Factors promoting schistosomiasis infection in endemic rural communities of Ifedore and Ile-Oluji/Oke Igbo local government areas in Ondo State, Nigeria

Schistosomiasis is one of the most prevalent Neglected Tropical Diseases (NTDs) [1] and is a disease of public health and socio-economic importance considered the most devastating parasitic disease in tropical countries [2]. Schistosomiasis is caused by infection with trematodes of the genus Schistosoma whose intermediate host is the freshwater snail, the Bulinus snail species. Schistosoma haematobium mostly in Africa causes genito-urinary schistosomiasis, while Abstract


Introduction
Schistosomiasis is one of the most prevalent Neglected Tropical Diseases (NTDs) [1] and is a disease of public health and socio-economic importance considered the most devastating parasitic disease in tropical countries [2]. Schistosomiasis is caused by infection with trematodes of the genus Schistosoma whose intermediate host is the freshwater snail, the Bulinus snail species. Schistosoma haematobium mostly in Africa causes genito-urinary schistosomiasis, while Abstract Schistosomiasis, a chronic parasitic disease, is highly endemic in Nigeria and causes severe morbidity among school children in many poor-resource communities in the country. We investigated the factors that promote schistosomiasis infection in rural hyper-endemic communities of two LGAs in Ondo State, South West Nigeria. Data were collected through a household survey, focus group discussions, indepth interviews, key informant interviews among different categories of stakeholders in schistosomiasis control that include community adult members, school pupils, health workers and disease control offi cers. The quantitative and qualitative data were analysed using the Epi Info (version 6.04a) and Textbase Beta software respectively. A large number (71.1%) of respondents described schistosomiasis as a prevalent infection in their communities and 34.6% reported having a member of their households who was infected with schistosomiasis. The LGA of residence of the respondents signifi cantly infl uenced the respondents' perception of the seriousness of the consequences of the disease as more respondents in Ile-Oluji/Oke Igbo LGA perceived it to be a very serious health problem than those in Ifedore LGA [27.8% Ile-Oluji/Oke Igbo LGA vs. 5.9% Ifedore LGA] (p<0.05). The results show that communities in the LGAs are endemic of schistosomiasis mainly because the people have little or no access to safe potable water thereby increasing their rate of contact with natural fl owing streams, ponds and or rivers which are or may be infested with susceptible snail intermediate hosts for domestic and occupational activities as about 52% of respondents admitted going to the stream/river. Other factors the study revealed to aid the prevalence of schistosomiasis in the communities is lack of political will and commitment to effective schistosomiasis control and eradication by the government. There was also evidence of community involvement and participation in schistosomiasis control in only one of the four communities studied. To eliminate schistosomiasis in the communities, efforts need to be made and sustained by the government at all levels to ensure increased political will with more community involvement and participation to achieve effective schistosomiasis control. of infection, 582 million [6]. These fi gures, for Nigeria are 35 million and 121 million respectively and the country by these fi gures lead in terms of burden of the disease in the region among the 10 highly infected countries that included Malawi, Ethiopia and Nigeria. According to Chitsulo, et al. [7], an estimated 101 million Nigerians need treatment.

Research Article
The high prevalence of schistosomiasis infection is closely correlated with poverty, poor personal and environmental hygiene and poor health services and awareness. Effort at improving hygiene and prevention of the disease will contribute to reducing both the disease and poverty since poor hygienic conditions are underlying cause of most parasitic diseases and of poverty-related infectious diseases in general. In most endemic areas, highest prevalence and intensities of infection are found in school-aged children (6-15 years) although high risk groups include not only school-aged children (including non-enrolled), but also adolescents and young adults, women of child bearing age and others which include those who are occupationally at risk [5].
Morbidity due to schistosome infection is expressed as impaired growth, physical fi tness, activity and reduced cognitive development. Blood loss due to schistosomiasis leads to iron defi ciency and anaemia may be precipitated. Poor iron status and iron defi ciency anaemia are closely linked to diminished educational performance. The severity and complexity of the pathology of schistosomiasis are related to the fate of the eggs that become trapped in the tissues. It has been shown that treatment with praziquantel drug causes worm burden to fall signifi cantly after single oral dose and reverses the morbidity.
Reversal of organ damage follows 6 months after cure of urinary schistosomiasis although resurgence can occur after another 6 months. Intestinal schistosomiasis regresses promptly after treatment and regression of periportal fi brosis and subsequent resurgence (as detected by ultrasonography) occur between 7 months and several years after cure. Quantitative improvements in periportal fi brosis, hepatomegaly and splenomegaly have been reported [8] as well as improvement in physical fi tness, appetite and school performance. Deterioration in iron status is arrested by treatment and iron supplementation improves iron status in school children, as shown in Tanzania.
Although there is no current estimate for the disease in Nigeria, past estimates have calculated infection rates of about 25 to 29 million people and 101 million at risk of infection [7,9].
Epidemiological studies in many endemic communities in Nigeria reported the infection in all the geographical zones of the country, particularly among the children of school age [10].
Many factors including routine agricultural practices, human behaviour, and water projects to meet the needs of people have attributed to sustained schistosomiasis infection in many endemic communities of the country [10].
Historically, Nigeria set up a National Schistosomiasis Control Program in 1988 which aside from conducting the 1991/1992 national prevalence survey on the disease [11] has not recorded any signifi cant achievement as a result of poor funding and lack of free donation of the drug praziquantel for the disease control. Control of other neglected Tropical Diseases (NTDs) such as onchocerciasis, guinea worm and lymphatic fi lariasis have been made possible through free donation of the needed drugs for either mass or targeted treatment. The nonfree donation of praziquantel, the drug of choice in the control of schistosomiasis has been a major impediment to the disease control in many developing countries such as Nigeria. Despite several reports on high level of endemicity of schistosomiasis in Nigeria, its control has been greatly hindered by fi nance and lack of free donation of the drug and this will continue to be a challenge unless adequate funding is provided for the control program. Even when the drug is donated free, program operation costs need to be met. It is therefore not only important to secure and ensure adequate donation of supplies but needed program budget must be provided for effective control. Baseline data need to be collected to develop Geographic Information System (GIS) map on the disease that will guide choice of treatment strategy and approach and, monitoring and evaluating impact of interventions. The Federal Ministry has recorded a milestone in its current attraction of free donation of praziquantel to Nigeria through WHO Geneva from E Merck Germany [12]. The two States that benefi tted from this fi rst free supply of the drug in 2009 were Ekiti, and Ondo States in South West Nigeria.
The big study on which this paper is based was an applied and operational health systems research in support of primary health care programs to strengthen and support State's control efforts, seeking to establish close partnership with States in South West Nigeria undertaking schistosomiasis control to ensure that appropriate strategy and approach are employed in the control of the disease and to generate scientifi c evidence on the process, impact and benefi ts of the control efforts while documenting the defi ciencies that will inform future improvement. The study also sought to garner scientifi c evidence on the effects of praziquantel on other intestinal parasites which has implications for the current government's commitment to triple drug administration for integrated control of common and prevalent diseases that affect the growing child (albendazole and ivermectin for lymphatic fi lariasis, ivermectin for onchocerciasis control and praziquantel for schistosomiasis). The focus of this paper is on the social aspects of the disease addressing the knowledge, attitude, practices on cause, transmission, manifestation and treatment and other interventions for schistosomiasis control to reveal risk factors promoting the infection in high schistosomiasis endemic communities.

Study design and locations
The sub-study on which the focus of this paper hinges was cross sectional. The study was conducted in rural communities of Ifedore (Ipogun and Bolorunduro) and Ile-Oluji/Okeigbo Population Census at 3.5% growth rate [13]. High prevalence rates of between 41.0% and 95.7% have been reported for these LGAs [14][15][16]. The two LGAs fall within the tropical forest zone of western Nigeria which is characterized by rainfall season from April to October with a short break in August. There are many surface water bodies used for different purposes varying from recreational, domestic, processing of farm produce, bathing, and occupational [17]. The main water sources in Ile-Oluji/ Oke Igbo LGAs include Olori and Ojege rivers. Public tap water points exist but are usually dry in the dry season. Aponmu and Owena rivers are the major water sources in Ifedore LGA.
Boreholes are also available in these LGAs but the long waiting time discourages use with preference for the rivers. Sanitation is generally poor and human and animal wastes are disposed of indiscriminately.

Study population
Target populations for the study were primary school children, school teachers, health workers at the local government (Schistosomiasis Control Programme Coordinators), health workers of health facilities closest to the study communities and adult community members.    The household survey involved the administration of semistructured questionnaires to adult members of the communities proving their knowledge and perception of the cause, signs and symptoms, perceived severity of schistosomiasis and treatment options available for the disease. Probing questions on sources of water for drinking and other household use and how domestic and human wastes are disposed were be posed as well as on knowledge of praziquantel as the drug of choice for schistosomiasis treatment alongside the frequency of its mass administration for control in the communities as well as challenges, if any. Respondents were further probed on their willingness to pay for schistosomiasis treatment using praziquantel and the extent to which community efforts will contribute to the control of schistosomiasis in the study communities.

Sample size and sampling procedures
The contents of the interview and FGD guides like the questionnaires sought to generate information relating to the prevalence and incidence of schistosomiasis in the communities, the knowledge of the pupils and adults alike about the cause, signs and symptoms, perceived severity of the infection, treatment options available for the disease and the extent to which community efforts have contributed to the control of schistosomiasis in the study communities was similarly probed. Probing questions mirrored those in the administered questionnaire.
In addition to the above, the Schistosomiasis Control Programme Coordinators, health workers and teachers trained for the mass treatment exercise in the study LGAs were asked questions relating to the contents of training they had. The issues probed using the interview and FGD guides included: cause of the infection, prevention, record keeping as it concerns basic socio-demographic information of those to be treated and number of drugs supplied and dispensed, dose determination and tool to use in achieving this, target population, and strategy to adopted for the mass treatment and how out-ofschool children in the communities will be reached.

Data analysis
Following data cleaning, the completed questionnaires were coded. The coded data were subsequently entered into the computer and analysed using the Epi Info (version 6.04a) software [19]. The analysis was essentially descriptive refl ecting the concerns expressed through the different objectives of the study.
On the other hand, following review and correction, transcripts from the FGDs and in-depth interviews were typed with a standard word processing package and converted into ASCII Text fi les. These were subsequently coded and sorted using the textual analysis programme developed by Bo Summerlund and distributed by Qualitative Research Management of Desert Hot Springs, California, Textbase Beta software [20,21].

Ethical issues
All necessary approvals were obtained from the State Ministry of Health, the selected LGAs and communities. Ethical approval for the study protocol was obtained from the Nigerian Institute of Medical Research Institutional Review Board.
Informed consent of each adult participant and the parents/ caregivers of each child participant was duly obtained prior to their enrolment in the study as an indicator of their willingness to participate in the study. The informed consent process involved careful explanation of the purpose and procedure of the study, the potential benefi ts (both individual and community) and possible risks of participating in the study.

Limitations of the study
The main limitation of this study is the non-evaluation of the respondents' actual willingness to pay for praziquantel as the recommended drug of choice for treatment. Another limitation of this study is the small sample size used to generate the quantitative data from the survey arm of the study in the two LGAs studied in Ondo State. The sample size is though anticipated to be adequate having used the table for a minimum sample size estimate for a population survey. Nonetheless, this limitation does not underestimate the validity of the fi ndings of this study as the fi ndings from the small sample size are complemented by the fi ndings from qualitative data.

Knowledge and perceived public health signifi cance of schistosomiasis in the community
There was a high level of awareness of schistosomiasis disease in the communities studied as displayed in Figure 2 and attested to by participants in the series of FGDs conducted.
A larger number (42.3%) of respondents described the disease as common while 28.8% believed it is very common and 23.1% said it is not common in their respective localities. Schistosomiasis is perceived to be a serious health problem by many respondents in the household survey as presented in Unfortunately, however, a few FGD participants were concerned that some parents do not usually take steps to ensure treatment. A male teacher in Oke Igbo, Ile-Oluji/Oke Igbo LGA, pointed out thus: "…It is sad that many parents and guardians are less concerned about this problem (schistosomiasis) in their children because they don't take it seriously as it ought to be."

Perceived at-risk groups of the disease among respondents
The illustration in Figure 3 shows that children of primary school age of ten years and below were perceived to be the age group most at risk of the infection in the study communities. The reasons given by the respondents for their choice of perceived at-risk age group were: because they like swimming in the river as an art of recreation (71.2%); and going to fetch water at river side (1.9%). However, about 27.0% were undecided on the reason to give to justify their choice of their perceived at-risk age group.
Statistical test showed gender difference in the respondents' perceived most at-risk group of schistosomiasis as more males than females perceived children aged ten years and below as the age group most at risk of the infection (96.3% males vs. 56.0% females). The odds ratio of 0.05 has a 95% confi dence interval of 0.00 -0.45, and chi square with Yates correction is 9.71 with a p-value < 0.05.
Similarly, it was a consensus among virtually all the FGD participants in the communities that the infection is predominant mostly among children of school age, though many adults were also reported to have manifested the main sign of the disease i.e. passing of blood in urine. A male focus group participant in Oke Igbo, Ile-Oluji/Oke Igbo LGA, for example said, "Children and, even adults, pass blood in urine." Another male focus group participant in Oke Igbo, Ile-Oluji/Oke Igbo LGA, pointed out that, "Our children are the most aff ected with this problem (schistosomiasis) even though some adults of my age still experience same problem." A male teacher interviewed in Oke Igbo, Ile-Oluji/Oke Igbo LGA, also revealed that, "The

Recognition of signs and symptoms of the disease
The way most parents know their children are infected with schistosomiasis is when the children's pants become stained with blood or when their siblings or friends report that one of them is passing drops of blood after urination as illustrated in

Prevention and treatment practices on schistosomiasis
The perceived preventive measure against schistosomiasis according to most people, particularly the adults, was said to be avoidance of contact with the rivers. Unfortunately, the communities are challenged by lack of alternative safe and According to FGD participants in the communities, there are different approaches to treatment of those identifi ed to be infected. Treatment practices mentioned included going to the clinic/hospital, buying drugs from chemist shop and, taking herbal remedies prepared using leaves, barks and roots of trees usually sourced from either the market or home environment.
The different forms of treatment people seek for schistosomiasis in the communities as well as their most preferred form of treatment according to respondents in the household survey are displayed in Table 2 and Figure 6 respectively. Sex of respondents had signifi cant infl uence on their most preferred form of treatment for schistosomiasis ( 2 = 13.17, df = 5, p < 0.05).
It is interesting to note that none of the FGD participants knew about praziquantel, the drug of choice used for schistosomiasis treatment. A male focus group participant in Oke Igbo, Ile-Oluji/Oke Igbo LGA, for example said, "I don't know anything about this drug. For example, I'm a carpenter and don't know anything about drug and infections." A female participant in Oke Igbo, Ile-Oluji/Oke Igbo LGA, similarly revealed that, "I don't know the drug that is being used to treat the infection." On the contrary, 23.1% of respondents in the survey reported knowing about praziquantel.

Community involvement and participation in the control of schistosomiasis
There was evidence of community involvement and participation in only one of the four communities studied. This was evident in Oke Igbo, Ile Oluji/Oke Igbo LGA through what was reported as the people's involvement in sensitisation and advocacy on control of the disease in their domain. A female focus group in Oke Igbo, Ile-Oluji/Oke Igbo LGA, revealed that, "…the community has been involved in advocacy eff orts through the churches and mosques to discourage and advise people particularly children from going to Olori river to swim in order to prevention the infection." On the contrary, a female focus group participant in Bolunduro, Ifedore LGA, pointed out that, "…I don't know of any programme that has been put in place for implementation to control the infection apart from the programme on immunization that I'm aware of." A male focus group participant in Bolorunduro, Ifedore LGA, similarly revealed that, "…I do not think there are any eff orts in this direction at all." Another male focus group participant in Bolorunduro, Ifedore LGA, responded that, "It is not that we do not know what to do but as we are poor farmers, we would only implore the government to come to our aid. We know that we need safe water here but we cannot aff ord to dig a borehole." There was evidence of previous mass treatment for schistosomiasis in the communities. Most pupils in focus groups in Ifedore LGA explained that they were treated a year ago whilst some of the pupils in focus groups in Ile-Oluji/Oke Igbo LGA reported that they were treated last three years ago.
This was also confi rmed by a teacher in Ile-Oluji, Ile-Oluji/Oke Igbo LGA, who stated that, "…children in this school were treated last through mass drug administration three years ago by the local government health workers."    Evidence showed that those trained as distributors usually include school teachers, health workers in public health facilities nearest to the communities concerned and community leaders.

Willingness to pay for schistosomiasis treatment using praziquantel
On the strategies to be adopted for treatment, the Ifedore LGA

Identifi ed challenges of past mass treatment exercise
Despite the successful take off of the implementation of the mass treatment in the two LGAs amidst the cooperation received so far, some identifi ed challenges militating against the smooth implementation of the exercise included fi nancial constraint, inadequate and delayed drug supply and noninvolvement of many schools in communities of the two LGAs.
In the response of the Ifedore LGA Schistosomiasis Control Programme Coordinator, he pointed out that, "The major challenge of the programme is the problem of fi nancial constraint as the local government authority did not support in anyway." This is unlike the authority in Ile-Oluji/Oke Igbo where the Schistosomiasis Control Programme Coordinator said, "The local government authority assisted in the organization of the training exercise and is even enthusiastic in getting more teachers not yet involved to be trained so that more pupils could be treated." In expressing his concern on the problem of inadequate drug supply, the Ile-Oluji/Oke Igbo LGA Schistosomiasis Control Programme Coordinator revealed that, "Presently, only ten of the available primary schools in the LGA could be covered with the fi ve thousand tablets I collected from the State Ministry of Health. I have already complained to the State Schistosomiasis Control Offi cer about this inadequacy and will be meeting with her to deliberate on how to get more drug supply that will go round all the schools. Now the children in the LGA will still require about thirty-four thousand tablets for wider and eff ective coverage through which the nonenrolled children will be covered too." Similarly, a female teacher in Oke Igbo, Ile-Oluji/Oke Igbo LGA, stated that, "For pupils in this school, I was fi rst given fi ve hundred tablets to use in treating them. However, after exhausting fi rst supply of fi ve hundred tablets and many pupils in the school were not treated, I then requested for additional supply and was given another fi fty tablets which would be administered to the outstanding pupils next week."

Household practices in the community relating to water usage and human waste disposal
When the respondents were asked how they dispose faeces and household wastes such as paper and leaves, most reported using pit latrine (50.0%) and throwing/dumping household wastes in the bush (75.0%) respectively as presented in Table  3. Respondents' LGA of residence had signifi cant effect on the ways they adopt for the disposal of household waste ( 2 = 9.50, df = 2, p < 0.05) respectively.
Twenty-seven (51.9%) of the fi fty-two respondents reported going to the streams or rivers around their communities while 48.1% claimed not going to any of the streams or rivers. Statistical test showed gender difference in the respondents' propensity to go to the stream or river as more males than females are more likely to go to the stream or river (70.4% males vs. 32.0% females) as shown in Table 4. The odds ratio of 5.05 has a 95% confi dence interval of 1.33 -20.04, and chi square with Yates correction is 6.20 with a p-value < 0.05. On the contrary, age of respondents had no signifi cant infl uence the possibility of their going to the river or stream or not ( 2 = 0.366, df = 1, p > 0.05).
Citation: Adeneye Table 5 showed that a larger number (61.5%) of the respondents knew that passing of urine or defaecating in the river or stream could contribute to the spread of schistosomiasis. The LGA of residence of the respondents signifi cantly infl uenced their knowledge that passing of urine or defaecating in the river or stream could contribute to the spread of schistosomiasis ( 2 = 7.25, df = 2, p < 0.05).

Discussion
The perceived seriousness of schistosomiasis as a health problem by a large number of respondents in LGAs studied in Table 1 confi rmed the hyper-endemicity of schistosomiaisis in the two areas of the State.
The fi ndings show that communities in the LGAs are endemic of schistosomiasis mainly because the people have little or no access to safe potable water thereby increasing their rate of contact with natural fl owing streams, ponds and or rivers which are or may be infested with susceptible snail intermediate hosts for domestic and occupational activities. Other factors the study revealed to aid the transmission of schistosomiasis in the communities is lack of adequate and appropriate knowledge of the disease among the population studied and lack of political will and commitment to effective schistosomiasis control and eradication by the government.
The results of the study on willingness to pay for praziquantel to treat schistosomiasis are similar to but a higher than the fi nding of 92.3% of respondents who expressed willingness to buy the drug for treatment of infected members of their household in a previous household survey that examined the willingness of people to pay for treatment with praziquantel in Imala-Odo, a hyper-endemic community for schistosomiasis in Ogun State, South West Nigeria [22]. In contrast to the observed gender difference reported in the earlier study reported by Adeneye et al [22], there was no gender difference among the population studied in the two LGAs in Ondo State.  Table 2 where orthodox medicine constituted a large chunk of forms of the pathway to care which the people seek for the treatment of schistosomiasis in the communities and as successfully implemented in a similar previous study by Adeneye, et al. [22]. The high knowledge and good perceptions about the use of praziquantel in the treatment of schistosomiasis in the study communities evident in this study is encouraging. Efforts therefore need to be made to ensure sustainable supply of the drug and at the same time guarantee that all families can afford to pay for praziquantel. This is in order to achieve the ultimate goal of controlling the infection in endemic communities of Nigeria as suggested by Adeneye, et al. [22].
Given that intensifi ed efforts are needed for NTDs including schistosomiasis targeted for eradication or elimination as public health problems by 2030 [23], the implementation of effective measures for interruption of transmission in all endemic communities targeting specifi c interventions that include provision of safe water, improved access to good sanitation, continuous health education, community mobilization for sustainable involvement and participation and treatment of selected water sources with temephos as recommended by World Health Organisation [24] becomes imperative.
Access to water and sanitation could be improved in the   It is suggested that the hygiene behaviour of people in the communities be improved through scaling up of health education with emphasis on personal and environmental hygiene and sanitation using appropriate information, education and communication/behaviour change and communication (IEC/ BCC) strategies targeted at school aged children, women who are mainly care-givers and home keepers and special occupational groups that include those who engage in fi shing and sand mining in rivers given results presented in Table 4 that showed that over half of respondents go to streams/rivers where they could easily be infected and or re-infected. This is equally important as it is evident in Table 3 that showed the poor and unsafe ways adopted in disposing faeces, knowing that though a larger number of the respondents knew that passing of urine or defaecating in the river or stream could contaminate the environment and contribute to the spread of schistosomiasis in Table 5, about one quarter of them who were unaware of this as a way of spreading schistosomiasis could continue to put the populations at risk of infection out of ignorance. The need to scale up health education becomes important because lack of awareness about mode of transmission of parasitic infections increases the risk of infection as reported by Nyantekyi, et al. [25].
The health education activities can be implemented through the collaboration of the State Ministries of Health, Information and Orientation and Education, Science and Technology. It is suggested that topics relating to cause, prevention and treatment of schistosomiasis are included in the school curriculum with emphasis on the importance of good hygiene and sanitation particularly at the primary level where we have children of age group identifi ed as most at risk of the infection in Figure 3.
The fact that schistosomiasis is also an environmental problem just as it is also a health challenge suggests the need for appropriate legislation and enforcement of the law against open defecation which the people predominantly indulge in the LGAs as their way of disposing human waste as confi rmed by virtually half the respondents in Table 2.
Despite the fact that the fi rst edition of the Integrated Disease Surveillance and Response (IDSR) in the African Region advocated for countries to establish Community-Based Surveillance (CBS) systems since 2001 and structures are not functional or are still to be built to detect, prevent and respond to public health events in some communities [26] such as the ones studied, the need to establish a community-based surveillance and reporting system in the communities with effective supervision and integration of such system with other major preventable diseases becomes imperative. Participation of targeted communities in the control efforts is one of the cardinal tools for the success and sustainability of disease control programmes as emphasised by Alemu, et al. [27]. The evidence of community involvement and participation only in Oke Igbo for example though is discouraging. Nonetheless, the willingness of some people in other communities to participate in the health care delivery programme if not for some constraints is encouraging and could serve as a good launchpad for successful establishment of a community-based surveillance and reporting system for effective control of schistosomiasis in communities of the LGAs.
It is encouraging that health workers were trained and involved in mass drug administration of praziquantel to pupils in schools of the study LGAs given the evidence of the effectiveness of community-based health workers in delivering health services is important in achieving universal health coverage as they can go beyond provision of care and foster community-based action [28]. The training and involvement of teachers is more encouraging in this respect and showed that a more inclusive community volunteer scheme health programme implementation in the State could be adopted based on the role of community volunteers demonstrated in supporting initiatives and programmes like intermittent preventive treatment of malaria in pregnancy and onchocerciasis [29], polio eradication, guinea worm eradication, trachoma control, integrated community case management, maternal and child health integrated programme, and early warning and response to public health emergencies in Africa [26]. Similarly, the participation of teachers and schools is very encouraging as it has successfully shown to be very useful in population coverage and health education in the control of schistosomiasis in the Gizan region of Saudi Arabia where prevalence of the predominant species, Schistosoma haematobium dropped from 43-91% to <1% between 1974 and 1979 [30].
Given the global vector control response on integrated approach for the control of vector-borne diseases [31], it will not be out of place to advocate for the integration of the schistosomiasis treatment programme into the communitydirected treatment approach for the control of onchocerciasis [32] which is also highly endemic in Ondo State. Such integration is expected to increase effi ciency, decrease the burden of health staff, improves access to treatment and improve the costeffectiveness of health spending while maintaining treatment coverage for the disease control programmes.
In view of some identifi ed challenges including fi nancial constraint similarly identifi ed by Federal Ministry of Health [11] to be militating against the smooth implementation of the mass drug administration in schools as enumerated from the results, this calls for strong political will and commitment to action from the State and local governments in making the  [23] which is expected to guide countries towards the achievement of Sustainable Development Goal target 3.3 on NTDs globally [33] including the communities of the Ondo State.
The World Health Assembly resolution 54.19 of 2001 [34] stipulates that member states should ensure access to essential drugs against schistosomiasis and STHs in all health facilities in endemic areas for the treatment of clinical cases and mass drug administration for groups at high risk of clinical morbidity such as women and children, with the goal of attaining a minimum target of regular administration of chemotherapy to at least 75% and up to 100% of all school-aged children at risk of morbidity (in-and out-of-school) given that the attainment of this will greatly reduce child morbidity [35]. This could be better operationalised through the Community-Integrated Management of Childhood Illnesses (C-IMCI) strategy [36] which has three components: improving partnerships between health facilities and communities they serve; improving the technical abilities of community health workers in managing child health and increasing appropriate, accessible care and information from them; and integrated promotion of key family practices critical for child health and nutrition.

Conclusion
The fi ndings of this study show that communities in the studied LGAs are endemic of schistosomiasis mainly because the people have little or no access to safe potable water. This increases the people's rate of contact with natural fl owing streams, ponds and or rivers for domestic and occupational activities and these natural water bodies are more often than not infested with susceptible snail intermediate hosts.
Other factors the study revealed to aid the transmission of schistosomiasis in the communities is lack of adequate and appropriate knowledge of the disease among the population studied and lack of political will and commitment to effective schistosomiasis control and eradication by the government.
There was also evidence of poor community involvement and participation in schistosomiasis control in most of the communities studied. To eliminate schistosomiasis in communities of Ondo State in general and communities of the studied LGAs in particular knowing the fact that there is a link between schistosomiasis and poverty [37], the government at all levels need to match effective public health interventions particularly those targeting schistosomiasis management and control with socio-economic policies that foster growth and prosperity of the population.