Public perceptions of snakes and snakebite management: implications for conservation and human health in southern Nepal

Background Venomous snakebite and its effects are a source of fear for people living in southern Nepal. As a result, people have developed a negative attitude towards snakes, which can lead to human-snake conflicts that result in killing of snakes. Attempting to kill snakes increases the risk of snakebite, and actual killing of snakes contributes to loss of biodiversity. Currently, snake populations in southern Nepal are thought to be declining, but more research is needed to evaluate the conservation status of snakes. Therefore, we assessed attitudes, knowledge, and awareness of snakes and snakebite by Chitwan National Park’s (CNP) buffer zone (BZ) inhabitants in an effort to better understand challenges to snake conservation and snakebite management. The results of this study have the potential to promote biodiversity conservation and increase human health in southern Nepal and beyond. Methods We carried out face-to-face interviews of 150 randomly selected CNP BZ inhabitants, adopting a cross-sectional mixed research design and structured and semi-structured questionnaires from January–February 2013. Results Results indicated that 43 % of respondents disliked snakes, 49 % would exterminate all venomous snakes, and 86 % feared snakes. Farmers were the most negative and teachers were the most ambivalent towards snakes. Respondents were generally unable to identify different snake species, and were almost completely unaware of the need of conserve snakes and how to prevent snakebites. Belief in a snake god, and the ability of snakes to absorb poisonous gases from the atmosphere were among many superstitions that appeared to predispose negativity towards snakes of BZ residents. Conclusion People with predisposed negativity towards snakes were not proponents of snake conservation. Fear, negativity, ambivalence towards, and ignorance about, snakes and the need for snake conservation were strong indicators of the propensity to harm or kill snakes. It seems that if wanton killing of snakes continues, local snake populations will decline, and rare and endangered snake species may even become locally extirpated. Moreover, inappropriate perception and knowledge about snakes and snakebites may put BZ people at increased risk of venomous snakebite. Therefore, intensive, pragmatic educational efforts focused on natural history and ecology of snakes and prevention of snakebite should be undertaken in communities and at schools and universities.


Background
Human attitudes towards snakes can be both positive and negative [1,2]. In some places, people possess a deep respect for snakes due to spiritual traditions [3], while in other places people value snakes for utilitarian reasons [2,4,5]. However, snakes are typically misunderstood, mistreated, feared or killed, even when humans consider snakes to be symbols of power and worthy of worship worldwide [3,[6][7][8]. The consequences of negativity, ambivalence, fear, and killing of snakes for biodiversity conservation and human welfare have rarely been studied. Because snakes and snake parts are used in many different ways by different cultures, human activities can influence snake populations and communities both directly and indirectly. Therefore, snake-human interactions and the importance of ethnoherpetology [9] must be considered when planning conservation actions [10,11].
A lack of knowledge and misguided perception of snakes threaten snake populations worldwide. Anthropogenic habitat fragmentation or destruction [12] and intentional killing of snakes [13,14] contribute to snake population decline. If wanton killing of snakes goes unchecked, it will likely add to the risk of population decline, and even local extirpation of rare and endangered snake species, which may have cascading community-and ecosystem-level effects. In Nepal, the conservation status of snakes is either unknown or poorly defined based on minimal survey efforts carried out in the distant past, or simply confined to expert opinion [15]. Human activity, including intentional killing of snakes, likely contributes to population declines in many species, some of which play an important role in agricultural and grassland ecosystems of southern Nepal, which in turn may lead to negative impacts to biodiversity and human health. In addition to increasing our knowledge of snake ecology and natural history, it is important to assess public perception and knowledge of snakes. From a human health perspective, it is vitally important to better understand snakebite care and prevention among people inhabiting snakebite prone regions, which in turn represents a key component of snake diversity conservation, snakebite prevention, and prehospital care of snakebites.
Human and snake conflicts are commonplace throughout the world. People engaged in agricultural practices that utilize local resources from protected or nonprotected areas for their living and sociocultural requirements, such as those living in the buffer zone of Chitwan National Park (BZCNP) in southern Nepal, suffer from life threatening snakebite envenoming. The threat of potentially fatal snakebite results in often ruthless killing of snakes. Therefore, it is important to understand the perceptions of rural villagers towards snakes, including assessing general knowledge about snakes, frequency and care of snakebites, and preventive measures taken. Armed with this knowledge, it is imperative to engage inhabitants in educational efforts that will lead to more appropriate responses towards snakes, which is expected to reduce snakebites and minimize life threatening interactions with snakes resulting in enhanced conservation of snake populations [16]. Although assessing attitudes and perceptions towards charismatic megafauna has been the subject of recent research [17] similar attention has not been given to assess attitudes, knowledge, and awareness of snakes and snakebite among people inhabiting BZCNP.
Snakes may be keystone predators [18,19], especially in agricultural and grassland ecosystems, because snakes are effective predators of rodents. Indeed, snakes likely help to regulate food webs in important ways that other predators cannot. Snakes are also excellent ecological indicators due to their sensitivity to temperature and climate change [20]. Therefore, massive killing of snakes likely influences trophic interactions in ecosystems and may alter predator-prey population dynamics in multifaceted ways.
It seems reasonable to assume that high levels of human-caused mortality of snakes will result in an increase in rodent populations that will lead to a reduction in pre-and post-harvest cereal grains, other agricultural products, and household goods [21][22][23][24][25]. Increased rodent populations may also increase the risk of epidemic plague [26,27] and diseases caused by Salmonella and Campylobacter [28]. Subsequently, snakes contribute directly to maintain natural trophic interactions, and indirectly to public health by reducing disease and famine. Although seemingly counterintuitive, unsustainable killing of snakes may also lead to increased snakebite [29], because individuals attempting to kill snakes are more likely to be bitten. Therefore, understanding causes of snake-human conflicts is essential.
Use of snakes for food, medicine, goods (e.g., snakeskin belts, purses, bags) and recreation (e.g., keeping snakes as pets, at zoos and for display by charmers) also threatens snakes. Worldwide, people use about 165 reptilian species, including snakes, for traditional medicine [10] and several ethnoherpetological studies indicate that traditional knowledge is important to herpetological conservation and human health [10,[30][31][32][33]. But similar studies are rare worldwide [34,35], including in Nepal [36]. This study also highlights the human exploitation of snakes in BZCNP.
To escape from anthropogenic disturbances (e.g., forest fires, deforestation), natural predators in protected and non-protected forests, and flooding, snakes may retreat to human habitations, where they can find food (prey animals) and shelter, leading to a potential increase in snakebite envenoming, which can lead to death if not properly treated. It is not yet known how rural people react to snakes encountered in their homes compared to human-snake interactions that take place outdoors (e.g., roads, agricultural fields).
To the best of our knowledge, this is the first study to investigate perceptions, knowledge, and awareness (AKA) of snakes and snakebite in Nepal. Our goal is to provide baseline data useful for conservation of local snake populations and for enhancing snakebite prevention. To achieve this goal, we assess AKA by occupation, gender, and literacy of people living in BZCNP. We also determine challenges to snake conservation and snakebite management and provide insights and measures to improve AKA to address these challenges. This study informs major questions associated with anthropogenic threats to snakes and broad challenges to snakebite management [37]. Because teachers, students, and farmers are important for dissemination of conservation and public health education, quantifying their AKA may be of heightened importance for effective snake conservation and public health policy making.

Study area
A total of 35 BZ communities (15 from Chitwan, 16 from Nawalparasi, two from Makawanpur, and two from Parsa Districts [38]) surround CNP. Approximately 364,000 people inhabit these communities [39]. These people depend, both directly and indirectly, on resources found in the park and buffer zone areas. A rapidly increasing population in the Chitwan Valley has resulted in increased impacts on biodiversity and other natural resources in the vicinity. There is nearly an equal proportion of agricultural (46 %) and forested lands (50 %) in the BZ of CNP [38]. Agricultural lands are comprised of rice paddies, maize, and wheat fields, and forested lands consist of Shorea robusta (Sal) (30 %), tropical mixed hardwood (19 %) and Accacia species (Khair) and Dalbergia sissoo (Sissoo) (1 %) [38]. Both agricultural and forested lands appear to provide suitable habitat for snakes and their prey (e.g., rodents, birds, reptiles, amphibians and fishes) and predators (e.g., raptors, carnivores, other snakes).
The study area is characterized by a tropical climate, with temperatures up to 38°C in summer, dropping to a minimum of 6°C in winter, and receiving approximately 240 cm of rainfall annually, with the bulk occurring during the monsoon season [40].
We purposely selected three distantly distributed Village Development Committees (VDCs) adjoining CNP to represent a diverse array of BZ communities (Fig. 1). We selected three institutions of higher education and randomly selected three wards (i.e., the smallest administrative unit of Nepal). From these study units, we randomly sampled 75 household heads from a current household list of respective wards, and 45 teachers and 30 students from the daily attendance-register of each institution (Table 1).

Data collection
We conducted a cross-sectional survey using semistructured and pre-tested questionnaires, qualitative and quantitative research methods [41,42] from January-February 2013. We performed personal, formal, and faceto-face interviews of 150 randomly selected respondents with a mean age of 37 years (range = 15-79) using a voice recording device and visual stimuli (i.e., A4-sized color photographs of adult snakes known to be distributed in the vicinity of CNP; Fig. 2, Table 2) [43]. We also included photographs of neonate and juvenile snakes for species with ontogenetic variation in color patterns.
Written informed consent was obtained from the participants for publication of this study and any accompanying images. For the informed consent, we clearly explained the main objectives of our research at the beginning of the interview and asked them if they would participate in the survey research. As for institutional respondents, we interviewed them after a formal request for permission to the principals of the respective institutions. We did not obligate any respondents to participate in this study.

Attitudes
We asked 15 questions designed to understand positive attitudes and 14 questions designed to examine negative attitudes towards snakes and snake conservation. We determined ambivalent attitudes if participants responded "yes" to both types of questions. To scrutinize and measure attitudes, we asked participants questions related to like, dislike or fear of snakes, intention of killing snakes, responses to snakes encountered in defined and undefined places, worship of snakes, realizing the need of snake conservation, and snakes as a "farmers' friend." We phrased the first type of question as, Do you …? Why?; we coded responses as 1 = Yes, 2 = No, 3 = Unknown, and we noted three types of logic for Yes or No responses. We phrased the second type of question as, What do you do when …?; we coded responses as 1 = I ignore it, 2 = I kill it, 3 = I call others to kill it, 4 = I kill it only if I know it a venomous snake, 5 = I just keep it out using sticks (snake hooks, tong, etc.). We phrased the third type of question as, Which of the following do you consider to be…?; we coded responses as 1 = All snakes around us should be killed, 2 = Only venomous snakes around us should be killed, 3 = All

Knowledge
The knowledge test questions included three types of questions: the first type tested whether or not people could identify the snake as venomous or non-venomous, and if they knew the local/English/scientific names of the snake; second, we tested their understanding of the need for snake conservation; and third, we asked about measures of snakebite prevention. We presented the first type of question as, Which one of the following snakes do you think were venomous or non-venomous? (we considered both rear-and front-fanged snakes as venomous) and which snake species do you know by their local/ English/scientific names? To measure knowledge of the need to conserve snakes, we phrased questions such as, Do you think snakes should be conserved? and If you do/don't think so, why? We asked respondents to give five reasons. To measure knowledge about snakebite prevention, we phrased questions such as, Do you know how to prevent snakebite? If yes, we asked them to give 10 preventive measures that they practice. We encircled the corresponding assigned snake photo numbers (i.e., 1-28) following their responses and noted names of respective snakes if they were able to identify the species. We crosschecked their replies with a corresponding list of snakes (Table 2) and published sources [44] during data entry.    (7), nature guide (3); b respondents able to read and write by informal education but never attained school, < less than, > greater than, n sample size i.e. total number of attitude test questions, D degree, W value for one-tailed one-sample Wilcoxon signed rank test, pos positive, neg negative, amb ambivalent; parentheses in column demographics show number of respondents involved in statistical analysis

Awareness
To examine the snake awareness level among BZCNP residents, we asked 33 "yes-no" questions, which included both useful and useless, deleterious, and fictitious aspects of snakes and snakebite management [45]. Of the 33 questions, 26 were designed to test belief in popular, deeprooted, and widely-held traditional beliefs or misconceptions regarding snakes (n = 13) and pre-hospital care of snakebites (n = 13). Two questions tested belief in doubtful benefits of pre-hospital care in the context of Nepal [45,46], and five questions were related to first aid measures (i.e., pressure immobilization bandaging (PIB) and local compression pad immobilization (LCPI)) recommended by the World Health Organization and the Government of Nepal [44,[47][48][49].
To better understand ethno-ophiological issues, we asked respondents whether or not they or their neighbor killed snakes for food or ethno-medicine during the 1-year period of this study.

Data analysis
We analysed composite AKA scores using the nonparametric Wilcoxon test with median scores as the dependent measure [50]. We used the one-sample Wilcoxon signed rank test to understand median scores for each demographic group for attitudes and knowledge, a two-tailed unpaired Wilcoxon rank sum tests to compare differences of scores among demographic groups, and a one-tailed unpaired Wilcoxon rank sum test to compare maximum scores among demographic groups. We did not conduct demographic-group analyses for sample sizes lower than six to minimize problems associated with measurement error.
We analysed awareness based on the percentage of median scores of respondents after conducting the Wilcoxon test. We classified BZCNP residents as "highly aware" (HA), if they scored ≥75 %, indicating rejection of traditional beliefs of snakes and snakebite care, doubt about refusing to seek medical attention for snakebites, and acceptance of suggested measures of pre-hospital care. Similarly, we considered respondents as "aware" (A) if they scored 50-74 %, "mildly aware" (MA) if they scored 25-49 %, and "unaware" (UA) if they scored 0-24 %.
We considered all tests to be significant at α = 0.05. We rounded p-values (p) to significant digits (values less than three significant digits were represented as p = < 0.001). We performed all analyses using the R statistical package (R version 2.15.1).

Attitudes
Residents of CNPBZ had higher scores for positive attitudes than for negative and ambivalent attitudes towards snakes and snake conservation issues. More than 47 % of respondents (n = 70) had positive attitude scores (median = 99, p = 0.047, Table 3) based on answering >8/15 questions (median = 9, p = <0.001, Table 4.a). Students,   6 I prefer to kill snakes/ all snakes should be conserved 7 5 teachers, and literate respondents were more positive (Table 5.i). Positivity was not significantly different between males and females (p = 0.213, Table 5). Respondents had a positive temperament towards snakes in unspecified areas and areas with less human activity. Respondents generally ignored snakes encountered while walking on paths and 77 % remained tolerant to snakes at unspecified localities (Table 6.a, b, Fig. 3). Although 55 % of respondents (n = 82) were generally positive towards snakes (Table 6.a), 86 % (n = 129) feared snakes and 43 % (n = 64) were repulsed by snakes, primarily due to preconceptions about shape, size, and movements and related nightmares (44 %, n = 27, Table 7.b). Proportionately, males, literate persons, farmers, and teachers feared snakes more than their counterparts did (Fig. 4). We found a greater degree of negative attitudes towards snakes encountered indoors or in areas with increased human activity, such as homes, and agricultural fields. Thirty-eight percent (n = 57) of respondents would kill a snake if encountered, but this attitude varied by locality (Fig. 3). Only 1 % (n = 2) of respondents intended to kill all snake species encountered, but 49 % (n = 74) would kill all venomous snakes observed (Table 6.b). Approximately 6 % of respondents (n = 9) were negative towards snakes (median = 13, p = 0.037, Table 3.b), as indicated by answering two or more out of 14 questions on the negativity test (median = 2, p = <0.001, Table 4.b). Farmers, females, students, and illiterate people were the most negative towards snakes (Table 5.a.ii).
A total of 81 % (n = 122) of CNPBZ inhabitants considered there to be a need for snake conservation (Table 7.a), but respondents below 35 years of age, teachers, students, and literate people only gave one reason to justify the need for snake conservation (Table 12.a). Although 85 % (n = 127) of respondents replied that they were aware of preventive measures for snakebite, their reasoning was poor. Respondents aged 15-24 years, teachers, students, and literate people mentioned slightly more than two appropriate preventive measures (Table 12.b), although their score for "yes" responses was higher. Snake conservation knowledge was greater among males (Table 10.g), and knowledge about     snakebite prevention was greater among younger respondents (Table 10.h).

Awareness
Awareness of recommended pre-hospital care of snakebite was below 50 % on average. We found that >48 % of respondents aware of proper snakebite care (n = 72, p = 0.045,  (Table 15), 95 % of respondents were aware of the need to visit a treatment center equipped with antivenom (95 %) to treat snakebite from venomous species (88 %, n = 132), and they also knew where the nearest snakebite treatment center was located (83 %, n = 125). Similarly, 95 % of respondents rejected the belief that all snakes are venomous and 85 % refused to seek treatment from traditional healers (Table 15). More than half of respondents accepted widely recommended first aid measures for venomous snakebite. However, a total of 61 % of respondents would apply PIB and 51 % would apply LCPI (Table 15). Overall, only >51 % of respondents (n = >76) agreed to apply suggested first aid measures (median = 125, p = 0.031, Table 13.b). The level of awareness of proper snakebite treatment was greater among males than females, among student and teachers than farmers, among teachers than students, and among literate than illiterate people (Table 5.b.i).

Ethno-ophiology
Ninety-nine percent of respondents replied that they made no use of snakes and snake products, and only 2/ 150 (1 %) respondents consumed Python meat. Five percent of respondents knew neighbors from native ethnic groups (i.e., Tharu, Mushahar, Kusunda, and Newar) that consumed snake meat, and 9 % (n = 14) of respondents knew about the killing of Pythons for gallbladder and fat, and Cobras for fat and intestines used to purportedly cure backache, burn or other infected wounds, hemorhoids, mastitis, and rheumatism (Table 6).

Discussion
Ignorance of the need for snake conservation, extreme disgust and fear of snakes (Fig. 4), a strong desire to kill snakes, confusion in differentiating venomous from nonvenomous species (Fig. 5), a willingness to exterminate all venomous snakes by nearly 50 % of respondents, and susceptible positivity to snakes appear to be challenges Fig. 6 Knowing snakes by English and local name by Chitwan National Park buffer zone people to snake conservation in the lowlands of Nepal. Killing and harassing snakes is common in CNPBZ [51] and elsewhere in Nepal [36]. General belief that most snakes are venomous and the desire to kill snakes is also known to occur in neighboring areas, such as Sikkim state in India [52]. Similar challenges were apparent in Brazil [53], Kenya [54], and Australia [14]. Indeed, wanton killing of snakes appears to be a worldwide phenomenon, which likely amplifies wide-ranging declines in snake population [13,55], and only serves to heighten the importance of snake conservation. Continued killing of snakes may negatively impact snake population dynamics, potentially resulting in a trophic cascade that leads to deterioration of ecosystems, which may ultimately impact human health. Extinction of species due to factors, such as climate change [56] may add to the global biodiversity crisis [57]. Therefore, authorities should consider humansnake conflicts as an important driver of snake population declines.
Killing of snakes appears to be the result of extreme negativity that originates due to fear. A lack of awareness about essential ecological services that snakes provide facilitates the killing of snakes. Although 95 % of the respondents in the current study were aware that all snakes are not venomous, more than two-thirds of respondents feared snakes. Furthermore, a lack of awareness of the need for snake conservation, and extreme fear of snakes (especially among farmers) has apparently led to large-scale killing of snakes in Nepal [58]. Increased tolerance of snakes in areas with less human activity further suggests that fear of snakes leads to human-caused mortality of snakes in Nepal. The fear of snakes may have originated since time immemorial [59], and was introduced into the scientific community by Linnaeus [60]. Irrational belief in snake mythologies propagates fear and negativity towards snakes [61,62]. Revulsion, accompanied by a lack of awareness about snakebite prevention, and inappropriate care of snakebites due to superstition likely induce fear of snakes in humans, which is compounded by the possible fear of snakes that was evolutionarily ingrained in the human brain [63,64]. Further, poor transportation, ill-equipped and inaccessible snakebite care facilities, and greater snakebite mortality as a consequence [65,66]), likely  Symbols and abbreviation: a hotel owner, miller, fisherman, boat-man, mason labourer, housewife, nature guide; b respondents able to read and write by informal education but never attained school; n number of snake species displayed, W value of one-tailed one-sample Wilcoxon signed rank test. I zeroed W and p values for confidence interval (CI) below 95% intensifies fear of snakes. Moreover, a famous Nepali proverb "Bish nabhyako sarpa ra ekh nabhyako manis hudaina (i.e., "there are no snakes without venom and no humans without jealousy") likely fortifies fear, leading to increased negativity towards snakes. And finally, a lack of understanding of ecological services provided by snakes appears to cultivate negativity, which predisposes people to kill snakes. Similar to teachers in Kenyan communities [54] and students in Brazilian communities [53], a fear of snakes is common in Nepal. Coupling fear and negativity with a poor aptitude for distinguishing venomous and nonvenomous snakes likely results in wanton killing of all snakes, including non-venomous species, in order to feel safe. In Nepal, killing snakes is common, even in and around biodiversity conservation hotspots [36,51]. Similar ruthless killing of snakes reported from other parts of Nepal [67], and intentional killing of snakes encountered elsewhere in our study, suggests a lack of education about snake ecology and effective practices of snakebite prevention and treatment.
Due to the relatively high rate of respondents that believed pythons are venomous places this species at risk from human-caused mortality. Less familiarity of snakes by teachers and students suggests the need for intensive educational efforts designed to minimize wanton killing of snakes. The fact that teachers and students, who are the backbone of the community, fail to recognize the difference between venomous and non-venomous snakes may impact snake conservation and public health in Nepal and elsewhere with similar circumstances.
In contrast to China, Vietnam, Brazil [4,68,69], and other parts of Nepal [51,70], the use of snakes for food and medicinal products does not appear to be a significant threat to snake conservation in the Chitwan Valley. Killing snakes for human use was rare in Nepal compared to past reports [67]. Similar to some areas in India [71], only people from sparsely populated ethnic communities used pythons and cobras as food and/or medicine. The majority of Tharu respondents in our study denied the eating of snake meat, although Zug and  Symbols and abbreviation: a hotel owner, miller, fisherman, boat-man, mason, labourer, housewife, nature guide; b respondents able to read and write by informal education and never attained school; n number of logical statements to support their "Yes" reply to the need of snake conservation and preventive measures of snake bite, W value for one-tailed one-sample Wilcoxon signed rank test. We zeroed W and p values for confidence interval below 95% Mitchell mentioned that the Tharus of Chitwan were known to consume snakes [51]. However, there is need for intensive research on the ethno-medicinal use of snake products nationwide. Humans have long been suffering from the consequences of our attitudes towards snakes [61]. Fear, bias, negativity, disregard, and superstition are behavioral risk factors for snakebite in Nepal and elsewhere with similar geosocioeconomic and cultural circumstances. Ignorant, negative, and fearful people who tend to encourage the killing of snakes put themselves at the risk of envenomation. Pronounced confusion in differentiating venomous and non-venomous snakes, even among teachers and students in Nepal, teachers in Kenya [54] and medical service providers in Sri Lanka [72] disclose the need for more effective education in southern Nepal and elsewhere with similar circumstances.
Like in this study, the inability to correctly identify snakes, or the illogical claim of being able to identify snakes [66], also occurs in developed countries [73]. People commonly identify non-venomous snakes as venomous [74]. This increases the risk of and vulnerability of rural inhabitants to snakebite envenomation. Therefore, finding out which of the snakes in residential or visiting area are venomous and which are not is essential. Accurate identification of snake species not only enhances snakebite prevention, may minimize the chance of multiple bites to a victim or a bite to the first aid provider. Correctly identifying snakes can also minimize snakebites for people who attempt to kill the a. All respondents' responses (n = 33, see Table 15) Aware (not believing on misbelief but believing on recommended care), H0 snake. If snakes are mishandled, envenoming by recently killed, decapitated or inadequately killed [75], preserved [76], and even frozen specimens [77] is possible. A lack of identification skills and knowledge about preventive measures against snakebite undoubtedly places inhabitants of agrarian lowlands in Nepal at increased risk of snakebite. Our findings that a large majority of people who claimed to be familiar with recommended snakebite preventive measures actually had very little idea of how to prevent snakebites. Although farmers and illiterate people may be expected to be at higher risk of snakebite, the fact that people with higher education were also at greater risk indicates that ignorance about snakes and snakebite are widespread among all sectors of the community, leading us to conclude that education about snakes and snakebite prevention at schools, universities [46] and within the community is inadequate. The relatively greater degree of negativity towards snakes among farmers, females, students, and illiterate people (Table 5.a.ii) may be associated with a lack of knowledge about the role that snakes play in ecosystems, the risk of snakebite, and proper preventative measures. The high degree of ambivalence towards snakes among teachers is especially troubling, because it indicates that educators are likely not utilizing factual information on snakes and snakebite issues to develop effective educational approaches.
On a positive note, 85 % of respondents rejected traditional healers as a legitimate alternative treatment for snakebite, which is supported by a decreasing trend of dependency on traditional healers for snakebite treatment in the Chitwan Valley [66,78,79]. Therefore, we conclude that traditional healing is not a challenge to snakebite management in this part of Nepal. However, the situation is different in other countries. For example, 86 % of snakebite victims in Bangladesh [80], 75 % in Pakistan [81], and 61 % in India [82] still visit traditional healers. Belief in traditional snakebite treatment methods may be a challenge to snakebite management in other regions of Nepal. Although CNPBZ   [79], a recent hospitalbased snakebite report from southwestern Nepal [83] and central Nepal [84] reported the common use of inappropriate snakebite first aid. Inadequate education related to the pre-hospital care of snakebite [46] likely influences chosen practices of pre-hospital care of snakebite. However, we suggest intensive research on the locally available (currently unreported) ethno-biological snakebite remedies because these home remedies may pacify snakebite victim, slow down pulse rate that slows down venom dissemination. This eventually keep patient less danger and prolong time to admit in snakebite treatment center before severe venom effect [74].
In evaluating weaknesses of our survey, we minimized sampling and non-sampling errors to the best of our ability by involving qualified interviewers, carrying out interviews primarily in isolation, and cross checking data entry to avoid measurement errors. We did not face any unit (respondent) non-responses (standard response rate = 1), but we noted item non-responses for certain questions (Table 6.b, 13.a, 14. Note 2, 15), likely due to lack of knowledge on the part of respondents. The item non-response for educational status was three. We provided nonmonetary incentive of books about snakes and snakebites [45,85] to each respondent (Fig. 2), which motivated them to participate in the survey and maximized the response rate. Further, we scheduled interviews at times when villagers were either less hectic or more involved in household chores to manage the already harvested crops, thereby maximizing the number of responses.
Photographs and captive specimens are deprived of additional ecological information that may help to a positive identification of the specimen [86,87]. Due to crepuscular and nocturnal habits of some snakes, which cause about 25 % of snakebites at night [66], they may not be visible clearly. As photographs subtracts the ecological information associated with specimens [87], this may increase the chance for misclassifying the materials. Nonetheless, ecological circumstances and habitat associated with those snakes can, in fact, be recognized by respondents. Thus, there is a need for trekking with respondents in nature park or serpentarium to gather more reliable data.

Conclusion
The cumulative effect of fear, antipathy, negativity, ignorance, and ambivalence to snakes among people represent potential threats to snake conservation. Apparent decline of local snake populations and extirpation of rare or endangered snake species in the lowlands of Nepal may occur if wanton killing of snakes is unchecked, which has multifarious and unforeseen negative impacts on biodiversity and human health. Therefore, potential factors responsible for large-scale killing of snakes should be considered when developing biodiversity conservation and public health strategies. Increasing knowledge and the awareness of people about snake and snakebite care and prevention through educational interventions, such as snake parks and snake museums, are cost effective ways of developing snake friendly attitudes of people. The ability to recognize venomous from nonvenomous snakebites should be considered in future studies, as this ability can be crucial in the decision to of whether or not to seek immediate medical attention.

Endnotes
1 Occupation of respondents was defined based on the work that they carried out within the previous 12 months. Therefore, the occupation of respondents for those 12 months and some interference may be encountered if case-by-case life histories were taken into account.