Hrev_master Healthcare in Low-resource Settings 2023; volume 11:11760 Identifying the risk factors of schistosomiasis in Indonesia Christine Christine,1 Herlina Susanto Sunuh,1 Fellysca Veronica Margareth Politon,1 Diana Vanda Daturara Doda2 1Politeknik Kesehatan Kemenkes Palu, Palu; 2Faculty of Medicine, Universitas Sam Ratulangi, Manado, Indonesia Abstract In Poso, Central Sulawesi, schistosomiasis prevalence has shown fluctuations, particularly in the Napu Highland, home to around 17,000 people, where there is a 0.15% risk of Schistosomiasis. This study aimed to analyze the risk factors asso- ciated with schistosomiasis in the Napu Highland. Conducted from April to June 2022, this case-control study included residents of schistosomiasis-affected villages. The sample consisted of 148 individuals (37 cases and 111 controls). Cases were residents aged over 2 years who had tested positive for schistosomiasis in a 2021 fecal survey conducted by the Poso District Health Office. Controls were selected as the nearest neighbors of the cases. Data on education, knowledge, occupation, sanitation practices, water sources, activities near water bodies, use of protective equipment, and livestock raising were collected through questionnaires. Statistical analysis involved the Chi-square test with α=5%. The results indicated that education (p=0.018; OR=3.147) and knowl- edge (p=0.056; OR=2.233) were associated with schistosomiasis. Individuals with lower education levels were 3.147 times more likely to contract the disease, while those with limited knowledge were 2.233 times more at risk. In conclusion, improving schisto- somiasis prevention in the Napu Highland should involve enhanc- ing knowledge, attitudes, and practices through health promotion initiatives that engage educators and community leaders. Introduction Schistosomiasis is an acute and chronic parasitic disease caused by blood flukes (trematode worms) of the genus Schistosoma. It remains a significant public health problem in many countries. According to estimates, as of 2021, at least 251.4 million people required preventive treatments.1 Schistosomiasis is most prevalent in tropical and subtropical regions, particularly in impoverished communities lacking access to safe drinking water and adequate sanitation. The disease primarily affects poor, rural populations, especially those engaged in agricultural and fishing activities.2 Children, due to their inadequate hygiene practices and contact with infected water, are particularly vulnerable to infec- tion.3 The socio-economic impact of Schistosomiasis is substan- tial, as the disease causes more disability than mortality.4,5 Human infection occurs through contact with freshwater sources contain- ing live cercariae, which penetrate the skin. However, it is impor- tant to note that Schistosomiasis is not transmitted directly from person to person; rather, it requires freshwater bodies where inter- mediate snail (Oncomelania hupensis lindoensis) hosts reside and reproduce.6 In Indonesia, Schistosomiasis is found in the Highlands of Bada, Napu, and Lindu, spanning across 28 villages in Poso and Sigi districts, Central Sulawesi.7 Recent data from the Central Sulawesi Provincial Health Office indicates a significant increase Correspondence: Christine Christine, Politeknik Kesehatan Kemenkes Palu, Palu, Indonesia. E-mail: christinekromoprawiro@gmail.com Key words: neglected tropical disease; risk; schistosomiasis; sanita- tion; socio-demographic. Contributions: CC Conceptualization, Data Curation, Formal Analysis, Methodology, Validation, Visualization, Writing – Original Draft, Review & Editing; HSS Conceptualization, Investigation, Methodology, Validation, and Writing – Original Draft, Review & Editing; FVMP Conceptualization, Methodology, Visualization, Writing – Review & Editing; DVDD Formal Analysis, Validation, Writing – Review & Editing. Conflict of interest: the authors declare no conflict of interest. Ethics approval and consent to participate: the research has received ethical approval from The Ethical Committee of Medical Research Faculty of Dentistry University of Jember, 1524/UN25,8/KEPK/DL/2022. During the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence, and non-maleficence. Patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. Availability of data and materials: all data generated or analyzed during this study are included in this published article. Funding: this research was supported by a research grant from Poltekkes Kemenkes Palu, Ministry of Health of Indonesia with con- tract number LB.02.03/3.b/0010/I/2022. Acknowledgement: the authors would like to acknowledge the Wuasa Health Center team for their assistance with the research. The authors would also like to thank the enumerator team for their dedi- cation and effort and, most importantly, the respondents who con- sented to their time to make this research possible. Received: 11 September 2023. Accepted: 10 October 2023. Early access: 20 October 2023. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2023 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2023; 11:11760 doi:10.4081/hls.2023.11760 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affili- ated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 40] [Healthcare in Low-resource Settings 2023; 11:11760] Non -co mmerc ial us e o nly in Schistosomiasis cases in the Poso District, with a total of 245 cases reported in 2021 compared to the previous 45 cases. Additionally, the Sigi District reported 12 new cases in 2022, bringing the total number of Schistosomiasis cases in Central Sulawesi in 2022 to 257. The prevalence of Schistosomiasis in the two districts has risen to 1.5% of the total population in the 28 treated villages. By early February 2023, the prevalence of Schistosomiasis reached 1.57%, surpassing the previous rate of below 1% recorded in 2019.8,9 The Napu Highland, particularly with a population of up to 17,000, faces a Schistosomiasis risk of 0.15%, warranting attention and concern.10 Schistosomiasis disproportionately affects impoverished rural communities, including agricultural and fishing populations, due to inadequate sanitation and frequent contact with infested water.3,11 Occupational exposure to infested water, such as in the case of fishermen, farmers, irrigation workers, and women engaged in household duties near infested water, further con- tributes to the disease’s prevalence.2,6 Studies conducted by Muslimin in Lore Lindu National Park and Rosmini, Jastal, and Ningsi in the Bada Highland of Poso Regency identified various risk factors for Schistosomiasis, such as lack of personal protective equipment, defecating in open areas, and bathing in infested rivers.12,13 Furthermore, the public’s awareness of the importance of pro- viding stool samples for investigation is an area of concern, partic- ularly in the Napu Highland region. Approximately 12% of the population studied did not collect their stool samples.14 Knowledge about Schistosomiasis can significantly influence people’s atti- tudes and actions. For instance, research conducted by Sulistin and Widajadnja in Lindu Sigi revealed a link between public awareness and attitudes towards Schistosomiasis.15 The impact of Schistosomiasis on health cannot be underestimated. Chronic Schistosomiasis can lead to reduced work capacity and, in severe cases, even death. The disease may also cause anemia, malnutri- tion, and impaired learning abilities in children.16 In Sub-Saharan African nations alone, Schistosomiasis is estimated to cause over 200,000 fatalities annually.17 Therefore, this study aimed to ana- lyze the risk factors for Schistosomiasis in the Napu Highland of Indonesia. Materials and Methods This analytic observational study with a case-control design was conducted in the Napu Highland, Poso, Central Sulawesi, Indonesia, from April to June 2022. The target population com- prised residents of the Napu Highland, with reachable population including residents of villages with Schistosomiasis based on data from the 2021 Schistosomiasis Program Fecal Survey. The villages included were Alitupu, Dodolo, Kaduwaa, Kalimago, Maholo, Mekarsari, Tamadue, Watumaeta, Winowanga, and Wuasa. Data was collected using a questionnaire administered through the KoboCollect application. The inclusion criteria for sampling were permanent inhabitants who were registered and inspected in the 2021 Schistosomiasis program fecal survey and were over two years old. Exclusion cri- teria for sampling included those who refused to participate and individuals with specific health issues, such as mental problems. The sample size was estimated using Schlesselman’s sample size formula18 for case-control research, resulting in 37 cases and 111 controls, making a total sample size of 148 individuals. In this study, cases refer to individuals who have tested positive for Schistosomiasis and were experiencing the disease. On the other hand, control were individuals who do not have Schistosomiasis and have tested negative for the disease. The research-dependent variable was the prevalence of Schistosomiasis, while the independent variables were risk factors related to Schistosomiasis, including education, knowledge about Schistosomiasis, occupation, use of latrines, clean water sources, passing through snail (Oncomelania hupensis lindoensis) focus areas, use of personal protective equipment (PPE) in water-related activities, and livestock raising activities. The education variable was categorized as either high (university and high school) or low (junior high school, elementary school, and no school). Knowledge about Schistosomiasis, including knowledge about causes, inter- mediate animals, habitat, mode of transmission, symptoms, ani- mals that can be infected, prevention and treatment of schistosomi- asis, was categorized as good or poor based on a median score of 6. A score of 6 or more was considered good knowledge, while a score below 6 was considered poor knowledge. The habits related to Schistosomiasis exposure, such as passing through snail (Oncomelania hupensis lindoensis) focus areas, having activities in rivers, gutters, or rice fields, and using PPE when working near water, were categorized as either ‘yes’ or ‘no’. Occupation was cat- egorized as either ‘farmer’ or ‘others. The use of latrine and raising livestock were categorized into ‘yes’ or ‘no’. The use of water sources was divided into three categories: wells, municipal water- works, and other sources like rivers and ditches. All variables were measured by interviewing the respondent’s using questionnaire through the KoboCollect application. Chi-square test was used to analyze the data at a significance level of α=5% to determine the relationship between variables. Results The research findings on the risk factors for Schistosomiasis in the Napu Highland, Poso Regency, Central Sulawesi, are presented in Tables 1 and 2. Table 1 contains data on the characteristics of respondents related to socio-demographics. The research findings showed that the gender most found with Schistosomiasis was male (56.8%). Schistosomiasis cases were also prevalent in the age group of 20–60 years (78.4%). Table 2 shows that variables with a p-value of ≤0.05 were edu- cation and knowledge about Schistosomiasis. The odds ratio (OR) for education was 3.147, indicating that individuals with lower education levels were 3.147 times more at risk of contracting Schistosomiasis compared to those with higher education. Similarly, the OR for knowledge was 2.23, suggesting that individ- uals with poor knowledge about Schistosomiasis were 2.233 times Transforming Healthcare in Low-Resource Settings: a Multidisciplinary Approach Towards Sustainable Solutions Table 1. Socio-demographic characteristics of respondents (N=148) Variable Case (N=37) Control (N=111) N n % n % Gender Male 21 56.8 63 56.8 84 Female 16 43.2 48 43.2 64 Age group (years) 0-10 2 5.4 0 0.0 2 11-19 2 5.4 4 3.6 6 20-60 29 78.4 93 83.8 122 >60 4 10.8 14 12.6 18 [Healthcare in Low-resource Settings 2023; 11:11760] [page 41] Non -co mmerc ial us e o nly more at risk of infection than those with good knowledge. On the other hand, factors such as employment status, latrine use, access to clean water sources, passing through the snail (Oncomelania hupensis lindoensis) focus area, use of PPE during water-related activities, use of PPE when passing through the snail (Oncomelania hupensis lindoensis) focus area, engaging in activi- ties in rivers or gullies, and raising livestock were not found to be significant risk factors for Schistosomiasis. Discussion The proportion of respondents with low education in the case group was higher than in the control group. There was a significant relationship between education and Schistosomiasis. People with low education were more at risk of contracting Schistosomiasis than those with higher education. Education plays a vital role in improving health behavior, especially in cases of environmentally transmitted diseases like Schistosomiasis.19 Research on Schistosomiasis in Zimbabwe concluded that poor sanitation (unsafe water sources for household needs), related to schistosomi- asis infections, was found more in women who had never received an education than those with education.20 Increased education can lead to better understanding of health messages and promote clean and healthy practices to prevent diseases. The study found a marginal association between participants’ knowledge of Schistosomiasis and its incidence. Lower knowledge increased the risk of infection. Effective community awareness programs can improve knowledge and preventive measures. Similar findings were observed in research from South Africa and the Philippines, persons with a good understanding of Schistosomiasis had favourable attitudes and actions toward Schistosomiasis prevention.21,22 Government programs in Napu include warning signs in the snail (Oncomelania hupensis lindoen- sis) focus area as an effort to reduce the incidence. Regular aware- ness programs are vital for infection prevention. Collaborative efforts between education and health sectors are essential for suc- cessful prevention initiatives.23,24 The most common occupation among the research respondents was farming. While there was no significant relationship between occupation and Schistosomiasis. Similar findings were reported by Rosmini et al. in the Bada Highland, Poso District, and Central Sulawesi, where no relationship was found between the type of work (farmers and non-farmers) and the incidence of Schistosomiasis.13 Study in Sudan even shows that school-age chil- dren of parents who work as farmers are at higher risk of being infected with Schistosomiasis than children of parents with other jobs.25 However, farming should still be a concern in preventing Schistosomiasis infection since farmers often work in areas like rice fields and rivers, which are known to be habitats for the inter- [page 42] [Healthcare in Low-resource Settings 2023; 11:11760] Transforming Healthcare in Low-Resource Settings: a Multidisciplinary Approach Towards Sustainable Solutions Table 2. Risk factors for Schistosomiasis Variable Case (n=37) Control (n=111) p OR 95% CI n % n % Education Low 30 81.1 64 57.7 0.018* 3.147 1.274-7.778 High 7 18.9 47 42.3 Occupation Farmer 22 59.5 71 64.0 0.768 0.826 0.386-1.771 Other 15 40.5 40 36.0 Knowledge related to Schistosomiasis Poor 22 59.5 44 39.6 0.056* 2.233 1.046-4.768 Good 15 40.5 67 60.4 Latrine use No 5 13.5 13 11.7 0.775 1.778 0.390-3.560 Yes 32 86.5 98 88.3 Using clean water sources Wells/municipal waterworks/pipes 37 100 111 100 - - - Other - - - - Passing snail (Oncomelania hupensis lindoensis) focus areas Yes 27 73 70 63.1 0.369 1.178 0.390-3.560 No 10 27 41 36.9 Having activities in water (rivers, gutter, or rice fields) Yes 27 73.0 68 61.3 0.276 1.707 0.752-3.876 No 10 27.0 43 38.7 Use personal protection equipment (PPE) when having activities in water No 13 35.1 30 27.0 0.404 1.463 0.661-3.237 Yes 24 64.9 81 73.0 Use personal protection equipment (PPE) when passing through snail (Oncomelania hupensis lindoensis) focus areas No 10 27.0 20 18.0 0.345 1.685 0.704-4.031 Yes 27 73.0 91 82.0 Raising livestock Yes 8 21.6 23 20.7 1.000 1.055 0.426-2.615 No 29 78,4 88 79,3 *p<0.05. Non -co mmerc ial us e o nly mediate host snail (Oncomelania hupensis lindoensis) of Schistosomiasis.21,26,27 The proportion of individuals with Schistosomiasis who did not use latrines for defecation was higher. Open defecation can contaminate water bodies with worm eggs, leading to potential infections.28,29 To prevent transmission, using clean and proper latrines is essential. Improving sanitary facilities and promoting latrine usage in Schistosomiasis-endemic regions through counsel- ing is crucial.29,30 All respondents use wells, municipal waterworks, or pipes as clean water sources. Several studies suggest that using unprotected or unsafe water sources can contribute to Schistosomiasis incidence.29,31–33 People’s knowledge and attitudes about Schistosomiasis prevention are good; however, having safe sources of clean water is still necessary to reduce the risk of infec- tion. The relationship between the habit of passing through the focus area of snails (Oncomelania hupensis lindoensis) and the incidence of Schistosomiasis was not statistically significant. Nevertheless, it is important to avoid these areas or use personal protection PPE such as boots to protect against potential exposure to snails (Oncomelania hupensis lindoensis).12,13,32,34 The analysis did not find a significant relationship between having activities in rivers, ditches, or rice fields and the incidence of Schistosomiasis.12,35,36 Nonetheless, it’s essential to be cautious, as these water bodies are potential habitats for snails (Oncomelania hupensis lindoensis). Using PPE, such as boots, when working or engaging in activities near water bodies is recommended to pre- vent Schistosomiasis.21,37 Several studies have emphasized the importance of PPE in reducing infection risk. Raising livestock did not show a significant relationship with Schistosomiasis.9,37–39 However, ensuring clean conditions for livestock is important to minimize potential risks. According to WHO, an integrated Schistosomiasis control strategy that combines large-scale preventive chemotherapy with praziquantel, the provision of potable water, improved sanitation, hygiene, education, snail control, and environmental modification can result in the interruption (elimination) of Schistosomiasis transmission. Praziquantel is effective for the treatment of human schistosomiasis.40 However, praziquantel treatment does not pre- vent reinfection and is hence ineffective in interrupting the trans- mission cycle. Praziquantel is primarily aimed to lowering the occurrence and severity of infection as well as controlling morbid- ity over time.41 The occurrence of fluctuations in Schistosomiasis infection despite the continuation of the treatment program implies that there is reinfection due to the continued cycle of transmission in humans, animals, and intermediary snails. Overall, preventing Schistosomiasis requires awareness of the disease transmission pathways and the importance of proper sanitation, using clean water sources, and adopting protective measures when in contact with water in endemic areas. Conclusions Our study identified education and knowledge as significant risk factors for Schistosomiasis in the Napu Highland. Lower edu- cation levels were associated with a higher likelihood of infection. 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[page 44] [Healthcare in Low-resource Settings 2023; 11:11760] Transforming Healthcare in Low-Resource Settings: a Multidisciplinary Approach Towards Sustainable Solutions Non -co mmerc ial us e o nly