RAW ATTITUDES: Socio-Cultures, Altered Landscapes, and Changing Perceptions of an Underestimated Disease.

Raw attitudes relate to the food cultures, eating habits, and behaviours of people in relation to the consumption of raw, partially cooked, and fermented freshwater fish dishes, which puts people at risk of Ophistochis viverrini and other parasitic infections. The chapter reviews raw attitudes within the countries and across the borders of the greater Mekong region, particularly northeast Thailand, Lao PDR, Vietnam, and Cambodia. Rather than treat each nation-state as an isolated epidemiological box, the chapter explores transborder complexity in relation to multiple anthropogenic transformations to the landscapes of the region and developmental impacts upon ecosystems and life cycles. Economic projects such as multiple hydropower dams, irrigation schemes, water-diversions, roads, and aquaculture ponds have significant impacts on FTZ life-cycle dynamics. In addition, many ecological changes are transboundary ones, and there are added complications relating human mobility, altered agrarian landscapes, and significant numbers of migrant workers. The chapter also examines public health programmes and educational interventions which are altering perceptions of O. viverrini and cholangiocarcinoma over time. A key argument is the need for transdisciplinary scientific and social science strategies alongside multi-pronged health interventions, such as 'the CASCAP model'. There exist many unknowns and gaps relating to widespread anthropogenic modifications upon life cycles, upon lifestyles, livelihoods, and human behaviours, which require research projects that span socio-economic, ecological, geographical, and public health dynamics of disease.

Masculinity and misinformation: Social dynamics of liver fluke infection risk in Thailand.

Liver fluke infection through the consumption of raw or undercooked freshwater fish is a major public health problem in the Mekong Region. Despite the extensive efforts of liver fluke health campaigns, Northeast Thailand still reports high human infection prevalence as consumption of raw fish dishes has diminished but not ceased. This study examines the roles of social-cultural factors, particularly the influences of masculinity and misinformation, on liver fluke infection risk. Participant observation, questionnaire surveys and semi-structured interviews were conducted in four villages in Kalasin Province, Thailand, to scrutinize reasons for raw fish consumption, gender differences in raw fish culture, processes of liver fluke information dissemination, and the extent of information mismatch. Our results show that one of the key reasons (76.9%) underlying continued raw fish consumption are deeply embedded cultural practices associated with ways of rural life. About 30% of the participants indicated that they would not avoid eating raw fish, regardless of knowing the health consequences. Gender difference is evident, with 75.6% of males consuming raw fish salad (koi pla), compared to 42.7% of females. Some male participants associate raw meat consumption with virility and strength. Such beliefs underscore the cultural linkage of koi pla consumption with masculinity. Misconceptions of liver fluke life cycle and risk of infection remain, as only 15.3% of the participants correctly selected raw fish as the food source for liver fluke infection while 84.2% misunderstood that other raw foods could lead to infection. The multi-layered and hierarchical structure of public health information dissemination from medical professionals to health officers and village health volunteers to villagers has contributed to information mismatch between different layers. Our study builds on others which call for multi-pronged scientific and social strategies, as well as culturally attuned approaches to public health messaging. The study raises masculinity and misinformation as relevant considerations in disease prevention. Incorporating grounded research and gendered perspectives are part of appreciating the cultural roots of raw fish consumption. Realizing the significant role of village health volunteers in information dissemination and in supplying coherent public health messages is vital for effective health campaigns.

Analysis of a school-based health education model to prevent opisthorchiasis and cholangiocarcinoma in primary school children in northeast Thailand.

Infection with the liver fluke Opisthorchis viverrini is the major causative factor inducing cholangiocarcinoma in the Mekong region of Southeast Asia. Northeast Thailand has the highest incidence of this cancer worldwide leading to about 20,000 deaths every year. Infection with the liver fluke comes from eating raw or undercooked fish, a tradition in this area that can potentially be countered by education programs at school level. Here we develop a school-based health education model, based on protection motivation theory (PMT), including module design, learning materials, student activities, and capacity building amongst teachers. This education program was applied and tested in primary school to pupils (9-13 years) in Khon Kaen province, northeast Thailand. Using a randomized control trial, four schools served as intervention groups (n = 118 pupils) and another four acted as controls (n = 113 pupils). Based on PMT constructs, we found that the pupils in the intervention group had significantly greater knowledge and perceived the severity, vulnerability, response efficacy, and self-efficacy parameters concerning the dangers of eating raw fish and of developing cholangiocarcinoma than those in the control schools (p < 0.05). All of the PMT constructs measured were significantly intercorrelated with each other (p < 0.001). At the same time, some background knowledge, from community-based education programs, was present in the control schools. The result from this initial study suggests that PMT can be used to predict protective attitude as well as behavior changes in evaluating the consequence of school health intervention programs.

The Socioeconomic Burden of Cholangiocarcinoma Associated With Opisthorchis viverrini Sensu Lato Infection in Northeast Thailand: A Preliminary Analysis.

The northeast of Thailand, which is the poorest region of the country, has the highest incidence of cholangiocarcinoma (CCA) worldwide. This is associated with infection with the liver fluke Opisthorchis viverrini. Although an estimated 20,000 people die every year of this disease, the socioeconomic impact of this mortality on the victims' family and the community in which he or she lived remains unknown. Here, we provide background information on the socioeconomic groups most effected by CCA and provide a qualitative estimate of the likely financial burden on the family and community. Most victims of CCA are small-scale farmers. Mortality occurs most commonly in males between the ages of 40 and 65, having either children or grandchildren to support. Costs can be divided between premortality with the family paying for transport and accommodation to the hospital, as well as costs not covered by the Thai Universal Health Coverage scheme. The main costs, however, are likely to be postmortem with loss of income and potentially the loss of a major contributor to farm work. What is urgently required is a quantitative estimate of the costs of CCA and long-term studies of the families and communities affected to determine where and how the burden of CCA falls.

Raw attitudes, wetland cultures, life-cycles: socio-cultural dynamics relating to Opisthorchis viverrini in the Mekong Basin.

Opisthorchis viverrini is one of the most common and medically important food-borne parasites in the Lower Mekong area of Southeast Asia. As we learn more about its ecology, pathology and epidemiology we see the need to consider more deeply the socio-cultural dynamics with which food-borne species complexes are associated. This paper argues that the Mekong region is characterized by strong livelihoods and life-style associations within wetland ecosystems, which are inseparable from human eating habits ("raw attitudes"). Within the fish-rice economies of the region there are many long-cherished food cultures based on eating raw, semi-cooked and fermented fish dishes, which are known to lead to opisthorchiasis, and potentially cholangiocarcinoma. This paper examines evidence from northeast Thailand showing that dedicated health outreach campaigns do help to reduce prevalence of opisthorchiasis over time. For disease prevention and health education approaches to be most effective, they must be sensitive to culture, livelihood economics, gender, and age. Further integrative, inter-disciplinary and international research must incorporate the complex dynamics of parasite ecology, human behavior, socio-economics, and public health awareness.

The ecology of the Bithynia first intermediate hosts of Opisthorchis viverrini.

Opisthorchiasis, together with its associated cholangiocarcinoma, is one of the most important human parasitic diseases on continental Southeast Asia. A great deal of epidemiological data from humans is available on this disease, particularly from the northeast of Thailand, however, only limited information is available on those aspects of the life cycle relating to its Bithynia (Gastropoda) and cyprinid fish intermediate hosts. Here we review the information which is available on the Bithynia hosts of Opisthorchis viverrini. Only one major ecological study has been carried out at one site on a single species of Bithynia. We show not only that detailed ecological studies are required to clarify the epidemiology of opisthorchiasis, but also that the taxonomic status of the Bithynia species transmitting O. viverrini requires clarification.