Intestinal parasitic infections cause one of the largest global burdens of disease. To identify possible areas for interventions, a structured questionnaire addressing knowledge, attitude, and practice regarding parasitic infections as well as the less studied role of culture and resource availability was presented to mothers of school-age children in rural communities around San Juan del Sur, Nicaragua. We determined that access to resources influenced knowledge, attitude, and behaviors that may be relevant to transmission of parasitic infections. For example, having access to a clinic and prior knowledge about parasites was positively correlated with the practice of having fencing for animals, having fewer barefoot children, and treating children for parasites. We also found that cultural beliefs may contribute to parasitic transmission. Manifestations of
There is a great need for social science research to improve the treatment and control of neglected tropical diseases (NTDs) through framing illness within the complex societal and cultural contexts in which it exists [
Health outcomes of intestinal parasitic infections include malnutrition, growth stunting, intellectual retardation, and cognitive as well as educational deficiencies [
However, the future success of these nonmedical interventions will require further understanding of the way in which culture, development, and hygienic behaviors interact with one another in communities afflicted with parasites. Several predictors of infection have been noted in previous studies, including greater susceptibility of females, lack of toilets, nonworking status of parents, lower socioeconomic status, younger age, household crowding, lower level of education, religion, nonuse of footwear, defecation practices, pig ownership, and lack of access to clean water [
The several rural districts around San Juan del Sur, Nicaragua, have been part of an ongoing anti-parasite campaign focused on the distribution of water filters by Newton-San Juan del Sur Sister City Project (an NGO which provides a city partnership between Newton, MA, and San Juan del Sur) that has proven ineffective in reducing parasitic prevalence. To analyze the inefficacy of this intervention and holistically analyze parasitic re-infection cycles with respect to the numerous afore-mentioned factors, we conducted questionnaire-based interviews in the communities. We specifically focused on the influence of resource availability and culture on behaviors that are known to affect parameter transmission. The standard approach to analyze public health problems includes a survey of participants’ knowledge of a particular disease, their attitude toward the disease, their behaviors and practices that make them more or less susceptible to acquiring the disease. Our study highlights and attempts to lessen the gap in disease treatment that can be bridged through the use of social science research which takes into account the host community’s physical and cultural infrastructures.
To determine the interplay of personal, social, and cultural trends associated with the transmission of parasitic infections, we performed a survey of mothers with school-aged children in ten rural communities around San Juan del Sur in the Rivas district of Nicaragua. These communities were part of a community-wide fecal examination study in 2006 conducted by the local medical clinic and a medical student working with Newton-San Juan del Sur which found an 80% prevalence rate of
The mother is the central figure with regards to household cleanliness and children’s health in Nicaragua and Latin America [
Interviews were conducted with a comprehensive, 47-item questionnaire (Appendix
The structured questionnaire was designed to address demographics, access to resources, knowledge and attitude toward health and intestinal parasites, practice of risky behaviors, and local cultural beliefs regarding parasites. We inquired about access to basic resources necessary for proper hygiene to create a basic assessment of a household’s poverty level and further understand how poverty influences the propensity of infection. Several questions were designed in a yes/no format while some required numerical answers. Three questions were open-ended, requiring participants to list from personal practice or beliefs the times when one washed his or her hands, the symptoms that parasites caused, and the ways that individuals acquire parasitic infections.
The rural culture depends on natural medicine for healing as lack of transportation and money can make hospital care inaccessible. Specific cultural questions involving traditional medicine were developed after focus group discussions with
The interviewers administering the questionnaires were chosen by the NGO and teachers in the San Juan del Sur public school and were chosen as responsible, well-liked members of their community who would be most capable of properly conducting the questionnaire according to the training that was administered by one of the authors (A. Karan). We sought to conduct this portion of the research in a bottom-up approach that utilized local residents so as to avoid biases that a foreign interviewer may incur. Roughly 2 to 3 interviewers conducted the interviews in each community and were members of the community to which they were assigned. Prior to the beginning of the study, the interviewers were trained together at the local public school with regards to reducing bias in questionnaire administration, proper probing techniques, and sensitivity to the interviewees’ decision to participate or answer specific questions. Verbal informed consent which explained the purposes, benefits, and risks of the study was provided to each participant prior to beginning the questionnaire. IRB approval was obtained from the Human Subjects Committee of Yale University as well as by a review committee consisting of members of the Newton- San Juan del Sur NGO.
The results of the questionnaire were tabulated into percentages and numerical averages which display trends in this study population. Analysis of these trends suggests several unique relationships between knowledge, attitude, behaviors, poverty, and culture as they relate to parasitic infections. The results allow for interpretation of a more comprehensive approach to tackling the problem of intestinal parasitosis.
Many questions were not completed by all 213 participants because they were only asked if a previous question was in the affirmative or the negative. For instance, only if a participant had a well he or she was asked if the latrine was located uphill from the well. Furthermore, some questionnaires were missing information because interviewers were accidentally skipping questions as the questionnaire was spatially condensed on two sheets of paper. Interviewer error was noted for questions which investigated participants’ previous knowledge regarding parasitic transmission and health outcomes. Other missing data was due to participants’ inability to understand certain questions. We did not hear any reports of participants refusing to answer questions that they understood.
Spearman correlation coefficients and
Women had an average age of 29 years with 3.6 years of education. The low levels of education are reflective of the cultural norms in which women work at home rather than pursuing higher education. On average a household had two children and each child averaged 4.9 years of age.
Table
Access to resources in communities.
Resource | Characteristic | Mean value ± SD/percentage |
---|---|---|
Water filter | Installed ( |
28% |
Functioning ( |
76% | |
Dirt floor | Present in household ( |
65% |
Well | Present on property ( |
51% |
Distance from latrine (m) ( |
|
|
More elevated than latrine ( |
45% | |
Latrine | Present on property ( |
86% |
Soap | Present in household ( |
97% |
|
Days since last visit ( |
|
Anti-parasite strategy | Have received information ( |
61% |
Treated children for parasites ( |
88% | |
Health center | Distance (km) ( |
|
Days since last visit ( |
|
|
Fencing | Animals running free ( |
81% |
Table
Knowledge, attitude, and practice regarding general hygiene and parasites.
Category | Question | Percentage (%) |
---|---|---|
Perceptions of general hygiene | Well water clean ( |
87 |
Sufficient to wash without soap ( |
5 | |
Animals free of infection ( |
13 | |
Dirt in yard clean ( |
20 | |
| ||
Attitude toward water filters | Desire to have filter ( |
75 |
Faith in efficacy of filter ( |
80 | |
| ||
Attitude toward hygiene | Believe they have good hygiene ( |
92 |
| ||
Parasites ( |
85 | |
Awareness about parasites | Worms ( |
83 |
Ameba ( |
72 | |
| ||
Infection ( |
27 | |
Bacteria ( |
53 | |
Perception of parasites | Virus ( |
21 |
Animal ( |
50 | |
Have seen a parasite in yard ( |
40 | |
| ||
Malnutrition ( |
33 | |
Lack of energy ( |
30 | |
Loss of appetite ( |
68 | |
Poor growth ( |
32 | |
Difficulty in school ( |
9 | |
Headache ( |
47 | |
Dizziness ( |
48 | |
Health outcomes* | Anal itch ( |
51 |
Diarrhea ( |
78 | |
Bloated stomach ( |
58 | |
Stomach ache ( |
80 | |
Anemia ( |
19 | |
Fever ( |
73 | |
Vomiting ( |
81 | |
Death ( |
38 | |
| ||
Drink dirty water ( |
87 | |
Walk barefoot ( |
83 | |
Eating with dirty hands ( |
81 | |
Transmission/high risk behaviors* | Eat uncooked meat ( |
55 |
Defecating outdoors ( |
57 | |
Leaving animals unfenced ( |
41 | |
Washing food with dirty water ( |
70 | |
Eating after touching animals ( |
50 | |
| ||
Perceived threat | Cause of death ( |
98 |
| ||
Attitude toward parasites | Afraid of parasites ( |
91 |
| ||
Children barefoot (observed) ( |
34 | |
Children barefoot (self-reported) ( |
51 | |
Practice of bad habits | Children without diaper (self-reported) ( |
19 |
Home-grow vegetables ( |
39 | |
Well water to wash vegetables ( |
87 | |
Well water to cook food ( |
88 | |
| ||
Before preparing food ( |
96 | |
Before eating ( |
71 | |
Knowledge regarding time of hand washing* | After using bathroom ( |
94 |
After changing baby’s diaper ( |
54 | |
After cleaning yard ( |
54 | |
After touching animals ( |
59 |
*
The “
Attitudes toward maintenance of good hygiene were explored through questions regarding water filters and other areas associated with transmission. 75% of participants who did not already have a filter installed indicated a desire for one. Nonetheless, 20% thought the filter did not actually work. Furthermore, 92% of participants felt they already had good hygiene in the house, an attitude which was not reflected in practice.
The population’s knowledge with regards to parasitic infections is listed in Table
Attitudes and practice toward general hygiene and parasitic infections are listed in Table
In Table
Cultural factors associated with parasites.
Category | Question | Percentage (%) |
---|---|---|
General practices | Husband help in household ( |
46 |
| ||
Cutting a child’s nails causes sickness ( |
15 | |
Local beliefs | Cold shower after hot day causes illness ( |
86 |
Everyone always has parasites ( |
92 | |
| ||
Influence of local healers |
|
10 |
Faith in healers ( |
77 | |
| ||
Parsley ( |
62 | |
Garlic ( |
77 | |
Natural anthelminthic | Wormseed (apasotes) ( |
61 |
Lemon water ( |
44 | |
Guava leaf ( |
56 | |
Faith in natural therapies ( |
67 |
Correlations among access to resources variables.
Variable |
Variable |
|
|
|
---|---|---|---|---|
Believe well water is clean | −0.16 | 0.04 | 168 | |
Animals running free on property | −0.28 | 0.0001 | 204 | |
Had previous information regarding parasites | Children barefoot at the time of interview | −0.30 | 0.0001 | 202 |
Distance to the closest clinic | −0.33 | 0.0001 | 203 | |
Children treated for parasites | 0.19 | 0.01 | 204 | |
| ||||
Children treated for parasites | −0.18 | 0.01 | 208 | |
Distance to the closest clinic | Number of days since last visit to the clinic | 0.16 | 0.02 | 181 |
Animals running free on property | 0.19 | 0.01 | 210 | |
Presence of dirt floor | 0.16 | 0.02 | 210 | |
| ||||
Want a water filter | −0.67 | 0.0001 | 48 | |
Number of days since last |
Water filter working | −0.38 | 0.01 | 44 |
Believe filter actually works | −0.51 | 0.0001 | 78 | |
| ||||
Presence of dirt floor | Education level of mother | −0.15 | 0.04 | 201 |
Correlations among knowledge, attitude, and practice variables.
Variable |
Variable |
|
|
|
---|---|---|---|---|
Believe that yards are absent of infections | Believe it is sufficient to wash hands without soap | 0.17 | 0.02 | 203 |
Believe that animals are absent of infections | 0.38 | 0.0001 | 188 | |
| ||||
Believe that parasites are animals | Claim to have seen parasite in yard | 0.21 | 0.002 | 207 |
| ||||
Had soap in house | 0.32 | 0.0001 | 190 | |
Have good hygiene (self-reported) | Husband helps in household | 0.14 | 0.06 | 199 |
Latrine present | 0.15 | 0.04 | 200 | |
| ||||
Children barefoot at the time of the interview | Number of children in a household | 0.25 | 0.0003 | 209 |
Children sometimes not wearing diapers (self-reported) | 0.27 | 0.0005 | 171 |
Correlations among cultural variables*.
Variable |
Variable |
|
|
|
---|---|---|---|---|
People who see |
Use any traditional medicine | 0.29 | 0.0001 | 212 |
Believe in traditional medicine | Cutting a child’s nails causes sickness | 0.15 | 0.04 | 179 |
Believe a cold shower on a hot day causes illness | 0.29 | 0.0001 | 188 | |
Believe traditional medicines cure parasites | Believe in traditional medicines | 0.28 | 0.0001 | 185 |
Use any traditional medicine | 0.40 | 0.0001 | 206 | |
Husband helps in household | Children barefoot at the time of the interview | −0.15 | 0.03 | 204 |
*
The five traditional medicinal items (garlic, lemon, water, worm seed, and guava leaf) were intercorrelated with Chronbach’s
The correlations between different variables indicate interesting individual and societal trends that through interpretation present new ways at looking at treatment and control of parasites.
Access to certain resources strongly correlated with several healthier practices (Table
Knowledge, attitude, and behavioral practice factors also showed unique correlations (Table
Attitudes toward personal hygiene were related to having certain resources. For example, participants who felt they had good hygiene also had soap, latrines, and husbands who helped around the house, which may explain why they had this belief. However, those who felt they had good hygiene did not show greater levels of self-reported hand washing than those who did not feel they had good hygiene. Thus, resources do not necessarily translate into practice.
Poor behavioral practices among children were also investigated. The greater number of children in a household correlated with a greater number of barefoot children present at the time of interview. This may be because with a greater number of children it is more likely to see a barefoot child, or because it is more difficult for the mother to ensure each child is practicing healthy habits. Furthermore, households which had barefoot children also were more likely to report children sometimes not wearing diapers.
The cultural aspects of rural life with regards to transmission are highly significant and an understudied topic. People who saw
Nonetheless, some expected correlations were not found. For example, hearing previous information about parasites did not correlate with a reduced misperception about parasites. This may be an area of cultural preconceptions that withstand the influence of outside information.
In this study, we examined knowledge, attitude, practice, poverty as measured by resource availability, and cultural influences with regards to parasitic infections in order to comprehensively evaluate the multidimensional nature demanded by effective treatment approaches. Our findings indicate that the households in San Juan had limited resources, moderate levels of knowledge, poor practices, and cultural influences that contribute to re-infection cycles. To effectively design prevention strategies, our study reveals the interplay between these spheres with a focus on poverty and cultural factors.
Many households reported children often playing outside barefoot. Lack of footwear is a known risk factor and combined with the presence of unfenced animals is a strong predictor for infections such as hookworm that are transmitted through the foot [
Furthermore, the system of potable water is of great concern with regard to helminth infections [
Food production and processing has been another route through which parasitic contamination can occur [
Correlations suggested that poor health practices tended to be clustered together in the same households and particularly larger sized households. Research has shown that poorer households tend to have greater numbers of children, particularly because children can serve as a labor source and provide additional income [
Culture has been shown to be closely intertwined with behaviors and health outcomes. Thus, we also examined cultural beliefs to gain a better understanding of parasites in the local context. Previous reports have shown differing attitudes toward parasitic infection in various cultures. For example, some indigenous African villagers believed worms to be a normal part of life and even health-promoting [
Reliance on traditional healers has been shown to interfere with modern healthcare structure and increase risk of helminth infection [
Traditional gender roles in Latin American culture have been shown to play into health in spheres such as the HIV epidemic and intimate partner violence [
The belief that cutting a child’s nails causes infection is a prime example of where culture and health conflict. Dirty nails in school-age children have been shown to be associated with high-parasitic infection, and children with longer nails are able to carry more fecal infected soil, increasing the risk of infection [
Although there was a widespread awareness of the term “parasite,” many women reported having seen a parasite in their yard. This suggests that there is a general lack of knowledge regarding what a parasite actually is. Perhaps more caution will be taken if people were educated on the microscopic nature of parasites. A majority of interviewees had reported having some previous education with regards to parasites. Nonetheless, the quality and relevance of the information that is relayed are imperative to changing attitudes and behaviors. Information dissemination needs to become more widespread and this may be done if the
The most commonly reported symptoms (diarrhea, fever, vomiting, and stomachache) were all symptoms that are associated with other common health maladies and not necessarily parasites. Symptoms that were less reported, such as anemia, poor growth, and difficulty in school, are ones that were less known and less readily recalled. If educational campaigns were to focus on these symptoms, the perceived risk presented by parasites could be increased and could result in more attention to hygienic behaviors. Only roughly half of participants understood that eating uncooked meat, defecating outdoors, or careless behavior with animals were facilitators of transmission. Campaigns should highlight these behaviors to spread more awareness in areas that are less wellknown.
As demonstrated in the correlation analysis, access to resources such as previous information did correlate with several health-promoting decisions and behaviors. Since education was linked to practice, further educational campaigns will be beneficial for this community. However, in some cases, such as the continued practice of children walking barefoot even after availability of shoes, access to resources did not result in good practices and may be more intertwined with culture.
Lastly, our study revealed the fundamental importance of filter distribution oversight and enforcement of
Our study had a number of limitations. In our analysis of the various correlations, we selectively reported the correlations which were significant, omitting some correlations that were not significant that one may otherwise expect to show significance. For instance, access to information about parasites did not correlate with reduced misperceptions about parasites. However, these were far outnumbered by correlations that we expected and found to be present. Moreover, our study did not correlate the interacting spheres with household infection status. However, we did not feel that this was a significant concern, particularly because we were not interested in redetermining predictors of parasitic infections on which there is already substantial literature. Additionally, because of the use of multiple interviewers, we could not control for interviewer bias in the administration of the questionnaires. Nonetheless, we attempted to control for this as best as possible through interview training workshops prior to the start of the study. Furthermore, we felt that using interviewers who were members of the communities themselves may provide more unbiased data and allow interviewees to feel more comfortable.
Due to the complexity and multiplicity of parasitic transmission, both treatment and prevention must be coupled with educational campaigns, development and antipoverty projects, and cultural integration. Our correlational results have highlighted the ways in which several spheres that are known to predict parasitic infections interact with one another, particularly poverty and culture. While it is known that unidimensional interventions will not be wholly effective against parasites, this study further elucidates the interactions of the multiple dimensions that cause parasitic infection and provides recommendations which are likely to create effective interventions.
While BioSand water filters will clean contaminated water, they will not prevent animals from defecating in soil that will then infect a child’s nails. Nor will they convince a mother that cutting a child’s nails does not cause tetanus. Providing necessary resources such as anti-parasitic medication, water filters, and antibacterial soap is only one aspect of a complete solution. Even with resources, communities may retain improper practice due to belief structures, retained behavioral practices, and poor awareness of disease transmission. Thus, social-science-focused research studies such as ours are critical in improving the control and treatment of parasites and other NTDs. By examining several areas of interest in both the hard and soft sciences surrounding the process of infection and re-infection, a better approach to disease control can be tailored.
do you know what parasites are? do you believe that parasites are a problem?
if so, do you know how to treat parasites? do you know how parasites are spread? do you know the health problems parasites cause?
Where do you usually get water for day to day tasks, washing, drinking, and so forth? Do you use filtered water for drinking?
If not, why?
do not want to (know that I should). do not have a filter. do not know it is necessary. other. do not want to (know that I should). do not have cooking appliances. do not know it is necessary. other. How do you cook food? Do you cook all the food you eat thoroughly, such as vegetables and meat?
If not, why?
do not want to (know that I should). do not have cooking appliances. do not know it is necessary. other. Where is it most comfortable to go to the bathroom? Most clean? Does your child defecate outdoors? Why? he/she wants to (knows not to). lack of toilet. do not know there are problems with defecating outside. other. Are shoes really important? Does your child walk barefoot outside? If so, why? does not want to wear shoes (but knows he should). he/she does not have shoes. does not know he should. other. What do you think about washing hands? Does your child wash his/her hands with soap after defecating and before eating? If not, why? does not want to (but knows he should). we do not have soap. does not know he should. other. Do you think your child has any “dirty” habits? Does your child eat dirt? does not want to (but knows he should). we do not have soap. does not know he should. other.
Is hygiene important? Where does the water you drink come from? Is the water here clean to bathe in? Wash clothes? Wash food like fruits and vegetables? Drink? What are some examples of good sanitation? What are some ways to clean the water? Are there functioning toilets in the houses? Do most houses have toilets and baths? Are the fruits and vegetables home-grown for the most part? Are stomach pains common among children here? What do you think causes these stomach pains? What is the cause of health illnesses in general? Have you heard of worms or parasites?
What do you think regarding intestinal parasites? What do you think regarding worms?
Are they good or bad for health? What are parasites and do they affect health in any way? Where do you usually go for treatment of general illness? Do you have traditional therapies with natural products? How do worms/parasites live or grow? What are shoes useful for? What are your thoughts on defecating outdoors?
Name of the community.
Animals running free around yard? Yes/No What kind of animals? Is the floor of the house made of dirt? Yes/No Were any kids not wearing shoes/sandals? Yes/No Mothers who have (ages 1–10) Age of mother. Years of education of mother. Number of children (ages 1–10). Age of children (1–10). How far is the closest health center? When was the last time you or family member went? Does your husband help with cleaning in the house? Yes/No Many people claim their wells are clean; can I drink water from your well is it clean? Yes/No Do you use well water directly to
Wash food? Yes/No Cook food? Yes/No We all forget to wash our hands sometimes; when do you usually wash your hands? (circle all that they say)
Before preparing food After preparing food Before eating food After using the latrine After changing baby’s diapers After cleaning the house/yard After touching the animals Other Sometimes we do not have soap; does washing hands with water alone still clean enough? Yes/No Do you have antibacterial soap or do you use regular dish-washing soap at home? AB/DW Babies often are more comfortable without diapers; do your babies always wear diapers or not? Yes/No Some animals keep clean while others are dirty and have infection; are your animals clean? Yes/No Some families here say they clean their dirt and yards; do you think your dirt is clean? Yes/No Do you grow your own vegetables here? Yes/No Wearing shoes can often be uncomfortable; Do your children like to wear shoes/sandals or do they like to be barefoot?
With shoes Without shoes Is there a water filter installed here? Yes/No
(if no, go to next question) Is the filter working properly? Yes/No Some families like filters and others do not; do you want a filter here? Yes/No
If no, why not? Do you think the filter actually cleans the water better? Yes/No When was the last time a brigadista came by? There is a belief that cutting a child’s nails can cause tetanus or other infection; do you believe this is true? Yes/No There is a belief that a cold shower after a hot day can cause sickness like fever; do you believe this is true? Yes/No Do you see a sobadore/curandero/partera? Do you believe this type of medicine works? Yes/No Do you feel you have good hygiene in the house? Yes/No
Do you think parasites are Sickness/Bacteria/Virus/Animal/Other?
Have you or anyone you know ever seen parasites? Yes/No
Have you ever been educated about parasites? Yes/No
People say that everyone always has parasites; do you think this is true? Yes/No
We know that parasites are bad for health; do you think they can kill people directly? Yes/No
Do you use hierba buena/ajo/agua de limón/apasotes/ojo de guayava/other?
Can these cure parasites? Yes/No
Have you ever treated your children for parasites? Yes/No
There are many symptoms of sickness our children have. List all the symptoms or bad health effects you know that parasites cause (interviewer circle the ones subject lists): Malnutrition (they eat what I eat) /Lack of energy/Lack of appetite/Poor growth/Difficulty in school/Pain in head/Dizziness/Anal itch/Diarrhea/Expanded belly Pain in stomach/Anemia/Vomiting/Death/Others
There are many ways to get parasites. List how you think parasites are transmitted (interviewer circle the ones subject lists): Drinking dirty water/Walking barefoot/Eating with dirty hands/Eating meat that is poorly cooked/Pooping outside in the air/Letting animals roam around/Washing food with dirty water/Eating after touching animals/Others
The authors would like to sincerely thank the students from the various communities sampled for their help in conducting interviews, as well as the Newton-San Juan del Sur Sister City Project for general support throughout the project. The authors would also like to acknowledge and thank their funders, The John E. Linck Fellowship (Yale University), the Gary Stein Summer Fellowship (Yale University), and the Yale College Fellowship for Research in Health Studies.