Impact of self-efficacy–based health education programs on behavior modification for Opisthorchis viverrini and cholangiocarcinoma prevention in Thailand: A systematic review and meta-analysis

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Parasites Hosts Dis. 2025;63(1):1-11

Publication date (electronic) : 2025 February 25

doi : https://doi.org/10.3347/PHD.24074

Worathon Busabong^1,2, Somkiattiyos Woradet^3,, Nopparat Songserm^1,

¹Department of Health Sciences, Faculty of Public Health, Ubon Ratchathani Rajabhat University, Ubon Ratchathani 34000, Thailand

²Sisaket Provincial Public Health Office, Sisaket 33000, Thailand

³Department of Public Health, Faculty of Health and Sports Science, Thaksin University, Phattalung 93210, Thailand

^*Correspondence: (sw, somkiattiyos@tsu.ac.th; ns, nopparat.s@ubru.ac.th)

Received 2024 October 24; Accepted 2024 November 24.

Abstract

Introduction

Opisthorchis viverrini (OV) infection and its associated cholangiocarcinoma (CCA) are critical public health concerns, especially in Southeast Asia, where the disease burden is highest. The International Agency for Research on Cancer has classified OV as a Group 1 biological carcinogen due to its well-established role in the etiology of CCA [1]. OV transmission occurs primarily through consuming raw or undercooked freshwater fish, particularly cyprinid species, commonly prepared in traditional dishes such as raw fish salad and fermented fish. Humans and domestic animals, including cats and dogs, act as definitive hosts, contributing to the contamination of water sources and sustaining the OV transmission cycle [2]. This ongoing transmission underscores the need for effective public health interventions to break the cycle and reduce the associated risks of CCA in endemic regions.

Although public health interventions have successfully reduced the prevalence of OV in Thailand—from 16.3% in 2016 to 4.3% in 2020—certain regions, especially in the northeast, continue to report high infection rates, with 4.97% still affected [3]. Despite this reduction, OV infection and CCA disproportionately affect individuals in their working years (40–60 years), creating significant economic and social burdens. The annual cost of treating CCA in Thailand is estimated at 1.96 billion Baht (approximately 56 million US dollars), exerting a substantial strain on the healthcare system and reducing the quality of life for affected individuals and their families [2–4]. These challenges emphasize the critical need for effective preventive measures that target OV infection at its source, with the potential to alleviate the long-term healthcare burden associated with CCA.

Behavior modification strategies have been at the forefront of efforts to prevent OV and CCA, with many interventions based on Albert Bandura’s self-efficacy theory [5]. According to Bandura [5], self-efficacy, or the belief in one’s ability to influence outcomes through personal actions, is a crucial determinant of motivation and persistence in health behavior change. Health education programs that enhance self-efficacy are thought to increase individuals’ likelihood of adopting behaviors that reduce the risk of OV infection, such as avoiding high-risk foods like raw or undercooked fish.

However, despite the theoretical promise of self-efficacy–based interventions, evidence regarding their effectiveness in preventing OV and CCA remains inconsistent. Some studies have reported positive behavior change following self-efficacy interventions, while others have found limited or no impact [6,7]. These variations may stem from differences in study design, target populations, and intervention delivery, making it challenging to draw definitive conclusions about the general effectiveness of self-efficacy approaches for OV and CCA prevention.

This gap in the literature underscores the need for a systematic review and meta-analysis to synthesize the available evidence on the impact of self-efficacy–based health education programs for OV and CCA prevention. A comprehensive analysis of these interventions could provide more precise guidance for public health authorities and policymakers on designing and implementing more effective behavior modification programs. Additionally, this study explores whether the principles of self-efficacy can be applied to other areas of infectious disease prevention, potentially broadening the impact of these findings across multiple public health domains. Consequently, this study aimed to review the literature on the effectiveness of self-efficacy–based health education programs in preventing OV and CCA.

Methods

Search outcomes

The initial search was performed independently by 2 researchers, followed by a third researcher who resolved any disagreements regarding study inclusion. A total of 702 studies were identified: 614 from PubMed, 49 from Google Scholar (English), 35 from Google Scholar (Thai), and 4 from ThaiLis and ThaiJo. In the first screening phase, titles and abstracts were reviewed, excluding 420 irrelevant studies, reviews, or articles without full text. This left 282 studies for further review. In the second round, abstracts and full texts were carefully analyzed, excluding 262 studies due to insufficient data. In the third round, the remaining studies were assessed for research design suitability for systematic review and meta-analysis. An additional 20 studies were excluded due to inadequate data for meta-analysis, leaving 13 studies for the final analysis (Fig. 1).

Fig. 1

Flowchart of study selection. This figure illustrates the systematic review process, including the initial number of studies identified, the screening phases, and the criteria for exclusion, leading to the final number of studies included in the meta-analysis.

Quality appraisal

The quality of the selected studies was appraised using the Cochrane Collaboration’s tool for assessing the risk of bias, and the results were visualized using a funnel plot in Review Manager version 5.4 (2020, The Cochrane Collaboration, London, United Kingdom). The risk of bias was evaluated in 3 categories: low, high, and unclear. For random sequence generation, 9 studies employed random sampling methods and were rated low risk. Ten studies reported allocation concealment, which is considered low risk, while 2 were rated as high risk. For blinding, 11 studies were rated as low risk, and 2 studies were rated as unclear due to insufficient information regarding participant blinding. All studies were assessed as low risk for incomplete outcome data, as the sample data were thoroughly analyzed. Selective reporting was not an issue in any of the studies, and no other biases were identified (Fig. 2).

Fig. 2

Risk of bias graph and summary. This figure shows the distribution of the risk of bias judgments across domains, including sequence generation, allocation concealment, blinding, outcome data, reporting, and other biases, categorized by color to indicate low, high, or unclear risk in key bias domains as per the Cochrane Collaboration tool.

Data extraction

Data extraction followed a systematic approach, summarizing key study details such as author, country of publication, age group, sample characteristics in both experimental and comparison groups, and the study outcomes (Table 1).

Table 1

Literature reviews of health education programs for preventing Opisthorchis viverrini and cholangiocarcinoma in Thailand

Effects of Health Education Programs on Knowledge, Self-efficacy, and Behavior Modification for Preventing OV and CCA before and after the Intervention

Knowledge

The analysis of health education programs on knowledge for behavior modification to prevent OV and CCA, using the standardized mean difference (SMD), indicated high heterogeneity (I²=76%, P<0.001). The pooled data from 292 participants across 8 studies demonstrated a significant increase in knowledge following the intervention, with a mean difference of 1.13 (95% CI=0.96–1.31) and an I² value of 76% (Fig. 3A). Subgroup analysis of knowledge outcomes after the intervention revealed an asymmetrical distribution in the funnel plot, suggesting potential publication bias. The random-effects model confirmed high heterogeneity (I²=76%, P<0.001) (Fig. 3a).

Fig. 3

The forest plot and funnel plot present the effects of health education programs on outcomes, respectively: (A), (a) knowledge; (B), (b) self-efficacy; and (C), (c) behavior modification for preventing Opisthorchis viverrini and cholangiocarcinoma before and after the experiment. IV, inverse variance; CI, confidence interval.

Effects of Health Education Programs on Knowledge, Self-efficacy, and Behavior Modification for Preventing OV and CCA between the Experimental and Comparison Groups

Knowledge

The comparison of knowledge outcomes between experimental and comparison groups, using the SMD, revealed moderate heterogeneity (I²=74%, P<0.001). Analysis of data from 405 participants across 9 studies showed a significant increase in knowledge in the intervention group, with a mean difference of 1.52 (95% CI=1.36–1.68) and an I² value of 74% (Fig. 4A). Subgroup analysis showed an asymmetrical distribution in the funnel plot, indicating potential publication bias. A random-effects model confirmed medium heterogeneity (I²=74%, P<0.001) (Fig. 4a).

Fig. 4

The forest plot and funnel plot present the effects of health education programs on outcomes, respectively: (A), (a) knowledge; (B), (b) self-efficacy; and (C), (c) behavior modification for preventing Opisthorchis viverrini and cholangiocarcinoma between the experimental and comparison groups. IV, inverse variance; CI, confidence interval.

Discussion

This study systematically reviewed the effects of self-efficacy–based health education programs on preventing OV and CCA by enhancing knowledge, self-efficacy, and behavior modification. The findings demonstrated significant improvements in these outcomes, confirming the effectiveness of such interventions. The following discussion addresses each of these issues in detail.

The results revealed a statistically significant increase in knowledge following the intervention, with the experimental group showing a higher increase than the comparison group. Before the intervention, participants generally lacked adequate knowledge about the risks of OV infection and CCA. After receiving targeted health education, which included detailed information on the causes, prevention, and consequences of OV infection, participants in the experimental group demonstrated significantly higher knowledge scores than theircomparison group counterparts (P<0.001). These findings suggest that health education programs are crucial in improving public understanding of OV and CCA prevention. The significant improvement in knowledge can be attributed to the structured delivery of information through various educational materials, such as brochures, videos, and group discussions, which cater to different learning styles [9–11].

A vital intervention component was enhancing self-efficacy, which is critical in behavior change. The analysis showed a significant increase in self-efficacy scores after the intervention, with participants in the experimental group reporting greater confidence in their ability to prevent OV infection and CCA than those in the comparison group (P<0.001). These results align with Bandura’s theory that self-efficacy influences motivation and the adoption of preventive behaviors [5]. By reinforcing participants’ belief in their ability to avoid high-risk behaviors, such as consuming raw fish, the intervention successfully empowered them to make healthier choices. The significant increase in self-efficacy observed in this study highlights the importance of using health education strategies that build individuals’ confidence in their ability to engage in preventive health behaviors [7,12,13].

The ultimate goal of the health education programs was to modify participants’ behaviors to reduce OV infection risk. The findings showed a significant improvement in behavior modification following the intervention, particularly among participants in the experimental group compared to the comparison group (P<0.001). The observed behavior changes included a notable reduction in raw or undercooked fish consumption, increased adherence to food safety practices, and improved overall hygiene. These results indicate that self-efficacy–based health education can effectively translate increased knowledge and confidence into tangible behavior changes. The high heterogeneity in behavior modification outcomes (I²=93%) suggests variability in participants’ responses to the intervention, possibly due to cultural differences or personal preferences. However, the consistent improvement across studies emphasizes the intervention’s effectiveness in promoting long-term preventive behaviors [6,9].

The comparison between the experimental and comparison groups across all 3 outcomes—knowledge, self-efficacy, and behavior modification—further supports the intervention’s efficacy. The experimental group consistently outperformed the comparison group, with significant improvements in knowledge (I²=74%, P<0.001), self-efficacy (I²=84%, P<0.001), and behavior modification (I²=92%, P<0.001). These findings highlight the critical role of structured, theory-driven health education programs in influencing health behaviors. Notably, the experimental group exhibited higher sustained behavior changes over time, suggesting that incorporating self-efficacy principles enhances immediate outcomes and contributes to long-term behavioral adherence [6,14].

This meta-analysis has some limitations. High heterogeneity across the included studies, particularly in behavior modification outcomes, suggests variability in intervention effectiveness across different populations. Potential publication bias, indicated by funnel plot asymmetry, may have inflated positive results by excluding non-significant studies. Additionally, varying follow-up durations raise concerns about the long-term sustainability of behavior changes. Finally, the analysis centers on self-efficacy–based programs, potentially overlooking other critical factors influencing behavior change.

Conclusion

This meta-analysis demonstrates that self-efficacy–based health education programs effectively increase knowledge, enhance self-efficacy, and promote behavior modification for preventing OV and CCA. The statistically significant improvements observed in the experimental group indicate that such interventions should be integral to public health strategies in endemic areas. Future research should explore applying these educational models to other health challenges as they broadly apply to various disease prevention efforts.

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