Diverse Information Sources and The Community’s High Level of Knowledge About Lymphatic Filariasis in Air Salobar and Waihaong, Ambon City, Indonesia

Background: Mass Drug Administration (MDA) is a strategy to eliminate lymphatic filariasis (LF) in endemic areas. However, individuals' decision to take LF drugs in MDA is associated with their knowledge and awareness about LF. This study examined the association between the community’s level of knowledge and awareness about LF with the number of informant types and media types for LF information in Waihaong and Air Salobar Health Centers, Ambon City, Indonesia. Methodology: We used data from a household survey conducted in January 2019 involving 944 respondents aged 18-70 living in the study sites. Data analysis was performed using multivariable logistic regression. Results: We found that only 33.3% of respondents had a high level of knowledge and awareness about LF. An increased odds of having a high level of knowledge and awareness about LF was associated with respondents receiving information from more than one type of informant and one type of media (aOR=10.55, 95%CI: 2.35-47.37, p=0.002), and among female respondents (aOR=1.92, 95%CI: 1.25-2.94). Conclusions: These findings emphasize the importance of comprehensive health promotion strategies using different types of informants and media to enhance the community's knowledge and awareness about LF, which is important to support the elimination of LF in Ambon City, Indonesia.


ORIGINAL RESEARCH ARTICLE
Diverse Information Sources and The Community's High Level of Knowledge About Lymphatic Filariasis in Air Salobar and Waihaong, Ambon City, Indonesia INTRODUCTION Lymphatic filariasis, or elephantiasis, is a persistent infectious disease caused by filarial worms invading the lymph nodes and ducts.The parasite is transmitted to humans via mosquitoes.There are three types of filarial worms: Wuchereria bancrofti, Brugia malayi, and Brugia timori.In Southeast Asia, nine countries, including Indonesia, are endemic to LF. 1,2 According to the World Health Organization, in 2021, an estimated 51.4 million people was infected with LF. 2,3 The WHO declared The Global Goal of eliminating LF as a Public Health Problem by 2020. 4,5This goal was pursued through the implementation of Mass Drugs Administration (MDA) involving the administration of three DEC tablets and one Albendazole tablet once a year for five consecutive years. 68][9] In Maluku Province, the largest archipelago province of Indonesia, 39 cases of lymphatic filariasis reported.Four of these cases were chronic and located in Ambon City, the province's capital. 10,11he MDA program in Ambon City was started in 2009.
During the initial five years of its implementation (2009-2013), Ambon City was declared unsuccessful as the MDA program reached less than 65% of the total population (only 51.3%). 9However, the MDA for the LF in Ambon City was relaunched in 2015 with the goal of expanding coverage and improving population compliance with taking LF drugs. 12,13To achieve the successful elimination of LF, it is crucial to address the issue of community non-compliance, which has been reported in various studies. 14,15Studies have also highlighted the correlation between low compliance and the community's lack of knowledge and awareness about LF. 13,14 In 2018-2019, Universitas Pattimura Faculty of Medicine, together with The Task Force of Global Health, Atlanta, USA, and in collaboration with Bruyère Research Institute (Ottawa, Canada) and Centers for Disease Control and Prevention (Atlanta, USA), conducted a study on community compliance with taking LF drugs in the working areas of Waihaong and Air Salobar Health Center, Ambon City.The study confirmed that community knowledge and awareness plays a critical role in their compliance with taking LF drugs during MDA. 13,16Based on the data collected from the survey, this study examined the association between the community's level of knowledge and awareness about LF with the number of informant types and media types for LF information in Waihaong and Air Salobar Health Centers, Ambon City, Indonesia.

METHODOLOGY
In this study, we used data from a cross-sectional survey administered by the Faculty of Medicine at Pattimura University in partnership with the Bruyère Research Institute in Ottawa, Canada, and the Centers for Disease Control and Prevention, Atlanta, USA.The survey, funded by The Task Force of Global Health in Atlanta, USA, was conducted in January 2019 in the community living in the cathcment areas of Waihaong and Air Salobar Health Center in Ambon City.
The respondents were selected using a two-stage cluster method.In each Health Center working area, 20 hamlets (rukun warga) were selected using the probability proportional to size (PPS) method, with the primary sampling unit using the hamlets list derived from the field coordinator in collaboration with local staff.The random sampling method was used to select sub-hamlets (rukun tetangga).Simple random sampling was also used to select 25 respondents per sub-hamlets.The total number of respondents included in the survey was 1010, with the criteria of individuals aged 18-70 who resided in the working areas of Waihaong and Air Salobar Health Center during the MDA implementation in 2018.This analysis, however, only used data from survey respondents who claimed to have heard about LF.Therefore, this analysis only used information from 964 survey respondents.
The survey used a structured questionnaire developed based on the Risk, Attitudes, Norms, Abilities, and Self-regulation (RANAS) framework. 12The instrument included information on respondents' risks, attitudes, norms, abilities, and self-regulation related to LF, receipt of LF drugs during MDA, and respondents' knowledge of LF.Data were collected using the Commcare application on an Android-based device. 17e dependent variable in this study was the community's level of knowledge and awareness about LF in the working area of Waihaong and Air Salobar Health Center (high/low).To evaluate the community's level of knowledge and awareness regarding LF, an inquiry was conducted to assess their comprehension of the disease and potential preventive measures.The assessment encompassed several key aspects: (1) the probability of contracting LF, (2) potential consequences associated with LF infection, (3) strategies for LF prevention, (4) the hereditary nature of LF, (5) the required commitment to LF medication during MDA, and (6) respondents' perspectives on the appropriate method for administering LF drugs.Respondents were classified as having a high level of knowledge if their correct answer rate surpassed 75%.Those falling below this threshold were categorized as having a low level of knowledge.
The independent variable examined was the source of LF-related information, which comprised two distinct factors: (1) the number of informant types (single informant and multiple informants), and (2) the number of media types (no media source, one media source, and multiple media sources).Additionally, the analysis included several socio-demographic var-iables, including the health center's working area (Air Salobar and Waihaong), respondents' age (17-25 years, 26-35 years, 36-45 years, 46-55 years, 56-65 years, and over 65 years), gender (male and female), education level (no school, junior high school, senior high school, diploma/university), and employment status (not employed and employed).
The study used univariable and multivariable logistic regression methods to analyze the data.Univariate logistic regression was used to examine the relationship of each independent and dependent variable without controlling for other variables.Multivariate logistic regression was used to examine the relationship of each independent and dependent variable while controlling for other variables.In the multivariable logistic regression analysis, we included variables showing a significance level of less than 0.25 in the univariate logistic regression analysis.We included the health center variable selected a priori to be retained in the model, to control for the role of environmental factors, regardless of its significance.
The multivariable analysis consisted of three different models.Model 1 was used to examine the association between the number of informants for LFrelated information and the level of knowledge and awareness about LF, after controlling for other covariates.Model 2 was used to examine the association between the number of media types for LFrelated information (replacing the number of informants) and the level of knowledge and awareness about LF, after controlling for other covariates.Model 3 was used to examine the association between the combined number of informants and media types with the level of knowledge and awareness about LF, after controlling for other covariates.The findings were presented using odds ratios (ORs) and 95% confidence intervals (95% CI).IBM SPSS Statistics version 15.0 was used to perform all analyses with complex sample procedures.
The study received ethical approval from the Medical and Health Research Ethics Committee of the Faculty of Medicine at Universitas Pattimura (Number 010/FK-KOM.ETIK/VIII/2022).All survey respondents who agreed to be interviewed were required to sign an informed consent form after receiving an explanation from the researcher indicating their willingness to participate.

RESULTS
The analysis was conducted using data from a total of 964 respondents, with 481 from Air Salobar Health Center and the remaining 483 from Waihaong Health Center catchment area.Out of all the respondents who participated in the survey, 88.69% had a high level of knowledge and awareness of LF, while 11.31% had a low knowledge and awareness.
Table 1 displays the frequency distribution of respondents based on various variables included in the analysis.It was found that most of the respondents were female and had completed senior high school.Moreover, the table shows the distribution frequency of respondents based on their knowledge and awareness of LF.The percentage of respondents with a high level of knowledge was found to be slightly higher in the community living in Air Salobar (90.6%) than in Waihaong catchment areas (86.7%).The percentage was also higher in female respondents (91.3%) than male respondents (84.3%).
Interestingly, respondents' level of knowledge and self-awareness about LF remained consistent across all levels of formal education.However, those who mentioned obtaining information about LF from multiple sources, including various informants and media types, had more knowledge and self-awareness.Specifically, 95.74% of respondents who received LF information from more than one informant type and 93.03% who received LF information from more than one media type had a high level of knowledge and self-awareness about LF.
Figure 1 shows that health workers were the primary source of information on LF, with around 80% of respondents receiving information from them.For male respondents, friends were the second most common source of information after health workers, while female respondents were more likely to obtain information from cadres after health workers.Figure 2 illustrates the distribution of sources of information on LF based on respondents' sex and type of media.More than 67% of the respondents received information about LF from TV, regardless of their sex.The distribution of sources of information about LF was similar among males and females.
Table 2 shows the results of the univariable logistic regression performed in our study.We found that respondents' knowledge and awareness about LF was associated with the number of informant types, media types, and respondents' sex and employment status, before controlling for other variables.
Model 1 (Table 2) shows the results of analyses conducted to examine the association between the number of informant types for LF information and respondents' level of knowledge and awareness about LF.After controlling for other covariates, the odds of having a high level of knowledge and awareness were significantly higher in respondents who received LF information from more than one type of informant (aOR=3.46;95%CI: 1.81-6.63,p<0.001).From the socio-demographic characteristics group, the odds were significantly higher among females than males (aOR=1.89;95%CI: 1.24-2.89,p=0.003).
When the variable representing the number of informants types was replaced by the number of media types for LF information (Model 2 in Table 2) in the multivariable regression model, we found that the odds of a high level of knowledge and awareness of LF were significantly higher among respondents who received information from more than one type of media (aOR=2.16;95%CI: 1.08-4.33,p=0.029).Note: level of knowledge and awareness of the community was measured by assessing the answers given to questions about: (1) how likely it is to get LF, (2) the possible effects of getting LF, (3) how to prevent LF, (4) whether LF is a hereditary disease, (5) how much is the obligation to take LF drugs during MDA, and (6) respondents' beliefs about the correct way to take LF drugs.Respondents were categorized as possessing a high level of knowledge if their percentage of correct answers exceeded 75% and as having a low level of knowledge otherwise.LF: Lymphatic Filariasis; MDA: Mass Drugs Administration   The odds remained significantly higher in female than male respondents (aOR=1.90;95%CI: 1.25-2.90,p=0.003).
Model 3 (Table 2) showed the results of multivariable regression methods when a combined variable of the number of informant types and media types for LF-related information was used.The results showed that the odds of having a high level of knowledge and awareness about LF were significantly higher among respondents who received information from more than one type of informant and more than one type of media (aOR=10.55;95% CI: 2.35-47.37,p=0.002).
The odds of having a high level of knowledge and awareness were still significantly in females than males (aOR=1.92;95% CI: 1.25-2.94,p=0.003).

DISCUSSION
This analysis shows a significant relationship between the number of informants type and media types with the level of knowledge and awareness about LF of the community living in the catchment areas of Waihaong and Air Salobar Health Center in Ambon City.Respondents who received information about LF from multiple informants and media had a higher level of knowledge and awareness about LF.This study also showed that female participants better understood LF than males.Program holders could use these findings to design practical health promotion efforts using different types of media and informant to improve community knowledge and the effectiveness of the LF elimination program in Ambon City.

Use of multiple types of informants and media to improve community knowledge and awareness
This study confirms that multiple types of informants and media are positively associated with the improved level of knowledge and awareness about LF of the community.This result aligns with previous studies reporting a significant relationship between the diversity of information sources and the level of health-related knowledge. 18,19The more sources of information used, the higher the level of knowledge and awarenesss. 12These findings emphasize the need for program managers to use multiple sources of information about LF to improve their knowledge which could positively lead to the community's improved compliance with taking LF drugs.Various information sources such as health workers, cadres, printed media, or audiovisual media are effective methods for health promotion.Those sources allow people to receive information through multiple sensory systems, which enhances their knowledge.The more senses used in receiving information, the better the knowledge gained.Furthermore, the easy accessibility of media such as TV, radio, and internet/social media may be the reason for the high frequency of information on LF in the community. 20is analysis found the highest proportion of the community received information from health workers, followed by cadres and friends/neighbours/ family.As reported in other studies 21 health workers and cadres are the backbone of various health programs.As expected, health workers play a crucial role in community health development, including LF control efforts.Health workers should be encouraged to use every contact opportunity to disseminate health information to the community.Apart from health workers, health cadres always play a vital role in various health programs in Indonesia.With a limited number of health workers, the role of health cadres is becoming increasingly vital.Previous literature 22 showed that the low level of activity among health cadres in providing community counselling has contributed to the suboptimal achievement of health programs.This highlights the need to enhance the capacity of health cadres through various activities such as training and coaching, in order to improve their knowledge and skills, including communication skills and the ability to deliver important health information to the community. 22,23he Ambon City Health Office has made commendable efforts to disseminate health promotion materials concerning LF and MDA through various means, including banners, flyers, and social media channels.Interactive dialogues on local radio and television were employed as a strategic approach before the implementation of MDA.While these initiatives have been valuable in raising awareness, establishing intersectoral collaborations could enhance the potential for impact and reach.By collaborating with various sectors and stakeholders, such as educational institutions, community organizations, and local businesses, disseminating crucial information about LF and MDA could expand to a wider and more diverse audience, fostering a more comprehensive and effective public health response.

Difference of knowledge and awareness about LF between males and females
We found that women had a higher level knowledge and awareness compared to men.This was also noted in a previous study which found that men have lower adherence to LF drugs than women. 23,24Men's higher activity outside the home may mean that they need more information on specific health topics, which could be provided by health cadres in their neighbourhood.Compared to males, females have shown higher knowledge and awareness about health-related matters.This could be attributed to the fact that most of their activities and time are traditionally spent at home, for example, as housewives.As a result, they might have more opportunities to receive information and guidance from health workers or cadres who visit their homes. 25,26others are also responsible for maintaining their family members' health by providing them healthrelated information and education. 27,28This can play a significant role in promoting good health.
To increase awareness and knowledge among male groups, social or religious meetings could be held where health information is shared with many men.
According to the study results, friends are the second most common source of information after health workers for male respondents. 29In addition, this analysis found that cadres were more of a source of information for female respondents than male respondents.This suggests that the timing of cadre visits to provide health information or drug distribution needs to be considered, allowing cadres to meet male household members working outside the home in the morning to afternoon.

STRENGTHS AND LIMITATIONS
This study used information from a large number of respondents, providing a representation of working conditions in the Waihaong and Air Salobar Health Centers.To our knowledge, only few analyses were conducted to assess the diversity of information sources on LF particularly Ambon City.These find-ings are expected to provide input for program holders to design appropriate interventions in both study areas.However, there are some limitations to note.As with other cross-sectional studies, the results of this analysis can only describe the association between independent and dependent variables and not showing any causal relationships.Our analyses were limited to the variables available in the datasets.Variables such as the information about the content of LF messages received were not available and thereby was not included in our analysis.

CONCLUSION
In summary, this study confirms that the use of multiple types of informants and media is positively associated with an improved level of knowledge and awareness about LF of the community.Health promotion efforts, including those related to LF, need to consider the diversity of information sources to reach various community components.Health efforts need to involve health workers, cadres, religious and community leaders, and friends, supported by the use of various mass media so that community knowledge and awareness can increase.Increased knowledge and awareness of the community are expected to help achieve the LF elimination target in Ambon City.
This study has found that using a variety of sources and methods to spread information about LF is linked to increased knowledge and awareness about the disease within the community.It emphasizes the importance of program managers using different sources to disseminate information about LF and MDA.The study highlights the need for collaborative efforts between health authorities, media outlets, and community leaders to enhance public understanding and engagement in LF prevention and control measures.Strategic investments in multi-faceted information campaigns are essential to achieve sustained progress in LF elimination, which will improve the health status of the community not only in Ambon City, but also in other parts of Indonesia. This

Figure 1 :
Figure1: Sources of information on lymphatic filariasis by sex of respondents and type of informant

Figure 2 :
Figure2: Sources of information on lymphatic filariasis by sex of respondents and type of media

Table 1 :
Distribution of factors analysed by the level of knowledge about lymphatic filariasis

Table 2 :
Factors associated with the level of knowledge and self-awareness about lymphatic filariasis in the working area of Waihaong and Air Salobar Health Center, Ambon City In the multivariable models, only variables with a significance level of p<0.25 were included.aOR: adjusted odds ratio; CI: confidence interval; OR: odds ratio survey conducted by the Faculty of Medicine Pattimura University received financial support from the Coalition for Operational Research on Neglected Tropical Diseases (https://www.cor-ntd.org/),grant number: NTDSC 140D, funded through The Task Force for Global Health primarily by the Bill & Melinda Gates Foundation, by the United States International Agency Development through the Neglected Tropics Disease Programme, and with UK assistance from the United Kingdom.The funder had no role in the study design, data collection, analysis, publication decision, or manuscript preparation.