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Leptospirosis is a neglected zoonotic disease and often under-reported. Municipal waste collectors, engaging mainly migrant labour are at risk to leptospirosis due to their nature of work. The present study aimed to determine the knowledge, attitudes, and practices (KAP) of the multinational municipal waste collectors towards prevention of leptospirosis, and further identify factors associated with the KAP.
Across-sectional study was conducted using face-to-face interview among 184 municipal waste collectors. They completed a questionnaire on sociodemographics and KAP towards leptospirosis. Multiple linear regression was performed to determine factors associated with KAP towards the leptospira infection.
The majority of participants were Bangladeshi (75.0%) and Indonesian nationals (20.7%), with poor knowledge of leptospirosis (92.93%).The attitudes towards leptospirosis were moderate (59.78%) while preventive practices were good (74.46%). Indonesians had significantly better knowledge as compared to other nationals (p < 0.001) but had poor practices (p = 0.021). Workers with upper secondary school education had better attitudes (p = 0.026) and preventive practices scores (p = 0.045). Individual monthly income had inverse association with attitudes scores (p = 0.036).
Overall, the preventice practices among municipal waste workers was good due to relatively ethical work behaviours. However, they had poor knowledge on the cause, modes of transmission, symptoms and treatment of leptospirosis. The study suggests that targeted education to increase knowledge and systematic preventive measures to reduce contact with the infection are necessary for this occupation group.
Leptospirosis is one of global health concern but there is lack of well-grounded figures on the global incidence. According to the World Health Organization (WHO), humid conditions increase the incidence from 10 – 100 per 100,000 to above 100 per 100,000 in highly-exposed groups especially during outbreaks.
Rodents are the main reservoirs for spirochetes, other rare potential sources of infection include farm animals like pigs and cows, as well as pets like cats and dogs. Infections in humans could be acquired through environmental reservoirs, such as soil, mud and water contaminated with the urine of these animals at recreational or at work place.
Occupations like farming, mining, fishing, working in a wet market, and collecting waste are known occupational hazards to leptospirosis. The current study focused on municipal waste collectors who mainly are migrant workers because they are at high-risk of being infected with leptospirosis in the process of their work which includes cleaning drains, contact with public and domestic wastes and animal faeces. One study in Malaysia reported that the seroprevalence of leptospirosis among town service workers was 24.7%, in which the waste collectors had the highest prevalence.
Understanding the knowledge, attitudes, and practices (KAP) towards leptospirosis is an appropriate strategy to identify effective ways to provide better education regarding leptospirosis, minimize the risk of the infection and to promote safe working environment for municipal waste collectors who are at risk to leptospirosis. Therefore, this study aimed to determine the KAP on leptospirosis prevention among the multinational municipal waste collectors and to identify factors associated with the KAP.
2. Materials and methods
2.1 Sampling procedure and participants
This cross-sectional study was conducted among municipal waste collectors in Penang Island, situated in the northern region of Peninsular Malaysia. The waste collectors, mainly responsible for managing waste are full time workers employed by nine contractors appointed by the City Council of Penang Island. Data collection was carried out from January 2018 to May 2018. The sample size needed for this study was 162 which determined using STATA/SE13.0 based on two-proportion formula according to at least 80% statistical power to detect a difference of 20% in the knowledge on leptospirosis among the waste collectors as compared to the previous study.
The final sample size was adjusted to 187 after the consideration of about 15% non-response rate. Relatively, 21 participants were sampled from each contractor to reach the required sample size. Simple random sampling was performed if the contractors have more than 21 workers; otherwise, researchers took all workers to be considered for the participation in the study. The workers must be able to comprehend either Malay or English language, aged at least 18 years old and working in Penang for at least 6 months. A structured face to face interview was conducted. Three researchers were trained prior to data collection to eliminate inter-rater bias.
2.2 Study instrument
The study instrument had eight sociodemographic questions and KAP section. The KAP section were adopted from previous literature focused mainly on waste collectors.
It was reviewed and modified through public health experts' consultation. The KAP section demonstrated Cronbach's alpha of 0.78 for the full scale; and for each subscale of knowledge, attitudes, and practices respectively at 0.86, 0.62 and 0.57. The possible total score for knowledge section ranged between 0 – 19. The items had three answer options of “yes”, “no” and “unsure”. The correct answer was scored as 1 and the incorrect or unsure was scored as 0. The attitudes section consisted of 8 items of 5 Likert-scale responses ranging from “strongly agree” to “strongly disagree”. The items were recoded into 1 for those answered “strongly agree” or “agree” for good attitudes question and ‘strongly disagree’ or ‘disagree’ for poor attitudes questions. Otherwise, the responses were coded as 0. The questions regarding attitudes included usage of personal equipment's such as gloves and boots, and avoidance of exposures behaviours. The attitudes scores were aggregated and ranged from 0 – 8. The practices section with similar scoring method as the knowledge section, consisted of 10 items of “yes”, “no” and “unsure” options on questions regarding health seeking practices, hygienic practices, control and preventive measures.
The total scores for each section were converted to overall percentage. Scores for KAP were divided into poor, moderate, and good categories based on original Bloom's cut off point.
The scores were divided into three groups of correct responses; good (80–100%), moderate (60–79%) and poor (less than 60%).
2.3 Data analysis
Data were entered into Excel spreadsheet and analysed using Stata/SE 13.0. All numerical variables were presented in mean and standard deviation for normally distributed data, whereas median and interquartile range was displayed for skewed data. All categorical variables were presented as frequencies and percentages. Kendall's tau b analysis was carried out to identify inter-correlation between KAP domains. Simple linear regression was performed as univariable analysis to determine the individual association between factor and each total KAP scores. Meanwhile, multiple linear regression was performed to identify the best fit model for the associated factors to each total KAP scores based on p value less than 0.05.
3.1 Sociodemographic characteristics
A total of 184 workers were recruited to participate in the study from the overall 221 waste collectors working with the nine contractors. Table 1 shows the sociodemographic characteristics of the workers. The mean age was 35.37 ranging from 18 to 68 years old. Majority were married and migrant nationals. Bangladeshi workers were the majority followed by Indonesians, Malaysian and Nepalese. Substantial numbers of participants were illiterate, but majority had attained at least primary school education. Fig. 1 showed the distribution of highest education level of the workers by nationality. More than half of the workers had average individual income of 1000 Malaysia Ringgit, MYR (1 USD = 4.67 MYR as off October, 2022) and had worked for 4 years.
Table 1Socio-demographic characteristics of the municipal waste collectors (N = 184).
The municipal waste collectors generally had poor knowledge, moderate attitudes and good practices regarding leptospirosis (Table 2). The Kendall's tau b analysis was only significant for correlation between attitudes and practices.
Table 2Descriptive and inter-correlation of KAP domains on leptospirosis (N = 184).
There were only 44 (23.91%) workers who had ever heard of leptospirosis or its local term ‘rat urine’ disease, and only few 29 (15.76%) knew leptospirosis is caused by bacteria. Fig. 2 shows the distribution of the correct responses for knowledge items according to the nationality. Less than 10% knew that leptospirosis can cause inflammation of liver and multiple organ failure (Fig. 2a). Not more than 15% knew the symptoms of leptospirosis such as fever (n = 26,14.13%), muscle pain (n = 21, 11.4%), headache (n = 26, 14.13%) and joint pains (n = 23, 12.5%) (Fig. 2b). More than half of participants believed that the disease only affected certain age groups (n = 94, 51.09%). More than three quarters (84%) wrongly reported how leptospirosis is transmitted (Fig. 2c); 26 (14.13%) identified the leptospirosis transmission for both (1) through contacts with infected rodents via urine or blood; and (2) contaminated food and drinks. For reverse questions such as transmission through contaminated needles or sharp items (n = 6, 3.26%), contaminated blood and blood products (n = 9, 4.89%) and bitten by mosquitoes (n = 7, 3.80%), only few workers were able to answer correctly.
Almost half of the participants identified that leptospirosis can be spread by someone who looks and feels healthy (n = 85, 46.20%) and those infected should restrict alcohol intake (n = 88, 47.83%). Most of them knew that leptospirosis is curable and treatable (n = 130, 70.65%). However, almost one third believed that human vaccine for leptospirosis is locally available (n = 268, 82.61%).
As for attitudes, those who answered ‘strongly agree’ or ‘agree’ for good attitudes question and those who answered ‘strongly disagree’ or ‘disagree’ for poor attitudes questions were categorized into good attitudes (Table 3). Majority had poor attitudes when it comes to precautionary measures against contracting leptospirosis.
Table 3Distribution of attitudes on leptospirosis prevention among waste collectors (N = 184).
Good attitudes, n (%)
I am not at risk of getting this disease
I do not believe that wearing PPE always, reduces my chances of contracting this disease
I think it is necessary to take precaution measures to avoid contracting this disease
I believe I am naturally protected against this disease
Wearing gloves during working make our work slower
Wearing gloves during working make me feel discomfort
Wearing boots make our work slower
I think patient with this infection need to be isolated
Meanwhile, majority had good preventive practices such as wearing gloves (n = 181, 98.37%) and safety boots (n = 183, 99.46%) while collecting garbage, covering the injured parts of body with bandages (n = 177, 96.20%), requesting the authority to provide new PPE's if any of the PPE is not intact (n = 171, 92.93%), and seeking medical treatment if injured at work (n = 177, 96.20%). Preventive practices of ever collecting garbage using bare-hands (n = 152, 82.61%) and bare-foot (n = 164, 89.13%), and sharing PPE's (n = 154, 83.7%) were fair but could be improved (Fig. 3). They were willing to get vaccinated (n = 148, 80.43%) if vaccine is available in local setting.
3.3 Factors associated with KAP towards leptospirosis
Multivariable model revealed five significant results (Table 4). Factors associated with knowledge were nationality in which Indonesians had relatively better knowledge than other nationals. Factors associated with attitudes were upper secondary school education and above; and the monthly average individual income. Whereas factors associated with practices were nationality; and upper secondary school education and above.
Table 4Factors associated with KAP towards leptospirosis prevention (N = 184).
Unadjusted regression coefficient (95% CI)c
Adjusted regression coefficient (95% CI)d
−0.01 (−0.09, 0.06)
0.0006 (−0.001, 0.003)
0.005 (−0.02, 0.03)
−0.52 (−1.76, 0.72)
−0.26 (−0.71, 0.19)
−0.17 (−0.61, 0.26)
2.80 (1.57, 4.03)
0.89 (−0.67, 2.45)
−0.444 (−0.892, 0.004)
2.80 (1.57, 4.03)e
−0.54 (-0.99, -0.08)h
1.21 (0.04, 2.39)
1.42 (0.01, 2.83)
0.32 (−0.09, 0.73)
0.48 (0.06, 0.90)f
0.42 (0.01, 0.84)i
Average income (MYR)
0.0004 (−0.002, 0.003)
−0.0009 (-0.002, -0.00003)
−0.0003 (−0.001, 0.0005)
−0.001 (-0.002, -0.0006)g
Work experience (years)
0.02 (−0.10, 0.15)
−0.02 (−0.07, 0.02)
−0.01 (−0.05, 0.03)
a Lower secondary and below; b Upper secondary and above; c Simple linear regression; d Multiple linear regression; ep < 0.001; fp = 0.026; gp = 0.036; hp = 0.021; ip = 0.045.
Most of the municipal waste collectors had fair attitudes and good practices regarding leptospirosis, but an overwhelming majority had poor knowledge. There was a significant correlation between workers’ attitudes and practices scores towards leptospirosis prevention. The final multivariable model revealed that Indonesian nationals had better knowledge on leptospirosis but poor practices in relation to prevention; those with upper secondary school education had better attitudes and practices regarding leptospirosis prevention; and those with lower income had better attitudes regarding the leptospirosis prevention.
4.2 Knowledge on leptospirosis and its prevention
In 2008, a study in a north eastern Malaysia peninsula found about 13% of the local town service workers had ever heard of leptospirosis.
The reason for the increase could possibly be due to interventional programmes done in public places such as wet markets and the active participation from Ministry of Health, Malaysia in improving health surveillance, and conducting health education or promotion program, especially media involvement during outbreaks. In North Wales, majority of the participants had not only heard about leptospirosis but were even aware of the severe form called Weil's disease because of the active health promotion among high risk groups and ensuring adherence to the preventive advices.
The present study found about 24% workers had heard about leptospirosis or its local term ‘rat urine’ disease, and only about 7% had good knowledge on leptospirosis. The findings are in agreement with a study conducted in Tiruchirapalli, India where poor knowledge concerning leptospirosis among majority of the municipal waste collectors was reported.
The probable reason for this could be because majority of the workers were from low-to lower-middle income countries with significant burden of infectious diseases including leptospirosis, notably Bangladesh, Indonesia and Nepal as listed in the World Bank Atlas.
Majority of the workers had education up to primary school, while some were illiterate and thus might be unaware of common infectious diseases in Malaysia. Even though leptospirosis is a leading zoonotic cause of morbidity and mortality worldwide, and is an endemic tropical disease in South-East Asia region. Poverty remains the major influence to the inequality in the access of education especially the secondary education which lead to the persistent poverty mainly in the rural areas.
There is no established surveillance system available, most importantly information for communities from non-governmental organisations, private hospitals and service providers to identify the disease risk and to prevent mortality is lacking.
Hence leptospirosis patients are underdiagnosed and under-reported resulting in less media attention causing less interest in the disease among the population. In Indonesia, the estimated annual morbidity of leptospirosis is similar to Malaysia
However, there is higher risk of contracting leptospirosis because almost half of the workers believed they are naturally protected against leptospirosis and they are free of risk of contracting leptospirosis. This is alarming because the situation reflects the insufficient knowledge on the routes of transmission of the leptospirosis.
Literature identified non-use of PPE's, drinking while working, and wearing inappropriate shoes were the apparent high risk attitudes that need to be changed.
As in some cases, most workers do not adhere to the use of PPE's often complaining of discomfort while wearing gloves and boots and complaining that the PPEs slows their work.
4.4 Practices towards leptospirosis prevention
Interestingly, the municipal workers in this study reported good practices towards leptospirosis prevention, even though almost all of them had poor knowledge regarding the disease. The reason for the good practices because all contractors must comply with the Occupational Safety and Health Act 1994.
It is the responsibility of the employers to provide training and PPE for employees and it is the duty of every employee to take reasonable care for their safety and health while at work. The use of PPEs could reduce exposure to hazards at the workplace. Literature reported PPE as an important protective factor for the leptospirosis prevention.
However, if the workers need to buy the PPEs using their own money, this could lead workers to wear poor quality PPEs which may contribute to high risk of exposure to leptospirosis. This was proven by a study among a rural community in Mexico that found people with a skin cut or abrasion and contact with animal discharges without protection and with a skin cut or abrasion increased the leptospirosis infection.
Other than doxycycline to treat the exposed workers, the immunization through vaccines could be one of the preventive measures for leptospirosis. Most of the workers in this study were willing to get vaccinated if vaccine is available in Malaysia. Currently, only France and Cuba have licensed commercial vaccines for humans.
But the there are few limitations of human leptospirosis vaccines. Apart from having a short-term protection against the infection, the vaccines are serovar-specific and could not give cross-protective immunity against heterogenous serovars. Thus, prevention is still the most effective method of leptospirosis control besides strengthening the surveillance systems.
4.5 Factors associated with KAP towards leptospirosis prevention
All the Indonesian workers in this study had formal education as compared to other nationals, they had significantly better knowledge concerning leptospirosis, but their preventive practices were poor. Most of the Indonesian workers complained of discomfort when wearing PPEs. This finding is consistent with a local study in Indonesia which reported that it was not a common practices for majority of workers to use PPEs while working making this a significant risk factor for the occurrence of leptospirosis.
A priori, we postulated that higher level of education would be associated with better knowledge and practices. This study identified that workers with the highest education of at least upper secondary had remarkably better attitudes and practices scores. The Kendall's tau b analysis supported that the likelihood of using preventive practices increased with more positive attitudes. This is opposite to a finding from one study among residents of riverside settlements of Santa Fe, Argentina that found no significant correlation between attitudes and preventive practices for leptospirosis.
This study showed that those with low income have better attitudes concerning leptospirosis prevention. This finding contradicts with previous study among rural communities that identified those with higher income had acceptable attitudes on leptospirosis.
The minimum monthly income for government workers including contract workers set by the Malaysia government was similar to the median income reported in the present study. Majority of the workers were married and played roles as the breadwinners of the family.
Every month they send a proportion of their money back to their hometown and limited amount is spent for their own monthly expenses including buying protective gloves, boots, and other PPEs. Some had to do extra jobs including odd jobs to earn more money. It is important to note that Health Belief Model (HBM) suggests that higher likelihood of positive behaviour towards a disease for those with higher perceived severity and perceived susceptibility to the disease.
These findings further highlight the needs of future study to understand the risk determinants of leptospirosis in the aspects of the socioeconomic and environmental factors. The workers are highly exposed to the infectious diseases not only due to the nature of their work but it can also be from the poor health status and reduce immunity for taking multiple jobs and insufficient rest.
4.6 What's next? Moving forward
Penang state capital, George Town, is designated by UNESCO as a World Heritage Site since 2008. The island manages to retain its colonial traditions while embracing the modernity. Some functions of the City Council are heritage preservation, urban planning, providing good public health facilities, sanitation, and waste management. Prevention and control of this occupational disease requires a sufficient understanding of the risk factors. More studies need to be conducted exploring the self-belief of natural protection against disease and the lifestyle of the migrant workers, as these could be one of the independent risk factors for contracting an infectious disease. Increased risk could be predicted in areas with poor housing and sanitation conditions, also during urban hazards such as heavy rains and floods. The waste collectors always are the first in line in clearing and cleaning the city after floods. Open wounds, contact with rodents, especially rats, and contact with contaminated water significantly associated with increased risk of occupational health outcomes.
The safety operational procedure concerning contact with sewages and proper protective equipment needs to be strengthened to promote a safe working environment.
The generalization of the findings is limited to municipal waste collectors, who majority are migrant workers under contractors hired by the City Council of Penang Island. There are few groups of local people employed directly by the City Council of Penang Island. The findings also could not be generalized to the mainstream population of Penang or Malaysia. Additionally, the study does not include immunoassays method to identify the seropositive of the leptospirosis upon resource-limited settings. Results from seropositive leptospirosis may provide better picture of leptospirosis in the past and current infections.
Poor knowledge status and practices for wearing quality protective equipment among the municipal waste collectors is a concern. They are routinely exposed to the animal discharges and at risk of the leptospirosis infection. Efforts to prevent and control leptospirosis are heavily dependent on public health education. An intensive awareness program should be conducted which targets the multinational population to improve the knowledge, increase the attitudes and maintain their good practices. Policy makers, employers and employees need to understand the risks factors associated with leptospirosis to ensure safe working practices.
Ethics approval and consent to participate
Ethical clearance to conduct the study was obtained from Penang Medical College Institutional Research & Ethics Committee (PMC RC-14). The purpose, benefits and risks in taking part in the study were explained in detail to all municipal workers before obtaining informed consent. They were given opportunities to ask questions, and their confidentiality and anonymity were assured. A written consent was obtained from all workers for the data collection and publication. They were allowed to withdraw at any time.
Human and animal rights
No animals were used in this study. All procedures that involved human were in accordance with the ethical standards of the research and ethics committee. The study is conformed to the Declaration of Helsinki of the most recent at the 64th World Medical Association General Assembly in Brazil, 2013.
Availability of data and materials
Anonymized raw data for this study could retrieved from the following link (https://doi.org/10.5061/dryad.7sqv9s4p7)
This study is supported by research funding from the RCSI & UCD Malaysia Campus (formerly Penang Medical College) with a seed grant numbered PMC RC-14.
Conflict of interest
The authors declare there are no conflicts of interest for this study.
The authors would like to thank the City Council of Penang Island for the approval and support for this study. Special gratitude to the contractors and the municipal workers for the participation, and not to be forgotten the warmth welcome received by the researchers. A big thank to the Research Committee of RUMC (formerly Penang Medical College) for the financial support by providing a seed grant numbered PMC RC-14.
Organization WH. World Health Organization
Human Leptospirosis: Guidance for Diagnosis, Surveillance and Control.