1.

INTRODUCTION

Lymphatic Filariasis, commonly known as elephantiasis, is a neglected

parasitic disease in tropical environment. The disease spreads from person to
person by mosquito bites. When a mosquito bites a person who has lymphatic
filariasis, microscopic worms circulating in the person's blood enter and infect the
mosquito. The two species of thread-like nematode worms most often associated
with this disease are Wuchereriabancrofti and Brugiamalayi. Wuchereriabancrofti
is responsible for 90% of the cases while Brugiamalayi causes most of the
remainder of the cases (National Organization for Rare Disorders (NORD),
2009).
The infected mosquito deposits microscopic larvae while biting a person.
The larvae migrate to the human lymphatic system, where they mature into adult
worms. In the lymphatic system, these worms cause blockages to the return of
fluids to the circulatory system. This lymphatic blockage results in fluid collection
in the tissues (most commonly the legs and genitalia), grotesque swellings, and
periodic fevers resulting from frequent bacterial infections of the collected fluid. A
longstanding infection with lymphatic filariasis results in a condition called
elephantiasis, in which changes in the affected limbs result in hardening that
resembles elephant skin (The Carter Center, 2016).
The prevalence of infection in children has become better understood in
recent years. Whereas the disease was once thought to affect only adults, it now
appears that most infections are acquired in childhood. Initial infection is followed

by a long period of subclinical disease, which progresses in later life to clinically

manifest disease. The painful and profoundly disfiguring visible manifestations of
the disease, lymphoedema, elephantiasis and scrotal swelling occur later in life
and lead to permanent disability. These patients are not only physically disabled,
but suffer mental, social and financial losses contributing to stigma and poverty
(World Health Organization, 2016).
The development of an Immunochromatographic Card Test (ICT) with high
sensitivity and specificity for detecting W. bancrofti infection has simplified
diagnosis, and test kits are commercially available. The test requires 100 l of
finger-prick blood drawn at any time, day or night. The ICT card test has been
shown to be a useful and sensitive tool for the detection of Wuchereriabancrofti
antigen and is being used widely by lymphatic filariasis elimination programs
(WHO, 2016).
As in any form of medical activity applied to children who appeared to be
physically healthy, parents have the tendency to question the administration of
such medication. The administration of ICT is not an exemption. Although the
introduction of ICT was considered another significant development in the
continuous campaigns for the eradication of filariasis, many parents were
observed as very apprehensive about the ICT. This visible uneasiness, if not
fearful behavior of parents regarding the administration of ICT for filariasis
detection to their children strongly encouraged the researchers to conduct a
study about parental compliance to ICT.

Objectives of the Study

This study was aimed to find out the parental compliance to ICT on
filariasis detection during the Transmission Assessment Survey (TAS) to the
Department of Health identified public elementary schools in Initao during the
school year 2016-2017.
Specifically, this study was aimed to:
1. Describe the demographic profiles of the respondents in terms
of:
1.1 age;
1.2 gender;
1.3 civil status, and;
1.4 highest educational attainment.
2. Discover the determinants of compliance to ICT from the
knowledge and practices of parents.
Definition of Terms
For better comprehension about the contents of the study, t he following

terms are conceptually or operationally defined:

Compliance.

The extent to which a persons behavior coincides with

medical advice (Fielding & Duff, 1999).

Elephantiasis. The most advanced or severe stage of lymphedema
characterized by a chronic, often extreme, enlargement and hardening of
cutaneous and subcutaneous tissue, especially of the legs, breasts, and external
male genitals.

Filariasis. An infectious tropical disease caused by any one of several

thread-like parasitic round worms.
Health protection or illness prevention. A behavior motivated desire to
actively avoid illness, detect it early, or maintain functioning within the constraints
of illness.
Immunochromatographic

Test

(ICT).

The

process

of

detecting

Wuchereria bancrofti antigen.

Parental compliance. This refers to the fulfillment of the parents of
children to agree with medical advice.
Significance of the Study
This study will benefit the following:
Department of Health RO X. This study will provide relevant additional
information for

the assessment of filariasis burden as a pre-requisite for

planning, implementation and evaluation of control strategies to eliminate

Lymphatic Filariasis as a public health problem in Philippines by year 2017.
Local Government Units. The results of the study will broaden their
knowledge about the importance of ICT in the implementation of community
health programs.
Nurse Researchers. Since the findings of the study will generate data on
parents compliance regarding ICT, such information will function as baseline
information for another research.
Community. This study will help increase community awareness
knowledge and compliance about filariasis prevention.

Future Researchers. This study will serve as reference for the future
researches, focusing on parental compliance on ICT for filariasis detection.
Scope and Delimitations
The study was performed at the DOH identified public elementary schools
in Initao, Misamis Oriental during the school year 2016-2017. These public
elementary schools were all located in the barangay areas of the municipality.
The Department of Health Central Office randomly selected only three out of 17
public elementary schools in Initao.
Considering the limited availability of time and place, the researchers
seized the opportunity to distribute the questionnaires during the Transmission
Assessment Survey (TAS) at the elementary schools as sites for data collection,
thus limiting the generalizability of the results. Parents who have been called at
the health department for the ICT of their children are likely more observe
compliance with their childrens ICT rather than at the school. The findings of this
study may not reflect the issues influencing compliance of all Initao parents
regarding ICT; rather they reflect only the issues influencing compliance of those
who actually included in the study. Therefore, the findings need to be interpreted
within the context of study limitations. A larger sample group may have yielded
results that were more accurately reflective of the population as a whole.
Review of Related Literature
Filarial infection spreads from person to person by mosquito bites. The
adult worm lives in the human lymph vessels, mates, and produces millions of

microscopic worms, also known as microfilariae. Microfilariae circulate in the

person's blood and infect the mosquito when it bites a person who is infected.
Microfilariae grow and develop in the mosquito. When the mosquito bites
another person, the larval worms pass from the mosquito into the human skin,
and travel to the lymph vessels. They grow into adult worms, a process that
takes 6 months or more. The adult worms mate and release millions of
microfilariae into the blood. People with microfilariae in their blood can serve
as a source of infection to others. (WHO, 2016).
Many mosquito bites over several months to years are needed to get
lymphatic filariasis. People living for a long time in tropical or sub-tropical areas
where the disease is common are at the greatest risk for infection. Short-term
tourists have a very low risk. Programs to eliminate lymphatic filariasis are under
way in more than 50 countries. These programs are reducing transmission of the
filarial parasites and decreasing the risk of infection for people living in or visiting
these communities (Global Health - Division of Parasitic Diseases, 2013).
Following the advances in diagnosis and treatment of the disease, WHO
classified lymphatic filariasis, along with five other infectious diseases, as
eradicable or potentially eradicable. The same year, the World Health Assembly
adopted Resolution WHA 50.29, which called on Member States to initiate steps
to eliminate lymphatic filariasis as a public health problem. In response to this
call, WHO launched the Global Programme to Eliminate Lymphatic Filariasis
(GPELF). The elimination strategy has two components: (1) to stop the spread

of infection (interrupting transmission); and (2) to alleviate the suffering of

affected populations (controlling morbidity).
In order to interrupt transmission, districts in which lymphatic filariasis is
endemic must be mapped and a strategy of preventive chemotherapy called
mass drug administration (MDA) implemented to treat the entire at-risk
population. Successful MDA will prevent new infections and no new cases of
clinical disease. To achieve the second aim of GPELF, a core strategy of
morbidity management and disability prevention (MMDP) is needed. Suffering
caused by the disease can be alleviated through a minimum recommended
package of care to manage lymphedema and hydrocele. These services should
be available within primary health care systems in all areas of known patients
(WHO, 2014).
Currently, 947 million people in 54 countries are living in areas that require
preventive chemotherapy to stop the spread of infection. Globally, an estimated
25 million men suffer with genital disease and over 15 million people are afflicted
with lymphoedema. Eliminating lymphatic filariasis can prevent unnecessary
suffering and contribute to the reduction of poverty. (WHO, 2016). Estimation of
prevalence through the use of an immuno-chromatographic card test (ICT) has
rapidly become the more popular method of estimating prevalence compared to
measuring mf in the peripheral blood due to its cheaper cost, easier
implementation and relatively little training to perform (Weil & Ramzy, as cited by
Irvine, et. al., 2015).

The Binax Now

Filariasis test is based

on the

principle of

immunochromatography test. Binax Now Filariasis test ICT card test has been
shown to be a useful and sensitive tool for the detection of Wuchereria bancrofti
antigen and is being used widely by lymphatic filariasis elimination programs to
collect 100l blood by finger prick using a calibrated capillary tube or measure
100l of blood from a microcentrifuge tube using a micropipettor. Blood sample is
to be added slowly to the white portion of the sample pad and wait for 10 minutes
then the results to be read in 10 minutes otherwise false positive results will be
obtained. The test was considered positive when both lines (test and control)
could be read through the visualisation window. Any line (light or dark) appearing
in the test position indicates that the result of the test is positive; it is negative
when the control line can be seen (RochaI, et al., 2009). ICT card, on the basis of
its and other practical advantages, represent a major step for post-MDA
surveillance.
The National Filariasis Elimination Program (NFEP), as the primary
national policy-making entity, intends to eliminate filariasis as a public health
problem in the Philippines, by reaching at least 85% MDA coverage among the
target population in all established endemic areas. NFEP also strengthen the
chronic disability prevention and management to ensure elimination of lymphatic
filariasis (DOH, 2005). In 2007, the MDA successfully covered 76% of its targeted
population (Mercado-Hernandez, as cited by DOH, 2008). The NFEP maps out
and identifies endemic areas and conducts MDAs using diethylcarbamazine

citrate (DEC) and albendazole, tapping local health volunteers to perform houseto-house drug distribution.
Within the Philippines, lymphatic filariasis is also known as elephantiasis
or tibak in the local language. Areas endemic for lymphatic filariasis are in
regions with the highest incidence of poverty. The disease affects mostly the
poorest municipalities in the country about 71% of the case live in the 4th-6th
class type of municipalities. Three million (3M) Filipinos are at risk of getting the
disease. To date, 44 provinces from the 80 provinces in the Philippines are
endemic of elephantiasis. As of 2011, nine (9) provinces have eliminated
lymphatic filariasis namely, Agusan del Sur, Biliran, Bukidnon, Compostela Valley,
Cotabato Province, Dinagat Island, Romblon, Sorsogon and Southern Leyte
(WHO, 2016).
Once a municipality is identified as endemic, the whole province will be
subjected to control and/or elimination of the disease as a public health problem.
Although the criteria used for the case detection and the MDA strategy are based
on WHO standards of blood smear examinations for the presence of microfilariae
before determining the microfilariae rate of the whole province, case finding in
the field is actually based on external physical observations and an examination
of blood smears for the presence of microfilariae In addition, MDA coverage
figures are generally based on reports rather than direct observation, with only a
few small-scale surveys for validation (DOH, 2008).
Theoretical Framework

10

This research study is anchored on the Health Promotion Model of Pender

(1987). The model was derived from social cognitive theory in which cognition;
actions, affect, and environmental events were proposed as operating
interactively in determining behavior and included determinants of health
promoting behaviors. The HPM model was meant to explain and predict the
factors that motivate individuals to engage in health promoting behaviors. These
health promoting behaviors have been directed toward maintaining or improving
the person's level of wellbeing, personal fulfillment, and self-actualization and
away from reacting to a threat of illness, thus improving quality of life and
expression of human growth (Pender, 1987).
Within the HPM, the primary predicators of health promoting behaviors
consisted of 3 components. The first component of the HPM consisted of
cognitive or perceptual factors that exert a direct influence on the individual and
act as the primary motivational mechanism for the individual to initiate, acquire,
and maintain health promoting behaviors.

The cognitive factors that directly

influenced the likelihood of health promoting actions included: (a) the importance
of health, (b) self-efficacy, (c) perceptions of health, (d) individual definition of
health, (e) current health status, and (f) perceived benefits or barriers to health
promoting behaviors (Pender, 1987).
The second component of the HPM consisted of modifying factors that
indirectly affect health promoting behaviors by their impact on cognitive
mechanisms. The modifying factors provided a foundation to enable or constrain
the person's decision to engage in health promoting behaviors. The modifying

11

factors included: (a) demographic characteristics such as age, sex, education,

and ethnicity, (b) biologic characteristics including body composition and body
weight, (c) interpersonal influences such as expectations of family, friends and
social norms, (d) situational events such as health promoting options within the
environment, and (e) behavior variables including prior experiences with health
actions (Pender, 1987).
The third component of the HPM was the likelihood of engaging in health
promoting action as described by "cues to action" that have a direct influence on
whether or not the individual was directed toward enhancing or maintaining wellbeing. The cues to action depended on activating cues of internal or external
origin that trigger a health related behavior. The internal or external cues derived
by the individual's experience moved them from the decision-making phase to
the action phase. Factors influencing the likelihood of taking action were
awareness of potential for growth, advice from others and mass media. Factors
for not taking health promoting action were inconvenience, cost, unavailability,
and extent of life change required (Pender, 1987).
According to HPM, the likelihood that a health promoting behavior or
lifestyle will occur was determined by combining individual cognitive factors,
modifying factors, and cues to action. The health promoting behavior themes are
different from disease prevention behavior themes (to keep from occurring) by
encouraging individuals to be engaged in health promoting activities to improve
their well-being rather than only engaging in behaviors that were meant to
decrease threats or insults to health (Pender, 1987).

12

Conceptual Framework
To comprehend better the direction of the study, Figure 1 illustrates the
schematic diagram showing the interplay of variables of the study. The figure of
the conceptual framework offers insight of both what is being measured by
linking it to the respondents and how the variables might interact. However, the
framework is fixed to its direction to find out parental compliance as the foremost
objective. For parental compliance to be attained there must always be a link, at
least at the conceptual level, with demographic profiles of the respondents. The
independent variables are the demographic profiles of respondents (age, gender,
civil status and highest educational attainment) and the knowledge and practices
of parents to ICT, while the dependent variables are the determinants of parental
compliance.

Demographic Profiles
of Respondents

Age
Gender
Civil Status
Highest
Educational
Qualification
Determinants of
Parental Compliance

Knowledge and
Practices of
Parents to ICT

13

Fig. 1. Schematic Diagram showing the Interplay of Variables of the Study

2. METHODOLOGY AND DESIGN

Research Design
The descriptive survey method of research was applied in this study. Gay
(1976) defines descriptive research as involving collection of data in order to test
hypotheses or to answer questions concerning the current status of the subject of
the study. A descriptive study determines and reports the way things are. The
type of survey utilized was the sample survey because it deals only with a portion
of the population. This sample survey was performed to describe the profile of
the respondents in terms of age, gender, civil status and highest educational
qualifications. The knowledge and practices of parents

regarding the

administration of ICT were also obtained.

Research Setting
The study was conducted at the DOH identified schools in Initao, Misamis
Oriental. Specifically, these were the Jampason Elementary School, Aluna
Elementary School and Tubigan Elementary School. Except for Aluna
Elementary School, which is several kilometers for the main highway, both

14

Jampason and Tubigan Elementary Schools were easily accessible from the
Municipal Health Office of Initao.
Respondents of the Study
The respondents of the study were the 228 parents of Grades 1 and 2
whose ages range from ages 6-7 years old who were chosen randomly given
that their child are eligible for ICT. The reason for applying the ICT at that age
bracket because children 67 years old represent the target age group for TAS
because they have lived most or all their lives during MDA and, therefore,
positive filarial serology would be more indicative of recent LF transmission than
it would be in older children or adults who may have been previously exposed.
For school surveys, 1st and 2nd grade children were chosen as a proxy for 67
year olds (Fischer, 2013)
Sampling Procedure
The purposive sampling was applied in this study. Simply put, purposive
sampling is when the researcher relies on his or her own judgment when
choosing specific people within the population who will participate in the study.
The main goal of purposive sampling is to focus on particular characteristics of a
population that are of interest, which will best enable to answer the research
questions (Leard Dissertation, 2012). Specifically, the type of purposive sampling
to be used will be the homogeneous sampling (sample members are similar,
such as a particular highest educational attainment). The idea is to focus on this
precise similarity and how it relates to the topic being researched.
Research Instrument

15

The questionnaire was the lone data gathering instrument used in the
study. This questionnaire was made after reading various literatures and studies
about ICT. The first segment of the questionnaire asked the demographic profiles
of the respondents, while the remaining segment tried to find out the knowledge
and practices of parents regarding the administration of ICT.

Data Gathering Procedure

A letter of permission to conduct the study was requested from the
Municipal Health Officer of Initao, Misamis Oriental. The letter was duly noted by
the assigned DMO IV of the municipality. The study was explained verbally in the
local language to the respondents. Written consent was obtained before the
questionnaire was given. Questionnaires were distributed personally during the
Transmission Assessment Survey (TAS). Retrieval of the questionnaires was
done immediately after the respondents finished accomplishing it.
Statistical Treatment
The following statistics were performed after the data were classified and
tallied:
1. Frequency and percentage was used to describe the demographic
profiles of the respondents.
2. Mean was applied to find out the knowledge and practices of parents

regarding the administration of ICT.

Ethical Considerations in Data Collection

16

Ethical considerations are always taken into action when gathering data in
the data collection process. This is done based on upholding that the principles
that govern stakeholders participation are followed. The principle of voluntary
participation which requires that people are not coerced into participating should
be followed. Further, the informed consent of the respondents is also ensured by
explaining the aim of the study and the procedures involved.
An utmost cordial approach was observed in the distribution of the
questionnaires to the respondents. Respondents were assured of anonymity and
confidentiality in terms of how the findings are revealed. In addition, they were
informed that only fictitious names would be used and specific reference would
not be made to schools or individuals to allow anyone to discern the real persons
or schools which were being referred to in the study. Once the data was analyzed
and the study was complete, all questionnaires and consent forms were
destroyed assure

17

3. RESULTS AND DISCUSSION

Results of the survey were analyzed and data were interpreted. For an
easier view of the results, data are shown in tables.
1. Describe the demographic profile of the respondents in terms of: age, gender,
civil status, and highest educational attainment.
Table 1. Demographic Profiles of the Respondents
Variable

Attribute

Frequency
n = 228

Percent (%)

Age (year)

18 - 30
31- 40
> 41

118
73
37

52
32
16

Gender

Female
Male

182
46

80
20

Civil Status

Single
Married
Widowed

9
210
9

4
92
4

No Schooling
(No Formal)
Elementary
Graduate

28

12

36

16

Highest Educational
Attainment

18

Secondary
Graduate
College Graduate

146
18

64
8

The results of demographic profiles in Table 1 showed that majority of the

respondents (52%) were 18 to 30 years old. It could be deduced that marriages
contracted 10 years ago. According Philippine Statistics Authority (2011), there
were 482,480 marriages that were recorded in 2010. The median age for brides
was 25.1 while for grooms was 27.9. Thus, the age range of 18 to 30 years old
was within the marriageable age of 25 and 28 for bride and groom, respectively.
There were more female respondents (80%) than male respondents
(20%). This big population of females was expected because children at early
childhood are being accompanied by females (mostly mothers) to school. As
Morrisey (2015) emphasized that childs development encompasses many
aspects including the physical social, emotional and cognitive/mental. In order for
children to develop in all aspects, they must be supported in all areas and the
one person most often responsible for this encouragement is the mother. While a
discussion of a childs relationship with their mother could easily become a highly
involved, deeply psychological or sociological dialogue, it neednt be so. Instead,
any such discussion can be boiled down to the basics: the mother child
relationship is probably the strongest relationship in a childs early life.
Additionally, in a stereotypical family, fathers are almost always a breadwinner.
This means that the father is away from his children for most of the day. Thats
the reason why mother was responsible in accompanying the child to school.

19

In terms of civil status, 92% of the respondents were married, 4% were

single, and widowed were 4% too. The quantity of married respondents was
understandable due to the fact that the marriageable age, as mentioned earlier,
for bride and groom was 25 and 27 years, respectively.
Twelve percent of the respondents received no schooling (no formal
education), 16% completed elementary education, 64% finished secondary
education and 8% were college graduates. Parents with higher educational
attainment are expected to be more compliant due to their better knowledge of
the medical activity. Patients' education regarding disease, medications used,
benefits of medication, and potential side-effects of medication can enhance
compliance (Berger, et al., 1990).
2. Discover the determinants of compliance to ICT from the knowledge and
practices of parents.
All the respondents claimed to have knowledge about ICT because they
were informed by the nurse/midwife (88%), while 12% came from other sources.
However, there were still some who have erroneous belief about ICT. They
wanted to have better understanding about the disease for which their child is
being tested and receive more explanations of the risks and benefits of the
testing. The administration of ICT might appear frightening; however, studies
have demonstrated that parents want information presented in a concise format
that can be accomplished with an increase in contact with the health-care
provider of only a few minutes (Dhanireddy, Maniscalco &, Kirk (2005). Of utmost
importance to parents is the mode of information transfer; while written

20

information is valued, it must be delivered in conjunction with a face-to-face

discussion with the health-care provider (Dietrich, Oxman, & Burns, 2003).
Multiple studies have demonstrated that the most valued factor and critical
component in a parents decision to participate in any healthcare activity is the
recommendation of their doctor or nurse (DiMatteo, 1995). In this study,
information from the teachers, nurses, midwife and doctors at the health centers
(80%) influenced the parents to have their child tested.
All the respondents admitted that they were informed about the procedure
in the administration of ICT. The indication of ICT (100%), how it is given to your
child (100%) and what age is it to be given (100%). However, in regard to
possible reaction 76% of the respondents disclosed they were informed and
24% were not. To increase parents awareness, good knowledge regarding ICT is
required. Health care personnel should explain to parents the correct information
about the risks and benefits of ICT.
Many respondents were satisfied (56%) and very satisfied (44%) with the
information education campaign conducted. The most important factor affecting
parental practice is communication between parents and the sources of
information. Improving communication will improve parents perceptions of the
benefits and risks of testing (Hall, Roter, & Katz, 2008). As a result, parents
family persuaded their friends (48%) to have their children tested.
In terms of the proximity of the testing area (public elementary schools),
respondents emphasized far (16%) and not too close (80%). Likewise going to
the testing area did not affect daily tasks/work (80%). Even though all

21

respondents claimed that they do not have other expenses to get their child
tested for filariasis, It is possible that some parents are reluctant to comply
because may not afford to buy enough medicine due to poverty , in case of their
perceived adverse reactions of the ICT.

4. SUMMARY, CONCLUSIONS AND RECOMMENDATIONS

Summary
This study was aimed to find out the parental compliance on ICT for
filariasis detection during the Transmission Assessment Survey (TAS) as
determinant to qualify Misamis Oriental as a lymphatic filarial free zone.
Specifically, this study aimed to: (1) describe the demographic profiles of the
respondents in terms of: age, gender, civil status, and highest educational
attainment; (2) discover the determinants of compliance to ICT from the
knowledge and practices of parents and; (3) explain the significant difference
between the determinants to ICT and the demographic profiles of the
respondents when grouped according to age, gender, civil status, and highest
educational attainment.

This study utilized a descriptive design. This was descriptive design

in nature since it described the determinants that influenced parental

22

compliance in regards to the administration of ICT. This study used the

following statistical tools: frequency and percentage and mean. The
demographic profiles of the respondents were: ( 1) one-half have an age
ranges from 18 years to 30 years old; (2) four -fifth were females; (3).nine-tenth
were married; and (4) three-fifth were high school graduates. Analysis from the
results of the study discovered the following determinants: These were
knowledge about the procedure; reliability of informant and implementer;
perceived benefits of the procedure; cost of the procedure; availability of the
parent; convenience of going to the testing center; and family and peer influence.
Conclusions
Based on the results and analysis made in the study, the following
conclusions are given below:
Compliance to medical activity is a major healthcare concern globally.
Results from this study suggest that some knowledge and practices of parents as
a whole may not be accurate determinants for parental compliance. Education
seems to be the most influential determinant of parental compliance. Though not
strongly suggested through data from this study, the availability of times outside
of normal business hours may help to increase the compliance for parents who
are unable to bring the child for testing at scheduled time. Health care
professionals can identify practically possible strategies to improve compliance
within the limits of their practice to eventually enhance therapeutic outcome.
Recommendations

23

Based on the findings and conclusions derived from the study, the
following recommendations are formulated:
1. The Department of Health RO X may include the results of the study,
particularly the parental compliance behavior in regards to filariasis detection as
a pre-requisite for planning, implementation and evaluation of control strategies
to eliminate Lymphatic Filariasis as a public health problem in Philippines by year
2017.
2. Local Government Units should enhance their community health
programs through the inclusion of some determinants of parental compliance to
ICT.
3. Nurse Researchers may employ the findings of the study as baseline
information for another research.
4.Future Researchers should conduct similar focusing on parental
compliance on ICT for filariasis detection so as to discover more significant
determinants of parental compliance..