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Community knowledge, awareness and preventive practices regarding dengue fever in Puducherry – South India
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Original Research
Community knowledge, awareness and preventive practices regarding dengue fever in Puducherry e South India S. Jeelani*, S. Sabesan, S. Subramanian Vector Control Research Centre, Indian Council of Medical Research (ICMR), Indira Nagar, Gorimedu, Puducherry 605006, India
article info
abstract
Article history:
Objectives: To ascertain the knowledge, attitudes and practices of adult population in
Received 24 June 2014
Puducherry, India, regarding Dengue Fever (DF).
Received in revised form
Study design: A cross-sectional survey was carried out to assess the Knowledge, Awareness
26 December 2014
and Preventive practices (KAP) among a selected community in Puducherry on DF,
Accepted 22 February 2015
following a major dengue outbreak in 2012.
Available online xxx
Methods: Between October 2012 & February 2013, an epidemiological survey was conducted among 400 households (HHs) from the most affected areas during dengue outbreak, which
Keywords:
came under eight health delivery jurisdictions i.e. Primary Health Centres (PHCs) in
Community knowledge
Puducherry. Knowledge of dengue and the use of preventive measures were assessed by
Dengue fever
means of a pre-tested structured questionnaire. Logistic regression analysis was done to
Puducherry
examine the association between different levels of education and income status with the knowledge of DF. The DF knowledge map was created based on the results achieved through the questionnaire using Arc GIS 10.2 software. Results: Although about 86% of the participants had heard of dengue, although there was no adequate knowledge on dengue vector breeding habitat as 68% of the respondents thought drains & garbage as breeding places of dengue vectors. Only 25% of participants were aware of clean water as a breeding habitat. Insufficient knowledge of disease symptoms was found, with fever (59%) being the most common symptom. Conclusions: There is a lack of in-depth knowledge on dengue epidemiology in the Puducherry community and observation revealed that more needs to be done by the Government as well as community members to prevent vector mosquito breeding. © 2015 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. Division of Vector Ecology and Surveillance, Vector Control Research Centre (ICMR), Indira nagar, Gorimedu, Puducherry 605006, India. Tel.: þ91 7358807101; fax: þ91 4132272041. E-mail address: [email protected] (S. Jeelani). http://dx.doi.org/10.1016/j.puhe.2015.02.026 0033-3506/© 2015 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Jeelani S, et al., Community knowledge, awareness and preventive practices regarding dengue fever in Puducherry e South India, Public Health (2015), http://dx.doi.org/10.1016/j.puhe.2015.02.026
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Introduction Dengue is one of the most dreadful arboviral diseases of humans with over half of the world's population living in areas of risk. An estimated 3.5 billion people, or half the world's population, are at risk for dengue virus (DENV) infection in tropical and subtropical countries.1 Sporadic outbreaks of Dengue fever (DF) have been reported in India for over two centuries2,3 but the earliest virologically confirmed outbreak occurred in 1956 in Vellore, Tamil Nadu.4 The first major outbreak of dengue began in 1963 in Calcutta, West Bengal, from where it spread to other states, eventually affecting most parts of the country.5 The frequency, magnitude and geographical distribution of epidemic dengue and potential occurrence of life-threatening dengue hemorrhagic fever (DHF) have increased dramatically in the past 40 years as the viruses and the mosquito vectors have both expanded geographically in the tropical regions of the world.6 The factors responsible for this increase and expansion are societal changes such as population growth, urbanization, changing habitats and behaviour, and lack of effective vector control.7e9 High human population density and inadequate water supply (water storage practice) are regarded as major contributors to dengue epidemics.10,11 The vector mosquitoes transmitting the DENV are Aedes species mainly Aedes aegypti & Ae. albopictus. The infection, earlier restricted to urban/semi-urban areas, can now be seen in rural areas as well.12 Over the last decade, the geographical distribution of DF has included new countries and more rural areas, making it the most rapidly expanding arboviral disease in the world.13 Despite mass communication and educational approaches, community participation is far below expectation. Community participation in turn depends on peoples' awareness, knowledge and attitude towards the disease.14 Several socio-economic studies in different countries indicate variations in knowledge and practice-related to mosquito-borne diseases.15,16 Puducherry experienced its first major outbreak in 2003 with 60 confirmed cases of infection from the district in 10 urban and 9 rural Primary Health Centres (PHCs).17 A four-fold increase of dengue cases had been observed in 2011 (n ¼ 230 cases). For the year 2012, a six-fold increase had been recorded with a total of 1391 dengue cases. The increasing incidence of DF and the lack of relevant studies on the knowledge, awareness and practice (KAP) of the Puducherry community regarding DF transmission and prevention prompted us to conduct the present study.
Methods Study area The study was conducted in Union territory of Puducherry, geographically located at 162 km south of Chennai, surrounded by the Bay of Bengal on the east, and on the other sides by the Cuddalore and Villipuram districts of Tamil Nadu (Fig. 1). Puducherry experiences hot and humid climate with temperature normally varying between 26 and 38 C.
Sampling design Areas from where the maximum number of dengue cases have been reported (under 8 PHCs) in the previous year were selected for the study. Knowledge of dengue fever was assessed using questions aimed at ascertaining the community's understanding of the disease epidemiology (symptoms, transmission, etiology and vector) and standard preventive strategies (mosquito nets, mats, water storage). In a population of 165,252, assuming 50% prevalence of good knowledge, with an error margin of 5% at a 95% level of confidence, the minimum number of respondents required to fulfil the objectives of this study was 383. The samples were distributed in proportion to the population in the dengue affected villages.
Field based data collection A household survey was carried out between October 2012 and February 2013 using a structured questionnaire, translated into local language i.e. Tamil. Head of the family or any adult family member above 18 years of age available at home during the survey was interviewed following informed consent. The questionnaire was divided into three sections. The first section covered the sociodemographic information about the respondents. The second section was about knowledge regarding the symptoms, spread of dengue and preventive practices in use against mosquitoes. The section third consisted of checklists that indicate data on water storage and waste disposal practices within the household, including vector indices.
Ethical clearance The protocol of this study was approved by the Institutional Human Ethics Committee (IHEC) of Vector Control Research Centre (VCRC) on 14th February, 2012. The objectives of the study were explained to the local community including community leaders and health professionals. Sufficient time was given to ask questions and it was emphasized that participation in the survey was voluntary and they could quit any time during the interview. Those who wished to participate were required to sign a consent form prepared in accordance with the guidelines of IHEC prior to the use of questionnaires.
Data analysis The data collected from the survey were accessed into an Excel database and later analysed using IBM SPSS version 20. Logistic regression analysis was done to examine the association between different levels of education, and income status with the knowledge of DF. Microsoft Excel version 2013 was used to draw graphs and charts wherever appropriate. Additionally, each question was assigned with a score (ranging from 0 to 4) depending upon the type of question, and the score achieved by a respondent was described as knowledge score of that particular respondent. The total knowledge score was determined by taking the average of score achieved by all the respondents in a particular area. Location of the areas surveyed was recorded using hand-held global
Please cite this article in press as: Jeelani S, et al., Community knowledge, awareness and preventive practices regarding dengue fever in Puducherry e South India, Public Health (2015), http://dx.doi.org/10.1016/j.puhe.2015.02.026
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Fig. 1 e Map showing the study sites.
positioning system (GPS) and a map was generated based on the knowledge score achieved by each area, using the GIS mapping software developed by Esri, Arc GIS 10.2 software (Fig. 2).
Dengue related knowledge
Results
The outcome of the survey pertaining to awareness on dengue transmission, its symptoms and treatment are shown in
The socio-economic details of the study population are given in Table 1. A total of 400 respondents were interviewed and the data so obtained was used for primary analysis. 40.5% of the people were from higher socio-economic group and 59.5% from lower socio-economic group. A majority of them was
Fig. 2 e Map showing the distribution of dengue knowledge in the study area. Dengue knowledge map was created based on the overall area-wise knowledge using licenced GIS software, Arc GIS 10.2 (Esri).
female (67.3%), house makers (53.7%) and had education up to high school (59.3%).
Table 1 e Sociodemographic characteristics of the study population. Distribution of respondents Gender distribution Male Female Age distribution 18e30 30e45 45e60 >60 Educational status Illiterate Primary High school Intermediate Diploma Graduation or above Occupation Labour Agriculture House wife Student Employed Business Income Low Medium High
No. of respondents
%
129 271
32.3 67.7
118 142 87 53
29.5 35.5 21.7 13.3
64 55 139 70 17 55
16.0 13.8 34.7 17.5 4.3 13.8
45 8 215 24 65 43
11.3 2.0 53.7 6.0 16.3 13.7
238 104 58
59.5 26.0 14.5
Please cite this article in press as: Jeelani S, et al., Community knowledge, awareness and preventive practices regarding dengue fever in Puducherry e South India, Public Health (2015), http://dx.doi.org/10.1016/j.puhe.2015.02.026
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Table 2 e Knowledge on dengue spread, symptom and treatment.
Table 4 e Knowledge of vector breeding, biting time and preventive practices.
Variable
Variable
n
%
a
Awareness of dengue Yes No Mode of spreadb Mosquito bite Contaminated food/water Don't know Human to human spread Yes No Don't know Common symptomsb Fever Body pain Headache Skin rashes Vomiting Don't know Medicines against dengue Yes No Don't know
342 58
85.5 14.5
283 28 44
82.7 8.2 12.9
91 215 36
26.6 62.9 12
203 80 72 58 49 139
59.4 23.4 21.1 15.5 14.3 40.6
33 93 214
10.2 27.2 62.6
a
Rest of the knowledge related questions were asked only to those respondents who replied ‘Yes’ to this question. b Multiple response options.
Table 2. Among the total respondents, 85.5% have heard of dengue fever and most of them (82.7%) were aware that it is transmitted through mosquito bites. A few of them (8.2%) opined that this disease is transmitted through contaminated water & food. When asked about the common symptoms, fever was the most consistent response (59%) followed by body pain (23%) and headache (21%). No significant association was found between DF knowledge and respondent's area of residence (refer: Table 3). The extent of knowledge regarding vector breeding sites, biting behaviour and preventive practices were summarized in Table 4. When respondents were asked about the breeding habitat of the vector mosquitoes, 67.8% of them answered drains and garbage, and only 42.5% of them were aware that they breed in stagnant water and 4.7% were ignorant about the breeding habitat of mosquitoes. Only 25.1% were aware that
Table 3 e Association between dengue fever knowledge and area of residence. Variable
Rural (n)
Awareness of dengue Yes 167 No 33 Transmission of dengue Yes 135 No 32 Symptoms of dengue Yes 92 No 75
n
%
146 33 232 86 16
42.5 9.6 67.8 25.1 4.7
152 37 201 77
44.4 10.8 58.8 22.5
251 97 27 26 51
62.7 24.3 6.8 6.5 12.8
a
Urban (n)
Chi-square (c2) P-value
175 25
c2 ¼ 1.29 P ¼ 0.26
148 27
c2 ¼ 0.84 P ¼ 0.30
111 64
c2 ¼ 2.46 P ¼ 0.12
No significant difference in dengue knowledge was found between rural and urban areas.
Common breeding sites Stagnant water Septic tank Drains & garbage Clean water holding containers Don't know Most frequent mosquito biting timea Morning Noon Evening Night Preventive practicesa Liquid vaporizer Coil Electric bat Mosquito net Nothing a
Multiple response options.
dengue mosquito breeds in clean water-holding containers. Most of the people knew that mosquito usually bites either at evening (58.8%) or at morning time (44.4%). Preventive practices regarding dengue were consistent with the knowledge about these practices, with majority of the people relying on liquid vaporizers (62.7%) and/or mosquito mats (24.3%).
Source of information on dengue fever Television (55%) was identified as the main source of public information followed by Newspaper (38%) and Radio (31%). 29% of the respondents have heard about dengue through Govt. awareness campaigns and only 6.8% heard it in school (Table 5).
Water supply and storage practices Most of the households were found to store water in different types of containers in all the study sites. Nearly 42% of HHs used small containers (plastic/metal vessel) for storing water, while as 31% of HHs used plastic fibre (‘Sintex’) tanks and only 12.5% used cemented tanks/cisterns for water storage. 19% of the HHs stated that they did not require water to be stored (Fig. 3).
Table 5 e Source of information about the dengue received by the respondent in the survey (n ¼ 342). Variable
Frequency (n)
Where participants have heard about denguea: Television 188 News paper 132 Radio 123 Awareness campaign 117 School 27 a
Percentage (%) 55.0 38.0 31.0 29.3 6.8
Multiple response options.
Please cite this article in press as: Jeelani S, et al., Community knowledge, awareness and preventive practices regarding dengue fever in Puducherry e South India, Public Health (2015), http://dx.doi.org/10.1016/j.puhe.2015.02.026
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Table 7 e Dengue fever knowledge among respondents of different educational status. Level of education Illiterate Up to High school Intermediate Graduation & above
No. of persons interviewed
Persons with dengue knowledge (%)
OR (95% CI)
64 194
70.3 59.3
1.0 1.6 (0.9e3.0)a
87 55
51.7 49.1
2.2 (1.1e4.4)b 2.5 (1.2e5.2)b
a
Respondents with qualification up to high school were 1.6 times more knowledgeable than illiterates, but there was no statistical significance. b Participants with a qualification of intermediate or above were more than two times more knowledgeable as compared to illiterate.
Fig. 3 e Water storage practices reported by participants during the survey (n ¼ 400). *Multiple responses. Nearly 42% of HHs used small containers (plastic/metal vessel) for storing water, while as 31% of HHs used plastic fibre (‘Sintex’) tanks.
high-income group, and it was still poor with the lowerincome group. Logistic regression analysis revealed that knowledge of dengue was independent of socio-economic group (c2 ¼ 1.54; P ¼ 0.46). There was no much difference in knowledge among the middle and high income groups (Fig. 4).
Waste disposal practices
Discussion Data regarding the waste disposal practices employed by study population is presented in Table 6. In only 48% of HHs, waste generated is collected by Municipality squad on daily or alternate day basis, while as 38% of the HHs were dumping it in vacant sites and 11% throwing indiscriminately outside their house. Out of the 400 HHs in study population, only 44% were found to have dustbins in their house. Respondents were also divided into different educational groups and their knowledge regarding dengue fever was assessed. A significant association was found between degree of knowledge and level of education among respondents. Participants with a qualification of intermediate (OR ¼ 2.2, 95% CI 1.1e4.4) or above (OR ¼ 2.5, 95% CI 1.2e5.2) were more than two times more knowledgeable as compared to illiterate. However, persons with qualifications up to high school were 1.6 times more knowledgeable than illiterates, but there was no statistical significance (Table 7). The respondents were also classified into different income groups using updated version of Kuppuswamy's Socioeconomic Scale18 to assess their knowledge related to DF. There was no adequate DF knowledge among the middle- and
Although most of the people (>50%) in this study have considerable knowledge about the DF, they did not fully recognize breeding sites of the dengue vector. People associated ‘dirty’ sites such as sewage drains & garbage, where they found larvae of other mosquito species, with dengue. There is a marked hierarchy of people's perceptions of breeding sites. Three manifestations of dengue are currently known; DF, DHF and dengue shock syndrome. However, fever is the most common presenting symptom in all of them.15 The level of knowledge on DF reported in this study is comparable to that found in similar KAP studies conducted in India,19,20 Pakistan,21 Thailand22 and Jamaica.15 Most respondents were not able to correctly identify typical symptoms of DF apart from a few who identified fever as an obvious symptom. Fever was also the most frequently stated symptoms in similar studies conducted in India,19,20 Thailand,22 Laos,23 Nepal,24,25
Table 6 e Waste disposal practices reported by respondents during the survey (n ¼ 400). Waste disposal practices
n
%
Collected by municipality Dumping in vacant sites Throwing indiscriminately Set on fire Dumping in drainage Have dustbin in house Yes No
191 151 43 8 7
47.7 37.7 10.8 2.0 1.8
176 224
44 56
Fig. 4 e Dengue fever knowledge among different income groups. No significant association was found between income and dengue knowledge (c2 ¼ 1.54; P-value ¼ 0.46).
Please cite this article in press as: Jeelani S, et al., Community knowledge, awareness and preventive practices regarding dengue fever in Puducherry e South India, Public Health (2015), http://dx.doi.org/10.1016/j.puhe.2015.02.026
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the Philippines26 and Jamaica.15 Presumably the participants in this study could not state typical symptoms of DF because they had not personally experienced the disease nor witnessed a case from a close relative or member of the community. The poor knowledge of symptoms associated with DF among the study population means that this disease may easily be confused with other common causes of fever such as influenza, typhoid, etc. Though there was a difference in knowledge among rural and urban areas, it was not statistically significant. Knowledge about vector breeding and biting behaviour was inadequate. Most of the respondents reported that mosquitoes transmitting DF breed in drains and garbage (67%) while less than half of them reported stagnant water as breeding source. More than half of the respondents reported that mosquitoes bite during morning (58%) and evening time (44%). This finding was consistent with some previous studies which indicated the majority of respondents knew that dengue vectors might bite at sunrise or sunset.21,27 In this study, television was reported as the most common source of information. This is similar to previous studies whereby mass media was cited to have a major role in disseminating information about dengue.28,20,29 However a study in Laos PDR friends and relatives were the major source of information regarding dengue fever.30 Another study in Thailand found that health personnel were the main source of dengue fever information.31 Generally, in all houses, people used to store water for bathing/drinking purposes in large containers viz., metal/ plastic drums, cemented tanks/cisterns etc. A large number of small containers viz., metal/plastic pots were also used to fetch water and for storage when the water supply was inadequate. These water-storing containers became ideal breeding grounds for Aedes mosquitoes, whenever it was stored for longer duration without a proper lid to cover the containers. In this study, the majority (81%) of HHs practice water storing in the containers and more than 40% of them store water in small plastic/steel containers. It was observed that in most of the areas, waste generated is collected by Municipality squad on daily or alternate day basis, but still people are throwing the waste indiscriminately outside their houses. This shows the non-seriousness and irresponsible behaviour of people, may be due lack of considerable knowledge regarding the consequences of improper waste disposal. Some groups need special attention in future health education programmes, i.e. housewives, unemployed youth and old persons. These people, together with small children, are highrisk groups for dengue conflagration because of their tendency to stay in and around home during the daytime.21 Normally, in a family, women members were more responsible for the household activity especially in water storage; cleaning of houses and caring children and more efforts should be focused to educate women members. In summary, the majority of population in Puducherry have poor knowledge about dengue disease, its mode of transmission, vector breeding habitat and mosquito biting behaviour. The preventive practices, against Aedes mosquito breeding in household containers and day-biting mosquito were low. The lack of basic knowledge of the community on dengue epidemiology and vector bionomics could also be a major cause for increasing trend of dengue in this highly populated urban environment.
There is an urgent need for the Public Health authorities to organize health education programmes on dengue disease to increase community knowledge and also to sensitize the community to participate in integrated vector control programme to resolve dengue problem.
Author statements Acknowledgements The authors are grateful to the Director, Vector Control Research Centre (VCRC) for providing the required facilities to carry out the present study. The help & support of Mr. KHK Raju, Technical assistant, VCRC for mapping and Mr. P. Kumaran, Technician C, VCRC in translating the questionnaire in English to local language, Tamil are greatly acknowledged. The Community Respondents are greatly acknowledged for their whole hearted participation in the survey.
Ethical approval The study was approved by the Institutional Human Ethics Committee (IHEC) with reference no. IHEC-1207, Dated: 14/02/ 2012.
Funding The author Mr. Suhail Jeelani Shah received financial support from University Grants Commission (UGC), New Delhi, India under Moulana Azad National Fellowship for Minority Students (No. F.1e17.1/2011MANF-MUS-JAM-5414).
Competing interests None declared.
references
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9. Brunkard JM, Cifuentes E, Rothenberg SJ. Assessing the roles of temperature, precipitation, and ENSO in dengue reemergence on the Texas-Mexico border region. Salud Publica Mex 2008;50:227e34. 10. Barreto FR, Teixeira MG, Costa MC, Carvalho MS, Barreto ML. Spread pattern of the first dengue epidemic in the city of Salvador. Braz BMC Public Health 2008;8:51. 11. Gubler DJ. Cities spawn epidemic dengue viruses. Nat Med 2004;10:129e30. 12. Kumar A, Sharma SK, Padbidri VS, Takare JP, Jain DC, Datta KK. An outbreak of dengue fever in rural areas of northern India. J Commun Dis 2001;33(4):274e81. 13. WHO/TDR Dengue. Guidelines for diagnosis, treatment, prevention and control. Geneva: World Health Organization (WHO) and the Special Programme for Research and Training in Tropical Diseases (TDR); 2009. 14. Sharma AK, Bhasin S, Chaturvedi S. Predictors of knowledge about malaria in India. J Vector Borne Dis 2007;44:189e97. 15. Shuaib F, Todd D, Campbell-Stennett D, Ehiri J, Jolly PE. Knowledge, attitudes and practices regarding dengue infection in Westmoreland, Jamaica. West Indian Med J 2010;59:139e46. 16. Yadav SP, Kalundha RK, Sharma RC. Socio-cultural factors and malaria in the desert part of Rajasthan, India. J Vector Borne Dis 2007;44:205e12. 17. Directorate of National Vector Borne Disease Control Programme (NVBDCP) Puduchherry. 2013. http://nvbdcp.gov. in/den-cd.html. [accessed on 05.05.13]. 18. Kumar N, Gupta N, Kishore J. Kuppusway's socioeconomic scale: updating income ranges for the year 2012. Indian J Pub Health 2012;56:103e4. 19. Gupta P, Kumar P, Aggarwal OP. Knowledge, attitude and practices related to dengue in rural and slum areas of Delhi after the dengue epidemic of 1996. J Commun Dis 1998;30:107e12. 20. Acharya A, Goswami K, Srinath S, Goswami A. Awareness about dengue syndrome and related preventive practices amongst residents of an urban resettlement colony of south Delhi. J Vector Borne Dis 2005;42:122e7. 21. Itrat A, Khan A, Javaid S, Kamal M, Khan H, Javed S, et al. Knowledge, awareness and practices regarding dengue fever among the adult population of dengue hit cosmopolitan. PLoS One 2008;3(7):e2620.
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Please cite this article in press as: Jeelani S, et al., Community knowledge, awareness and preventive practices regarding dengue fever in Puducherry e South India, Public Health (2015), http://dx.doi.org/10.1016/j.puhe.2015.02.026
Available online at www.sciencedirect.com
Public Health journal homepage: www.elsevier.com/puhe
Original Research
Community knowledge, awareness and preventive practices regarding dengue fever in Puducherry e South India S. Jeelani*, S. Sabesan, S. Subramanian Vector Control Research Centre, Indian Council of Medical Research (ICMR), Indira Nagar, Gorimedu, Puducherry 605006, India
article info
abstract
Article history:
Objectives: To ascertain the knowledge, attitudes and practices of adult population in
Received 24 June 2014
Puducherry, India, regarding Dengue Fever (DF).
Received in revised form
Study design: A cross-sectional survey was carried out to assess the Knowledge, Awareness
26 December 2014
and Preventive practices (KAP) among a selected community in Puducherry on DF,
Accepted 22 February 2015
following a major dengue outbreak in 2012.
Available online xxx
Methods: Between October 2012 & February 2013, an epidemiological survey was conducted among 400 households (HHs) from the most affected areas during dengue outbreak, which
Keywords:
came under eight health delivery jurisdictions i.e. Primary Health Centres (PHCs) in
Community knowledge
Puducherry. Knowledge of dengue and the use of preventive measures were assessed by
Dengue fever
means of a pre-tested structured questionnaire. Logistic regression analysis was done to
Puducherry
examine the association between different levels of education and income status with the knowledge of DF. The DF knowledge map was created based on the results achieved through the questionnaire using Arc GIS 10.2 software. Results: Although about 86% of the participants had heard of dengue, although there was no adequate knowledge on dengue vector breeding habitat as 68% of the respondents thought drains & garbage as breeding places of dengue vectors. Only 25% of participants were aware of clean water as a breeding habitat. Insufficient knowledge of disease symptoms was found, with fever (59%) being the most common symptom. Conclusions: There is a lack of in-depth knowledge on dengue epidemiology in the Puducherry community and observation revealed that more needs to be done by the Government as well as community members to prevent vector mosquito breeding. © 2015 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. Division of Vector Ecology and Surveillance, Vector Control Research Centre (ICMR), Indira nagar, Gorimedu, Puducherry 605006, India. Tel.: þ91 7358807101; fax: þ91 4132272041. E-mail address: [email protected] (S. Jeelani). http://dx.doi.org/10.1016/j.puhe.2015.02.026 0033-3506/© 2015 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Jeelani S, et al., Community knowledge, awareness and preventive practices regarding dengue fever in Puducherry e South India, Public Health (2015), http://dx.doi.org/10.1016/j.puhe.2015.02.026
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Introduction Dengue is one of the most dreadful arboviral diseases of humans with over half of the world's population living in areas of risk. An estimated 3.5 billion people, or half the world's population, are at risk for dengue virus (DENV) infection in tropical and subtropical countries.1 Sporadic outbreaks of Dengue fever (DF) have been reported in India for over two centuries2,3 but the earliest virologically confirmed outbreak occurred in 1956 in Vellore, Tamil Nadu.4 The first major outbreak of dengue began in 1963 in Calcutta, West Bengal, from where it spread to other states, eventually affecting most parts of the country.5 The frequency, magnitude and geographical distribution of epidemic dengue and potential occurrence of life-threatening dengue hemorrhagic fever (DHF) have increased dramatically in the past 40 years as the viruses and the mosquito vectors have both expanded geographically in the tropical regions of the world.6 The factors responsible for this increase and expansion are societal changes such as population growth, urbanization, changing habitats and behaviour, and lack of effective vector control.7e9 High human population density and inadequate water supply (water storage practice) are regarded as major contributors to dengue epidemics.10,11 The vector mosquitoes transmitting the DENV are Aedes species mainly Aedes aegypti & Ae. albopictus. The infection, earlier restricted to urban/semi-urban areas, can now be seen in rural areas as well.12 Over the last decade, the geographical distribution of DF has included new countries and more rural areas, making it the most rapidly expanding arboviral disease in the world.13 Despite mass communication and educational approaches, community participation is far below expectation. Community participation in turn depends on peoples' awareness, knowledge and attitude towards the disease.14 Several socio-economic studies in different countries indicate variations in knowledge and practice-related to mosquito-borne diseases.15,16 Puducherry experienced its first major outbreak in 2003 with 60 confirmed cases of infection from the district in 10 urban and 9 rural Primary Health Centres (PHCs).17 A four-fold increase of dengue cases had been observed in 2011 (n ¼ 230 cases). For the year 2012, a six-fold increase had been recorded with a total of 1391 dengue cases. The increasing incidence of DF and the lack of relevant studies on the knowledge, awareness and practice (KAP) of the Puducherry community regarding DF transmission and prevention prompted us to conduct the present study.
Methods Study area The study was conducted in Union territory of Puducherry, geographically located at 162 km south of Chennai, surrounded by the Bay of Bengal on the east, and on the other sides by the Cuddalore and Villipuram districts of Tamil Nadu (Fig. 1). Puducherry experiences hot and humid climate with temperature normally varying between 26 and 38 C.
Sampling design Areas from where the maximum number of dengue cases have been reported (under 8 PHCs) in the previous year were selected for the study. Knowledge of dengue fever was assessed using questions aimed at ascertaining the community's understanding of the disease epidemiology (symptoms, transmission, etiology and vector) and standard preventive strategies (mosquito nets, mats, water storage). In a population of 165,252, assuming 50% prevalence of good knowledge, with an error margin of 5% at a 95% level of confidence, the minimum number of respondents required to fulfil the objectives of this study was 383. The samples were distributed in proportion to the population in the dengue affected villages.
Field based data collection A household survey was carried out between October 2012 and February 2013 using a structured questionnaire, translated into local language i.e. Tamil. Head of the family or any adult family member above 18 years of age available at home during the survey was interviewed following informed consent. The questionnaire was divided into three sections. The first section covered the sociodemographic information about the respondents. The second section was about knowledge regarding the symptoms, spread of dengue and preventive practices in use against mosquitoes. The section third consisted of checklists that indicate data on water storage and waste disposal practices within the household, including vector indices.
Ethical clearance The protocol of this study was approved by the Institutional Human Ethics Committee (IHEC) of Vector Control Research Centre (VCRC) on 14th February, 2012. The objectives of the study were explained to the local community including community leaders and health professionals. Sufficient time was given to ask questions and it was emphasized that participation in the survey was voluntary and they could quit any time during the interview. Those who wished to participate were required to sign a consent form prepared in accordance with the guidelines of IHEC prior to the use of questionnaires.
Data analysis The data collected from the survey were accessed into an Excel database and later analysed using IBM SPSS version 20. Logistic regression analysis was done to examine the association between different levels of education, and income status with the knowledge of DF. Microsoft Excel version 2013 was used to draw graphs and charts wherever appropriate. Additionally, each question was assigned with a score (ranging from 0 to 4) depending upon the type of question, and the score achieved by a respondent was described as knowledge score of that particular respondent. The total knowledge score was determined by taking the average of score achieved by all the respondents in a particular area. Location of the areas surveyed was recorded using hand-held global
Please cite this article in press as: Jeelani S, et al., Community knowledge, awareness and preventive practices regarding dengue fever in Puducherry e South India, Public Health (2015), http://dx.doi.org/10.1016/j.puhe.2015.02.026
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Fig. 1 e Map showing the study sites.
positioning system (GPS) and a map was generated based on the knowledge score achieved by each area, using the GIS mapping software developed by Esri, Arc GIS 10.2 software (Fig. 2).
Dengue related knowledge
Results
The outcome of the survey pertaining to awareness on dengue transmission, its symptoms and treatment are shown in
The socio-economic details of the study population are given in Table 1. A total of 400 respondents were interviewed and the data so obtained was used for primary analysis. 40.5% of the people were from higher socio-economic group and 59.5% from lower socio-economic group. A majority of them was
Fig. 2 e Map showing the distribution of dengue knowledge in the study area. Dengue knowledge map was created based on the overall area-wise knowledge using licenced GIS software, Arc GIS 10.2 (Esri).
female (67.3%), house makers (53.7%) and had education up to high school (59.3%).
Table 1 e Sociodemographic characteristics of the study population. Distribution of respondents Gender distribution Male Female Age distribution 18e30 30e45 45e60 >60 Educational status Illiterate Primary High school Intermediate Diploma Graduation or above Occupation Labour Agriculture House wife Student Employed Business Income Low Medium High
No. of respondents
%
129 271
32.3 67.7
118 142 87 53
29.5 35.5 21.7 13.3
64 55 139 70 17 55
16.0 13.8 34.7 17.5 4.3 13.8
45 8 215 24 65 43
11.3 2.0 53.7 6.0 16.3 13.7
238 104 58
59.5 26.0 14.5
Please cite this article in press as: Jeelani S, et al., Community knowledge, awareness and preventive practices regarding dengue fever in Puducherry e South India, Public Health (2015), http://dx.doi.org/10.1016/j.puhe.2015.02.026
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Table 2 e Knowledge on dengue spread, symptom and treatment.
Table 4 e Knowledge of vector breeding, biting time and preventive practices.
Variable
Variable
n
%
a
Awareness of dengue Yes No Mode of spreadb Mosquito bite Contaminated food/water Don't know Human to human spread Yes No Don't know Common symptomsb Fever Body pain Headache Skin rashes Vomiting Don't know Medicines against dengue Yes No Don't know
342 58
85.5 14.5
283 28 44
82.7 8.2 12.9
91 215 36
26.6 62.9 12
203 80 72 58 49 139
59.4 23.4 21.1 15.5 14.3 40.6
33 93 214
10.2 27.2 62.6
a
Rest of the knowledge related questions were asked only to those respondents who replied ‘Yes’ to this question. b Multiple response options.
Table 2. Among the total respondents, 85.5% have heard of dengue fever and most of them (82.7%) were aware that it is transmitted through mosquito bites. A few of them (8.2%) opined that this disease is transmitted through contaminated water & food. When asked about the common symptoms, fever was the most consistent response (59%) followed by body pain (23%) and headache (21%). No significant association was found between DF knowledge and respondent's area of residence (refer: Table 3). The extent of knowledge regarding vector breeding sites, biting behaviour and preventive practices were summarized in Table 4. When respondents were asked about the breeding habitat of the vector mosquitoes, 67.8% of them answered drains and garbage, and only 42.5% of them were aware that they breed in stagnant water and 4.7% were ignorant about the breeding habitat of mosquitoes. Only 25.1% were aware that
Table 3 e Association between dengue fever knowledge and area of residence. Variable
Rural (n)
Awareness of dengue Yes 167 No 33 Transmission of dengue Yes 135 No 32 Symptoms of dengue Yes 92 No 75
n
%
146 33 232 86 16
42.5 9.6 67.8 25.1 4.7
152 37 201 77
44.4 10.8 58.8 22.5
251 97 27 26 51
62.7 24.3 6.8 6.5 12.8
a
Urban (n)
Chi-square (c2) P-value
175 25
c2 ¼ 1.29 P ¼ 0.26
148 27
c2 ¼ 0.84 P ¼ 0.30
111 64
c2 ¼ 2.46 P ¼ 0.12
No significant difference in dengue knowledge was found between rural and urban areas.
Common breeding sites Stagnant water Septic tank Drains & garbage Clean water holding containers Don't know Most frequent mosquito biting timea Morning Noon Evening Night Preventive practicesa Liquid vaporizer Coil Electric bat Mosquito net Nothing a
Multiple response options.
dengue mosquito breeds in clean water-holding containers. Most of the people knew that mosquito usually bites either at evening (58.8%) or at morning time (44.4%). Preventive practices regarding dengue were consistent with the knowledge about these practices, with majority of the people relying on liquid vaporizers (62.7%) and/or mosquito mats (24.3%).
Source of information on dengue fever Television (55%) was identified as the main source of public information followed by Newspaper (38%) and Radio (31%). 29% of the respondents have heard about dengue through Govt. awareness campaigns and only 6.8% heard it in school (Table 5).
Water supply and storage practices Most of the households were found to store water in different types of containers in all the study sites. Nearly 42% of HHs used small containers (plastic/metal vessel) for storing water, while as 31% of HHs used plastic fibre (‘Sintex’) tanks and only 12.5% used cemented tanks/cisterns for water storage. 19% of the HHs stated that they did not require water to be stored (Fig. 3).
Table 5 e Source of information about the dengue received by the respondent in the survey (n ¼ 342). Variable
Frequency (n)
Where participants have heard about denguea: Television 188 News paper 132 Radio 123 Awareness campaign 117 School 27 a
Percentage (%) 55.0 38.0 31.0 29.3 6.8
Multiple response options.
Please cite this article in press as: Jeelani S, et al., Community knowledge, awareness and preventive practices regarding dengue fever in Puducherry e South India, Public Health (2015), http://dx.doi.org/10.1016/j.puhe.2015.02.026
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Table 7 e Dengue fever knowledge among respondents of different educational status. Level of education Illiterate Up to High school Intermediate Graduation & above
No. of persons interviewed
Persons with dengue knowledge (%)
OR (95% CI)
64 194
70.3 59.3
1.0 1.6 (0.9e3.0)a
87 55
51.7 49.1
2.2 (1.1e4.4)b 2.5 (1.2e5.2)b
a
Respondents with qualification up to high school were 1.6 times more knowledgeable than illiterates, but there was no statistical significance. b Participants with a qualification of intermediate or above were more than two times more knowledgeable as compared to illiterate.
Fig. 3 e Water storage practices reported by participants during the survey (n ¼ 400). *Multiple responses. Nearly 42% of HHs used small containers (plastic/metal vessel) for storing water, while as 31% of HHs used plastic fibre (‘Sintex’) tanks.
high-income group, and it was still poor with the lowerincome group. Logistic regression analysis revealed that knowledge of dengue was independent of socio-economic group (c2 ¼ 1.54; P ¼ 0.46). There was no much difference in knowledge among the middle and high income groups (Fig. 4).
Waste disposal practices
Discussion Data regarding the waste disposal practices employed by study population is presented in Table 6. In only 48% of HHs, waste generated is collected by Municipality squad on daily or alternate day basis, while as 38% of the HHs were dumping it in vacant sites and 11% throwing indiscriminately outside their house. Out of the 400 HHs in study population, only 44% were found to have dustbins in their house. Respondents were also divided into different educational groups and their knowledge regarding dengue fever was assessed. A significant association was found between degree of knowledge and level of education among respondents. Participants with a qualification of intermediate (OR ¼ 2.2, 95% CI 1.1e4.4) or above (OR ¼ 2.5, 95% CI 1.2e5.2) were more than two times more knowledgeable as compared to illiterate. However, persons with qualifications up to high school were 1.6 times more knowledgeable than illiterates, but there was no statistical significance (Table 7). The respondents were also classified into different income groups using updated version of Kuppuswamy's Socioeconomic Scale18 to assess their knowledge related to DF. There was no adequate DF knowledge among the middle- and
Although most of the people (>50%) in this study have considerable knowledge about the DF, they did not fully recognize breeding sites of the dengue vector. People associated ‘dirty’ sites such as sewage drains & garbage, where they found larvae of other mosquito species, with dengue. There is a marked hierarchy of people's perceptions of breeding sites. Three manifestations of dengue are currently known; DF, DHF and dengue shock syndrome. However, fever is the most common presenting symptom in all of them.15 The level of knowledge on DF reported in this study is comparable to that found in similar KAP studies conducted in India,19,20 Pakistan,21 Thailand22 and Jamaica.15 Most respondents were not able to correctly identify typical symptoms of DF apart from a few who identified fever as an obvious symptom. Fever was also the most frequently stated symptoms in similar studies conducted in India,19,20 Thailand,22 Laos,23 Nepal,24,25
Table 6 e Waste disposal practices reported by respondents during the survey (n ¼ 400). Waste disposal practices
n
%
Collected by municipality Dumping in vacant sites Throwing indiscriminately Set on fire Dumping in drainage Have dustbin in house Yes No
191 151 43 8 7
47.7 37.7 10.8 2.0 1.8
176 224
44 56
Fig. 4 e Dengue fever knowledge among different income groups. No significant association was found between income and dengue knowledge (c2 ¼ 1.54; P-value ¼ 0.46).
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the Philippines26 and Jamaica.15 Presumably the participants in this study could not state typical symptoms of DF because they had not personally experienced the disease nor witnessed a case from a close relative or member of the community. The poor knowledge of symptoms associated with DF among the study population means that this disease may easily be confused with other common causes of fever such as influenza, typhoid, etc. Though there was a difference in knowledge among rural and urban areas, it was not statistically significant. Knowledge about vector breeding and biting behaviour was inadequate. Most of the respondents reported that mosquitoes transmitting DF breed in drains and garbage (67%) while less than half of them reported stagnant water as breeding source. More than half of the respondents reported that mosquitoes bite during morning (58%) and evening time (44%). This finding was consistent with some previous studies which indicated the majority of respondents knew that dengue vectors might bite at sunrise or sunset.21,27 In this study, television was reported as the most common source of information. This is similar to previous studies whereby mass media was cited to have a major role in disseminating information about dengue.28,20,29 However a study in Laos PDR friends and relatives were the major source of information regarding dengue fever.30 Another study in Thailand found that health personnel were the main source of dengue fever information.31 Generally, in all houses, people used to store water for bathing/drinking purposes in large containers viz., metal/ plastic drums, cemented tanks/cisterns etc. A large number of small containers viz., metal/plastic pots were also used to fetch water and for storage when the water supply was inadequate. These water-storing containers became ideal breeding grounds for Aedes mosquitoes, whenever it was stored for longer duration without a proper lid to cover the containers. In this study, the majority (81%) of HHs practice water storing in the containers and more than 40% of them store water in small plastic/steel containers. It was observed that in most of the areas, waste generated is collected by Municipality squad on daily or alternate day basis, but still people are throwing the waste indiscriminately outside their houses. This shows the non-seriousness and irresponsible behaviour of people, may be due lack of considerable knowledge regarding the consequences of improper waste disposal. Some groups need special attention in future health education programmes, i.e. housewives, unemployed youth and old persons. These people, together with small children, are highrisk groups for dengue conflagration because of their tendency to stay in and around home during the daytime.21 Normally, in a family, women members were more responsible for the household activity especially in water storage; cleaning of houses and caring children and more efforts should be focused to educate women members. In summary, the majority of population in Puducherry have poor knowledge about dengue disease, its mode of transmission, vector breeding habitat and mosquito biting behaviour. The preventive practices, against Aedes mosquito breeding in household containers and day-biting mosquito were low. The lack of basic knowledge of the community on dengue epidemiology and vector bionomics could also be a major cause for increasing trend of dengue in this highly populated urban environment.
There is an urgent need for the Public Health authorities to organize health education programmes on dengue disease to increase community knowledge and also to sensitize the community to participate in integrated vector control programme to resolve dengue problem.
Author statements Acknowledgements The authors are grateful to the Director, Vector Control Research Centre (VCRC) for providing the required facilities to carry out the present study. The help & support of Mr. KHK Raju, Technical assistant, VCRC for mapping and Mr. P. Kumaran, Technician C, VCRC in translating the questionnaire in English to local language, Tamil are greatly acknowledged. The Community Respondents are greatly acknowledged for their whole hearted participation in the survey.
Ethical approval The study was approved by the Institutional Human Ethics Committee (IHEC) with reference no. IHEC-1207, Dated: 14/02/ 2012.
Funding The author Mr. Suhail Jeelani Shah received financial support from University Grants Commission (UGC), New Delhi, India under Moulana Azad National Fellowship for Minority Students (No. F.1e17.1/2011MANF-MUS-JAM-5414).
Competing interests None declared.
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Please cite this article in press as: Jeelani S, et al., Community knowledge, awareness and preventive practices regarding dengue fever in Puducherry e South India, Public Health (2015), http://dx.doi.org/10.1016/j.puhe.2015.02.026