Knowledge, Attitude, and Practices of Primary Health-Care Workers toward NOMA Disease in Sokoto : Dentistry and Medical Research

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Knowledge, Attitude, and Practices of Primary Health-Care Workers toward NOMA Disease in Sokoto

Bala, Mujtaba; Omotayo, S. A.1; Braimah, R. O.; Taiwo, A. O.; Jaafar, R.; Abubakar, A. B.2; Abubakar, M. K.3; Saleh, A. A.

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Dentistry and Medical Research 10(1):p 24-28, Jan–Jun 2022. | DOI: 10.4103/dmr.dmr_33_22
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Noma is a quickly progressing and neglected opportunistic infection which if left untreated can result in a sequelae of severe facial destruction and death. Early detection and prompt treatment is paramount to the prevention of its sequelae. The aim of this study, was therefore, to evaluate the knowledge, attitude and practices of primary healthcare workers towards Noma in Sokoto state, Nigeria.


This was a cross-sectional study approved by the Sokoto State ministry of health. Participants consented were recruited using self-administered questionnaire between July, 2022 and August, 2022. The questionnaire consisted of 10 and 16 questions covering the domains of knowledge and, attitude/practices respectively. The total score for each domain was obtained and then categorized as low (less than or equals to 50%), fair (51 to 69%) and good (70% and above). Data was analyzed using SPSS version 25.


A total of 251 participants filled and returned the questionnaires. There were 151(60.2%) males and 100(39.8%) females in the age range of 22-57years with a mean±SD of 34.9±8.5 years. Out of 251 participants, 210(83.7%) were aware of Noma. The total score recorded in both the knowledge and attitude/practice domains were 75% and 78% respectively.


The basic knowledge and attitude/practices of NOMA among primary healthcare workers in our clime was good. Therefore, there is need for continuing medical education among this groups of healthcare workers considering their role as the first contact health personnel in the community.


NOMA, also known as Cancrum oris, is an infectious disease that destroys the orofacial tissues and surrounding structures in its fulminating course and has mortality as high as 70%-90% if not promptly treated.[1] The true incidence and prevalence of NOMA were difficult because of its associated high mortality rate in underdeveloped countries and the difficulty in compiling cases that have to do with patients being isolated because of the social stigma associated with the disease.[2] However, the annual global incidence and prevalence of this disease were reported to be 140,000 and 770,000 cases, respectively.[34] It is not clear which stages of NOMA are included in these estimates.

The majority of NOMA cases are reported from the NOMA belt, which is situated in the south of the Sahara that runs from Senegal to Ethiopia.[5] A study was done in Nigeria in 2019, which estimated the period prevalence of NOMA from 2010 to 2018 and found it to be 1.6 per 100,000 population at risk.[56] These estimates are founded on expert judgment, number of hospital admissions, and the data collected retrospectively.[6] In 2018, during the National NOMA Day Workshop, the Nigerian Ministry of Health established that NOMA was a national public health priority, and emphasized the urgent need to produce robust evidence on the country's disease burden for effective planning.[7]

The bacteriology of acute NOMA is awkward especially due to secondary infection.[2] Fusiformis fusiformis and, Borrelia vincenti are the main causative organisms.[89] Malnutrition was reported to be the main predisposing factor.[1011] Others include; puberty, poor oral hygiene, immunosuppression, and exanthematous diseases, including measles and malaria.[9] Noma is seen most commonly in children between the age of 3 and 12 years.[12] NOMA usually begins as gingival ulceration which rapidly spreads through the orofacial tissues establishing a well-demarcated perimeter surrounding a darkened necrotic center. The gangrene could extend to involve the mandible, maxilla nose, and other facial structures in a destructive fashion.[13] NOMA is reversible in the early stages and can be treated with antibiotics, oral hygiene measures, and nutritional.[11] This is only feasible with early diagnosis and prompt referral, and quick institution of treatment. Primary health-care workers are most times the first contact with these patients and could be used as an arsenal in tackling NOMA disease at a preventive level. This study aimed to assess the level of knowledge, attitude, and practices of the primary health-care workers toward NOMA. To the best of our knowledge, this is the first study assessing the knowledge, attitude, and practices of primary health-care workers in our NOMA endemic clime. This study could provide a baseline clue about the level of information possessed by this group of health-care workers and justify the necessary training to be tailored to them with the ultimate goal of preventing or reducing the rapidly destructive burden of this disease due to late diagnosis and referral.


This was a cross-sectional study conducted among primary health care workers in Sokoto state Nigeria. Approval was obtained from the Sokoto State ministry of health. The detail of the research was explained to the participants, and only those who consented were recruited using a self-administered questionnaire between July 2022 and August 2022. The primary health-care workers were categorized into Junior Community Health Extension Workers (JCHEW), Community Health Extension Workers (CHEW) and, Community Health Officers (CHO) and; then a simple random sampling method was used to select participants from each category. The identity of the participant was preserved to maintain confidentiality. Copies of the questionnaire were given to two experts at Usmanu Danfodiyo Teaching Hospital Sokoto who are well-equipped in the management of Noma to ensure its validity. These experts examined both the language and the contents of the questionnaire. Pretests were done on five randomly selected primary health-care workers to evaluate the reliability of the questionnaire.

The questionnaire was separated into two domains, namely: The knowledge domain and the attitude/practice domain. The knowledge and attitude/practice domain consisted of 10 and 16 questions, respectively, and participants were asked to choose against what they felt among “Yes, No, and I do not know” to be the correct answers on the questionnaire sheet and each correct response in the questionnaire was scored 1 mark while a wrong or I do not know answer scored 0 mark. The knowledge and attitude/practice domains had a maximum of 10 and 16 marks, respectively, for each participant. Possible scores ranged from 0 to 26 marks per participant and a total score of 2510 (100%) and 4016 (100%) marks for all the answers in each domain. The total scores of all the participants were then graded as low (less than or equals to 50%), fair (51 to 69%), and good (70% and above) for each domain. The data were analyzed by using IBM SPSS software version 25.


A total of 251 participants filled out and returned the questionnaires. There were 151 (60.2%) males and 100 (39.8%) females [Table 1] in the age range of 2257 years with a mean ± standard deviation of 34.9 ± 8.5 years. The age of the participants was categorized, and the highest number 96 (38.2%) of the participants were in the 3rd decade, with the least 15 (6%) in the 6th decade of life [Table 1]. Figure 1 shows distribution of those that have heard and those that have not heard of noma. Out of the 251 participants, 210 (83.7%) were aware of Noma, and the remaining 41 (16.3%) have not heard of Noma before. Figure 2 shows the distribution of primary health-care workers into JCHEW, CHEW, and CHO. The variable answers obtained from the participants from the various questions asked in both the knowledge and attitude/practice domains are depicted in Tables 2 and 3, respectively. The total score recorded in the knowledge domain was 75%, whereas a total of 78% was recorded in the attitude/practice domain. Table 4 shows both the total score and grading in both domains.

Table 1:
Distribution of gender and age categories of the study participants
Figure 1:
Awareness of NOMA disease among the study participants
Figure 2:
Categories of the primary health-care workers among the study participants
Table 2:
Answers of the participants (n=210) who claim to know about Noma disease
Table 3:
Attitude and practice score of the study participants toward Noma disease
Table 4:
Overall knowledge, attitude, and practices score and grading


Prevention and management of NOMA disease require a multidisciplinary approach by a team of several cadres of health-care workers, including Dentists, Oral and Maxillofacial surgeons, Plastic surgeons, Nurses, Physiotherapists, Primary health-care workers, and, Nutritionists among others.[14] This study explored the knowledge, attitude, and practices of primary health-care workers toward NOMA.

There were more males 151 (60.2%) than females 100 (39.8%) in this study. This is similar to the findings from previous studies by Bala et al.[15] and Ahlgren et al.[16] The higher male proportion in this study could be related to the areas of the study (primary health-care centers) located mostly in the rural areas with a reported incidence of insecurity in which female health-care workers may not be allowed by their husbands or parents to work in those areas.

This study recorded knowledge of NOMA of about 75% of the study participants, which was graded as good. This is in contrast with similar studies by Ahlgren et al.[16] in Zambia and Brattström-Stolt et al.[17] in Burkina Faso. Bala et al.[15] in a study assessing the knowledge, attitude, and practices of health-care workers reported 73%, which was also graded as good. Primary health-care workers demonstrated good knowledge about NOMA in this study likely because of their exposure to these patients, considering the strategic location of primary health centers where NOMA cases are emanating. The majority of these primary health-care workers (93.8%) in Sokoto (the large pulling force for NOMA in Nigeria) are aware of this disease condition. About 81.4% of the participant in this study claimed to have seen cases of Noma, which is not unexpected because they may be the first to be contacted by NOMA patients. The majority of the participants (99%) knew that Is NOMA an emergency in its early stage, which is a vital development and a key to assisting in the proper handling of these patients by this group of health-care workers.

In the attitude and practices domain of this study, pertinent questions were asked concerning the handling of NOMA patients, prevention, and management, with a total score of about 78% and this was graded as good. This demonstrated the correct utilization of the knowledge of NOMA acquired by this group of health-care workers. Brattström-Stolt et al.[17] and Bala et al.[15] recorded about 30% and 42.7%, respectively, and these were graded as low. These studies evaluated a range of health-care workers constituting Doctors, Dental auxiliaries, Nurses, Nutritionist, and other health-care workers, while the current study was exclusive to primary health-care workers, namely JCHEW, CHEW, and CHO cadres, in which they are expected to have some level of training about NOMA identification and referral. The presence of the nongovernmental organization, notably medicine sans frontier, in the handling of this disease condition may have played a vital role in the dissemination of information as well as training of health-care workers, particularly in the act of screening and quick referral of NOMA patients.

About 69.5% are aware of NOMA children's hospital, a referral center in Sokoto that caters for NOMA patients across Nigeria and some other West African countries, including the Niger Republic and the Benin Republic. About 63.4% knew that it is a referral center for NOMA cases and only 42.2% of the participants previously referred a patient to the NOMA children's hospital. These responses are encouraging, and when more strategies are put in place, there could be an improvement in the holistic management of NOMA patients. Among the participants, only 22.4% claimed to have received basic training about NOMA disease. This is obviously on the low side. More frequent training is required to strengthen the attitude and practice competence of primary health-care workers toward NOMA. Challacombe et al.[18] emphasized the need for training primary health-care workers since most of the NOMA patients come from rural communities. Frequent and tailored training of primary health-care workers will greatly influence prevention, early detection, and appropriate referral. The incorporation of dentists and other dental auxiliaries as part of the primary health-care system in Nigeria, especially in the NOMA endemic regions, will have a positive impact on the model of care for NOMA patients.


NOMA is a rapidly progressive infection that affects vulnerable children living in areas with limited access to quality healthcare. The basic knowledge and attitude/practices of NOMA among primary health-care workers in our clime were good. Therefore, there is a need for continuing medical education among this group of health-care workers, considering their role as the first contact health personnel in the community.

Ethical statement

The study was approved by the institutional Ethics Committee of Sokoto State Ministry of Health with approval number SKHREC/065/2022.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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