Improving the Use of Curcuma Aeruginosa Roxb. as Anthelmintic for Children in Indonesia

This article based on the study results aims to improve the knowledge, attitude and practice (KAP) of mothers about self-medication of worm infections using Curcuma aeruginosa Roxb., a natural plant easily found in Indonesia. It consists of assessment and intervention to mothers(189) and children(204). Samples were collected from two Village Integrated Health Post in Cibungbulang village Bogor Municipality West Java Province. The KAP of mothers increased after they got health education & information and 95% of children who joined Curcuma treatment confirmed curing from worm infections, most of them 3 years old. Deworming program for children with Curcuma should be carried out routinely at least twice a year.

One of the contributors of the malnutrition and high morbidity in Indonesia is worm infections. Based on available data from Ministry of Health, in 2008 the prevalence of worm infections in Indonesia was 33.1% with the wide range from 0 to 60.98%. Several researches VKRZHG WKLV ¿JXUH WHQG WR UHPDLQ FRQVWDQW XQWLO 1, 2,3,4 Worms are passed to person through contact with contaminated feces, for instance eating of poorly FRRNHG ÀHVK RI DQLPDO FRQWDPLQDWHG ZLWK IHFHV 6RPH worms may cause diarrhea in addition to weakness and progressive anemia. It may creates and worsens malnutrition, and in some cases can lead to heart failure and death. 3,5,6 To combat worm infections, the appropriate public health program is needed.
Deworming children by medicinal plant is one of the easiest, cheapest and most effective public health interventions. Deworming would lower anemia levels, and support their growth and their ability to be more focus, in studying and playing; the children more protective to get sick and would have much healthier. 5 Mothers have the important role in preventing child's health. Several researches showed that there is an association between mother's education and children's health state. 7 If mothers have knowledge about worm infection, purposively they will put a better efforts to prevent their child to free on such infections through a better or healthier life style. 2 The effective health edu cation should be focused, comprehensive and delivered with communicative languages. It will empower community to solve their health problems by themselves. 8 People who live in rural areas have poor knowledge on basic health and hygiene practices, poor access to health facilities, as well as clean water and decent accommodation. 2 Accordingly, some of them may not realize that they are susceptible of worm infections. 3,5,6 So that the government need to focus RQ WKH GHZRUPLQJ EHQH¿FHQW WDUJHW 8QIRUWXQDWHO\ the regional/local government has limited resources i.e. budgets, so that the availability of the medicinal plants in their surrounding can be a good and EHQH¿WWHG VROXWLRQ IRU WKHLU ZRUP SUREOHPV Curcuma aeruginosa is a natural plant which is easy WR ¿QG LQ ,QGRQHVLD LQ KRXVH \DUG DQG DORQJ WKH street and its rhizomes are sold in the market with the cheap price (Rp.300,-/100gr). Its local name is temu ireng. Traditionally, our great grand parents have used Curcuma as an anthelmintic or as an appetite stimulant. Clinical tests to adults and children proved that the rhizome of Curcuma aeruginosa is the most effective anthelmintic among other medicinal plants in Indonesia. 9,10 The toxicity rate is also very low. In vitro research showed that the rhizome juice suppressed the spontaneous contraction of rabbit's jejunum. 11 Other researches state that the Curcuma's extract possessed spasmolytic effects in the rat intestine and uterus and they also showed that the immersion of Ascaris in Curcuma solution, concentrate 60% for 24 hours, killed 68% Ascaris. 9,12 Another research found that extracted Curcuma consists of essential oil and active substances. These essential oils have work mechanism similar like acetylcholine antagonize to suppress the contraction of the smooth muscles. 13 Koesdianto Tantular conducted clinical test of Curcuma's rhizome in Surabaya towards 79 students from elementary school, comparing treatment of worm infections using 15 ml (25 gram) Curcuhita moscata versus Quiscalis indica, Curcuma heyneana, Curcuma aeruginosa, and Mebendazol 500 mg. The results found that only Curcuma aeruginosa showed the equivalent CR (Composite Reliability) as compared to Mebendazol with the least side effects. 14 Other research also found that Curcuma aeruginosa was the most effective anthelmintics compared to other medicines in Indonesia. 6,9,10,11 However, the use of Curcuma aeruginosa as herbal medicines has not yet popularized and well understood. The community have not known that Curcuma is has an anthelmintic remedy.
This study aims to improve mothers' knowledge, attitude and practice on child's medication on worm infections using easily available plantation of Curcuma aeruginosa Roxb.

METHODS
Type of study was a community intervention taken place in Cibungbulang municipality, Bogor, West Java. Cibungbulang is one of backward areas with poor hygiene and sanitation condition. Based on health district reports in 2005-2006 the prevalence of worm infections was >50%. Before the study EHJDQ ZH GLG WKH RULHQWDWLRQ LQ RUGHU WR FRQ¿UP that the prevalence of worm infections for children in Cibungbulang was about 50%. We tested several children's feces, and the result was 25 of 45 children FRQ¿UPHG VXIIHULQJ IURP ZRUPV LQIHFWLRQV LQ other words, ± 56% of children suffered from worm infections. This area was also chosen as Curcuma is easy available and grew in this area. Samples were taken from two Village Integrated Health Posts or Posyandu during 3 months, of intervention, that was May to July 2009.
The study populations were mothers at Cibungbulang villages in 2009. Samples for this study was mothers with children age 3 to 10 years old by the reason these children were more likely to be exposed by dirty ground area or open environment. The number of samples calculated by using the following Lemeshow formula n = Z² . P (1-P) / d² .
:H XVHG WKH FRQ¿GHQFH LQWHUYDO GHYLDQFH 10%. The proportion is 0.50. Based on this formula, the sample calculation result is 167, which means the minimal samples should be 167 mothers. In this study, the total sample at the beginning were 189 mothers with the total children of 204. After the feces examination, FKLOGUHQ FRQ¿UPHG ZRUP LQIHFWHG 7KH QXPEHU RI eligible mothers became 80 persons. However, only 77 mothers including 80 children continued join the study.

Data collection process:
Mothers whose children were participating stool test were asked to participate the KAP interview on worm infections. Before the interview was started, the mother KDV WR VLJQHG IRU WKH LQIRUPHG FRQVHQW WR FRQ¿UP WKHLU participation. Structured interviewed was conducted involving 16 questions with yes or no type of answers. 0RWKHU ¶V FKDUDFWHULVWLFV ZHUH LGHQWL¿HG VXFK DV DJH education, job, and monthly household expenditures.
Then we delivered health education and information to these mothers whose children approved suffer from worm infection. The materials of health education about anything related to the worm infections including medicinal plants for worm treatment. Mothers were involved in their child's treatment using Curcuma namely accompanied their children to drink the Curcuma at Posyandu in 3 (three) consecutive days. Mothers were also asked to bring their children's feces to be tested to the primary health care. Researchers presented the result of the stool examinations to the mothers together with delivering health related promotion and information Furthermore, WKH\ ZHUH DVNHG WR ¿OO WKH VDPH TXHVWLRQQDLUHV DV EHIRUH about the KAP of worm infections.
Curcuma drink preparation: Materials: Rhizomes of Curcuma aeruginosa Roxb. were collected from local market in Cibungbulang village. The rhizomes were cleaned, washed and minced with knife. The minced Curcuma's were boiled with enough water and sugar. The concentrate of Curcuma drink was 10 ml equal to 10 gram fresh rhizome for children age 3 to 5 year and 25 ml equal to 25 gram fresh rhizome for children above 5 years old. The Curcuma drink was given to children one time a day along 3 days. 14 In this study the Curcuma drink prepared by researchers together with cadres and mothers.
At the end of the study we gave the mothers the Curcuma rhizomes and asking them to plant the rhizomes at their house yards.
Data Analysis: all data were analysed statistically using SPSS ver.12.0. We present descriptive and bivariate using chi-square test.  Table 2 shows the proportion of characteristic of children.
Generally, the KAP of mothers related to worms infection and how to treat their families to be free from worms infection increased after they got health education and information, for example, formerly only 52% mothers knew that the way of worm get inside into the body can be through dirty/poor cooked meals, then after intervention there were 71% of mothers knew about it. In addition from 14 to be 68% of mothers knew that Curcuma can treat their families when suffering from worms infection. The KAP results of the mothers, either pre and post intervention, can be seen in Table 4.

DISCUSSION
The intervention on knowledge improvements of mothers was able to increase mothers understanding on the worm infections as a contagious disease. They have become well understood that dirty environment as well as inappropriate food cooking could bring about infection caused by entering the worm's larva into our stomach. Previous study mentioned comprehensive health intervention and education can be a good way to enlarge people's knowledge. 7,8 Curcuma, a plantation that easily available, culturally acceptable and hence affordable has become a good type of herbal medicine. This study found, that the number of worm after it has been intervene with the KHUE KDV EHHQ UHGXFLQJ VLJQL¿FDQWO\ 6HYHUDO VWXGLHV also proved that Curcuma aeruginosa is one of the most effective herbs for deworming. 9,10 With regard to mother attitude and practice, this study found that the mothers can realized that Curcuma can help the children against worm infection The economic reasons would become a good consideration to insist mothers in using Curcuma as a remedy to prevent worm's infection. The background characteristic showed that the household expenditures of their family mostly were about 5S PRQWK 7KLV ¿JXUH ZDV RQ DUHD RI poor people. 15 The fact that mothers were not given the kids a worm medicines by the reason having no money should not be happening again in the future after they have got intervention as an impact of this study. This assumption should be applicable as has been proved by a study that Curcuma effective as anthelmintic can remove economic barrier.
The study showed that 91 of 204 children (45%) FRQ¿UPHG VXIIHULQJ IURP ZRUP LQIHFWLRQV ,Q addition 76 of 80 children (95%) who joined Curcuma WUHDWPHQW FRQ¿UPHG FXULQJ IURP ZRUP LQIHFWLRQV 7KH study supported previous studies state that Curcuma is effective as anthelmintic. Its essential oils that works effectively against worms. 9,10,11 Majority children who suffered from worm infection were 3 years old. In addition, ±78% of children was not going to the school. Generally, it is assumed that children who have already attended school would have a better knowledge & practice about cleanness & personal health. 6,11 In addition, the majority education background of the mothers were only elementary school (70%), accordingly the knowledge of the mothers about worm infections, environment & personal health were limited. However, the existence of posyandu with the dedicated community cadres helped them to improve their KAP related to their health. It is clear that public health intervention is able to change community's behavior on positive direction. This study shows that intervention by giving curcuma and health education can decrease the prevalence of worm infections among children. This can be a good model in Indonesia because it is possible to do, especially with posyandu cadres supports. The local government should maintain the existence of the community cadres who work voluntary for the VIHP. Cadres provide information and help to connect health and social support services, and to engage posyandu members to do improvement activities. Furthermore, the government should support the posyandu with budget and suitable facilities, such as computer, audio visual and mobile vehicle. These community cadres should also be trained with many health programs. 16 Several references studies recommend that health education & information should be conducted comprehensively & intensively to mothers in enhancing their KAP related health. 17, Health education is a tool to increase people's knowledge in addition to motivating community to keep their healthy life style. The improvement of mother's knowledge may stimulate the change of their attitude and practices in a positive way such as preventing disease occurance. 16,18 In this study the health education was delivered only with health presentation, discussion and demonstration. It did not involve the interpersonal communication and nice video audio visual such as short movies, symbols. etc. Those may lead to the better improvement of the KAP of mothers and the recorder can be a tool for repeating other same health education programs.
Sustainability of the use of Curcuma to prevent or cured worm infections in the community need to be strengthened. To gain sustainability a regular refreshment and or dissemination may needed, so that, the mothers and community get use and keep practicing this traditional herb as well as better sanitation until the incidence of worm infection is declined. 8 The next programs can be carried out without feces tested as the Curcuma drink is safe, similar like ginger and tea.
Program on deworming has been implemented in Indonesia, the program mostly conduct at schools. 6,19 However, the incidence of worm infection is still be in problem. As found out by this study, it seems that delivering pills only through the scholl children may not enough, but changing behaviour from home through mothers' informal education should be considered as well. The study recommends that not only at school, deworming programs in posyandu should be one of its routine programs, because PRWKHUV DQG FKLOGUHQ XQGHU ¿YH \HDUV YLVLW WKH posyandu regularly. 20 In conclusion, the use of Curcuma aeruginosa Roxb is potential remedy to medicate worm infections. This herb is easily available in the yard or market, economically affordable price and can be done without examination of stool. Dissemination information of this herb and its function through informal education to mothers and or community is considered to be an effective way to reduce the disease prevalence. This study showed that mothers knowledge improvement on worm medication using Curcuma was able to change their attitude and practice to healthier life style. In addition, the program of deworming children that conducted by government can be conducted by using Curcuma.

Ethical approval
Ethical clearance was provided by the National Commision of Ethics, National Institute of Health Research and Development, Ministry of Health-Republic of Indonesia.