Knowledge and Awareness of Residents in Barangay Pinsao Pilot Project on the Health Effects of Betel Nuts (Moma)

Researchers: Archiel Marie Bawiga Jumar James Briones Aurita Cudia Darrel Joy Gamisera Jolina Mae Loniza Andrea Paningbatan Madoka Tanaka Brylle Domerson Turalba

Abstract: Betel nut is widely used mostly in the local areas all over the country. One of which is Barangay Pinsao Pilot Project, where chewing of betel nuts has became a part of their culture. Betel nuts are believed to cause a beneficial effect to a person who is using it, but it also causes unfavorable effects to health. This research aims to measure the awareness of the residents in Brgy. Pinsao Pilot Project regarding the health effects, both good and bad, of betel nuts. And it has been found out that they are aware of its effects.

Keywords: betel nuts, moma, awareness, knowledge, Barrage Pinsao Pilot Project, health, effects

Introduction: Betel nut (also known as areca nut) is the seed of the fruit from a palm (Areca cachu) belonging to the Palmacae family. It is also called supai, pan parag, marg, maag, pugua, suparim, puwak, gua, mak, pinang and daka. In the locality, it is commonly called moma. Betel nut is often used as a narcotic drug that creates elation and euphoria, and is chewed as fresh, dried or cured forms. Around 10%-20% of the worlds population is chewing it, which makes it the fourth most widely-used psychoactive substance, after nicotine, alcohol and caffeine. (Australian Drug Foundation, 2011) Some people use betel nuts when it is unripe and green; others wait until it is ripe and is a brown or orange to yellow in color. For the Cordilleran people, chewing betel nuts has become their tradition and part of their culture. One of their beliefs is that chewing of betel nuts can stave off hunger and tiredness during long hours in their rice fields. It is believed that betel nuts give a warm sensation to the body and low to moderate sweating (Mirza, Shafique, Vart and Arain). Baguio City has a cool climate. As a result, betel nuts are used as an alternative way for heating the body. Rural areas or less urbanized areas, such as the Barangay Pinsao Pilot Project, have a higher prevalence of habit (Wang, Tsai, Huang and Hong), since they have a higher tendency to engage in chewing betel nuts compared to urban people. This is because rural areas have less recreational parks or places

and people in rural places are less busy in engaging in different activities such as sports, works, parties and the like, rendering them more time to employ in chewing betel nuts. According to a research conducted by Dr. Darawoth Yel of the World Health Organization, betel nuts make users more susceptible to infectious diseases, such as HIV, tuberculosis, dengue, and typhoid fever. In another research from the Australian Drug Foundation, it has been found out that arecoline, which is one of the several chemicals present in betel nuts, affect the central and autonomic nervous system. It has also been found out that the risk of developing health problems is higher when betel nuts are used together with tobacco. Despite these unpleasant effects of chewing betel nuts, many still claim that chewing betel nuts can be used to help treat parasitic infections, strengthen teeth and gums, help with symptoms of mental illness such as schizophrenia, suppress hunger, stimulate appetite, reduce nausea, and treat diarrhea. But at this stage, there is little scientific evidence to support these claims. And even if these curative capabilities may be true, still the health hazards of betel nuts prevail over its benefits. It is evident that many of the community residents in the Barangay Pinsao Pilot Project are using betel nuts. The reasons for the continual practice of chewing betel nuts may be because of the social acceptability of the betel nuts, the residents beliefs, their perceived health benefits, or their addiction. The purpose of this research is to measure the awareness of the residents of Barangay Pinsao Pilot Project about the health effects of chewing betel nuts. In this research, the researchers aim to measure the percentage of the residents of Barangay Pinsao Pilot Project who are using betel nuts; the awareness of the residents who are users and who are non-users, and the residents in general, regarding the good effects of betel nuts; and their awareness regarding its bad effects. In relation to the objectives of this research, the specific research questions include: What percentage of the residents of Barangay Pinsao Pilot Project is using betel nuts or moma? How aware are they regarding the good or beneficial effects of betel nuts? How aware are they regarding the bad or adverse effects of betel nuts? The hypothesis of the researchers is that the residents of Barangay Pinsao Pilot Project are aware of the health effects, both good and bad, of betel nuts.

To the researchers, the significance of this study is to increase their knowledge about the possible health effects of betel nuts. To the community, the significance of this study is to increase their awareness regarding the health effects of betel nuts and not just depending on their beliefs. When the community residents are already aware of the effects, they would be knowledgeable in preventing its effects and complications. To the future researchers, the significance of this study is to serve as a basis for them to focus on other factors such as their beliefs, practices and why they engage in using betel nuts.

Methodology: This study is a descriptive research. Descriptive research provides data about the population being studied. But it can only describe the "who, what, when, where and how" of a situation, not what caused it. Descriptive research refers to a research that provides an accurate portrayal of characteristics of a particular individual, situation, or group. These studies are means of discovering new meaning, describing what exists, determining the frequency with which something occurs, and categorizing information. Short descriptive research deals with everything that can be counted and studied, which has an impact of the lives of the people it deals with. The advantages of a descriptive research include the following: (a) the persons or individuals being studied are unaware, therefore they act naturally or as they usually do in everyday situation; (b) it is less expensive and time consuming; (c) it collects a large amount of notes for detailed studying; and (d) as it is used to describe and not make any conclusions yet, it is used to start a research. The disadvantages of a descriptive research include the following: (a) descriptive research requires more skills; (b) it does not identify a cause behind a phenomenon; (c) the response rate is low in this type of research; and (d) the results of this research can change over the period of time. The descriptive type of research was used by the researchers for this study because it describes data and characteristics about the population or phenomena being studied, in this case the awareness of the residents of Barangay Pinsao Pilot Project regarding the health

effects of betel nuts (moma). The researchers wanted to measure the extent of knowledge of the residents about betel nuts, as well as their awareness on its possible health effects, whether good or bad. This study is a descriptive research because the researchers only wanted to measure their awareness, and it does not deal with experimentations. The approach used by the researchers in conducting this research is quantitative approach. This is a research involving the collection of data in numerical form for quantitative analysis. The numerical data can be durations, counts of incidents, or ratings. Quantitative data can be collected in either controlled or naturalistic environments, in laboratories or field studies, from special populations or from samples of the general population. The defining factor is that numbers result from the process, whether the initial data collection produced numerical values, or whether non-numerical values were subsequently converted to numbers as part of the analysis process. The advantages of a quantitative approach include the following: (a) the results can be interpreted by comparing to each other or to other data or researches already established; (b) it makes data collected that have numerical values comparable; (c) most non-numerical data collected can be converted to numerical values for comparison and easier interpretation; (d) it is more accurate than qualitative approach; (e) the values expressed in numbers are very meaningful and has a higher significance compared to the other approaches; and (f) it requires a shorter period of time. The disadvantages of a quantitative approach include: (a) it is limited to data which can be converted to numerical values and is not therefore applicable for data which are subjective in form such as beliefs, values, perceptions, and attitudes; and (b) even a small error in the calculation of data may lead to incorrect and unreliable interpretations or conclusions. The researchers have used the quantitative approach because this study deals primarily with the measurement of awareness of the residents of Barangay Pinsao Pilot Project regarding the health effects of betel nuts. And this measurement can only be done quantitatively. This is to make the data gathered by the researchers comparative. It is comparative in the sense that it allows the researchers to evaluate the awareness of the residents by the virtue of using numbers. Secondly, it requires a shorter period of time to gather data, because the researchers have only a limited amount of time to finish the study. And lastly, so as it can be used for future reference in case there is another study regarding their awareness to evaluate whether their awareness has increased or remained the same.

In order to gather data for this study, the researchers have utilized the use of a questionnaire, and had asked 147 respondents in Barangay Pinsao Pilot Project to answer it. By-standers, entrepreneurs, jeepney drivers and other local residents were personally asked by the researches to answer the questionnaire. The questionnaire used, consists of a series of questions regarding the health effects of chewing betel nuts, and have corresponding choices which may depict the ideas or answer of the respondent. Some of the choices which were given are facts about chewing betel nut, while the remainder was false beliefs. This is done in order to test how ignorant or how familiar a respondent is, regarding the health effects of chewing betel nuts. The respondents were asked to answer each question by selecting or putting a check mark on the predefined choices. The answers were tallied and used for interpretation. The advantages of using a questionnaire include: (a) it is systematic; (b) it is objective; (c) it is relatively quick to collect information; (d) potential information can be collected from a large portion of a group; (e) it is practical; and (f) it can be carried out by the researcher or by any number of people with limited affect to its validity and reliability. The disadvantages of using a questionnaire include: (a) it is standardized and it is not possible to explain any points in the questions that respondents might misinterpret; (b) openended questions can generate large amounts of data that can take a long time to process and analyze; (c) respondents may answer superficially especially if the questionnaire takes a long time to complete; (d) there is no way of telling how truthful a respondent is being; (e) there is no way of telling how much thought a respondent has put in answering; and (f) there is a level of researcher imposition.

Graphs: Figure 1. Users and Non-users of Betel Nuts

Users and Non-users of Betel Nuts

45% 55%

User Non-user

The graph shows that 55% of the residents of Barangay Pinsao Pilot Project are nonusers of betel nuts. And 45% are betel nut users. Majority are non-users, but almost half of the residents are users which depicts that chewing betel nut is now became a generally accepted habit in their community, and not just a practice, done by the residents. Figure 2. Good Effects of Using Betel Nuts

Good Effects of Using Betel Nuts

2% 2% 12% 4% 42% Strengthens teeth Gives intelligence Makes the body strong and gives energy Relax Strengthens the bones 25% Brightens the mood Gives nutrition Heal diarrhea, headache, etc.

7%

6%

The graph shows the knowledge of the residents regarding the good effects of using betel nuts. The researchers have included options in the questionnaire related to the good effect that are based on beliefs and on facts. Their knowledge would be measured according to the options they have chosen. According to scientific studies, it has been proven that none of its effects would really give benefit to an individual but instead betel nuts only cause bad effects. Therefore, none of these choices or options is correct, and they are only false beliefs. For the purpose of measuring their knowledge, the researchers included significant options that would coincide to the respondents common knowledge. The graph shows that majority (42%) of the respondents answered that chewing betel nut strengthens their teeth. It is due to their belief and practices associated to their culture. It is also their common knowledge which is passed down from generation to generation. While only 2% have answered that it heals diarrhea, headache, and other common diseases, because only a small percentage of them perceive that chewing betel nuts have medicinal components to cure various illnesses. Only 2% have also answered that it is a source of nutrition. This is due to their perception that it is used like a cigarette, and not eaten as a food.

Figure 3. Bad Effects of Using Betel Nuts

Bad Effects of Using Betel Nuts

1% 10% 6% 24% Bleeding gums Discoloration of the teeth Diarrhea, headache, etc. 12% Oral cancer Liver cancer 6% 41% Increase blood pressure Diabetes

The graph illustrates the awareness of the residents regarding the bad effects of betel nuts. In order to measure their awareness, the researchers have included choices in the questionnaire which are scientifically-based facts and choices which are false beliefs. The bad effects which are included in the questionnaire that has a scientific basis are oral cancer, bleeding gums, discoloration of teeth, increased in blood pressure, diarrhea and headache, whereas the liver disease and diabetes are just false beliefs. The graph shows that majority which is 41% of the respondents have answered discoloration of teeth as a bad effect of using betel nuts. This is because many of the betel nut users in their barangay have evidently yellowish to brownish color of teeth. Only 1% of the respondents have answered diabetes. This is due to the fact that the residents see themselves as healthy, and most likely there is only a low prevalence of diabetes in their barangay. And as they see it, most, if not all, of the betel nut users does not have diabetes. Figure 4. Rating on the Personal Level of Awareness Regarding the Health Effects of Betel Nuts

Rating on the Personal Level of Awareness Regarding the Health Effects of Betel Nuts
6% 10% 22% 5-Fully aware 4- Almost fully aware 17% 20% 25% 3- Aware 2-Slightly aware 1-Somehow aware 0-Unaware

The graph shows the personal opinions of the residents regarding their extent of personal awareness about the health effects of betel nuts. The respondents rated their personal awareness from 0-5 and 5 being the highest. 5 representing that they are fully aware about the health effects of betel nuts whether it is good or bad. They know what will be the effect of it physically and mentally as well as emotionally, including its complications. 4 representing almost fully aware. This means that the respondents are on the state of being fully aware, they just need more information that would satisfy and confirm their knowledge about the health effects of betel nuts. 3 represents that the respondents are aware and know the basic things about the health effects of betel nuts. 2 represents that the respondents are slightly aware about the health effects of betel nuts. It means that the respondents have a little or few idea about the effects of betel nut. 1 in the choices means that somehow they are aware and this is due to the information they get from other people. And 0 represents that they are unaware. They do not have any idea about the health effects of betel nut and they do not care. Based on the conducted survey, the graph shows that majority of the residents (25%) rated 3, which means that they are quite familiar of the effects since some of them use betel nuts. Some of them may have read information about it and/or some have encountered people who are using it. 6% of the respondents rated 0 or no idea at all. Only a small number of the

respondents have admitted that they do not know anything about the health effects. This may also indicate that they do not care at all.

Computations: To compare the awareness of the residents, the answer of each respondent concerning the health effects of betel nuts, both good and bad, was taken as a percentage according to number of items or choices they have answered correctly. This is on the basis of true-or-false principle, where the choices which are scientifically-based are considered true and the false beliefs considered false. The respondents were instructed to check the option which they think is true and leave it blank if they think it is false. The number of correct items a respondent got was tallied. And the percentage of correct items was taken. The percentages computed were used for further computation and evaluation. 50% awareness was considered a minimum value for an individual to be aware, and it is used as a standard value in this study. To compare the awareness between the betel nut users and non-users in the Barangay Pinsao Pilot Project regarding its health effects, both good and bad, the researchers have used a two-sample t-test with a confidence level of 95%. The following data shows what they have computed: Their awareness regarding its Good Effects: USERS Mean of sample Minimum percentage awareness to become aware (Proposed mean of population or Standard Value) Standard Deviation Variance Population (n) Minimum percentage awareness to become aware (Proposed mean of population 50 or Standard Value) 15.81139 Standard Deviation 250 Variance 66 Population (n) Degree of freedom (df) 145 50 12.40901 153.9834 81 77.46212 Mean of sample NON-USERS 85.03086

Confidence interval 95% t-value -3.173285268 Critical value 1.960 H0: 1 = 2 (There is no significant difference between the awareness of users and non-users regarding the good effects of betel nuts.) H1: 1 2 (There is a significant difference between the awareness of users and non-users regarding the good effects of betel nuts.)

Decision Rule: Reject H0 if |tc| |t| Accept H0 otherwise Decision: Since |tc = 3.173285268| > |t = 1.960|, therefore reject H0 Conclusion: Based on these data, we can conclude that there is a significant difference between the residents in the Barangay Pinsao Pilot Project who use and do not use betel nuts regarding their awareness of its good effects. Those who are not using betel nuts are more aware of its effects. Their awareness regarding its Bad Effects: USERS Mean of sample Minimum percentage awareness to become aware (Proposed mean of population or Standard Value) Standard Deviation Variance Population (n) Minimum percentage awareness to become aware (Proposed mean of population 50 or Standard Value) 14.67826 Standard Deviation 215.4512 Variance 66 Population (n) Degree of freedom (df) 145 Confidence interval 95% 50 16.88258 285.0214 81 NON-USERS 53.4632 Mean of sample 51.14638

t-value 0.8895597984 Critical value 1.960

H0: 1 = 2 (There is no significant difference between the awareness of users and non-users regarding the bad effects of betel nuts.) H1: 1 2 (There is a significant difference between the awareness of users and non-users regarding the bad effects of betel nuts.)

Decision Rule: Reject H0 if |tc| |t| Accept H0 otherwise Decision: Since |tc = 0.8895597984| < |t = 1.960|, therefore accept H0 Conclusion: Based on these data, we can conclude that there is a no significant difference between the residents in the Barangay Pinsao Pilot Project who use and do not use betel nuts regarding their awareness of its bad effects. The researchers have also measured the awareness of the residents, in general, regarding the health effects of using betel nuts, both good and bad, using a one-sample t-test with a confidence interval of 95%. The following data shows what they have computed: GOOD EFFECTS Mean of sample Minimum percentage awareness to become aware (Proposed mean of population or Standard Value) Standard Deviation Variance Population (n) Degree of freedom (df) Confidence interval t-value 50 14.43174 208.2751 147 146 95% 26.4846 81.63265

Critical value

1.645

H0: 1 (The residents are not aware of the good effects of betel nuts.) H1: < 1 (The residents are aware of the good effects of betel nuts.) Decision Rule: Reject H0 if |tc| |t| Accept H0 otherwise Decision: Since |tc = 26.4846| > |t = 1.645|, therefore reject H0 Conclusion: Based on these data, we can conclude that the residents in the Barangay Pinsao Pilot Project, in general, are aware of the good effects of chewing betel nuts. BAD EFFECTS Mean of sample Minimum percentage awareness to become aware (Proposed mean of population or Standard Value) Standard Deviation Variance Population (n) Degree of freedom (df) Confidence interval t-value Critical value 50 15.91959 253.4332 147 146 95% 1.659632 1.645 52.18659

H0: 1 (The residents are not aware of the bad effects of betel nuts.) H1: < 1 (The residents are aware of the bad effects of betel nuts.)

Decision Rule: Reject H0 if |tc| |t| Accept H0 otherwise Decision: Since |tc = 1.659632| > |t = 1.645|, therefore reject H0 Conclusion: Based on these data, we can conclude that the residents in the Barangay Pinsao Pilot Project, in general, are aware of the bad effects of chewing betel nuts.

Conclusion: The respondents, who are using betel nut, are aware of the bad effects of betel nuts. Yet, they werent able to stop or eradicate their habit of chewing betel nuts because they were already addicted to it. The substance, nicotine, is responsible for their addiction and is relatively similar to nicotine found in cigarette. In addition, chewing betel nuts have the so called psychostimulating capacity which gives difficulty for the users to stop. Chewing a betel nut is seen not only a habit for them, but rather, it is already part of their practices embedded in their culture. While those who are not using betel nut are more aware of the bad effects compared to those who are using. And because they are more educated and oriented about betel nuts, they are able to resist and refuse chewing betel nut. They are afraid of getting acquiring disease because health care services nowadays are at high costs. They are aware of the complications and diseases that they might acquire if they engage in the said activity. As a result, they value their health and see it as an important thing and investment for their everyday living. In general, we have found that the residents of Barangay Pinsao Pilot Project, inclusive whether betel nut users or not, are aware of the effects of betel nuts to their health. They are able to differentiate and quantify its beneficial and harmful effects. Although they seem to be trapped on their beliefs about betel nut, they are still open for accepting facts on the subject of betel nuts. Though betel nut is already part of their being and individuality, they still manage to balance their belief and awareness, and differentiate what is fact from fallacy.

Recommendation:

We, the researchers, would like to help the future researchers by giving some suggestions which will make their future researches easier and more manageable, and recommendations for the improvement of this research. We suggest that the future researchers, before conducting their survey, must acquire a background knowledge with regards to the community where they are conducting their study, especially on the beliefs and culture of the people about betel nuts. In terms of constructing questionnaire, one must have appropriate and answerable questions that will not cause false conclusion. In addition, the number of population of the community should be considered in gathering data from samples. This is to ensure that the total respondents would be able to represent the whole community. This study focuses only on the knowledge and awareness of the residents. We recommend that future researchers shall focus also on other aspects regarding betel nuts such as their beliefs, their practices or way of using it, and why they engage in using betel nuts. We also recommend that further studies, particularly experimental studies, regarding the health effects of betel nuts should be done, so as to obtain a concrete basis of its beneficial and adverse effects. Future studies should be done in Barangay Pinsao Pilot Project in order to determine whether their awareness has increased, or remained the same.

Acknowledgment: We gratefully acknowledge the outstanding contributions made by our ever helpful collaborators who have served as a guide for us to successfully complete our research; first, the barangay kagawads in Brgy. Pinsao Pilot Project who gave us permission to gather data regarding our study in their barangay. To the ever supportive respondents who answered the questionnaires honestly. And most especially to our research adviser, Mr. John McKeveen V. Lerma who has contributed a very big part for the completion of our research. They all have made extensive contributions to the quality of this research and to the development of everyone. We are very grateful. Thank you!

References: 1. A. Tan. 2010. 10 Things You May Not Know About Betel Nut Culture. February 25, 2010. Retrieved: January 14, 2013. http://blog.asiahotels.com/10-things-you-may-not-knowabout-betel-nut-culture/ 2. Auluck, G. Bishop, C. Poh, L. Zhang, and MP Rosin. 2009. Areca Nut Betel and Betel Quid Chewing among South Asian immigrants to Western Countries and its implications for oral cancer screening. May 14, 2009. Retrieved: January 14, 2013.

http//www.ncbi.nlm.bih.gov/pmc/articles/PMC2726113/ 3. F. Javed, F. O. Bello Correra, M. Chotaii, A.R. Tappuni, K. Almas. 2010. Review Article:Systemic Review. Conditions Associated 2010. with Areca Nut Usage: A 14, Literature 2013.

December

Retrieved:

January

http://www.ncbi.nlm.nih.gov/pubmed/20688790 4. J.B. Saley. 2011. Province Prohibits Indiscriminate Spitting of MT Betel Nut. Aug 27, 2011. Retrieved: January 14, 2013. http//www.baguiocity.com/news_article/mt-provinceprohibits-indiscriminate-spitting-betel-nut/ 5. N.W. Burkhart, RHD, EdD. Areca Nut and Betel Quid Use. Retrieved: January 14, 2013. http://www.rdhmag.com/articles/print/volume-31/issue-7/columns/areca-nut-and-betelquid-use.html 6. R. Dacawi. 2011. Cordillera on My Mind. May 2, 2011 7. R. Dacawi. 2012. On moma and Traffic Discipline. Dec. 15, 2012. 8. R.F.H. Taylor MRCP, N.Al-Jarad MRCP, L.M.E. John, N.C. Barnes MRCP, D.M. Conroy PhD. 1992. Betel-nut Chewing and Asthma. May 9, 1992. Retrieved: January 14, 2013. http://www.ncbi.nlm.nih.gov/pubmed/1349367 9. S. Kessman. 2011. Health Hazards of Betel Nuts. February 20, 2011. Retrieved: January 14, 2013. http://voices.yahoo.com/health-hazards-betel-nuts7904006.html 10. S.S. Mirza, K. Shafique, P. VArt, and M.I. Arain. 2011. Areca Nut Chewing and Dependency Syndrome: Study. IS the dependence August 18, comparable to somking? A Cross 14, Sectional 2013.

2011.

Retrieved:

January

http://www.substanceabusepolicy.com/content/6/1/23 11. Su, Chi, Shun, Yu. 2003. Betel Nut Chewing and Related Factors in Adolescent Student in Taiwan. Volume 117, Issue 5, September 2003, Pages 339345. Retrieved: January 14, 2013. http://www.sciencedirect.com/science/article/pii/S0033350603000829

12. Website by Salsa Internet; Betel Nut Facts. Jan 18, 2012. Retrieved: January 14, 2103. http//www.druginfo.adf.org.au/drug-facts/betel-nut/

Appendix: