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Knowledge and Preventive Practices of Rural Residents against Schistosomiasis in an Endemic Community in Eastern Philippines
Joseph U Almazan1*, Jhunlie E Escala2, Ma Azyl Verdeflor Merida2, Dorothy R Permelona2 and Jonas P Cruz3
1Nursing Department, College of Applied Medical Sciences, Majmaah University, Majmaah, Saudi Arabia
2Samar Provincial Hospital, Catbalogan, Samar
3Nursing Department, College of Applied Medical Sciences, Shaqra University, Saudi Arabia

ABSTRACT
Background: Schistosomiasis is one of the most widespread parasitic infections in the world. Although there were several studies about the effect of health education against schistosomiasis, no empirical data was established concerning to its knowledge and preventive practices of rural residents in this disease among its rural residents.

Aim: To assess the health knowledge and preventive practices of rural residents against schistosomiasis in an endemic rural community in Eastern Philippines.

Design: A Cross-sectional study was conducted to 140 conveniently selected rural residents.

Methods: The data was gathered through the use of standardized questionnaire developed by HD Mazigo et al. The researchers utilized random sampling technique in the endemic schistosomiasis community.

Results: Knowledge of the respondents towards schistosomiasis was associated with their age and income. Preventive practices towards schistosomiasis have significant relationships with toilet facility.

Conclusion: There was still lack of understanding concerning transmission schistosomiasis. Consequently, modifying their knowledge and behavioral practices related to schistosomiasis transmission is highly recommended.
KEYWORDS
Knowledge; Parasitic infections; Preventive practices; Rural residents; Schistosomiasis; Toilet facility

Introduction
Schistosomiasis is one of the most widespread parasitic infections and has a high prevalence in tropical countries [1].This infection describes as an ignored tropical infection [1]. Furthermore, this infectious disease is common in Africa, South America and Asia [2]. Meanwhile, in Asia such as in the Philippines, there were 560,000 known reported cases [3].

The occurrence of this disease in the country is still very high. There were 10 among the 16 regions have reported cases of clinical schistosomiasis, with 6.7 million people living in the endemic areas [4-6]. In addition, within these endemic areas, millions of people were exposed, risk for infection through their daily lifestyle and contact with water including farming, fishing, domestic activities (bathing and washing) and recreation [4-6].

In Samar, a high incidence of this disease was reported [4,5]. Although there was mass treatment in the province, increase household access to toilet and safe water facilities, conduct sentinel surveillance through stool examination, still, the prevalence rate was very high [7]. In order to halt transmission of the parasite in such community, treatment regimen, as well as other control programs such as community awareness, is necessary [8]. Health education is effective means to prevent schistosomiasis with particular emphasis on the factors influencing such beliefs and practices [8]. Previous studies regarding knowledge, attitudes and practices in schistosomiasis that explained a crucial need for focusing health messages among endemic communities [9], but no empirical studies were conducted especially in endemic schistosomiasis communities in Samar. This demonstrates that schistosomiasis remains a major public health problem in the province. Thus, the researcher was motivated to conduct this investigation.

Finally, this study would help the farmers, Local Government Units and Healthcare providers to strengthen health programs and redirect policies regarding prevention of schistosomiasis. This also enlightens them that knowledge is not only a man’s factor to treat this disease but also their practices. The study aims to provide depth assessment on the rural residents against schistosomiasis in an endemic community in Eastern Philippines.
Methodology
Design
A descriptive cross-sectional design was used in the study in assessing the knowledge and preventive practices of rural residents against schistosomiasis in an endemic rural community in the Philippines.
Participants
There were 162 households living in Endemic Schistosomiasis community. Thus, a total enumeration was applied in recruiting all the respondents. They were interviewed from their own houses based on the reported cases of Schistosomiasis in Gandara, Samar. For the purpose of the survey, a household was defined as a group of people who routinely live and eat together in one house. One person per selected household was interviewed. The target individual for interviews was the person best placed to answer questions about the household’s health as nominated by the acting household head. Only household members over 18 years of age were eligible. The researchers make at least two additional attempts to interview an eligible household member at different times of the day. Households that could not be located, those where no eligible respondent was encountered despite at least three visits to the household and those where consent to be interviewed was not given were dropped from the sample without replacement.

Each respondent was given enough time to answer each question. The researchers discussed that the answers remain confidential; the whole research instruments were accomplished according to the purpose of this study. However, None of this respondents were infected of the disease.
Settings
Gandara, Samar province has one of the highest prevalence rate of S. japonicum in Samar province, based on both the presence of fecal eggs and the quantification of S. japonicum DNA in fecal samples [6,10]. The most common schistosome species in the region is S. japonicum [11]. Specifically, this study was undertaken in three villages namely; San Miguel, Diaz and Hinugacuan, which all were located in Gandara, Samar Province, Eastern Philippines. In the study, the village is the smallest organizational unit in a region, which is also referred to as a production group or natural village. These three villages mentioned were among the highest prevalence rate of schistosomiasis in Gandara, Samar [6]. Although there was mass treatment in the province, increase household access to toilet and safe water facilities, and conduct sentinel surveillance through stool examination, still, the prevalence rate was very high [7].
Ethical consideration
Gandara, Samar province has one of the highest prevalence rate of S. japonicum in Samar province, based on both the presence of fecal eggs and the quantification of S. japonicum DNA in fecal samples [6,10]. The most common schistosome species in the region is S. japonicum [11]. Specifically, this study was undertaken in three villages namely; San Miguel, Diaz and Hinugacuan, which all were located in Gandara, Samar Province, Eastern Philippines. In the study, the village is the smallest organizational unit in a region, which is also referred to as a production group or natural village. These three villages mentioned were among the highest prevalence rate of schistosomiasis in Gandara, Samar [6]. Although there was mass treatment in the province, increase household access to toilet and safe water facilities, and conduct sentinel surveillance through stool examination, still, the prevalence rate was very high [7].
Instrument
The main source of data was gathered based on the adapted questionnaire [12]. Since the questionnaire was developed in Africa, this was subsequently translated into Tagalog. Its validity was assessed by a group of native Filipino language experts in the field. Pre-testing was employed in determining consistency and suitability of language using households different from the ones who participated in an interval of one day. The test-retest reliability coefficient was 0.80 [12].

The questionnaire has three parts. Part 1: Discussed the demographic profile such as name (using only code numbers), age, sex, educational attainment, occupation and monthly family income. Part 2: Assessed the knowledge in schistosomiasis with 5 subscales. The scale of yes or no response options used in assessing the knowledge. Part 3: Discussed the 10 item preventive practices against schistosomiasis with five choices per item ranging from 1(not practice at all) to 5(extremely practice).
Data Collection
The researchers approached the village head and asked permission to conduct the study. This was done before the interview to the eligible household. The interviews were conducted in the participants’ houses and ran within two weeks (January 2014).
Data analysis
In presenting the socio-demographic profile, name (optional), age, sex, educational attainment, occupation and the respondents’ monthly family income, frequency counts, percentage, mean and standard deviation were used. Associations were explored between knowledge and preventive practices and different socio-demographic profile of respondents (sex, age group, education level and district), with a statistical significance of the association tested using p-values less than 0.05 were considered statistically significant.
Results
This study interviewed a total of 162 households; however, 22 were omitted from the analysis because the interviewee was less than 18 years of age. Thus, only 140 households were included in the analysis. In this case, the response rate was 86.49 %.

As shown in table 1, 140 respondents participated in the study which composed of 57 (40.71) male and 83 (59.29) female. More than half of the respondents were married, Roman Catholic, have toilet facilities, with monthly income Php 1,000-5,000, but only a few of them were college graduates.

Knowledge about schistosomiasis. Table 2 presents the multiple responses concerning the knowledge of respondents about schistosomiasis. More than half of the respondents (both male and female) indicated that worms, dirty water, swimming in lakes and drinking dirty water cause schistosomiasis. The symptoms to which respondents reported were varied considerably and usually not associated with schistosomiasis were also reported (Table 2).

About 121 or 86.9 percent from the male respondents responded swimming in dirty water can transmit the disease. However, there were some of the respondents in male and female answered sexual intercourse and mosquitoes which are not considered a mode of transmission. Meanwhile, more than half from the male respondents responded that they could acquire the disease through a lake, rivers, rice field, water collection areas and toilet. Meanwhile, more than half of the female respondents answered that they could acquire the disease through toilet facility. Finally, a significant number of respondents are knowledgeable about preventive and control measures.

Respondent’s preventive practices on schistosomiasis. Table 3 shows the respondents’ preventive practices on schistosomiasis. Results showed that respondents had attained relatively scores on these preventive practices.

The regression model knowledge towards schistosomiasis, as described in the table 4, the coefficient determination table of the regression model is 0.474 which indicates that about 47.4 percent of the variation of knowledge explained by age and income. This means a weak prediction of the independent variable to dependent variables. To fully disclose the knowledge of the participants, 52.6 percent of the variation of knowledge explained by other factors. Furthermore, for every 1 point unit increase of age level, there is a corresponding 0.214 unit increase in knowledge. It has a p-value of 0.000, which is lesser than the significant level of 0.05. Next, for every one unit increase in income, there is a corresponding 0.142 increase in knowledge. It has a p-value of 0.000, which is lesser than the significant level of 0.05.

The regression model preventive practices, as described in the table 5, the coefficient determination table of the regression model is 0.367 which indicates that about 36.7 percent of the variation of preventive practices explained by age. This indicates a weak prediction of the independent variable to dependent variables. To fully disclose the preventive practices of the participants, 63.3 percent of the variation of preventive practices explained by other factors. Furthermore, for every 1 point unit increase of age level, there is a corresponding 0.258 unit increase of preventive practices. It has a p-value of 0.000, which is lesser than the significant level of 0.05.
Discussion
Schistosomiasis preventive control in the Philippines can only be achieved if the households have sound knowledge and correct preventive practices. Based on the findings, respondents were knowledgeable in schistosomiasis. Specifically, the results on the knowledge of the causes and symptoms of schistosomiasis are similar to previous studies in which more than half of the respondents were knowledgeable [13]. A recent study described that people learned the cause and symptoms because they heard using the local most common term [14]. However, this is only limited to the local term of disease and not the cause and symptoms. Thus, a further qualitative research could be explored using local term cause and symptoms and prevention. Approximately 17% of the respondents reported that sexual intercourse could transmit the disease misconceptions relating to sexual contact is consistent with the previous study in Africa [14]. These findings represent a large of the discrepancy of correct information. Incorrect information leads to wrong actions which place the entire community at risk [15,16]. Overall, these findings affirm to the previous studies in Brazil and Kenya in which schistosomiasis is endemic in these countries. In contrary, poor knowledge about schistosomiasis were found in Malawi, Western Kenya and Senegal [17-20]. Misconceptions were also widespread in developing countries [20]. This implies that common misconception needs to be improved through a health promotion education campaign. Respondents have very low preventive practices. This is in line with the recent study in Nigeria and Mozambique [21,14].

Emphasizing the preventive practices is vital against schistosomiasis. However, most of the studies were conducted in small villages. Thus, further research is needed to explore the relationships between the knowledge and preventive practices on schistosomiasis in a wider region. Another highlight of the study is the age and income which have significant relationships with the knowledge and preventive practices on schistosomiasis [14,22]. This is worth noting since the previous study pointed out that age, was the most important factor significantly associated with the knowledge and preventive practices on schistosomiasis, but not the income level [21]. However, the previous study discussed that age was generally found not to be statistically significant [14]. Thus, more empirical data is needed to determine the significance of age to knowledge and preventive practices. Other findings of the study revealed that income has significant relationships in knowledge towards schistosomiasis. These results showed that the family income of the respondents was below the poverty monthly per capita income of Php 8,378 per month [23]. Poverty increases the chance of getting infected with this disease. Previous studies also described that lack of money was cited as reasons for failure to visit a hospital/health center. Nevertheless, this suggests that people with higher economic status could have better access to information combined with the effect of generalized education. This could assure a better understanding and comprehension of information. Thus, further research could be developed in determining the effect of poverty in schistosomiasis endemic community.
Limitations
This study was conducted during 2014, at a particular point in time (one day only) which could limit the generalizability of the result. Moreover, the study is confined only to three villages in Gandara, Samar Philippines. The researchers depend on a self-administered questionnaire, which is vulnerable to bias recall. This study also used convenience sampling that gives inability in generalizing the results. In addition, focusing on household is also the limitations of the study. However, the response rate from the respondents is very high which serves as a strength of the study.
Conclusion
Schistosomiasis has been documented as a significant public health concern and calls for active intervention. However, there was still a lack of understanding concerning transmission and prevention. In addition, misconceptions remain a barrier in effective disease prevention. A productive and sustainable intervention however cannot be achieved without adequate education especially among working population. Therefore, there is a need for adequate health education for the disease transmission, feasible control strategies as well as other preventive measures.

In order to halt transmission of the parasite in such community, treatment regimen as well as other control programs should also target especially younger age groups and lower socioeconomic class.

Tables
Age GroupMale (%)Female (%)Total
20 - 269(6.43)14(10)23
27 - 3311(7.86)18(12.86)29
34 - 4010(7.14)6(4.29)16
41 - 4712(8.57)13(9.29)25
58 - 546(4.29)8(5.71)14
55 - 614(2.86)13(9.29)17
62 – 683(2.14)6(4.29)9
69 – 752(1.43)5(3.57)7
Mean43.1249.74 
SD2.373.61 
Civil status
Single16(11.43)13(9.29)29
Married32(22.86)56(40)88
Widowed9(6.43)14(10)23
Educational Background
Elementary Graduate11(20.75)15(10.71)26
High School Level14(26.42)24(17.14)38
High School Graduate21(39.62)21(15)42
College Level7(13.21)14(10)21
College Graduate4(7.55)9(6.43)13
Religion/Denomination
Roman catholic46(7.55)74(52.86)120
Born again11(19.30)9(6.43)20
Occupation
Fisherman11(19.30) 11
Farmer46(80.70)9(6.43)55
Housewife-74(52.86)74
Income
Php 1,000-5,00029(20.71)54(38.57)83
Php 6,000 -10,00013(9.29)18(12.86)31
Php 11,000 - 15,00010(7.14)12(8.57)22
Php 16,000 - 20,0003(2.14)1(0.71)4
Toilet facility
With toilet facility50(87.72)63 (75.90)113
Without toilet facility7(12.28)20 (24.10)27
Table 1: Demographic profile of the respondents.

Knowledge on SchistosomiasisMaleFemale
Yes(%)Yes(%)
Knowledge on the cause of schistosomiasis
Worms7150.76949.3
Dirty water12387.91712.1
Swimming in lakes causes schistosomiasis11682.92417.1
Drinking dirty water causes schistosomiasis10877.13222.9
Knowledge about the symptoms of schistosomiasis
Abdominal pain10675.72424.2
Haematuria6345.07765.0
Pain during micturation3122.110977.9
Swelling of the abdomen10575.03525.0
Knowledge about the transmission of schistosomiasis
Swimming in dirty water12186.92913.1
Air9668.64432.4
Sexual intercourse2417.143222.86
Urinating in water7050.07050.0
defecating in water9064.35035.7
Stepping over human feces10272.93827.1
Snails9366.44733.6
Mosquitoes3927.862719.29
Knowledge about areas one can get infected with schistosomiasis
Lakes12287.12812.9
Rivers10172.13927.9
Rice fields10373.64726.4
Open air11280.02820.0
water collection areas9265.73834.3
Toilets5942.98157.1
Knowledge about preventive and control measures of schistosomiasis
Avoiding swimming in lakes11380.72719.3
Avoiding urinating in lakes10977.93122.1
Avoiding defecating in lakes11481.42618.6
Use of toilets when defecating10776.43324.4
Wearing of slippers10373.63724.7
Wearing of boots11380.72719.3
Wearing of gloves9970.74129.3
Avoiding the use of water from river10776.43324.6
Hand washing11481.42618.6
Boiling water before drinking11380.72719.3
Table 2: Dynamic and static light scattering data for PIC micelles in 0.1 M NaCl.
aEstimated by SLS in 0.1 M NaCl, bEstimated by DLS in 0.1 M NaCl, cAggregation number of PIC micelles calculated from Mw(SLS) of PIC micelles determined by SLS and Mw of the corresponding unimers determined by 1H NR and GPC, dDensity calculated from Equation (3).
 MaleFemale
 MeansStandard DeviationMeansStandard Deviation
Avoids swimming in rivers2.940.973.041. 13
Avoids urinating in rivers3.011.083.121.19
Avoids defecating in rivers3.491.153.330.94
Uses toilet when defecating2.900.863.081.02
Wearing slippers4.411.494.551.26
Wear boots in the rice  fields2.960.782.470.83
Wear gloves in the rice fields2.260.472.260.47
Avoids use of water from river when washing clothes2.660.772.660.77
Wash hands and feet after contact with dirty water3.641.113.641.11
Boils water before drinking it2.600.862.600.86
Table 3: Dynamic and static light scattering data for PIC micelles in 0.1 M NaCl.
aEstimated by SLS in 0.1 M NaCl, bEstimated by DLS in 0.1 M NaCl, cAggregation number of PIC micelles calculated from Mw(SLS) of PIC micelles determined by SLS and Mw of the corresponding unimers determined by 1H NR and GPC, dDensity calculated from Equation (3).
VariableRR2Adjusted R2Std. Error of the Estimate
0.641(a)0.4740.4690.575
Unstandardized Coefficients
bStd. ErrorT-ValueP-Value
(Constant)-0.6930.699-0.8640.375
Age 0.2140.1633.664**0.000**
Gender0.0110.0140.643ns0.541
Civil status 0.1370.7430.855 ns0.685
Educational Background0.1860.3140.643ns0.753
Religion0.1790.6880.856ns0.585
Occupation0.0350.3050.756ns0.854
Income 0.0240.1902.764**0.000**
Toilet Facility 0.1420.8540.535ns0.256
Table 4: Regression model knowledge towards scistosomiasis.
Dependent variable: Knowledge.
Variable  R R2 Adjusted R2 Std. Error of the Estimate
0.441(a)0.3670.3340.586
Unstandardized Coefficients
bStd. ErrorT-ValueP-Value
(Constant)-0.3300.175-0.168-2.156
Age 0.2581.022-0.081**-0.000
Gender0.0960.8070.0110.113
Civil status 0.3910.683-0.853 ns0.685
Educational Background0.9610.1830.172ns0.284
Religion0.1790.6880.128ns0.462
Occupation0.0350.3050.738ns-0.194
Income 0.0350.1920.3460.196
Toilet Facility 0.9440.1630.363ns0.743
Table 5: Regression model preventive practices.
Dependent variable: preventive practices.
Note: ** Significant at p<0.01 (2 tailed).

Citation: Almazan JU, Escala JE, Merida MAV, Permelona DR, Cruz JP (2017) Knowledge and Preventive Practices of Rural Residents against Schistosomiasis in an Endemic Community in Eastern Philippines. J Pract Proff Nurs 1: 002.