Open Veterinary Journal, (2025), Vol. 15(9): 4322-4336

Research Article

10.5455/OVJ.2025.v15.i9.39

Knowledge gaps and risk behaviors among cat owners in Opisthorchis viverrini endemic areas: Implications for public health interventions

Petcharat Chompo^1,2, Banchob Sripa^2,3, Apiporn Thinkhamrop Suwannatrai³, Prasarn Tangkawattana¹ and Sirikachorn Tangkawattana^1,2*

¹Faculty of Veterinary Medicine, Khon Kaen University, Khon Kaen, Thailand

²WHO Collaborating Center for Research and Control of Opisthorchiasis (Southeast Asian Liver Fluke Disease), Tropical Disease Research Center, Khon Kaen University, Khon Kaen, Thailand

³Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand

*Corresponding Author: Sirikachorn Tangkawattana. Faculty of Veterinary Medicine, Khon Kaen University, Khon Kaen, Thailand. Email: sirikach [at] kku.ac.th

Submitted: 01/05/2025 Revised: 08/08/2025 Accepted: 18/08/2025 Published: 30/09/2025

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Abstract

Background: According to the World Health Organization’s “A roadmap for neglected tropical diseases 2021–2030,” controlling Opisthorchis viverrini infection in humans requires interventions targeting animal reservoirs, particularly cats and dogs. Understanding the knowledge, attitudes, and practices (KAP) of animal owners in endemic areas is essential for designing targeted interventions.

Aim: This study aimed to assess the KAP of O. viverrini infection and its prevention among cat owners in the endemic area of Thailand.

Methods: A cross-sectional study was conducted from April 2022 to December 2023, involving 292 cats from 41 villages across seven provinces. Two hundred ninety two fecal sample were collected from the cats of 175 owners, and KAP data were obtained through structured questionnaires. Descriptive statistics, chi-square tests, and multivariate logistic regression were used to analyze factors associated with O. viverrini infection and KAP outcomes.

Results: Opisthorchis viverrini was infected in 21.58% of the cats, with a mean egg count of 70.56 eggs per gram. The findings showed that 28.57% of the participants owned cats infected with O. viverrini. They were female, aged 40–60 years, and worked in the agricultural sector. Most cat owners exhibited moderate to good knowledge, positive attitudes, and poor preventive practices. Knowledge was significantly associated with better practices (p=0.015). The key risk factors for O. viverrini infection included feeding risky scraps (adjusted OR (aOR)=2.10, 95% confidence interval [CI]: 0.99–4.41) and lack of participation in O. viverrini-related public health campaigns (aOR=2.45, 95% CI: 1.15–5.22). Furthermore, older age (>60 years) was less knowledgeable (aOR=0.28, 95% CI: 0.10–0.78) but more likely to engage in good practices (aOR=2.68, 95% CI: 1.02–7.26), whereas those in agriculture showed higher knowledge (aOR=4.37, 95% CI:1.73–12.14) and better preventive behavior (aOR=3.19, 95% CI: 1.29–8.60).

Conclusion: These findings underscore the need for integrated, community-based interventions to enhance knowledge and practices. Strengthening veterinary involvement, improving public health education, and applying the One Health framework are essential for reducing O. viverrini transmission and controlling liver fluke infections in both humans and animals.

Keywords: Cat owner, KAP, Liver fluke, Preventive practices, Risk factors.

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Introduction

Opisthorchis viverrini infection is a significant foodborne parasitic disease affecting over 12 million people in Southeast Asia, particularly in Northeast Thailand (Sripa et al., 2021; Suwannatrai et al., 2021). The transmission of O. viverrini involves a complex cycle that involves humans and animals, particularly cats and dogs, who serve as definitive hosts. Snails and cyprinid fish act as the first and second intermediate hosts, respectively. Humans are infected by consuming raw or undercooked cyprinid fish containing metacercariae. Subsequently, infected hosts shed eggs into water bodies through defecation, thereby continuing the parasite’s lifecycle and maintaining transmission (Tangkawattana and Tangkawattana, 2018). In the endemic area of the Greater Mekong Subregion, O. viverrini infection is a leading cause of cholangiocarcinoma (CCA) (Sripa et al., 2011; Suwannatrai et al., 2019). Despite the implementation of an intensive national fluke control program, infection in animal reservoirs remains a significant challenge (Tangkawattana and Tangkawattana, 2018).

A One Health approach is essential to sustainably interrupt the transmission of O. viverrini and effectively control this zoonotic disease (Tangkawattana and Sripa, 2018). Addressing animal reservoirs requires integrating veterinary interventions with human health initiatives, in line with the World Health Organization (WHO)’s “A roadmap for neglected tropical diseases 2021–2030” (World Health Organization, 2021). However, although the Ministry of Public Health’s efforts through the Decade Strategic Plan to Eliminate O. viverrini and CCA (2016–2025) (Department of Disease Control and Ministry of Public Health, 2016), there remain significant gaps. These obstacles include insufficient data on animal reservoirs, behavioral challenges among pet owners, and limited collaboration between veterinary and public health systems.

Understanding and utilizing knowledge, attitudes, and practices (KAPs) related to O. viverrini infection is essential for developing effective health education programs that drive sustainable behavior change (Phatisena et al., 2016; Tidman et al., 2023; Mationg et al., 2024). The effectiveness of comprehensive strategies that enhance community knowledge and awareness while modifying practices to reduce O. viverrini transmission has been demonstrated (Songserm et al., 2021; Charoensuk et al., 2024; Sripa et al., 2025). Conducting KAP surveys among animal owners is valuable for identifying knowledge gaps and practical challenges, ultimately improving public health interventions and reducing O. viverrini transmission. This study aimed to assess the KAP of cat owners regarding O. viverrini transmission in human-endemic areas. The objective of this study is to evaluate the role of cat owners in sustaining O. viverrini transmission and inform targeted, community-based interventions that integrate human and animal health practices, thereby contributing to the broader goal of eliminating O. viverrini.

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Materials and Methods

Study design

This analysis was based on a cross-sectional study conducted from April 2022 to December 2023. Cat samples were collected from 41 villages across seven provinces in Northeast Thailand, an area endemic to O. viverrini infection. The provinces included in the study were Chaiyaphum, Khon Kaen, Maha Sarakham, Nakhon Phanom, Nong Bua Lam Phu, Roi Et, and Ubon Ratchathani. The villages were purposively selected based on prior epidemiological evidence of the high human prevalence of O. viverrini infection, surrounding wetland habitats, proximity to water resources, and data collection feasibility.

Study population

Cats of any breed and sex were included in this study. Cats younger than 3 months of age, pregnant or lactating females, and unhealthy cats were excluded. Only cats whose owners provided informed consent were enrolled in the study. After obtaining consent, the eligible cats underwent a physical examination. Healthy cats were then administered saline enemas to collect fresh stool. All enrolled cats were treated with praziquantel and pyrantel during stool collection. Owners then participated in a structured interview using a knowledge, attitudes, and practices (KAPs) questionnaire (Fig. 1).

Fig. 1. Data collection process: A) physical examination and administration of saline enema; B) immediate collection of fresh stools after cat defecation; C) treatment with praziquantel and pyrantel; D) owner interview using a KAP questionnaire.

Fecal samples (2 g) were collected and processed using the modified formalin-ethyl acetate concentration technique (M-FECT). The samples were microscopically examined for O. viverrini eggs based on their morphological characteristics. Egg counts per gram (EPG) were calculated to assess infection intensity. Households were classified as O. viverrini-positive if at least one cat tested positive. A total of 292 cats were included in this study.

Data collection and the KAP questionnaire

A structured questionnaire was developed to collect data across five sections: (1) owners’ demographic characteristics (age, gender, occupation, O. viverrini examination history, and participation in O. viverrini-related campaigns), (2) cat information (raising practices, feeding habits, and health history), (3) owners’ knowledge regarding O. viverrini infection in animals, (4) attitudes toward O. viverrini infection risk in pets, and (5) O. viverrini prevention practices in animals.

The KAP section included multiple-choice, dichotomous,—and Likert-scale questions. The knowledge domain (10 items) assessed the understanding of animal reservoir types, transmission routes, associated risk behaviors, diagnosis, and preventive measures. The attitude domain (7 items) explored perceptions of O. viverrini infection severity, susceptibility, and prevention in animals. The practice domain (10 items) included food consumption habits, leftover food management, and pet health care practices.

A scoring system for the KAP index was established. Only correct responses to multiple-choice and dichotomous questions were assigned positive scores (1 point for correct answers and 0 for incorrect answers). For Likert-scale items, responses were scored as follows: “always”=2 points, “sometimes”=1 point, and “never”=0 points for positive statements, with reversed scoring for negative statements. The maximum possible scores were 10 for knowledge, 7 for attitudes, and 20 for practices. The total household KAP scores were classified using three methods: Bloom’s taxonomy (Bloom et al., 1971), mean and SD, and median-based scoring. Bloom’s taxonomy categorizes scores as good (≥80%), moderate (≥60%), and poor (≤60%), providing a standardized and structured way to compare the knowledge, attitudes, and practices of respondents with those of other studies. Using the group mean and SD, the scores were defined as good (> mean + SD), moderate (mean ± SD), and poor (< mean – SD). Additionally, median-based scoring classified participants into binary categories (good vs. poor KAP). The questionnaire was validated by three experts from our university, achieving an Index of Item–Objective Congruence (IOC) of 0.84. It was then pilot tested with 30 individuals, yielding a Cronbach’s alpha of 0.70 for reliability.

Statistical analysis

The average KAP scores and O. viverrini prevalence in cats across provinces were compared. To visualize the spatial distribution of these variables, prevalence and KAP score maps were created using Quantum Geographic Information System (QGIS), version 3.34.13. Descriptive statistics were used to summarize the study data. Frequencies and percentages were reported for categorical variables. Means and standard deviations of continuous KAP scores were used to classify the levels into good, moderate, and poor. Medians were used to classify the participants into good and poor groups. To compare KAP scores between O. viverrini-infected and non-infected households, the Mann–Whitney U test was applied due to the non-normal distribution of the data. Associations between knowledge and attitudes or practices were examined using the chi-square test.

As part of preprocessing before modeling, variables with a single response category or extreme class imbalance addressed by merging levels where appropriate. To identify the predictors of O. viverrini infection and factors associated with good KAP, multivariate logistic regression was used. For infection predictors, univariate analysis was performed, and variables with p < 0.20 were entered into the multivariate model. Model selection was based on forward, backward, and stepwise approaches using the Akaike information criterion (AIC). Direct multivariable regression was applied for good KAP outcomes due to the limited number of predictors. Multicollinearity was assessed using variance inflation factors (VIFs) in all models, and adjusted odds ratios (aOR) with 95% confidence intervals were reported. The results are presented in both tabular form and forest plots for clarity and ease of understanding. All statistical analyses were performed using R software version 4.3.2 (R Core Team, 2023), with the “ggpub,” “finalfit,” “car,” and “likert” packages.

Ethical approval

This study received ethical approval from the Animal Ethics Committee of Khon Kaen University (KKU) (IACUC-KKU-4/67 and IACUC-KKU(C)-1/67).

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Results

Demographic characteristics of cat owners and status

A total of 292 fecal samples from owned cats were collected, of which 21.58% (95% confidence interval [CI]: 16.86-26.29) tested positive for O. viverrini infection, with an average of 70.56 (95% CI: 47.96–93.17) eggs per gram. Table 1 summarizes the demographic characteristics of cats and their owners, stratified by the O. viverrini infection status of the cats. Adult cats (>1 year old) had a higher infection rate (23.80%) than younger cats (15.70%). Male cats showed higher infection prevalence (24.70%) than females (17.50%), and unsterilized cats (23.20%) were more infected than sterilized ones (10.50%). Overall, 28.57% (n=50) of the owners had cats infected with O. viverrini. The majority of participants were between 40 and 60 years old (45.7%) and had a higher proportion of infected cats (46.00%). Most participants were female (72.00%), with a similar trend among those who owned infected cats (76.00%). In terms of occupation, 34.3% of the respondents were farmers, with a slightly higher proportion among infected cat owners (30.00%). Additionally, 25.10% of the infected cat owners worked in other agricultural roles (22.00%), while 40.60% had various other occupations (48.00%). Regarding O. viverrini examination history, 10.00% of infected cat owners had a positive test result (16.60%), compared with 19.20% of non-infected cat owners. Participation in public health campaigns or projects related to O. viverrini was higher among non-infected cat owners (80.00%) than infected cat owners (64.00%).

Table 1. Demographic characteristics of cats and owners categorized by O. viverrini infection status.

KAP scores and prevalence across provinces

Figure 2 illustrates the average KAP scores and O. viverrini prevalence in cats across the provinces. Ubon Ratchathani and Nakhon Phanom showed high practice scores (53.13 and 49.38 out of 100, respectively) and high infection rates (62.50% and 50.00%, respectively). Despite the highest knowledge score (71.25/100), Nakhon Phanom still exhibited a high prevalence. In contrast, Chaiyaphum, with moderate knowledge (51.05/100) and practice scores (41.71/100), had the lowest prevalence (18.42%) and the largest sample size (n=76). These findings indicate that higher knowledge or practice scores are not necessarily correlated with lower infection rates.

Fig. 2. Prevalence of O. viverrini infection in cats and average KAP scores across seven provinces in northeastern Thailand. The figure illustrates regional variations in infection rates and KAP scores, providing insights into potential knowledge gaps and preventive behaviors among cat owners.

Cat owner categorization

Cat owners’ responses regarding O. viverrini were evaluated using three classification criteria: Bloom’s cut-off points, mean and standard deviation, and the group median. Based on Bloom’s cut-off, 13.71%, 30.29%, and 56.00% had good, moderate, and poor knowledge, respectively. In contrast, 61.71% of respondents had good attitudes, while 87.43% demonstrated poor practices. Most cat owners demonstrated moderate knowledge (64.00%), with a smaller proportion exhibiting good knowledge (13.71%) and poor knowledge (22.29%) when classified by mean and standard deviation (Table 2). Regarding attitudes, 42.29%, 30.86%, and 28.86% had good, moderate, and poor attitudes, respectively. The majority of cat owners (74.29%) exhibited moderate behaviors, while 12.57% had good practices and 13.14% had poor practices. The median-based method grouped participants into binary categories: 58.29%, 61.71%, and 60.57% had good knowledge, attitudes, and practices, respectively. Despite variations across methods, practices were generally weaker than knowledge and attitudes.

Table 2. Cat owner categories by means and their standard deviation of group (N=175).

Comparison of KAP scores between positive and negative households

Figure 3 illustrates the comparison of knowledge, attitudes, and practices regarding O. viverrini between households with and without O. viverrini-infected cats. The knowledge scores were comparable between the two groups. Households with O. viverrini-infected cats had a slightly higher mean knowledge score (48.40, 95% CI: 41.40–55.40) than those with non-infected cats (47.36, 95% CI: 42.95–51.77), but the difference was not statistically significant (p=0.800). For attitudes, households with O. viverrini-infected cats had a higher average score (85.14; 95% CI: 80.15–90.14) than those with non-infected cats (78.63, 95% CI: 74.46–82.80), but the difference was not statistically significant (p=0.111). The results that households with infected cats had more positive attitudes toward O. viverrini prevention. However, the practice scores were lower in households with cats infected with O. viverrini. The mean practice score for households with O. viverrini-infected cats was 41.70 (95% CI: 37.81–45.59), whereas non-infected households had a higher score of 44.04 (95% CI: 41.65–46.43) (p=0.333). These findings that, despite having more positive attitudes, households with O. viverrini-infected cats still require improvements in O. viverrini prevention practices.

Fig. 3. The mean comparison of KAP scores between non-infected and infected households. Most owners exhibited the highest scores in attitudes, whereas those in knowledge and practices exhibited lower scores. No significant differences were observed in the mean KAP scores between the two groups.

Association between knowledge levels and attitudes, and practices

The relationship between cat owners’ knowledge levels and their attitudes and practices toward O. viverrini infection was assessed using chi-square tests (Table 3). A higher proportion of knowledgeable individuals demonstrated good attitudes (69 participants) than non-knowledgeable individuals (39 participants). However, the difference was not statistically significant (x²=3.07, df=1, p=0.080). In contrast, a significant association was found between knowledge and practices. Among the knowledgeable participants, 70 demonstrated good practices, whereas only 36 non-knowledgeable individuals exhibited good practices. The chi-square test indicated a statistically significant relationship (x²=5.86, df=1, p=0.015). Higher levels of knowledge were positively associated with better practice behaviors.

Table 3. Association between knowledge level and attitudes and practices toward O. viverrini infection in cats

Demographics of owners and KAP toward O. viverrini infection in cats

The results revealed significant knowledge gaps regarding the control of O. viverrini in animal reservoirs among cat owners. In terms of knowledge, only 1.14% of owners correctly identified praziquantel as the anthelmintic drug for O. viverrini infections in cats, whereas 9.71% accurately identified the animal species that serve as O. viverrini reservoirs Supplementary data. Regarding attitudes toward O. viverrini prevention, most cat owners underestimated the risk of infection in animals. Specifically, 75.14% of the respondents did not believe their cats could be infected with O. viverrini, 61.58% did not perceive any risk, and only 54.24% expressed concern about the possibility of infection Supplementary data. Preventive control practices for their cats were also limited. The majority of owners were unaware of the need for veterinary visits (81.14%) or diagnostic examination for opisthorchiasis (97.71%). Furthermore, 95.43% of owners had never administered praziquantel to their cats or provided any deworming treatment after O. viverrini diagnosis Supplementary data.

Logistic regression was used to examine the association between owner demographics, KAP factors, and O. viverrini infection in cats. Univariate analysis was performed on 31 variables (Fig. S1A and Fig. S1B) to identify potential risk factors, of which seven had p-values of 0.20. These variables were included in the multivariate analysis. The final stepwise model identified key O. viverrini-infected household predictors, with an AIC of 204.72. In the multivariable analysis, as shown in Table 4, owners who did not attend the O. viverrini prevention campaign had a 2.45 times higher risk of having O. viverrini-infected cats than those who had participated (adjusted odds ratio [aOR]=2.45, 95% CI: 1.15–5.22, p=0.020). Feeding cats with leftover food containing risky fish products was also associated with an increased risk of infection (aOR=2.10, 95% confidence interval: 0.99–4.41, p=0.050). Owners who disagreed that deworming treated O. viverrini showed a marginally significant association with lower odds of infection (aOR=0.15, 95% CI: 0.01–0.87, p=0.083). In the final model, other demographic and KAP variables were not significantly associated with infection.

Table 4. Univariate and multivariate analyses of owner demographics and KAP predictors associated with O. viverrini infection in cats. The study identified two key risk factors: owner non-attendance at prevention campaigns and feeding cats leftover food containing risky fish products.

Demographics of owners toward good KAP

Figure 4 illustrates the contribution of owner characteristics to achieving good KAP. Owners aged were approximately 72% less likely to have good knowledge than those aged under 60 years (aOR=0.28, 95% CI: 0.10–0.78, p=0.017). Agricultural workers had more than four times the odds of possessing good knowledge compared with those with other occupations (aOR=4.37, 95% CI: 1.73–12.14, p=0.003). Regarding attitudes, both middle-aged and older adults were significantly less likely to have positive attitudes toward O. viverrini infection compared with younger owners (middle-aged: aOR=0.24, 95% CI: 0.07–0.68, p=0.011, older adults: aOR=0.25, 95% CI: 0.07–0.71, p=0.014). Moreover, owners aged over 60 years had significantly better practices than those under 60 years (aOR=2.68, 95% CI: 1.02–7.26, p=0.048). Individuals working in agriculture were significantly more likely to engage in good O. viverrini prevention practices compared to those with other occupations (aOR=3.19, 95% CI: 1.29–8.60, p=0.016).

Fig. 4. Contribution of the demographic characteristics of cat owners to good KAP. Although cat owners aged tend to have lower knowledge and attitudes, they exhibit better practices. Meanwhile, agricultural workers demonstrate good knowledge and practices.

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Discussion

The persistence of O. viverrini infection in animal reservoirs, particularly in cats, continues to hinder control efforts despite prolonged human interventions. The WHO emphasizes the need to target animal hosts to control foodborne trematodiasis. Strengthening veterinary public health and community engagement through a multidisciplinary strategy is crucial for effective surveillance and intervention. Our study was conducted in human endemic areas, providing insight into the KAP of cat owners regarding O. viverrini infection.

KAP scores and prevalence across provinces

This analysis identified a disconnect between self-reported KAP scores and the actual prevalence of O. viverrini infection among cat owners. Notably, despite the high levels of knowledge and practice scores, Ubon Ratchathani and Nakhon Phanom exhibited high infection rates, that the reported practices may not translate into effective preventive behaviors. Several factors, including cultural norms, low perceived risk, and limited access to veterinary or public health services, may contribute to this discrepancy. Consistent with previous studies in Ubon Ratchathani, additional behavioral risks, such as alcohol consumption and nitrosamine-rich food intake, may contribute to persistent infection and opisthorchiasis-associated cholangiocarcinoma progression (Songserm et al., 2020).

Conversely, despite moderate knowledge and practice scores, Chaiyaphum had the lowest prevalence. Field observations suggest that this may be linked to higher rates of cat sterilization (19.53%) and greater engagement with local animal health services, including the Department of Livestock Development and nearby veterinary clinics. In addition, misconceptions about human opisthorchiasis may influence preventive behaviors. For example, it is commonly believed that O. viverrini in raw fish can be treated by adding lime, formic acid from red ants, or whiskey (Sornpom et al., 2023). These findings highlight the limitations of KAP scores and underscore the need for behavior-focused strategies that consider local beliefs and practices.

Knowledge-informing practice

KAP surveys are valuable tools for evaluating the outcomes of public health programs. These surveys aim to measure changes in people’s knowledge, attitudes, and practices following interventions, reflecting behavioral changes at the community level (Macías, 2014). Our findings reveal a notable KAP gap among cat owners in O. viverrini-endemic areas. Most owners demonstrated good attitudes and moderate knowledge, but their actual practices were poor, indicating behavioral barriers. These findings contrast with findings from other KAP surveys in endemic areas of Thailand, where participants exhibited high levels of knowledge, positive attitudes, and good practices regarding O. viverrini infection in humans (Kaewpitoon et al., 2016).

Furthermore, higher levels of knowledge were associated with better preventive behaviors (p=0.015), whereas attitudes and practice were not significantly associated. Notably, most cat owners lacked knowledge about praziquantel use (98.86%) and failed to recognize animals as potential O. viverrini reservoirs (90.29%). In addition, most owners had never taken their pets for veterinary visits or administered deworming treatment despite living in endemic areas. These practices are similar to those observed in a previous study conducted in the endemic area more than a decade ago (Aunpromma et al., 2012). Additionally, these results align with studies that demonstrate how knowledge and positive attitudes can lead to more effective prevention behaviors (Xu et al., 2021). Positive attitudes toward animal health have been linked to increased O. viverrini and cholangiocarcinoma (CCA) prevention behaviors in human O. viverrini studies (Busabong et al., 2025). However, our findings suggest that attitude alone may not be sufficient to trigger effective behavioral change without a corresponding increase in knowledge. Knowledge plays a crucial role in shaping practice, emphasizing the importance of translating education into action. The Lawa model provides a successful example of how community engagement can effectively implement knowledge. Interventions must be culturally relevant, align with community needs, and foster improved practices at the community level to sustainably eliminate parasitic infections (Sripa et al., 2025).

Another key factor in driving behavior change is self-efficacy, the belief in one’s ability to take meaningful action (Sørensen et al., 2012). Studies suggest that both knowledge and perceived self-efficacy strongly influence prevention behaviors (Busabong et al., 2025). Therefore, interventions that increase knowledge and self-efficacy are key for sustainable behavior change. Public health efforts that improve these factors on O. viverrini prevention and behavior change significantly help reduce infection rates (Songserm et al., 2021).

Risky cat infection predictors

Poor practices among cat owners contribute to O. viverrini infection, as indicated by multivariate regression analysis. Feeding leftover food containing risky fish products significantly increased the risk of infection (aOR=2.45). These findings highlight the crucial role of feeding practices in O. viverrini transmission. Owners of O. viverrini-positive households commonly reported that fish was prepared as daily cat food. Despite owners’ confidence that grilling and cooking ensured thorough preparation, O. viverrini-positive cats were still identified in these households (Fig. 5).

Fig. 5. Cat food prepared by owners in households with O. viverrini-positive cats. (A) Grilled fish destroys the infective stage of the fluke. (B) Leftover human food containing fish may pose a risk to cats if undercooked.

Although feeding raw fish scraps was included in the multivariate analysis, it was not included in the final model. However, as evidenced by high infection rates among animal reservoirs, this practice likely plays a critical role in sustaining the transmission cycle of O. viverrini (Vonghachack et al., 2017; Sakamoto et al., 2023). Previous studies have consistently shown that cats fed raw or undercooked fish are at significantly higher risk of infection, with raw fish consumption (OR=4.52) and feeding raw fish to cats (OR=16.41) identified as key risk factors (Aunpromma et al., 2012; Sota et al., 2024).

These high-risk behaviors are often reinforced by inadequate knowledge, misbeliefs, and deeply rooted cultural norms within endemic communities (Suwannahitatorn et al., 2013; Pumidonming et al., 2016), which hinder the adoption of good practices and the effective implementation of prevention strategies.

Demographic characteristics of the owners and risk of infected cats

Non-participation in O. viverrini-related campaigns was associated with a higher risk of infection (aOR=2.45). Participation in O. viverrini-related campaigns acted as a protective factor against infection. This finding underscores the vital role of public health campaigns and community engagement in mitigating the risk of O. viverrini infection in domestic cats. Public health campaigns enhance health literacy, improve understanding, and promote O. viverrini and CCA prevention measures. Such campaigns are essential for developing effective programs when combined with multidisciplinary approaches (Moonsan et al., 2023). In this study, demographic factors of cat owners, such as gender, age, occupation, and a history of family O. viverrini examination, were not associated with O. viverrini infection. This finding aligns with other studies that these factors are not risk factors for O. viverrini infection in cat owners (Sota et al., 2024). However, certain demographic factors, including male sex, age over 40 years, and occupations such as fishing or farming, as well as education level, have been recognized as risk factors for human O. viverrini infection (Prakobwong et al., 2017; Pengput and Schwartz, 2020; Charoensuk et al., 2024).

Influence of cat owners’ demographic characteristics on good KAP

Age and occupation were identified as key predictors of KAP outcomes related to O. viverrini prevention. Older participants (≥60 years) had significantly lower good knowledge (OR=0.28) and positive attitudes (OR=0.25) but were more likely to demonstrate good preventive practices (OR=2.68). Similarly, participants aged 40–60 years had less positive attitudes (odds ratio=0.24). In contrast, individuals with agricultural occupations were more likely to exhibit good knowledge (OR=4.37) and appropriate practice behaviors (OR=3.19). These findings show a generational gap in knowledge and attitudes. Although older individuals may have less health knowledge, their life experience and long-term exposure to health practices help them adopt better preventive behaviors. Cultural norms may also play a role. Previous studies have shown that older people, particularly those from northeastern Thailand, continue to consume raw fish because of their traditional beliefs, whereas younger generations tend to have a better understanding of the associated risks (Suwannahitatorn et al., 2019). It is important to consider targeted segmentation of animal owners to enhance the efficacy of interventions. Although older adults may have limited knowledge, they can serve as valuable role models within their communities. Moreover, leveraging agricultural networks can facilitate community-based interventions that are well-aligned with occupational and generational contexts.

The main role of veterinarians in the animal health sector

Our study highlights several areas for improvement within the veterinary and animal health sectors in addressing O. viverrini transmission. Strengthening the One Health framework with the active involvement of veterinarians and related stakeholders is essential for reducing transmission in endemic areas. According to Tangkawattana and Sripa (2018), the veterinary and animal health sectors play a crucial role in O. viverrini control through key activities such as diagnosing and treating infected animals, promoting regular deworming, preventing environmental contamination, and managing the animal reservoir population. Collaboration between animal owners and local communities is necessary to enhance infection prevention efforts.

Improving anthelmintic treatment protocols is crucial for enhancing animal health and minimizing zoonotic disease risk. O. viverrini-infected cats often remain asymptomatic; thus, active case detection is necessary, particularly in areas with high prevalence (Sereerak et al., 2017). The key strategies for disrupting O. viverrini transmission include routine deworming of reservoir hosts, educating pet owners, and promoting collaboration with local veterinarians and animal health professionals (Sripa et al., 2025). Innovative technologies could play a supporting role to address the current gap in practices. For example, IoT-based systems can assist in monitoring and evaluating intervention outcomes (Yang et al., 2021). Sustainable O. viverrini control requires the integration of veterinary services, active community participation, and technology-driven approaches to effectively combat the infection and its transmission.

Limitations and further study

This study was limited by its narrow demographic scope and restricted occupational categories. Future research should investigate effective educational strategies for cat owners in endemic areas, with a focus on promoting behavior change and risk reduction. Applying the Socio-Ecological Model could help clarify the causal relationships between KAP and demographic factors. Additionally, comparing practices between infected and non-infected groups and across different animal reservoirs, such as cats and dogs, could inform more targeted interventions.

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Conclusion

This study highlights the critical role of animal reservoirs, particularly cats, in sustaining the transmission of O. viverrini in endemic areas of northeastern Thailand. Although cat owners generally exhibited moderate knowledge and positive attitudes toward O. viverrini, preventive practices were often poor, indicating a gap between awareness and behavior. Risky scrap feeding and lack of participation in O. viverrini-related campaigns were identified as significant risk factors for O. viverrini infection in cats. Demographic factors, such as age and occupation, also influenced KAP. Older owners exhibited better preventive practices, despite having lower knowledge levels, whereas individuals in agricultural occupations demonstrated both strong knowledge and effective practices. The findings underscore the importance of integrated, community-based interventions that promote knowledge and preventive behaviors. Strengthening veterinary involvement and public education through the One Health framework is crucial for addressing awareness gaps and enhancing animal health care. Targeted approaches that consider factors such as age, occupation, and cultural practices can improve the effectiveness of interventions. Empowering animal owners through better education and collaboration with veterinarians is essential for reducing O. viverrini transmission and achieving sustainable liver fluke control in both humans and animals.

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Acknowledgments

The authors would like to acknowledge the Faculty of Veterinary Medicine at Khon Kaen University, Faculty of Medicine at Khon Kaen University, Grant No. VM03/2567, and the 30th Year Anniversary of the Faculty of Veterinary Medicine, Khon Kaen University, for their assistance. This study was also partially funded by the National Research Council of Thailand –e-Asia JRP (Grant #920413), the Lancang-Mekong Cooperation Special Fund (LMCSF) Year 2018. We sincerely thank all participating cat owners for their contributions in providing samples and data. We also express our gratitude to the staff of the Tropical Disease Research Center, Khon Kaen University, for their support in facilitating this project. In addition, we would like to extend our appreciation to Dr. Sutin Chanabun, Sirindhorn College of Public Health, Khon Kaen, Thailand, for providing valuable guidance on the KAP analysis.

Funding

Faculty of Veterinary Medicine, Khon Kaen University, Grant No. VM03/2567 and the 30^th Year Anniversary of Faculty of Veterinary Medicine, Khon Kaen University. The National Research Council of Thailand –e-Asia JRP (Grant #920413). The Lancang-Mekong Cooperation Special Fund (LMCSF) Year 2018.

Authors’ contributions

Petcharat Chompo: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Funding acquisition, Validation, Visualization, Original draft writing. Banchob Sripa: Funding acquisition, project administration, and resources. Apiporn Thinkhamrop Suwannatrai: Resources and supervision. Prasarn Tangkawattana: Methodology, Resources, and Supervision. Sirikachorn Tangkawattana: Conceptualization, Funding acquisition, Investigation, Methodology, Project administration, Resources, Supervision, Validation, Original draft writing, Review and editing.

Conflicts of interest

The authors have no conflicts of interest to declare.

Data availability statement

Data supporting the findings of this study are available upon request from the corresponding author.

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Supplementary Material

Supplementary data. Knowledge, attitudes, and practices of O. viverrini infection in cats based on the Likert response (N=175). (A) Percentage of correct answers (K1-K10) assessing the understanding of cats regarding O. viverrini infection, transmission, and risks. (B) Percentage of correct answers (A1-A7) evaluating their attitude toward O. viverrini infection in cats. (C) Percentage of correct answers (P1-P10) assessing preventive practices for O. viverrini infection in cats.

Fig. S1A. Knowledge domain as predictor for cat opisthorchiasis.

Fig. S1B. Attitudes domain as predictor for cat opisthorchiasis.