Leptospirosis is a zoonotic disease caused by pathogenic Leptospira
bacteria that are excreted in the urine of infected animals, such as rodents, livestock, and domestic pets [1
]. It can be acquired by direct contact with an infected animal or by indirect contact with an environment contaminated with the urine of infected animals [3
]. The infection can manifest a wide range of symptoms, from a mild flu-like illness to more severe complications such as jaundice, meningitis, hemorrhage, and renal dysfunction [1
]. Leptospirosis is highly endemic in the Philippines, and has been reported in a variety of environmental settings and risk exposures. Urban leptospirosis outbreaks have been associated with the expansion of slum communities, poor sanitation and waste disposal, and occurrences of excessive rainfall and floods that create ecological conditions for rat-borne disease transmission [4
]. In rural areas, leptospirosis is reported as an occupational disease among agricultural and animal workers [6
]. It is also recognized among the health constraints of workers engaged in integrated animal-fish farming systems [9
]. One epidemiological report estimated that an average of 680 cases and 40 leptospirosis-related deaths occurred every year in the Philippines, with a prevalence rate of 10 per 100,000 person-years [10
]. Another seroprevalence survey, however, derived an annual incidence rate of 10,655 per 100,000 population, indicating that leptospirosis may be grossly under-reported in the country [11
Despite the increasing incidence, leptospirosis remains a neglected disease that suffers from lack of awareness especially among high risk groups [11
]. Agricultural workers engaged in crop farming, fish culture, and livestock raising and slaughtering are among the groups at high risk of acquiring leptospirosis because their work entails close contact with infected animals or urine-contaminated water and soil [13
]. Moreover, agricultural workers typically lack awareness and basic knowledge of leptospirosis, hence making them more vulnerable to infection [19
The understanding of individual knowledge of the disease and health behavior plays an important role in disease prevention, and in improving occupational health and safety. The Knowledge, Attitude and Practice (KAP) survey model offers a conceptual framework for analyzing human behavior and its effects on choices or interventions by characterizing knowledge, feelings, and actions [20
]. The model considers the importance of an individual’s knowledge and attitude in influencing behavior change [21
]. It also recognizes the impact of external factors, such as socioeconomic and environmental influences, on individual behavior [23
]. There are few KAP studies on leptospirosis among agricultural workers. Previous studies have focused mainly on describing the knowledge and awareness of leptospirosis among farmers in Sri Lanka and Thailand [19
]. A recent study in the Philippines described leptospirosis-related knowledge, attitude, and practices among residents, health workers, and officials [27
]. In all these studies, the causal relationship between knowledge or attitudes and leptospirosis prevention were excluded from the analyses. Moreover, the influence of socio-demographic characteristics on leptospirosis prevention practice was also not considered. Socio-demographic characteristics have been recognized as independent factors for leptospirosis transmission and therefore can affect individual preventive health behavior [28
]. Identifying and understanding the influence of socio-demographic characteristics, knowledge and attitudes about leptospirosis on prevention practice could facilitate the management of specific targeted factors in the overall leptospirosis prevention strategy.
This study was undertaken to examine the knowledge, attitudes and practices towards leptospirosis among the lakeshore communities of Calamba and Los Baños, Laguna, Philippines. Recognizing the occupational nature of leptospirosis, the KAP responses were further differentiated according to occupation, i.e., agricultural and non-agricultural workers. Aside from knowledge, attitude and practices, the study examined pertinent factors that influenced leptospirosis prevention practice. This information is important for tailoring public health strategies, and for establishing baseline levels for future evaluation of the progress of health interventions. It is hypothesized that leptospirosis prevention practice would be significantly associated with socio-demographic characteristics, knowledge, and attitude.
This study is the first attempt to describe the knowledge, attitude and prevention practices of leptospirosis among agricultural and non-agricultural workers living in the coastal communities of Calamba and Los Baños, Laguna, Philippines. The total mean attitude score (80.89%) of all respondents was higher than their total mean knowledge (68.50%) and practice (61.28%) scores. The results may imply that a highly positive attitude toward one’s ability to control the disease is not sufficient alone to transform behavioral practices. Positive attitude should be complemented with knowledge to enhance the ability of individuals to integrate prevention measures into practice.
The study found significant difference on the leptospirosis practice score between agricultural and non-agricultural workers. Agricultural workers scored lower than non-agricultural workers on items related to the use of protective gear and safety measures, as well as rat control measures. Previous studies cited limited funds as one reason for poor usage of personal protective equipment and poor rat control practices among farmers in the Philippines [36
]. This could be one possible explanation, considering that the mean income of agricultural workers was lower than that of non-agricultural workers. Ensuring access to relevant personal protective equipment and pest control programs could encourage the adoption of health and safety measures within the community, and more specifically, among agricultural workers. Recent government health interventions providing protective boots during heavy flooding and implementing community-based rat control measures could be further expanded to those communities or occupations with higher risk of leptospirosis to facilitate prevention and control practices [38
]. Encouraging the private sector to support these programs as part of corporate social responsibility policies would also be beneficial in managing the costs of implementation. Additionally, worker education and safety training on zoonotic disease prevention could be incorporated into the occupational health and safety program of the agricultural sector, and implemented in partnership with various farming groups or cooperatives.
The regression analysis indicated that gender, broadcast media, and knowledge and attitudes about leptospirosis were significant factors for leptospirosis prevention practices that were common to both agricultural and non-agricultural workers. Male respondents were less likely than female respondents to engage in leptospirosis prevention practices. This finding supports previous claims that leptospirosis is less prevalent in women because they engage in less risky behavior than men [42
]. Being male is commonly cited as a risk factor for leptospirosis, and an excess of leptospirosis cases in men were often observed in previous studies [43
]. Encouraging men to adopt healthy practices may help in reducing the risk of leptospirosis. The positive association between broadcast media and leptospirosis prevention practices is consistent with previous findings indicating that mass media can produce positive changes or prevent negative changes in health-related behaviors [45
]. The finding emphasizes the importance of developing tailored media-based health promotion programs. Considering that only 6.74% of the respondents were familiar with the health information, education, and communication programs available from the local government health units, the study suggests that improving the direct engagement between local health workers and the community would be beneficial in both increasing positive health behaviors, and increasing public trust in local health authorities [47
The causal associations of knowledge, attitudes, and leptospirosis prevention practices were not explored in previous KAP studies [19
]. Literature on zoonotic disease prevention practices shows varying relationships between knowledge, attitude, and prevention practices. Some studies on dengue fever reported finding a non-significant relationship between knowledge about a disease and preventive practices [50
] or attitudes about a disease and preventive practices [52
]. Other studies on rabies and dengue fever indicated significant associations between knowledge and attitudes and prevention practices [53
]. The findings from this study are consistent with the latter findings, indicating that knowledge and attitudes about a zoonotic disease are significant predictors of preventive practices. Our study findings further suggest that increasing one’s knowledge and attitude towards leptospirosis may be likely to increase one’s engagement in prevention practices. These findings reiterate the importance of education and behavioral health interventions to improve knowledge and attitude about leptospirosis. Nonetheless, it also important to determine how these health interventions should be delivered. This study suggests that public health officials may be able to take advantage of the highly positive attitude among respondents as a good indication of a welcoming disposition towards health intervention initiatives. It was also found that respondents scored low (below 50%) on questions related to the signs and symptoms of leptospirosis. Health education efforts should address this gap, considering that poor knowledge of the signs and symptoms of the disease has serious implications for an individual’s help-seeking behaviors, thereby delaying early detection and treatment of the disease [56
This study found that leptospirosis prevention practice scores increased significantly with increasing age and household income among non-agricultural workers. The risk of leptospirosis infection is commonly reported among younger and low-income groups [57
]. Considering that younger and lower-income groups were less likely to engage in leptospirosis prevention practices, a more concerted effort of changing the health behavior of these groups would be beneficial in reducing the risk and potential economic burden of leptospirosis. The findings also indicated that agricultural workers who attained high school and college levels of education were more likely to engage in leptospirosis prevention practices. One possible explanation could be that individuals with higher education are in a better position to gather, process, and interpret information on healthy behaviors [60
]. The risk of leptospirosis is often associated with a lower educational level [61
], and hence the delivery of health information should be tailored to those agricultural workers with a low level of literacy in accessible and easy-to-understand formats.
This study has some limitations worth noting. First, the study did not cover the range of reasons for engaging or not engaging in specific prevention practices. Future studies may attempt to address this limitation using open-ended qualitative questionnaires to explore in detail the reasons for respondents’ choices. Second, the study did not examine individual perceptions of leptospirosis risk. Although risk perception is an entire field of study in its own right, its influence on leptospirosis prevention practices could be examined in future research. Third, the respondents in this study were adults. While leptospirosis is more common and more severe in adults, it also known to affect children [62
]. Future research may examine the knowledge, attitudes, and practices among children.
The present study surveyed the knowledge, attitudes, and prevention practices of leptospirosis among agricultural and non-agricultural workers living in lakeshore communities in the Philippines. Apart from prevention practices, no significant differences were found for the knowledge and attitude scores between agricultural and non-agricultural workers. While both groups of respondents had highly positive attitude scores, their knowledge and practice scores were lower compared with those in the literature. A highly positive attitude score is not sufficient alone to transform behavioral practices. Community-based health education and promotion activities are needed to increase knowledge about leptospirosis, and subsequently improve prevention practices. Potential delivery strategies could include using broadcast media to disseminate well defined, behaviorally focused disease prevention messages, and improving the capacity of local government health units to conduct health promotion activities. Although leptospirosis prevention programs should generally be designed for a broad audience, a more concerted effort is needed to target younger and low-income male non-agricultural workers, as well as less-educated male agricultural workers, who are the groups with highest risk of contracting leptospirosis, and are less likely to engage in prevention practices. Health communications tailored to agricultural workers with low literacy should be designed in easily understandable formats. The occupational health and safety entities in the agricultural sector should be strengthened by incorporating measures to prevent and control leptospirosis and other zoonotic diseases, providing health and safety and pest control training programs, and encouraging collaboration between health and agriculture policymakers, local governments, the private sector, and farmers’ organizations and cooperatives.