Knowledge of Chagas disease in Latin American migrant population living in Japan and factors associated with knowledge level

Background Chagas disease (CD), typically confined to the Latin America (LA) region, is emerging as a global health problem. In Japan, as in the rest of world, the under-diagnose rate of CD is alarmingly high. Various studies have highlighted the importance of informed knowledge in the seeking behavior. Educational integrative activities, with consideration for socio-cultural factors, can help increase the knowledge of the participants. There has been no studies that analyze the difference in knowledge, before and after these educational activities. This study aimed to qualitatively and quantitatively investigate the knowledge, behavior and attitude toward CD among LA migrants in Japan and to evaluate the effectiveness of the community educational activity in increasing knowledge of CD. Methodology This cross-sectional study involved two questionnaires to analyze the knowledge of the LA migrant participants before and after the community activity (CA) in four cities in Japan (Oizumi, Suzuka, Hadano, and Nagoya). Principal Findings A total of 75 participants were enrolled, predominantly Bolivians from hyperendemic areas. The baseline knowledge of CD was low. However, most of them were familiar with the disease although less than 10% of them had been tested for CD before. Living in Japan for more than 10 years and previously being tested for CD were the factors associated with better knowledge. The conducted CA significantly improved the knowledge of the participants. They associated the term “Chagas” mostly with fear and concern. In contrast to other studies, the level of stigmatization was low. The barriers in care seeking behavior were language, migration process and difficulties to access to the healthcare system. Conclusion Educational activities with integrative approach are useful to increase knowledge of CD. The activity brings the possibility to explore not only the level of knowledge, but also to reveal the experience and to understand the needs of the people at risk. Author Summary Though the incident rate of Chagas disease (CD) has fallen, more than 7 million people are affected worldwide. The CD prevalence is under-estimated because just 1% of these affected people can access to the diagnosis and treatment. This situation is maintaining mainly for the lack of implication of socio-cultural factors in the interventions to decrease the burden of the disease. Educational activities with integral approach are useful to increase the knowledge of the people at risk. People that have being tested for CD before or living in Japan for more than 10 years have better knowledge about the disease, suggesting the importance of knowledge in the seeking behavior. The authors recommend the implementation of educational activities with integral approach as a strategy to improves the knowledge of Chagas disease among Latin America migrants in Japan.

Introduction 90 It has been more than 100 years since the discovery of Chagas disease (CD) and although 91 the number of incident rate has fallen, more than 7 million people are affected worldwide. 92 The prevalence is under-estimated because just 1% of these affected people can access to 93 the diagnosis and treatment [1]. Each year 39,000 new cases occur of which 9,000 results 94 from congenital transmission [2]. In Latin America (LA), CD presents as one of the 95 tropical disease with the highest burden, which is measured in 806,170 disability-adjusted 96 life-years (DALYs). The economic impact is about 627 million dollars in health 97 expenditure worldwide [3].

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As a result of increasing migration in the last few years, the disease silently 99 spreads into the United States, Europe and the Western Pacific region [4]. Japan ranks 106 The fact that CD is an emerging disease in non-endemic countries, along with 107 the lack of awareness of the health personnel and its silent course, makes it difficult 108 for detection. In addition to this challenging situation, migrant population are exposed 109 to many barriers to access to the health system. 110 The migrant population has a disadvantageous situation compared with the native 111 citizens of the of the host country. Language, lack of adaptability of the health system      333 The vector-borne transmission was most frequently identified as the only way of 334 transmission. Some people who recognized blood transfusion as a way of transmission 335 had the experience of a relative that was diagnosed during blood donation. Since they 336 couldn't donate blood, they associated the transmission with blood transfusion. Other 337 routes as mother to child, organ transplantation or oral route were not considered before 338 they were given information about it (PC3-4).

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The participants identified the symptom of the disease mostly with cardiac 340 problems. Digestive problem was less recognized but also was commented during FGD 341 (PC5-7).
342 What is the first word that came to your mind when I say "Chagas"? The most 343 frequent answer was related to the feelings of fears, worries and memories. 348 Worries. Concerns were expressed for the transmission of the disease to their relatives.
349 Women expressed more the concern when they learnt about the possibility of mother to 350 child transmission (PC10-11).
351 Memories. The memories expressed during the FGD were related to the recent cases of 352 CD that they experienced and were linked to feelings as fear or pain (PC12-13).
353 They also associated with the vector "vinchuca" and related with symptoms. The 354 symptoms described were non-specific, related with pains or heart problems (PC14-15).

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In conclusion, educational activities with integral approach are useful to 520 increase the knowledge of CD. This activity brings the possibility to explore not only 521 the knowledge but also the characteristic, experiences, opinions and needs of those at 522 risk. This information is essential in order to guide the efforts to improve the CD 523 problem, considering the people at risk as part of the improvement and development.