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Zika virus disease—knowledge, attitudes and practices among pregnant women—implications for public health practice
p u b l i c h e a l t h 1 6 5 ( 2 0 1 8 ) 1 4 6 e1 5 1
Available online at www.sciencedirect.com
Public Health journal homepage: www.elsevier.com/puhe
Original Research
Zika virus diseasedknowledge, attitudes and practices among pregnant womendimplications for public health practice S. Pooransingh a,*, R. Parasram b, N. Nandram c, B. Bhagwandeen d, I. Dialsingh d a
Faculty of Medical Sciences, The University of the West Indies, St Augustine, Trinidad and Tobago Office of the Chief Medical Officer, The Ministry of Health Trinidad and Tobago c Insect Vector Control Division, The Ministry of Health, Trinidad and Tobago d Faculty of Science and Technology, The University of the West Indies, St Augustine, Trinidad and Tobago b
article info
abstract
Article history:
Objective: Mosquito-borne diseases continue to pose a threat to Latin America and the
Received 22 February 2018
Caribbean. Zika virus disease entered the Caribbean in 2013 with increased reporting of
Received in revised form
cases across the region in 2016, affecting more than 50 countries. This study aimed to
1 September 2018
ascertain the knowledge of, attitudes and practices towards Zika virus disease among
Accepted 18 September 2018
antenatal clinic attenders in Trinidad and Tobago during the 2016 outbreak. Study design: A cross-sectional questionnaire survey was undertaken. Methods: A knowledge attitudes and practices survey was conducted among antenatal
Keywords:
clinic attenders at publicly funded primary care health centres. All counties of Trinidad
Zika
(except St Patrick, Caroni and Victoria) and Tobago were included in the study. Within each
Pregnancy
county, three health centres were selected at random. At the antenatal clinic of each
Knowledge
selected health centre, antenatal clients were selected by randomly selecting their patient
Attitudes
file from that day's antenatal clinic patient files. Data collection occurred from September
Practices
to November 2016. The knowledge, attitudes and practice survey was administered by an
Global health
interviewer-administered questionnaire. The World Health Organization Knowledge, Attitudes and Practice surveys Zika virus disease and potential complications Resource pack was adapted for use as the data collection tool. All data collected were analysed using SPSS software, version 23. Tests with P-values less than 0.05 were deemed significant. Results: Seventy-four percent (74%) of responders did not think there was a link between sexual transmission and Zika. About 19% stated that abstaining could prevent Zika but only 6.6% actually practiced this. Seventy-six percent knew the risk of microcephaly, and this knowledge of the risk of microcephaly was found to be significantly associated with the number of weeks' gestation. Less than 40% knew the risk of GuillaineBarre syndrome. Doctors at health centres followed by private doctors were the top two trusted information sources for responders. Responders thought that the government could spray insecticide, clean drains, educate community members and clean overgrown vacant lots of land.
* Corresponding author. Faculty of Medical Sciences, UWI St Augustine, Mount Hope, Champs Fleurs, Trinidad and Tobago. E-mail address: [email protected] (S. Pooransingh). https://doi.org/10.1016/j.puhe.2018.09.025 0033-3506/© 2018 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
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Conclusion: The government and healthcare workers need to reach specific target groups with accurate messages to minimize the associated morbidity and thereby safeguarding national and global health security. © 2018 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
Introduction Mosquito-borne diseases continue to plague Latin America and the Caribbean and thus continue to present a threat to global health security. Yellow fever, malaria, dengue and chikungunya are ever-present dangers in this part of the world.1,2 Countries are working to develop their health systems' capacities to detect and respond to acute public health threats through the International Health Regulations (2005) framework3 and the Global Health Security Agenda in the region.4,5 Disease outbreaks serve to periodically test these systems. The most recent addition to the list of threats is Zika virus disease which was introduced into the Americas in 2013 with an outbreak reported in 2015 in Brazil and which spread rapidly across the Americas and the Caribbean affecting in excess of 50 countries.6e9 Since its identification in 1947 in Uganda up until 1981, globally there were fourteen reported cases of illness in Africa and Southeast Asia.10 The current globalisation of Zika began in the Pacific Island of Yap in the Federated States of Polynesia in 2007.10e13 Cases were reported in 2013 in French Polynesia followed by cases on Cook Island and Easter Island.14 The first case of Zika virus in Trinidad and Tobago was reported in February 20169 when Zika was declared a Public Health Emergency of International Concern by the World Health Organization (WHO) Director General.15 Trinidad and Tobago with a population of approximately 1.4 million persons reported more than 700 laboratory-confirmed cases of Zika virus in 2016 with more than 60% in pregnant women.16,17 Trinidad and Tobago is a twin island state southernmost in the Caribbean archipelago, 15 km from Venezuela in mainland South America, with daily flights to the United States of America and being a popular tourist destination for travellers from North America and Europe. Trinidad and Tobago is, therefore, well placed to facilitate the spread of disease across the Americas and the world as has happened with Zika. Indeed, the Canadians found that 50% of travel-associated Zika was acquired in the Caribbean. In addition, the secondary sexual transmission of Zika is now well documented.4,5 Therefore, not only public health alert and response capacities should be robust but also prevention and awareness among the public must be viewed as a priority in an effort to prevent the global spread of disease.6 This study aimed to assess the knowledge, attitudes and practices of antenatal patients regarding Zika virus in healthcare facilities in Trinidad and Tobago in the midst of the 2016 outbreak, 7 months after the first case was reported nationally. The expected outcome was to determine which health messages are needed and to which target groups to reduce the Zika-associated morbidity of microcephaly and
brain damage in the foetus, GuillaineBarre in adults and sexual transmission among adults.
Methods The study was set in antenatal clinics in publicly funded health centres in Trinidad and Tobago. A cross-sectional study, a knowledge, attitude and practice (KAP) survey, was undertaken with a target population of antenatal patients attending publicly funded health centres as this is where clients from the general population attend, unless they develop complications in pregnancy at which time they are referred to the hospital specialist in the obstetrics and gynaecology clinic. The study population comprised all counties of Trinidad (except three for which approvals were delayed); Tobago was also included. Within each county, three health centres were selected at random using random digit selection. At the antenatal clinic in each health centre, seven clients were selected by randomly selecting their patient file from that day's antenatal clinic patient files using random digit selection. Data were collected from September to November 2016. The survey was administered via an intervieweradministered questionnaire. The interviewers were the County Medical Officers of Health (n ¼ 5) who are the public health physicians for their respective counties. Each conducted the interviews in the health centres within their county. They were trained by the medical officer at the Insect Vector Control Division, who was also a public health physician. The trainer went through each question of the survey. The WHO Knowledge, Attitudes and Practice surveys Zika virus disease and potential complications. Resource pack18 was adapted for use. The final questionnaire comprised 67 questions. It took an average of 25 min to complete each interview. All data collected were analysed using SPSS software, version 23. Tests with P-values less than 0.05 were deemed significant.
Results The response rate for the survey was 91/105 ¼ 86.7%. A total of 91 participants were interviewed. The participants' ages ranged from 18 to 40 years, with an average age of 26.32 years (standard deviation [SD] ¼ 4.89). The average number of weeks' gestation was 25.16 weeks (SD ¼ 10.09). Forty-four (48.4%) of the participants indicated residence in an urban area, while 42 (46.2%) documented residence in rural parts of the country. In terms of knowledge and awareness about Zika, 96.7% of responders became aware of the Zika virus during the period
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2015e2016. Ninety-two percent of the responders believed that there was the possibility of contracting the virus in the local community at the time of the survey (2016), and 95.6% believed that it was possible for anybody to contract the Zika virus. The majority (53%) of responders obtained their information on Zika from the Internet. Regarding the cause of Zika, almost 97% believed mosquitoes to be the cause. Just more than 60% did not think that a dirty environment contributed to acquiring the infection. In terms of prevention, 89.0% of responders were of the opinion that Zika could be prevented. Seventy-one percent said they knew to use mosquito nets at night to prevent mosquito bites, and 39.6% said they practised this; 48.4% said they knew to use mosquito nets during the day time, and 24.2% said they practiced this. Table 1 shows what participants believed to be the ways to prevent Zika. Table 2 shows urban/rural residence and knowledge about removing standing/stagnant water sources to prevent contracting the Zika virus. Seventy-four percent of responders did not think that there was a link between sexual transmission and Zika. Approximately 19% stated that abstinence could prevent Zika, and 6.6% said they practised this. Seventy-six percent of responders knew the associated risk of microcephaly, and the knowledge of the risk of microcephaly was found to be significantly associated with number of weeks' gestation. Table 3 shows what respondents thought were risks to the foetus/baby. In terms of risks to patients, 37.4% agreed that there is a link between Zika and GuillaineBarre syndrome (Table 3). Regarding treatment, 61.5% of respondents believed that there was a treatment for the Zika virus and that doctors in health centres can treat someone for Zika. Almost 43% agreed that aspirin or ibuprofen should not be used to treat the virus, while 40.7% were unsure.
Table 2 e Residence and knowledge about removing standing/stagnant water sources to prevent contraction of the Zika virus. Area of residence
Ways to prevent Zika
Agree [no. (%)]
Use mosquito nets at night Use mosquito nets during the day Use mosquito repellants/body sprays Use mosquito coils/fires Wear covering clothes Use condoms in sexual relations Abstain from sexual intercourse Clean water storage containers Remove standing/stagnant water sources Spray/fumigate house Put window and door screens Clean household environment
65 44 71 40 46 22 17 50 65 58 34 68
(71.4) (48.4) (78.0) (44.0) (50.5) (24.2) (18.7) (54.9) (71.4) (63.7) (37.4) (74.7)
Disagree [no. (%)] 16 37 10 41 35 59 64 31 16 23 47 13
(17.6) (40.7) (11.0) (45.1) (38.5) (64.8) (70.3) (34.1) (17.6) (25.3) (51.6) (14.3)
Chi-squared tests of independence were carried out to determine whether the areas of residence (rural/urban) and the woman's knowledge with respect to the methods of prevention of the Zika virus are related. Table 2 shows the findings.
P-value
Yes [no. (%)] No [no. (%)] Total [no. (%)] Urban Rural Total (%)
26 (33.8) 35 (45.5) 61 (79.2)
12 (15.6) 4 (5.2) 16 (20.8)
38 (49.4) 39 (50.6) 77 (100.0)
0.021
Chi-squared tests revealed that the woman's knowledge of removing standing/stagnant water sources was dependent on the area of residence (P-value ¼ 0.021).
Table 3 e Knowledge about the possible risks to a foetus/ baby. Risks
Agree [no. (%)]
Disagree [no. (%)]
Risk of not growing/developing normally in the womb Risk of miscarriage Risk of a premature birth Risk of a stillborn birth Risk of birth with microcephaly Risk of being born with a disability
61 (67.0)
29 (31.9)
18 31 14 69 43
72 59 76 21 47
(19.8) (34.1) (15.4) (75.8) (47.3)
(79.1) (64.8) (83.5) (23.1) (51.6)
Chi-squared tests of independence were carried out to determine whether the number of weeks pregnant and the woman's knowledge with respect to risks the foetus/baby faces, should she contract the Zika virus, are related. Table 4 shows the findings.
Table 4 e Gestational age and knowledge about the risk of microcephaly. Weeks pregnant
Table 1 e What participants believed to be the ways to prevent the Zika virus.
Remove standing/stagnant water sources
0e12 13e24 >24 Total (%)
Risk of microcephaly Yes [no. (%)]
No [no. (%)]
Total [no. (%)]
5 18 44 67
8 5 8 21
13 23 52 88
(5.7) (20.5) (50.0) (76.1)
(9.1) (5.7) (9.1) (23.9)
(14.8) (26.1) (59.1) (100.0)
P-value 0.002
The Chi-squared tests revealed that the woman's knowledge of the risk of birth with microcephaly was dependent on the number of weeks pregnant (P-value ¼ 0.002).
Regarding the attitude of responders towards Zika, 90% of responders viewed the Zika virus as an important issue in the local community. Seventy-nine percent stated that they would consider having a test for Zika if they currently had a fever. Thirteen percent conveyed that they would not have a test performed because fevers were fairly common and there are other signs of the Zika virus. Regarding attitudes to pregnant women, 88.0% of the participants believed that all pregnant women should be tested for the virus, and 76.9% suggested that if a woman gets a fever while pregnant, she should either visit her doctor or get tested at a medical centre for the virus. Sixty-two percent of the
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responders disagreed that women who get the Zika virus during pregnancy should have access to abortions, while 44.0% agreed that women should avoid getting pregnant at the present time because of the Zika virus. Fifty-nine percent believed that much more information about the virus is required as 50.6% related a lack of understanding in some aspects of the virus. Eighty-three percent of responders stated that they would consider having a vaccine for Zika, should one be available. In terms of responders' attitudes towards whose responsibility is it to prevent the spread of Zika in the household/community, 84.6% of responders said that it was the household head/family responsibility to prevent the spread of Zika. Almost 66% thought that it was the responsibility of the regional corporation, and 40.7% said that the Ministry of Health has responsibility for preventing the spread of Zika. Participants believe that the government agencies can prevent the Zika virus in the community by spraying insecticide for mosquitoes (84.6%), cleaning drains (75.8%) educating community members (70.3%) and cleaning vacant/overgrown lots (60.4%). The views on who can effectively treat Zika were as follows: most responders, 79.1%, thought that doctors at public or private health facilities have the necessary resources to treat someone, while 76.9% of participants did not think that this treatment could be received from a local healer and 67.0% believed that a pharmacist cannot effectively treat persons with Zika. The top five trusted information sources on the Zika virus were healthcare workers at the health centre (69.2%) followed by private doctors (48.4%), the WHO/Pan American Health Organization (PAHO) (23.1%), birth attendants/midwives (16.5%) and pharmacists (14.3%). Concerns of responders about Zika are shown in Tables 5 and 6. Regarding practices among responders, just more than 81% of the participants stated that they were undertaking practices to alleviate the threat of the virus. Table 7 shows what responders do to prevent Zika.
Discussion The study was an important one for determining the KAP regarding Zika in a key population subgroup in a small developing country, which is endemic for mosquito-borne illnesses. The study response rate was high at approximately 87%. Table 5 e Participants' concerns about the Zika virus. Concerns
Agree Disagree [no. (%)] [no. (%)]
Zika can make you sick Zika can kill you Zika can cause babies to have disabilities Zika can cause adults to have disabilities Zika can be sexually transmitted Zika will cause children to be sick Safe abortion is not available if Zika is contracted while pregnant
35 20 74 11 25 45 13
(38.5) (22.0) (81.3) (12.1) (27.5) (49.5) (14.3)
54 69 15 78 64 44 76
(59.3) (75.8) (16.5) (85.7) (70.3) (48.4) (83.5)
Table 6 e Actions participants believe can reduce mosquitoes in the household. Actions
Agree [no. (%)]
Spray/fumigate Keep environment clean Keep water sources clean Keep water sources covered Remove standing/stagnant water Burn mosquito coils Burn fires Impossible to reduce mosquitoes
76 74 70 70 72 38 21 8
(83.5) (81.3) (76.9) (76.9) (79.1) (41.8) (23.1) (8.8)
Disagree [no. (%)] 13 15 19 19 17 51 68 81
(14.3) (16.5) (20.9) (20.9) (18.7) (56.0) (74.7) (89.0)
Table 7 e Practices participants have taken to prevent contraction of the Zika virus. Practice
Agree Disagree [no. (%)] [no. (%)]
Used mosquito nets at night Used mosquito nets during the day Used mosquito repellant/body spray Used mosquito coils Wore covering clothes Used condoms in sexual relations Used modern family planning method Abstinence from sexual intercourse Cleaned water storage units/containers Removed standing/stagnant sources of water Sprayed home with insecticide Used natural insect repellants Installed window and door screens Cleaned household environment Prayed to God
36 22 51 35 28 6 4 6 38 43 40 40 6 49 18
(39.6) (24.2) (56.0) (38.5) (30.8) (6.6) (4.4) (6.6) (41.8) (47.3) (44.0) (44.0) (6.6) (53.8) (19.8)
31 45 16 32 39 61 63 61 29 24 27 27 61 18 49
(34.1) (49.5) (17.6) (35.2) (42.9) (67.0) (69.2) (67.0) (31.9) (26.4) (29.7) (29.7) (67.0) (19.8) (53.8)
The potential complications of Zika virus are serious. Antenatal women are at risk of delivering a baby with neurological effects, suffering from GuillaineBarre syndrome and transmitting the infection to and acquiring the infection from their partners. The level of knowledge in pregnant women should intuitively be high as one would expect women to be concerned about the well-being of their babies; on the contrary, studies have shown that knowledge about health matters is low among pregnant women studied.19,20 Responders in our study who were at later weeks of gestation were significantly more aware of the risk of microcephaly. The government should note this finding when tailoring health education messages. Fifty-three percent of responders indicated that they obtained their information on Zika from the Internet. The remaining 47% obtain their information from other sources such as the newspaper, radio and healthcare workers. Southwell et al.21 found that information searching and sharing on a subject occurred at peak briefly after public health authority announcements. This would suggest that governments and health educators should ensure reliable and key information is available when they decide to make announcements on diseases and risks of diseases. They should direct the public to credible sources of information in their announcements and use these periods of information seeking to address perceptions and concerns and target those who are
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at greatest risk. The respondents trusted doctors and the WHO/PAHO as credible sources of information. Governments should take note and hold health education sessions for the front-line workers who are key to informing the public. Doctors and other healthcare workers as part of their duty of care should also ensure they are up to date with the latest evidence and information on diseases such as Zika. In the midst of Zika outbreaks across the Latin American and Caribbean region, more than 70% of a key subgroup in our study was unaware of the potential for sexual transmission of the disease and therefore would not have engaged in preventive practices. This finding is not unlike the findings in Greece where a similar survey was undertaken22 and 63.3% of the responders were unaware of the risk of sexual transmission. The Greek survey was undertaken in July 2016, while this study was undertaken between September and November 2016. Greece was not undergoing active Zika transmission at the time of their study unlike in our study where Trinidad and Tobago was in the midst of increasing cases. In contrast to our findings, Whittemore et al.23 found that their population was well informed about the risks of sexual transmission and that of birth defects and attributed this to being in the midst of active transmission. So what is unique about our study population? There is clearly a gap in our capacity to reach our publicdto adequately inform and educate our public or perhaps the phenomenon is a characteristic of our population subgroup. Boggild et al. showed that 50% of Canadian cases identified through their travel medicine surveillance were acquired in the Caribbean.8 A study in California highlighted the importance of travel in the transmission of Zika with the majority of the travel-associated Zika cases originating in Mexico and Central America but with the potential for limited local transmission in the resident country.24 Visiting Trinidad and Tobago can, therefore, pose a risk to visitors from all parts of the world who visit relatives, the beaches and attend the annual carnival event. Hastings et al.25 in their review of sexual transmission report that the virus persists for months in the genital tracts. Gaskell et al. recommend barrier contraceptive use for 6 months after symptomatic Zika infection.26 This study revealed that the level of knowledge of Zika among a group of persons who should be well informed, because the disease can adversely affect their baby and they too can spread the disease to their partners, is low. Health literacy and a healthier lifestyle are associated with a higher level of education.27 Attenders at the publicly funded health centres where this survey was undertaken are less likely to possess health insurance as those with health insurance and those who could afford to would attend the private health facilities. It is important to ensure that all sectors of the population are informed about the complications of Zika, the risk of sexual transmission and the role each citizen plays in the national and global spread of the disease. Government and healthcare workers have a responsibility to reach the public.
Limitations Attenders at health centres, which are free at the point of care, are generally from the lower socio-economic groups. Those with health insurance or those who could afford to pay for their
care would present privately, and therefore, their knowledge, attitudes and practices in this setting are unknown. Our findings are, therefore, not generalisable to the wider population but are important in that they demonstrate important gaps in knowledge and practices among a critical population subgroup. These gaps can lead to increased morbidity with resultant effects on the economy and healthcare systems in a country trying to regain its position on the economic landscape.
Conclusion The level of knowledge on general aspects of mosquito control was good; specific knowledge related to Zika was low. The government needs to address this gap. Good practice examples can be borrowed from the management of the HIV epidemic.28 Community participation to deliver accurate messages and to dispel myths, such as the existence of treatment for Zika, is one approach. To achieve a truly healthy society, the gap between those who know and practice preventive medicine and those who do not know and therefore do not practise needs to be narrowed.29 Apart from the need to increase knowledge to safeguard an individual's health and well-being, the whole of society is affected when a baby is born with microcephaly in terms of the time taken off work for parents with resultant healthcare and economic costs. The government needs to target the messages about the risks and transmission of Zika. The government also needs to invest in health literacy and harness national and local intersectoral strategies to augment the messages they disseminate.27,28,30
Author statements Acknowledgements The authors wish to express their gratitude to their colleagues who collected the data.
Ethical approval The ethical approval was obtained from the University of the West Indies and from the respective Regional Health Authorities. All subjects gave their consent to participate.
Funding None declared.
Competing interests None declared.
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Public Health journal homepage: www.elsevier.com/puhe
Original Research
Zika virus diseasedknowledge, attitudes and practices among pregnant womendimplications for public health practice S. Pooransingh a,*, R. Parasram b, N. Nandram c, B. Bhagwandeen d, I. Dialsingh d a
Faculty of Medical Sciences, The University of the West Indies, St Augustine, Trinidad and Tobago Office of the Chief Medical Officer, The Ministry of Health Trinidad and Tobago c Insect Vector Control Division, The Ministry of Health, Trinidad and Tobago d Faculty of Science and Technology, The University of the West Indies, St Augustine, Trinidad and Tobago b
article info
abstract
Article history:
Objective: Mosquito-borne diseases continue to pose a threat to Latin America and the
Received 22 February 2018
Caribbean. Zika virus disease entered the Caribbean in 2013 with increased reporting of
Received in revised form
cases across the region in 2016, affecting more than 50 countries. This study aimed to
1 September 2018
ascertain the knowledge of, attitudes and practices towards Zika virus disease among
Accepted 18 September 2018
antenatal clinic attenders in Trinidad and Tobago during the 2016 outbreak. Study design: A cross-sectional questionnaire survey was undertaken. Methods: A knowledge attitudes and practices survey was conducted among antenatal
Keywords:
clinic attenders at publicly funded primary care health centres. All counties of Trinidad
Zika
(except St Patrick, Caroni and Victoria) and Tobago were included in the study. Within each
Pregnancy
county, three health centres were selected at random. At the antenatal clinic of each
Knowledge
selected health centre, antenatal clients were selected by randomly selecting their patient
Attitudes
file from that day's antenatal clinic patient files. Data collection occurred from September
Practices
to November 2016. The knowledge, attitudes and practice survey was administered by an
Global health
interviewer-administered questionnaire. The World Health Organization Knowledge, Attitudes and Practice surveys Zika virus disease and potential complications Resource pack was adapted for use as the data collection tool. All data collected were analysed using SPSS software, version 23. Tests with P-values less than 0.05 were deemed significant. Results: Seventy-four percent (74%) of responders did not think there was a link between sexual transmission and Zika. About 19% stated that abstaining could prevent Zika but only 6.6% actually practiced this. Seventy-six percent knew the risk of microcephaly, and this knowledge of the risk of microcephaly was found to be significantly associated with the number of weeks' gestation. Less than 40% knew the risk of GuillaineBarre syndrome. Doctors at health centres followed by private doctors were the top two trusted information sources for responders. Responders thought that the government could spray insecticide, clean drains, educate community members and clean overgrown vacant lots of land.
* Corresponding author. Faculty of Medical Sciences, UWI St Augustine, Mount Hope, Champs Fleurs, Trinidad and Tobago. E-mail address: [email protected] (S. Pooransingh). https://doi.org/10.1016/j.puhe.2018.09.025 0033-3506/© 2018 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
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Conclusion: The government and healthcare workers need to reach specific target groups with accurate messages to minimize the associated morbidity and thereby safeguarding national and global health security. © 2018 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
Introduction Mosquito-borne diseases continue to plague Latin America and the Caribbean and thus continue to present a threat to global health security. Yellow fever, malaria, dengue and chikungunya are ever-present dangers in this part of the world.1,2 Countries are working to develop their health systems' capacities to detect and respond to acute public health threats through the International Health Regulations (2005) framework3 and the Global Health Security Agenda in the region.4,5 Disease outbreaks serve to periodically test these systems. The most recent addition to the list of threats is Zika virus disease which was introduced into the Americas in 2013 with an outbreak reported in 2015 in Brazil and which spread rapidly across the Americas and the Caribbean affecting in excess of 50 countries.6e9 Since its identification in 1947 in Uganda up until 1981, globally there were fourteen reported cases of illness in Africa and Southeast Asia.10 The current globalisation of Zika began in the Pacific Island of Yap in the Federated States of Polynesia in 2007.10e13 Cases were reported in 2013 in French Polynesia followed by cases on Cook Island and Easter Island.14 The first case of Zika virus in Trinidad and Tobago was reported in February 20169 when Zika was declared a Public Health Emergency of International Concern by the World Health Organization (WHO) Director General.15 Trinidad and Tobago with a population of approximately 1.4 million persons reported more than 700 laboratory-confirmed cases of Zika virus in 2016 with more than 60% in pregnant women.16,17 Trinidad and Tobago is a twin island state southernmost in the Caribbean archipelago, 15 km from Venezuela in mainland South America, with daily flights to the United States of America and being a popular tourist destination for travellers from North America and Europe. Trinidad and Tobago is, therefore, well placed to facilitate the spread of disease across the Americas and the world as has happened with Zika. Indeed, the Canadians found that 50% of travel-associated Zika was acquired in the Caribbean. In addition, the secondary sexual transmission of Zika is now well documented.4,5 Therefore, not only public health alert and response capacities should be robust but also prevention and awareness among the public must be viewed as a priority in an effort to prevent the global spread of disease.6 This study aimed to assess the knowledge, attitudes and practices of antenatal patients regarding Zika virus in healthcare facilities in Trinidad and Tobago in the midst of the 2016 outbreak, 7 months after the first case was reported nationally. The expected outcome was to determine which health messages are needed and to which target groups to reduce the Zika-associated morbidity of microcephaly and
brain damage in the foetus, GuillaineBarre in adults and sexual transmission among adults.
Methods The study was set in antenatal clinics in publicly funded health centres in Trinidad and Tobago. A cross-sectional study, a knowledge, attitude and practice (KAP) survey, was undertaken with a target population of antenatal patients attending publicly funded health centres as this is where clients from the general population attend, unless they develop complications in pregnancy at which time they are referred to the hospital specialist in the obstetrics and gynaecology clinic. The study population comprised all counties of Trinidad (except three for which approvals were delayed); Tobago was also included. Within each county, three health centres were selected at random using random digit selection. At the antenatal clinic in each health centre, seven clients were selected by randomly selecting their patient file from that day's antenatal clinic patient files using random digit selection. Data were collected from September to November 2016. The survey was administered via an intervieweradministered questionnaire. The interviewers were the County Medical Officers of Health (n ¼ 5) who are the public health physicians for their respective counties. Each conducted the interviews in the health centres within their county. They were trained by the medical officer at the Insect Vector Control Division, who was also a public health physician. The trainer went through each question of the survey. The WHO Knowledge, Attitudes and Practice surveys Zika virus disease and potential complications. Resource pack18 was adapted for use. The final questionnaire comprised 67 questions. It took an average of 25 min to complete each interview. All data collected were analysed using SPSS software, version 23. Tests with P-values less than 0.05 were deemed significant.
Results The response rate for the survey was 91/105 ¼ 86.7%. A total of 91 participants were interviewed. The participants' ages ranged from 18 to 40 years, with an average age of 26.32 years (standard deviation [SD] ¼ 4.89). The average number of weeks' gestation was 25.16 weeks (SD ¼ 10.09). Forty-four (48.4%) of the participants indicated residence in an urban area, while 42 (46.2%) documented residence in rural parts of the country. In terms of knowledge and awareness about Zika, 96.7% of responders became aware of the Zika virus during the period
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2015e2016. Ninety-two percent of the responders believed that there was the possibility of contracting the virus in the local community at the time of the survey (2016), and 95.6% believed that it was possible for anybody to contract the Zika virus. The majority (53%) of responders obtained their information on Zika from the Internet. Regarding the cause of Zika, almost 97% believed mosquitoes to be the cause. Just more than 60% did not think that a dirty environment contributed to acquiring the infection. In terms of prevention, 89.0% of responders were of the opinion that Zika could be prevented. Seventy-one percent said they knew to use mosquito nets at night to prevent mosquito bites, and 39.6% said they practised this; 48.4% said they knew to use mosquito nets during the day time, and 24.2% said they practiced this. Table 1 shows what participants believed to be the ways to prevent Zika. Table 2 shows urban/rural residence and knowledge about removing standing/stagnant water sources to prevent contracting the Zika virus. Seventy-four percent of responders did not think that there was a link between sexual transmission and Zika. Approximately 19% stated that abstinence could prevent Zika, and 6.6% said they practised this. Seventy-six percent of responders knew the associated risk of microcephaly, and the knowledge of the risk of microcephaly was found to be significantly associated with number of weeks' gestation. Table 3 shows what respondents thought were risks to the foetus/baby. In terms of risks to patients, 37.4% agreed that there is a link between Zika and GuillaineBarre syndrome (Table 3). Regarding treatment, 61.5% of respondents believed that there was a treatment for the Zika virus and that doctors in health centres can treat someone for Zika. Almost 43% agreed that aspirin or ibuprofen should not be used to treat the virus, while 40.7% were unsure.
Table 2 e Residence and knowledge about removing standing/stagnant water sources to prevent contraction of the Zika virus. Area of residence
Ways to prevent Zika
Agree [no. (%)]
Use mosquito nets at night Use mosquito nets during the day Use mosquito repellants/body sprays Use mosquito coils/fires Wear covering clothes Use condoms in sexual relations Abstain from sexual intercourse Clean water storage containers Remove standing/stagnant water sources Spray/fumigate house Put window and door screens Clean household environment
65 44 71 40 46 22 17 50 65 58 34 68
(71.4) (48.4) (78.0) (44.0) (50.5) (24.2) (18.7) (54.9) (71.4) (63.7) (37.4) (74.7)
Disagree [no. (%)] 16 37 10 41 35 59 64 31 16 23 47 13
(17.6) (40.7) (11.0) (45.1) (38.5) (64.8) (70.3) (34.1) (17.6) (25.3) (51.6) (14.3)
Chi-squared tests of independence were carried out to determine whether the areas of residence (rural/urban) and the woman's knowledge with respect to the methods of prevention of the Zika virus are related. Table 2 shows the findings.
P-value
Yes [no. (%)] No [no. (%)] Total [no. (%)] Urban Rural Total (%)
26 (33.8) 35 (45.5) 61 (79.2)
12 (15.6) 4 (5.2) 16 (20.8)
38 (49.4) 39 (50.6) 77 (100.0)
0.021
Chi-squared tests revealed that the woman's knowledge of removing standing/stagnant water sources was dependent on the area of residence (P-value ¼ 0.021).
Table 3 e Knowledge about the possible risks to a foetus/ baby. Risks
Agree [no. (%)]
Disagree [no. (%)]
Risk of not growing/developing normally in the womb Risk of miscarriage Risk of a premature birth Risk of a stillborn birth Risk of birth with microcephaly Risk of being born with a disability
61 (67.0)
29 (31.9)
18 31 14 69 43
72 59 76 21 47
(19.8) (34.1) (15.4) (75.8) (47.3)
(79.1) (64.8) (83.5) (23.1) (51.6)
Chi-squared tests of independence were carried out to determine whether the number of weeks pregnant and the woman's knowledge with respect to risks the foetus/baby faces, should she contract the Zika virus, are related. Table 4 shows the findings.
Table 4 e Gestational age and knowledge about the risk of microcephaly. Weeks pregnant
Table 1 e What participants believed to be the ways to prevent the Zika virus.
Remove standing/stagnant water sources
0e12 13e24 >24 Total (%)
Risk of microcephaly Yes [no. (%)]
No [no. (%)]
Total [no. (%)]
5 18 44 67
8 5 8 21
13 23 52 88
(5.7) (20.5) (50.0) (76.1)
(9.1) (5.7) (9.1) (23.9)
(14.8) (26.1) (59.1) (100.0)
P-value 0.002
The Chi-squared tests revealed that the woman's knowledge of the risk of birth with microcephaly was dependent on the number of weeks pregnant (P-value ¼ 0.002).
Regarding the attitude of responders towards Zika, 90% of responders viewed the Zika virus as an important issue in the local community. Seventy-nine percent stated that they would consider having a test for Zika if they currently had a fever. Thirteen percent conveyed that they would not have a test performed because fevers were fairly common and there are other signs of the Zika virus. Regarding attitudes to pregnant women, 88.0% of the participants believed that all pregnant women should be tested for the virus, and 76.9% suggested that if a woman gets a fever while pregnant, she should either visit her doctor or get tested at a medical centre for the virus. Sixty-two percent of the
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responders disagreed that women who get the Zika virus during pregnancy should have access to abortions, while 44.0% agreed that women should avoid getting pregnant at the present time because of the Zika virus. Fifty-nine percent believed that much more information about the virus is required as 50.6% related a lack of understanding in some aspects of the virus. Eighty-three percent of responders stated that they would consider having a vaccine for Zika, should one be available. In terms of responders' attitudes towards whose responsibility is it to prevent the spread of Zika in the household/community, 84.6% of responders said that it was the household head/family responsibility to prevent the spread of Zika. Almost 66% thought that it was the responsibility of the regional corporation, and 40.7% said that the Ministry of Health has responsibility for preventing the spread of Zika. Participants believe that the government agencies can prevent the Zika virus in the community by spraying insecticide for mosquitoes (84.6%), cleaning drains (75.8%) educating community members (70.3%) and cleaning vacant/overgrown lots (60.4%). The views on who can effectively treat Zika were as follows: most responders, 79.1%, thought that doctors at public or private health facilities have the necessary resources to treat someone, while 76.9% of participants did not think that this treatment could be received from a local healer and 67.0% believed that a pharmacist cannot effectively treat persons with Zika. The top five trusted information sources on the Zika virus were healthcare workers at the health centre (69.2%) followed by private doctors (48.4%), the WHO/Pan American Health Organization (PAHO) (23.1%), birth attendants/midwives (16.5%) and pharmacists (14.3%). Concerns of responders about Zika are shown in Tables 5 and 6. Regarding practices among responders, just more than 81% of the participants stated that they were undertaking practices to alleviate the threat of the virus. Table 7 shows what responders do to prevent Zika.
Discussion The study was an important one for determining the KAP regarding Zika in a key population subgroup in a small developing country, which is endemic for mosquito-borne illnesses. The study response rate was high at approximately 87%. Table 5 e Participants' concerns about the Zika virus. Concerns
Agree Disagree [no. (%)] [no. (%)]
Zika can make you sick Zika can kill you Zika can cause babies to have disabilities Zika can cause adults to have disabilities Zika can be sexually transmitted Zika will cause children to be sick Safe abortion is not available if Zika is contracted while pregnant
35 20 74 11 25 45 13
(38.5) (22.0) (81.3) (12.1) (27.5) (49.5) (14.3)
54 69 15 78 64 44 76
(59.3) (75.8) (16.5) (85.7) (70.3) (48.4) (83.5)
Table 6 e Actions participants believe can reduce mosquitoes in the household. Actions
Agree [no. (%)]
Spray/fumigate Keep environment clean Keep water sources clean Keep water sources covered Remove standing/stagnant water Burn mosquito coils Burn fires Impossible to reduce mosquitoes
76 74 70 70 72 38 21 8
(83.5) (81.3) (76.9) (76.9) (79.1) (41.8) (23.1) (8.8)
Disagree [no. (%)] 13 15 19 19 17 51 68 81
(14.3) (16.5) (20.9) (20.9) (18.7) (56.0) (74.7) (89.0)
Table 7 e Practices participants have taken to prevent contraction of the Zika virus. Practice
Agree Disagree [no. (%)] [no. (%)]
Used mosquito nets at night Used mosquito nets during the day Used mosquito repellant/body spray Used mosquito coils Wore covering clothes Used condoms in sexual relations Used modern family planning method Abstinence from sexual intercourse Cleaned water storage units/containers Removed standing/stagnant sources of water Sprayed home with insecticide Used natural insect repellants Installed window and door screens Cleaned household environment Prayed to God
36 22 51 35 28 6 4 6 38 43 40 40 6 49 18
(39.6) (24.2) (56.0) (38.5) (30.8) (6.6) (4.4) (6.6) (41.8) (47.3) (44.0) (44.0) (6.6) (53.8) (19.8)
31 45 16 32 39 61 63 61 29 24 27 27 61 18 49
(34.1) (49.5) (17.6) (35.2) (42.9) (67.0) (69.2) (67.0) (31.9) (26.4) (29.7) (29.7) (67.0) (19.8) (53.8)
The potential complications of Zika virus are serious. Antenatal women are at risk of delivering a baby with neurological effects, suffering from GuillaineBarre syndrome and transmitting the infection to and acquiring the infection from their partners. The level of knowledge in pregnant women should intuitively be high as one would expect women to be concerned about the well-being of their babies; on the contrary, studies have shown that knowledge about health matters is low among pregnant women studied.19,20 Responders in our study who were at later weeks of gestation were significantly more aware of the risk of microcephaly. The government should note this finding when tailoring health education messages. Fifty-three percent of responders indicated that they obtained their information on Zika from the Internet. The remaining 47% obtain their information from other sources such as the newspaper, radio and healthcare workers. Southwell et al.21 found that information searching and sharing on a subject occurred at peak briefly after public health authority announcements. This would suggest that governments and health educators should ensure reliable and key information is available when they decide to make announcements on diseases and risks of diseases. They should direct the public to credible sources of information in their announcements and use these periods of information seeking to address perceptions and concerns and target those who are
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at greatest risk. The respondents trusted doctors and the WHO/PAHO as credible sources of information. Governments should take note and hold health education sessions for the front-line workers who are key to informing the public. Doctors and other healthcare workers as part of their duty of care should also ensure they are up to date with the latest evidence and information on diseases such as Zika. In the midst of Zika outbreaks across the Latin American and Caribbean region, more than 70% of a key subgroup in our study was unaware of the potential for sexual transmission of the disease and therefore would not have engaged in preventive practices. This finding is not unlike the findings in Greece where a similar survey was undertaken22 and 63.3% of the responders were unaware of the risk of sexual transmission. The Greek survey was undertaken in July 2016, while this study was undertaken between September and November 2016. Greece was not undergoing active Zika transmission at the time of their study unlike in our study where Trinidad and Tobago was in the midst of increasing cases. In contrast to our findings, Whittemore et al.23 found that their population was well informed about the risks of sexual transmission and that of birth defects and attributed this to being in the midst of active transmission. So what is unique about our study population? There is clearly a gap in our capacity to reach our publicdto adequately inform and educate our public or perhaps the phenomenon is a characteristic of our population subgroup. Boggild et al. showed that 50% of Canadian cases identified through their travel medicine surveillance were acquired in the Caribbean.8 A study in California highlighted the importance of travel in the transmission of Zika with the majority of the travel-associated Zika cases originating in Mexico and Central America but with the potential for limited local transmission in the resident country.24 Visiting Trinidad and Tobago can, therefore, pose a risk to visitors from all parts of the world who visit relatives, the beaches and attend the annual carnival event. Hastings et al.25 in their review of sexual transmission report that the virus persists for months in the genital tracts. Gaskell et al. recommend barrier contraceptive use for 6 months after symptomatic Zika infection.26 This study revealed that the level of knowledge of Zika among a group of persons who should be well informed, because the disease can adversely affect their baby and they too can spread the disease to their partners, is low. Health literacy and a healthier lifestyle are associated with a higher level of education.27 Attenders at the publicly funded health centres where this survey was undertaken are less likely to possess health insurance as those with health insurance and those who could afford to would attend the private health facilities. It is important to ensure that all sectors of the population are informed about the complications of Zika, the risk of sexual transmission and the role each citizen plays in the national and global spread of the disease. Government and healthcare workers have a responsibility to reach the public.
Limitations Attenders at health centres, which are free at the point of care, are generally from the lower socio-economic groups. Those with health insurance or those who could afford to pay for their
care would present privately, and therefore, their knowledge, attitudes and practices in this setting are unknown. Our findings are, therefore, not generalisable to the wider population but are important in that they demonstrate important gaps in knowledge and practices among a critical population subgroup. These gaps can lead to increased morbidity with resultant effects on the economy and healthcare systems in a country trying to regain its position on the economic landscape.
Conclusion The level of knowledge on general aspects of mosquito control was good; specific knowledge related to Zika was low. The government needs to address this gap. Good practice examples can be borrowed from the management of the HIV epidemic.28 Community participation to deliver accurate messages and to dispel myths, such as the existence of treatment for Zika, is one approach. To achieve a truly healthy society, the gap between those who know and practice preventive medicine and those who do not know and therefore do not practise needs to be narrowed.29 Apart from the need to increase knowledge to safeguard an individual's health and well-being, the whole of society is affected when a baby is born with microcephaly in terms of the time taken off work for parents with resultant healthcare and economic costs. The government needs to target the messages about the risks and transmission of Zika. The government also needs to invest in health literacy and harness national and local intersectoral strategies to augment the messages they disseminate.27,28,30
Author statements Acknowledgements The authors wish to express their gratitude to their colleagues who collected the data.
Ethical approval The ethical approval was obtained from the University of the West Indies and from the respective Regional Health Authorities. All subjects gave their consent to participate.
Funding None declared.
Competing interests None declared.
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