Causal Factors Influencing Liver Fluke Disease Prevention Behaviors in Health Region 10: A Structural Equation Modeling Study with Qualitative Behavioral Insights

Abstract

Despite control programs, liver fluke (Opisthorchis viverrini) prevalence remains at 6.62% in Health Region 10, northeastern Thailand. This study investigated the causal factors influencing prevention behaviors among people with a history of infection using Structural Equation Modeling (SEM) and supplementary qualitative interviews. A cross-sectional survey was conducted among 630 individuals across five provinces (Ubon Ratchathani, Sisaket, Yasothon, Amnat Charoen, and Mukdahan), alongside in-depth interviews with 50 participants.SEM analysis revealed that communication was the strongest predictor of prevention behavior (β = 0.705, p < 0.001), while knowledge had a minimal direct effect (β = 0.022$). The model explained 49.23% of the variance in behavior (R² = 0.492). Economic factors exerted a moderate negative effect (β = -0.139). Qualitatively, a distinct knowledge–behavior gap emerged: 60% of interviewees continued to consume raw fish primarily driven by taste preference (83%) yet 50% reported that witnessing local illness or death was a more powerful behavioral motivator than abstract health knowledge. Liver fluke prevention in Health Region 10 is driven by local communication infrastructure and visible community consequences rather than knowledge expansion alone. Public health strategies should transition from conventional, knowledge-focused education to spatially targeted communication systems and community-level risk messaging that addresses socio-cultural and structural barrier.