or NGOs, 90% of
respondents said no, while 30% said yes. This result suggests that there is currently little awareness and a dire need
for public education. Because it increases the detection rate, government-sponsored public education is essential for
disease prevention and control. It is crucial for enhancing public health by lowering stigma, discrimination, and low
rates of disease-related treatment compliance. The government should collaborate with non-governmental
organizations and other interest groups to increase public awareness of communicable diseases. Some organizations,
like the IFRC, which assists the National Society in addressing non-communicable diseases by hosting community
sessions on healthy lifestyles and raising awareness of prevention and discrimination surrounding communicable
diseases, have made significant contributions to raising awareness in many different countries.
In assessing the knowledge of the spread of HBV,73.3% of the participants agreed that HBV infection could
cause liver cancer. 220 participants (73.3%) indicated that HBV could not be transmitted during childbirth, while
26.6% indicated it could. These results indicate a low level of awareness of the spread of HBV.
In assessing the knowledge of the prevention of HBV, 76.7 per cent of the respondents believe that HBV cannot
be prevented by vaccination, while 23.3% believe that it can. This outcome indicates that most people do not know
that despite the progress of antiviral therapy against HBV to suppress viral replication and reduce complications in
those with chronic hepatitis B, a cure for infection is still not possible. Hence, prevention of HBV infection by
immunization is the best way to eliminate HBV-related diseases.
In assessing the level of knowledge of the symptoms of tuberculosis, 70 per cent of the respondents could
describe the symptoms of tuberculosis, whereas 90 (30 per cent) could not. Eighty per cent (240) of the study
participants reported that TB could be transmitted through coughing and sneezing.
On average, the score on the knowledge of communicable diseases in Somalia was 50%.

V. CONCLUSION
The awareness of the transmission of HBV is very low, scoring at 26.6% of correct responses. Additionally, the
study indicates that as much as many seek the modern solution for medical health, the traditional systems are still
widely viewed as part of the solution for health. While many people know that Tb is spread through coughing and
sneezing, the knowledge of the spread of HBV is deficient. A large number of respondents perceive that HBV
cannot be prevented through vaccinations. Overall, according to this study's results, the average knowledge of
communicable diseases was 50%.
These results indicate that there is a need for awareness programs in the country to increase public awareness of
communicable diseases. It is recommended that the government should collaborate with non-governmental
organizations and other interest groups. Some organizations, like the IFRC, which assists the National Society in
addressing non-communicable diseases by hosting community sessions on healthy lifestyles and raising awareness
of prevention and discrimination surrounding communicable diseases, have made significant contributions to raising
awareness in many different countries.

VI. REFERENCES
[1] Infectious Disease - an overview | ScienceDirect Topics [Internet]. [cited 2022 Jul 28]. Available from:
https://www.sciencedirect.com/topics/social-sciences/infectious-disease
6
[2] Getzzg. Health disparity and mortality trends of infectious diseases in BRICS from 1990 to 2019 [Internet].
JOGH. 2022 [cited 2022 Jul 28]. Available from: https://jogh.org/2022/jogh-12-04028/
[3] Perceived poverty and health, and their roles in the poverty-health vicious cycle: a qualitative study of major
stakeholders in the healthcare setting in Hong Kong | International Journal for Equity in Health | Full Text
[Internet]. [cited 2022 Jul 28]. Available from:
https://equityhealthj.biomedcentral.com/articles/10.1186/s12939-020-1127-7
[4] Ali MK, Karanja S, Karama M. Factors associated with tuberculosis treatment outcomes among tuberculosis
patients attending tuberculosis treatment centres in 2016-2017 in Mogadishu, Somalia. Pan Afr Med J
[Internet]. 2017 [cited 2022 Jul 18];28(1). Available from:
https://www.ajol.info/index.php/pamj/article/view/167299
[5] Administrator. World TB Day 2022: Getting back on track to diagnose and report TB cases, to save lives
[Internet]. World Health Organization - Regional Office for the Eastern Mediterranean. [cited 2022 Jul 19].
Available from: http://www.emro.who.int/somalia/news/world-tb-day-2022-getting-back-on-track-to-
diagnose-and-report-tb-cases-to-save-lives.html
[6] Hassan-Kadle MA, Osman MS, Ogurtsov PP. Epidemiology of viral hepatitis in Somalia: Systematic review and
meta-analysis study. World J Gastroenterol. 2018 Sep 14;24(34):3927–57.