This is the first study in Malaysia on the knowledge, attitude and practices (KAP) of Orang Asli on soil-transmitted helminth (STH) infection. The results of the present study showed that knowledge about intestinal helminths among the participants was generally poor with low awareness about the symptoms, ways of transmission and preventive measures.
Our results showed that about 40% of the respondents had no prior knowledge of intestinal worms. This is in agreement with the findings from a recent study in western Cote d’Ivoire, where more than half of the respondents indicated being aware of the common intestinal helminth infections. However, a recent Zimbabwean study reported that only 26.2% of the grade 3 children in four selected schools expressed a prior knowledge on intestinal helminths. However, a recent study among two communities in Rio de Janeiro, Brazil reported a higher awareness among their respondents. Moreover, our findings showed that only one-tenth of the respondents mentioned some common intestinal worms by their names. These are contrary to the findings from a previous study in Nepal which demonstrated that the majority of their subjects had an excellent knowledge of intestinal helminths and this was attributed to the active health education programmes taking place in the study area. This programme is however lacking in the communities where our study was conducted.
Moreover, the findings from this study showed that about a quarter of the respondents knew about the common signs and symptoms associated with intestinal helminth infections. This is in agreement with the Nepalese study which indicated that the knowledge of symptoms was described in general and vague terms by their subjects. Conversely, similar studies from Cote d’Ivoire and Brazil demonstrated greater knowledge on the symptoms of intestinal helminths among their subjects[24, 25]. This could be attributed to the nature of intestinal helminth infections which tend to be asymptomatic and remain in salience as chronic infections.
In our study, knowledge about transmission among the respondents showed little information as only about a quarter of them know about the ways of helminths transmission. This is in agreement with a previous study in rural Bangladesh. It was surprising that in our study, none of the respondents mentioned open/indiscriminate defecation as a possible way of helminth infection transmission. Similarly, only 6% of the total respondents (about 19% of those had prior knowledge on worms) mentioned that playing with soil could be a possible way of acquiring helminth infection. In Cote d’Ivoire, soil was an unknown source of transmission for intestinal helminth infections while the majority of the respondents mentioned open defecation in water. On the other hand, a previous study in Nepal showed that more than one-third of the respondents indicated playing with soil as a possible source of infection.
Our survey on the knowledge about prevention revealed that about 16% of the respondents had knowledge of some preventive measures such as washing hands before eating, wearing shoes when outside the house, boiling untreated drinking water, and use of de-worming drugs. Similar findings were reported in Zimbabwe while higher level of knowledge on the preventive measures was reported in Egypt and western Cote d’Ivoire[18, 24].
In the present study, the majority of the respondents who had prior knowledge on the intestinal worms thought that they are harmful to peoples’ health. A similar study in Brazil demonstrated that 95% of the respondents think that worms are harmful. The fact that most of the respondents who know about worms also assumed that worms are harmful, showed that they most likely had this knowledge from health personnel in clinics/ hospitals or during community health campaigns. Interestingly, one of the respondents in our study had the opinion that worms are good for peoples’ health. On being questioned, she explained that a person with helminth infections will eat more than usual.
Regarding the practices towards helminth infections, we found that about two-thirds of the respondents practice hand washing before eating and after defecation. However, our findings regarding these practices among the children demonstrated a poor implementation on the daily practice as more than half and one third of the children living in these households do not wash their hands before eating and after defecation, respectively. The importance of hand washing in reducing the prevalence of STH infections is well documented[16, 30]. However, a previous study in Zimbabwe showed that more than two-thirds of the respondents do not wash their hands before eating and after defecation. On the other hand, a better situation was reported in Bangladesh where almost all of the participated children were said to wash their hands before eating and after defecation. However, researchers should not always rely on the respondents’ answers to this kind of questions, and observations should be made.
In our study, about three-quarters and two-thirds of the respondents and their children commonly wear shoes/slippers when outside the house. This may explain the low prevalence of hookworm infections, which are transmitted by skin penetration by the infective larvae, among the children (17.6%). In rural Bangladesh, although most of the rural children had slippers many of them tend not to wear them when outside the house. Moreover, we found that about half of the respondents and their children do not cut their fingernails regularly. This is in agreement with previous studies conducted in Bangladesh and Ethiopia[29, 31]. While playing with soil, helminth eggs (Ascaris and Trichuris) tend to reside under the fingernails, and from there they are easily reintroduced into the body and start the infections. Thus, mothers and food handlers should keep their fingernails short and clean in order to prevent the parasites transmission to children and other people.
In the present study, more than two-thirds of the respondents do not boil their untreated drinking water. Similarly, only 14% of the participants in a previous study in Ethiopia boil their water before drinking. The poor knowledge and practices towards avoiding the sources of STH infections among the participants in the present study could be attributed to general ignorance and lack of proper information through well coordinated health awareness programmes in Orang Asli communities. A promising finding about treatment-seeking behaviour was reported by the present study; almost all the participants seek treatment for abdominal pain and diarrhoea at the nearest clinic.
The findings of the present study showed that the males had more awareness of the intestinal helminths compared to the females and this could be attributed to the increased mobility of the males for work purposes, which provided them with more exposure to sources of knowledge. This low level of knowledge about intestinal helminths reported among the mothers may contribute to the high prevalence rate of STH among the studied children. In a focus group discussion in Cote d’Ivoire, none of the women who participated in a KAP survey was able to give an accurate description of signs of schistosomiasis.
Our findings showed that educated and working respondents had significantly better knowledge of the intestinal helminths, their signs and symptoms, ways of transmission and prevention, compared to the illiterate and unemployed respondents. Moreover, our findings confirmed that the educational level was the most important factor significantly associated with the KAP on STH among this population. In general, educated individuals are likely to be more exposed to information about intestinal helminths and good hygiene practices than illiterate individuals. Hence, our finding implies that improving the level of education in the community will probably increase the ability of people to better gain a wider understanding of intestinal helminth infections. A recent community-based study in Bangladesh showed that the educational level of the respondents positively associated with the knowledge and practices towards intestinal worms. Similarly, a previous study showed that the better the educational level of the mothers, the lower the parasitic infection prevalence among their children in Iran. On the other hand, a previous study found no significant association between the educational level of the respondents and their KAP on intestinal worms. Nevertheless, a previous study on the KAP on malaria, measles, intestinal helminths, scabies, schistosomiasis and diarrhoea among two Kenyan communities showed that most of the respondents, particularly educated individuals, had knowledge on the intestinal helminths but compared with the other health problems, intestinal worms did not rank highly in people’s minds as an important health problem. Compared to the asymptomatic and chronic nature of the intestinal helminth infections especially of low intensity, the acute and serious signs and symptoms caused by the other 5 diseases made people more aware of these diseases.
The present study showed that respondents from families with a household monthly income of ≥ RM500 were significantly more knowledgeable about the signs and symptoms, ways of transmission and prevention of intestinal helminths infections compared to those from poor families. Similarly, higher level of knowledge was also reported among the respondents from large size families (≥7 members) compared to those from smaller families. However, the majority of the respondents still do not take care to prevent transmission and this could be attributed to some economic limitations such as inability to buy shoes and soaps and a lack of proper sanitation facilities. Previous studies showed that children from lower-income families and with unemployed and less educated parents were at higher risk of STH than their counterparts[21, 34].
With regard to STH situation among children living in these households, our findings suggest that by practising good hygiene measures (such as hand washing and wearing shoes when outside the house) heads of families are more likely to protect their children and other family members from acquiring STH infections. Hand washing, especially by mothers and food handlers will help in preventing food contamination and will eventually prevent STH transmission. On the other hand, those who walk barefooted may acquire the infections and indirectly become a source of infection to other family members. Since the significant association of wearing shoes was reported with trichuriasis and ascariasis, the mechanism here could be mechanical transmission by bringing the STH infective stages (ova) on the dirty feet into the house. In Egypt, a significant reduction in risk of STH infections has been reported among children of mothers who practise hand washing after defecation.
The present survey provides a community-based picture of the KAP on STH among Orang Asli people in Lipis, Pahang. Poverty and underdevelopment are the predominant features of Orang Asli communities, and education levels still lag far behind those achieved by other communities. Moreover, several studies have indicated a continued high prevalence of STH among these people. Hence, we believed that our results are generalisable to the entire Orang Asli population in Malaysia. However, further studies among other rural Malaysian populations are required.