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Dengue in peri-urban Pak-Ngum district, Vientiane capital of Laos: a community survey on knowledge, attitudes and practices

Dengue in peri-urban Pak-Ngum district, Vientiane capital of Laos: a community survey on... Background: Dengue remains an important cause of morbidity in Laos. Good knowledge, attitudes and practices (KAP) among the public regarding dengue prevention are required for the success of disease control. Very little is known about dengue KAP among the Lao general population. Methods: This was a KAP household survey on dengue conducted in a peri-urban Pak-Ngum district of Vientiane capital, Laos. A two-stage cluster sampling method was used to select a sample of participants to represent the general community. Participants from 231 households were surveyed using an interviewer-administered questionnaire. Results: Although 97% of the participants heard of dengue, there was a lack of depth of knowledge on dengue: 33% of them did not know that malaria and dengue were different diseases, 32% incorrectly believed that Aedes mosquito transmits malaria, 36% could not correctly report that Aedes mosquitoes bite most frequently at sunrise and sunset; and < 10% of them recognized that indoor water containers could be Aedes mosquito breeding sites. Attitude levels were moderately good with a high proportion (96%) of participants recognizing that dengue was a severe yet preventable disease. Self reported prevention methods were quite high yet observation of the participants’ yards showed use of prevention methods to be only moderate. The majority (93%) of the interviewees did not believe that they had enough information on dengue. There was an association between good knowledge and better practices, but good knowledge was associated with worse attitudes. Conclusions: There is a lack of depth of knowledge regarding dengue in Pak-Ngum community and observation methods revealed that more needs to be done by community members themselves to prevent the spread of Aedes mosquitoes. Keywords: Dengue, Knowledge, Attitude, Practice, Vientiane, Laos Background [3]. Annually, there are approximately 50 to 100 million Dengue - an Aedes mosquito-borne, viral and prevent- cases of dengue infection with 500,000 severe cases re- able disease – remains an important public health prob- quiring hospitalization which result in approximately lem in the tropical and subtropical world [1,2]. It is 24,000 deaths, mainly among children [2]. estimated that ~2.5 billion people globally are at risk of In Lao PDR (Laos), dengue is still an important cause dengue infection, of which 52% reside in Southeast Asia of morbidity particularly in urban areas. The disease is endemic in nine out of seventeen provinces and 3.9 mil- lion residents are presently at risk of infection [4]. Over * Correspondence: [email protected] the past decade, the burden of dengue has increased dra- Faculty of Postgraduate Studies, University of Health Sciences, matically and in 2006 it was ranked one of the top ten Vientiane, Lao PDR Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), causes of death in Laos [5]. It is observed that dengue Mahosot Hospital, Vientiane, Lao PDR epidemics occur cyclically, every few years [6,7]. The Full list of author information is available at the end of the article © 2013 Mayxay et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Mayxay et al. BMC Public Health 2013, 13:434 Page 2 of 8 http://www.biomedcentral.com/1471-2458/13/434 first reported dengue outbreak in Lao PDR was in the Capital of Laos. Ethical clearance for the study was capital of Vientiane in 1983, where there were 1,759 granted by the Ethics Committee of the University of cases of dengue hemorrhagic fever or DHF [8]. Since Health Sciences, Ministry of Health, Laos. then, there have been multiple reports of outbreaks, Pak-Ngum District is approximately 60 Km south of which are now no longer restricted to just the capital. the center of Vientiane Capital and is inhabited predom- The largest of these outbreaks was in 1987, where there inantly by rice farmers of the Lao Loom ethnic group were 9,699 cases and 295 deaths, mostly in children (~98%) with a GDP of ~1,039 $US. It is home to 53 vil- under fifteen years of age [8]. In 2009, 7,835 dengue lages with 9,403 households and a total population of cases and 19 deaths were reported to the national sur- 50,265. There is one district hospital, 9 health centers veillance system (facility-based), which increased to and 11 private pharmacies in the district. The climate in more than 22,000 dengue cases and 45 deaths in the Pak-Ngum is tropical with a distinct monsoon season 2010 epidemic [9]. Although most dengue outbreaks in (April - October) and a dry season (November - March). Laos have occurred in urban areas, an ecological survey The climate tends to be hot and humid throughout the of Aedes mosquitoes conducted in a central province of course of the year. Although the number of dengue Laos suggested that dengue might be more prevalent in cases presented and admitted to Pak-Ngum District rural than urban areas and that peri-urban areas may be Hospital was low in recent years (36 cases in 2009 and the hotspot for dengue infection [10]. Indeed, dengue 54 in 2012), the 2012 Aedes mosquito larvae survey was the leading cause of non-malaria febrile illness found that 91% of households tested positive for Aedes among patients seen at a rural Salavan Province in larvae and there were 125 containers with Aedes larvae southern Laos between 2009–2010 [Mayxay et al., The per 100 households. causes of non-malaria fever in Laos - evidence to inform empirical treatment of fever, submitted]. Sampling procedure and survey Despite its severity, dengue is a preventable disease A two-stage cluster sampling method [11-15] was used [1]. The only method to prevent the transmission of to select a sample of participants to represent the gen- dengue virus is to control the vector mosquito breeding eral community of Pak-Ngum. First, 30 clusters/villages sites. Good knowledge, attitudes and practices (KAP) were randomly selected from 40 accessible villages using among the public are required to successfully prevent or probability proportionate to size cluster sampling (there minimize dengue outbreaks. However, very little is were 13 additional villages in this district which could known about the public’s KAP on dengue and dengue not be accessed). Once the clusters were selected, we used prevention in Laos. Only one KAP study regarding simple random sampling from village household lists to dengue was conducted in Pakse City of southern identify 8 households to survey for each cluster. We calcu- Champasack province of Laos in 2009. Out of 230 inter- lated a desired sample size of 240 households (8 house- viewees, 93.5% knew that dengue was transmitted by holds from each of the 30 clusters). This was based on a mosquitoes and 93.9% recognized water containers as 95% confidence level, a ± 10% margin for error, a response breeding sites for these mosquitoes. The most com- distribution of 50% (which requires the largest sample monly named symptom was fever, which was named by size), and allowance of 10% for non-response and a con- 75.2% of the participants. However, the participants in servatively estimated design effect of two. this study were comprised of people who had been diag- We sought to interview the adult (>18 years of age) nosed with dengue in the past two years by both symp- head of each of the selected households. After written toms and laboratory tests from the hospital – the results consent was obtained, the head of each household was were not able to be generalized to the whole community face-to-face interviewed by two local interviewers (ST in Pakse [5]. and KP) using an interviewer-administered questionnaire Understanding the KAP of the general community on in the local language. dengue and prevention will provide valuable information The questionnaire comprised questions on knowledge, for effective strategic planning and engaging the public attitudes, practices related to dengue and dengue pre- in dengue control. This paper reports on a survey of vention. After completing the questionnaire, the inter- KAP on dengue and dengue prevention among the viewer made an observation of the area around the general community of Pak-Ngum District – a peri-urban participant’s dwelling to assess it with regard to dengue area of Vientiane Capital of Laos. prevention. The questions in the questionnaire were de- termined by reviewing previous KAP studies assessing Methods the levels of knowledge, attitudes and practices regarding Study duration and location dengue. A KAP questionnaire used in Swaziland to test A household survey was conducted in January 2009 in the public’s knowledge on malaria was also used as a Pak-Ngum District - a peri-urban area of Vientiane template for beginning to build our own questionnaire Mayxay et al. BMC Public Health 2013, 13:434 Page 3 of 8 http://www.biomedcentral.com/1471-2458/13/434 Table 1 Socio-demographic characteristics of the [16]. The questionnaire was first translated into Lao and participants in the survey (n = 231) then back translated into English to make sure the first Variable n % translation was accurate. We piloted the questionnaire on students at the University of Health Sciences in Gender Vientiane, Laos. Male 77 33.5 Female 153 66.5 Data analysis Age (years): Data were entered into a Microsoft Excel spreadsheet 18 – 24 9 3.9 and then transferred to Stata version 13.0 for analysis 25 – 34 52 22.6 using survey commands to adjust for the two-stage clus- 35 – 44 74 32.2 ter sampling design. Descriptive statistical analysis was 45 – 54 65 28.3 used to provide estimates of population proportions with 55 – 64 22 9.6 their respective 95% confidence intervals. Cross tabula- 65+ 8 3.5 tions were performed with Chi-square or Fisher’s Exact tests to assess statistical significance (α = 0.05). Education (years): 0 18 7.9 Results 1 – 6 116 50.7 Of the 240 households randomly selected to be sur- 7 – 12 92 40.2 veyed, 231 (96.2%) gave consent and participated in the 12+ 3 1.3 study. Nine households were not surveyed because no Occupation one was at home during the survey despite the third at- Farmer 192 83.1 tempt of visit. The socio-demographic details of the in- Merchant 16 6.9 formants are shown in Table 1. Housewife 8 3.5 Labourer 8 3.5 Dengue knowledge of and dengue information source received by the respondents Gardener 4 1.7 Of all participants, 225 (97.4%, 95% CI = 95.0 - 99.8) had Civil servant 1 0.4 heard of dengue. Most participants could recognize fever Government worker 1 0.4 as a symptom of dengue and a considerable proportion Unemployed 1 0.4 recognized headache and muscle pain but fewer could Religion (Buddhist) 231 100 name bleeding and skin rash as signs of dengue infection Previous family experience with dengue (yes) 38 16.4 (Table 2). We found that 94.1% (n = 209, 95% CI = 89.2- 99.1) knew that mosquitoes were the transmitting vec- tors, and 93.3% (n = 195) of these knew that Aedes n = 202, 95% CI = 84.5-95.9) knew that malaria was aegypti were the specific mosquito that transmitted den- transmitted by a mosquito but there was some confusion gue. Almost all participants [n = 212, (94.2%, 95% CI = between the mosquito vectors for malaria and dengue. 90.6-97.8)] recognized outdoor containers (tyres, river/ Only 28.0% (n = 63, 95% CI = 16.1-39.8) could name the ponds) as breeding sites for Aedes mosquito, but less Anopheles mosquito as the vector for malaria, while than 10% recognized that indoor water containers (forest 31.6% (n = 71) incorrectly believed that Aedes mosqui- areas, sewage, drains, dirty water, and stagnant water) toes transmit malaria. were also potential breeding sites. A small proportion in- correctly believed areas with running water could be breeding sites for Aedes mosquitoes. In addition, 63.6% Table 2 Signs and symptoms of dengue recognized by (n = 143, 95% CI = 51.1-76.0) correctly reported that the respondents in the survey (n = 231) Aedes mosquitoes bite most frequently at sunrise and Symptoms/signs n % (95% C.I.) 93.3% of them (n = 210, 95% CI = 89.2-97.5) correctly Fever 182 80.9% (71.4 - 90.4) identified that rainy season was when Aedes mosquitoes Headache 103 45.8% (30.9 - 60.7) were most prevalent. Muscle pain 70 31.1% (20.9 - 41.2) Two-thirds (67.4%, n = 151, 95% CI = 59.3-75.5) of par- Bleeding 57 25.3% (13.4 - 37.3) ticipants knew that dengue and malaria were different Skin rash 33 14.7% (8.1 - 21.2) diseases, the rest either thought they were the same dis- Nausea 16 7.1% (2.5 - 11.7) ease (22.8%, n = 51, 95% CI = 13.9-31.7), or reported that they did not know if they were different (9.8%, n = 22, Don’t know 32 14.2% (6.9 - 21.5) 95% CI = 5.2-14.5). The majority of interviewees (90.2%, NB: Multiple response options. Mayxay et al. BMC Public Health 2013, 13:434 Page 4 of 8 http://www.biomedcentral.com/1471-2458/13/434 Respondents were asked where they had heard about Thirty-nine percent (n = 88) mentioned that dengue pre- dengue and where they hoped to get more information. vention was the responsibility of health care workers. The results are presented in Table 3. The majority [n = 209 (92.9%), 95% CI = 88.7-97.1] of the interviewees Dengue prevention practice by the respondents did not believe that they had enough information on When the participants were asked on what methods they dengue. Forty-seven percent of them wanted more infor- used to protect themselves from Aedes mosquito bites, mation on control and prevention methods, and 25.3% almost all said they would use mosquito nets (Table 4). wanted to know more about signs and symptoms of Most interviewees recognized that water containers were dengue. a major breeding site for Aedes mosquitoes. Approxi- mately half of the participants reported that they cover their water containers and just less than half reported Attitudes of the respondents on dengue that they clean water containers to prevent breeding. Ninety-six percent (n = 211, 95% CI = 92.0-99.9) of par- One quarter reported that they treat the water in water ticipants believed that dengue was fatal, but only 28.0% containers. From observation of the respondents’ houses (n = 216, 95% CI = 17.7-38.3) would seek treatment there were signs that participants weren’t taking mea- within the first 24 hours. All respondents said they sures to eradicate Aedes breeding sites. There were many would seek treatment at some stages at a health facility. yards containing rubbish, water jars and tanks, as well as Ninety-four percent (n = 211, 95% CI = 88.2-99.3) of discarded tyres. Despite 50.7% of participants reporting them believed that dengue was preventable. More than that they covered their water containers, only 21.5% of half of these participants (64.9%, n = 146) considered water jars and 10.2% of water tanks outside the partici- themselves at least partly responsible for dengue preven- pants’ dwelling were covered on observation (Table 5). tion, leaving approximately one-third believing that they were not in any way responsible for dengue prevention. Comparison between the groups or variables Table 3 Sources of information about dengue received by There were no statistical differences across gender, edu- the respondent in the survey (n = 231) cation, age, and previous experience with dengue infec- Variable n % (95% C.I.) tion between: (1) the respondents who were able to list Where participants have heard about dengue: 0, 1–2, and 3 or more symptoms/signs of dengue; (2) the Television 128 56.9 (46.9 – 66.8) participants who would seek treatment within 24 hours, Friends 125 55.6 (45.0 – 66.1) 2–3 days, and after 4 or more days if they suspected they had dengue; and (3) the interviewees who reported to Health facilities 112 49.8 (37.9 – 61.6) use 1, 2, and 3 or more methods to protect themselves Community meetings 91 40.4 (28.0 – 52.9) from mosquito bites. Health care workers 83 36.9 (24.5 – 49.3) Radio 46 20.4 (13.3 – 27.6) Table 4 Dengue prevention practices reported by the Family 40 17.8 (8.9 – 26.6) respondents in the survey (n = 231) Temple/Church 27 12.0 (6.1 – 17.9) Variable n % (95% C.I.) Poster/pamphlets 5 2.2 (0 – 5.2) Mosquito bite prevention practices: Newspaper 2 0.9 (0 – 2.2) Mosquito nets 223 99.1 (97.8 - 100) School 1 0.4 (0 – 1.3) Mosquito coils, mats and liquid vapourisers 94 41.8 (33.3 - 50.3) Where participants hope to hear about dengue: Indoor insecticide spraying 80 35.6 (24.5 - 46.6) Television 114 50.7 (39.0 – 62.3) Fans 23 10.2 (5.9 - 14.5) Community meetings 107 47.6 (36.9 – 58.1) Clothing 13 5.8 (1.6 – 10.0) Health care workers 94 41.8 (28.6 – 54.9) Personal mosquito repellents 8 3.6 (1.0 - 6.2) Health facilities 78 34.7 (22.9 – 46.3) Window and door screens 1 0.4 (0–1.4) Friends 73 32.4 (17.5 – 47.4) Methods to eradicate Aedes breeding sites: Radio 54 24.0 (15.8 – 32.2) Covering water containers 114 50.7 (37.3 - 64.0) Temple/Church 22 9.8 (4.1 – 15.4) Cleaning water containers regularly 105 46.7 (32.7 - 60.7) Family 22 9.8 (1.4 – 18.1) Treated water in water containers 60 26.7 (15.8 - 37.5) Poster/pamphlets 21 9.3 (3.7 – 14.9) Not store water 52 23.1 (13.3 - 32.9) School 2 0.9 (0 – 2.2) Cut down vegetation around the home 43 19.1 (10.5 - 27.7) Newspapers 1 0.4 (0 – 1.4) Dispose old tyres 25 11.1 (4.1 - 18.1) NB: Multiple response options. NB: Multiple response options. Mayxay et al. BMC Public Health 2013, 13:434 Page 5 of 8 http://www.biomedcentral.com/1471-2458/13/434 Table 5 Dengue prevention practices by the respondents by observing the participants’yards in the survey (n = 231) Yards containing objects Objects filled with water Water collection points that were covered n (%) [95% C.I.] n (%) [95% C.I.] n (%) [95% C.I.] Discarded tyres 63 (27.3%) 7 (11.1%) [13.8 - 40.7] [1.1 - 21.1] Not applicable Cans 46 (19.9%) 2 (4.5%) [10.2 - 29.7] [0–11.3] Not applicable Plastic bottles 47 (20.3%) 0 (0%) [8.6 - 32.1] [0.00-0.00] Not applicable Coconut shells 38 (16.4%) 1 (2.6%) [9.2 - 23.7] [0–8.2] Not applicable Flower vases 9 (3.9%) 2 (22.2%) [0.5 - 7.3] [0–76.9] Not applicable Holes in ground 106 (45.9%) 20 (18.7%) [31.9 - 59.9] [6.3 - 31.0] Not applicable Window/door screens 11 (4.8%) Not applicable [1.1 - 8.4] Not applicable Water jars 190 (82.2%) 41 (21.5%) [74.2 - 90.3] Not applicable [12.5 - 30.4] Water tanks 118 (51.1%) 12 (10.2%) [38.9 - 63.2] Not applicable [2.3 - 18.1] If suspected of having dengue, 65.6% of the respon- There was no significant association between treat- dents who were not able to name any dengue signs/ ment behavior and mosquito bite protection practices. symptoms would seek treatment within 24 hours com- However, there was a significantly negative relationship pared to those who were able to list 1–2 symptoms/signs between good attitudes (people believe they are person- (31.0%), and those who managed to list 3 or more symp- ally at least partly responsible for dengue prevention) toms/signs (15.0%), (p < .01). Seventy-nine percent of the and a higher number of protection methods: the propor- participants who could only name one Aedes aegypti tion of the participants who reported that they used 3 or breeding site held themselves solely responsible for den- more protection methods was significantly lower in the gue prevention as compared to 37.0% of those who group with good attitudes (13.9%) compared with the could name 2, and 37.5% of those who were able to list group with negative attitudes (who does not believe they 3 or more breeding sites (p < .01). These results suggest are responsible for dengue prevention) (29.8%), (p < .01). that attitudes regarding dengue care and prevention are There was also a statistically negative association be- negatively correlated with knowledge. tween good attitudes and incorrect observed practices Those respondents with better knowledge reported bet- (uncovered water jars in yard): the percentage of the in- ter practices. The proportion of respondents who reported terviewees with good attitudes (88.7%) was statistically using three or more methods to protect themselves from higher in the group with observed uncovered water jars mosquito bites was significantly higher in the group who in yard when compared with the group with observed were able to name three or more symptoms/signs of den- covered water jars in yard (11.3%) (p < .01). gue(40.2%)comparedtothe groupwho couldnameonly 1–2 (18.8%) and the group who did not know any dengue Discussion symptoms/signs (9.4%), (p < .01). Forty-four percent of the We conducted a survey to assess the dengue knowledge, interviewees who named 3 or more Aedes aegypti breeding attitudes and practices of the Lao villagers in a peri- sites reported using more methods (3 or more) to eradicate urban area of Vientiane, Laos and found that although Aedes aegypti breeding sites when compared with those almost all of the participants heard of dengue, the depth who named 2 breeding sites (25.3%), and those who named of their knowledge on dengue was still lacking. For ex- one breeding site (5.6%), (p < .01). A higher percentage of ample, approximately one third of interviewees failed to participants with less knowledge of breeding sites (one and differentiate between malaria and dengue and incorrectly two) had uncovered water jars in their yard (90.1% and believed that Aedes mosquito transmits malaria; many 76.1%, respectively) when compared to those with more could not correctly report that Aedes mosquitoes bite knowledge of breeding sites (3 or more – 64.4%), (p < .01). most frequently at sunrise and sunset and few Mayxay et al. BMC Public Health 2013, 13:434 Page 6 of 8 http://www.biomedcentral.com/1471-2458/13/434 recognized that indoor water containers could be Aedes for Aedes breeding. The reasons why people are not mosquito breeding sites. A study in a semi-urban town practicing prevention methods is not due to lack of of Malaysia also found that although 95% of the study knowledge, but other factors which are as yet unknown. participants had heard about dengue, their knowledge In this survey, good knowledge was negatively associ- on dengue transmission and control remained insuffi- ated with good attitudes amongst our study population. cient [17]. Another pilot study among people visiting For example, a higher proportion of participants who tertiary care hospitals in Karachi, Pakistan showed that scored worse in the knowledge section would seek treat- although 90% of the interviewees had heard of dengue, ment immediately. A possible explanation is apprehen- only 38.5% of them were found to have sufficient know- sion towards unfamiliar symptoms, thus prompting the ledge about dengue [18]. Another survey among adults individual to seek medical advice. We also found that a of high and low socio-economic groups in Pakistan higher proportion of those with less knowledge would demonstrated that only 35% of the study sample had ad- take personal responsibility in dengue prevention. equate knowledge about dengue fever and its vector Dengue knowledge and ways to prevent disease is one [19]. Almost all participants in our study appear to want of the crucial aspects in the strategy to improve disease more information about dengue as they believed that prevention, and improving education as a method to they did not have enough dengue information - this is a promote better usage of prevention practices should be very encouraging opportunity to improve the depth of implemented. Insufficient proof to link knowledge as a their knowledge regarding dengue prevention in the determinant for improving practice seems to be a recur- community. ring theme in much of the literature [25]. Community’s This survey confirmed what was found in a previous good knowledge on dengue does not often translate into study conducted in southern Laos that fever was the better practices [5,22,25,26]. For example, participants in most recognized symptom, that most participants recog- Kuala Kangsar of Malaysia had good knowledge of den- nized mosquitoes as the transmitting vector and knew gue prevention practices, yet only half covered their that water containers were a mosquito breeding sites for water containers [23]. However, our study found an asso- dengue [5]. A study in slum areas of metropolitan city of ciation between better knowledge and both better self- West Bengal demonstrated that approximately 69% of reported practices and better-observed practices – the the study subjects recognized fever as the main symp- finding that was consistent with the report from Malaysia tom of dengue but 83% of them were unaware of dengue [17]. This was also seen in Taiwan’s successful application transmission [20]. The survey in northern Thailand of better practices through education and cleanliness pro- showed that fever (81%) and rash (77%) were the most grams [27], as well as the great decrease of Aedes infest- frequently mentioned symptoms by the study partici- ation after education programs in Colima Mexico [28]. pants [21]. Despite the association between better knowledge and Knowledge of the link between mosquitoes and dengue better practice, we found that good attitudes did not lead in the current and previous study [5] in Laos suggests that to better self-reported or observed practices. This trend the mosquito education campaigns across the nation have was not what we expected, as improving attitudes have been effective. However, the respondents in our survey previously been shown in Taiwan to also improve pre- were still confused between dengue and malaria – a find- vention practice use [28]. This shows that having the ing that was also found in Karachi Pakistan [18]. right attitude does not necessarily mean the participant Lack of personal responsibility was found to be prob- will translate it into practice, and be motivated to act lematic in dengue control in many countries such as against dengue infection. This indicates that we need to Thailand [22], Malaysia [23] and Puerto Rico [24]; and promote the utilization of protection strategies through this was also the case in Pakse City of Laos where 22% encouragement of compliance with prevention practices, which will result in more efficient dengue control. This of the study participants held the government solely ac- countable [5]. In our current study, although the major- further highlights that in order to bring about behavioral ity of participants believed that dengue is a severe, yet change we need to implement a multi-factorial ap- proach, which also targets other important facets, such preventable disease; one-third of them do not think they are at least partly responsible for dengue control. as local compliance and the sustainability of disease con- As found in a study in northern Thailand [21], ap- trol programs. Limitations of our study include the exclusion of 13 proximately half of our study participants reported that they cover their water containers in order to minimize inaccessible villages at the time of data collection which the risk of Aedes mosquito breeding. However, from ob- may have introduced selection bias and a possibility that servation, many households had uncovered water jars or a social acceptability bias could have been introduced as tanks in their yard, as well as discarded tyres and rub- the local researchers conducting the surveys were doc- bish that could collect water and provide a possible site tors from the district hospital (participants may have felt Mayxay et al. BMC Public Health 2013, 13:434 Page 7 of 8 http://www.biomedcentral.com/1471-2458/13/434 pressured to give the answers they felt were socially ap- 2. WHO: Dengue and severe dengue, fact sheet No. 117 January 2012. Geneva: WHO; 2012. http://www.who.int/mediacentre/factsheets/fs117/en/. propriate). The study would have been improved by the 3. WHO: Situation of dengue/dengue haemorrhagic fever in South East Asia development of scales with a scoring system to measure region. Geneva: WHO; 2007. http://www.searo.who.int/en/Section10/ knowledge, attitudes and practices – this would have Section332_1098.htm. 4. The Centre of Malariology Parasitology and Entomology (CMPE), Vientiane added greater weight to measures of association between Capital: National vector control policy in Lao PDR, review. Vientiane: CMPE; these three constructs. In addition knowledge and atti- 2008. http://www.actmalaria.net/files/vector_control/vc_policy/vc_laos.pdf. tudes about dengue could differ by important confounders 5. Nalongsack S, Yoshida Y, Morita S, Sosouphanh K, Sakamoto J: Knowledge, like age, gender, education, site of survey, social status and attitude and practice regarding dengue among people in Pakse, Laos. Nagoya J Med Sci 2009, 71:29–37. other relevant characteristics in the population, which 6. Peyerl-Hoffmann G, Schwobel B, Jordan S, Vanisaveth V, Phetsouvanh R, could not be accounted for in this analysis. Further re- Christophel EM, Phompida S, Sonnenburg FV, Jelinek T: Serological search would benefit from adopting a design that would investigation of the prevalence of anti-dengue IgM and IgG antibodies in attapeu province, South Laos. Clin Microbiol Infect 2004, 10:181–184. allow for more detailed multivariate analysis. 7. Mayxay M, Phetsouvanh R, Moore CE, Chansamouth V, Vongsouvath M, Sisouphone S, Vongphachanh P, Thaojaikong T, Thongpaseuth S, Conclusions Phongmany S, Keolouangkhot V, Strobel M, Newton PN: Predictive Good dengue prevention demands the involvement of the diagnostic value of the tourniquet test for the diagnosis of dengue infection in adults. Trop Med Int Health 2010, 16:127–133. community. Better information is required that helps guide 8. Fukunaga T, Tadano M, Shinjo M, Phommasack B, Makino Y, Insisiengmay S: dengue prevention programmes in their efforts to engage Epidemiological situation of dengue infection in Lao PDR. Trop Med 1994, with the community. In summary, in Pak-Ngum district 35:219–227. there is a lack of depth of knowledge regarding dengue in 9. National Center of Laboratory and Epidemiology (NCLE) of Laos: Dengue surveillance data 2010. Ministry of Health; 2010. Unpublished report of the community and observation methods revealed that Ministry of Health. more needs to be done by community members them- 10. Tsuda Y, Kobayashi J, Nambanya S, Miyagi I, Toma T, Phompida S, Manivang selves to prevent the spread of Aedes mosquitoes. Fortu- K: An ecological survey of dengue vector mosquitos in central Lao PDR. Southeast Asian J Trop Med Public Health 2002, 33:63–67. nately, the majority of the community believes they need 11. Singleton Jnr RA, Straits BC: Approaches to social research. 4th edition. more information about dengue. These results will guide Oxford: Oxford University Press; 2005. future research in this area and help to instruct dengue 12. Alecxih L, Corea J, Marker D: Deriving state-level estimates from three national surveys: a statistical assessment and state tabulations, The U.S. Department of prevention programs. health & human services. 1998. http://aspe.hhs.gov/daltcp/reports/derives.htm. 13. Ahmed S: Methods in sample surveys: cluster sampling, John Hopkins Competing interests Bloomberg school of public health. 2009. http://ocw.jhsph.edu/courses/ The authors declare that they have no competing interests. StatMethodsForSampleSurveys/PDFs/Lecture5.pdf. 14. Shackman G: Sample size and design effect. 2009. http://www.ncbi.nlm.nih. Authors’ contributions gov/pubmed?term=Shackman%20G%3A%20Sample%20size%20and% WC, GA, and MM designed the study including the questionnaire and 20design%20effect. two-stage cluster sampling methodology. WC, VV, LI, VS, ST, KK and MM 15. Teck YW: Probability proportional to size (PPS) cluster sampling: application in piloted and refined the questionnaire in the field and implemented the the military setting. 2005. http://www.internationalmta.org/Documents/2005/ sampling methodology. MM wrote the first draft of this manuscript. All 2005134P.pdf. authors have contributed to the further development of the manuscript. All authors read and approved the final manuscript. 16. Hlongwana KW, Mabaso ML, Kunene S, Govender D, Maharaj R: Community knowledge, attitudes and practices (KAP) on malaria in Swaziland: a country earmarked for malaria elimination. Malar J 2009, 8:1–8. Acknowledgements 17. Naing C, Ren WY, Man CY, Fern KP, Qiqi C, Ning CN, Ee CW: Awareness of This study was funded by the Nossal Institute for Global Health, Melbourne, dengue and practice of dengue control among the semi-urban community: Australia. We thank all the participants from Pak-Ngum Districts who kindly a cross-sectional survey. J Community Health 2011, 36:1044–1049. involved in this survey. We are very grateful to Dr. Phouthone and Timothy 18. Itrat A, Khan A, Javaid S, Kamal M, Khan H, Javed S, Kalia S, Khan AH, Sethi Moore for their kind assistance in setting up this survey. MI, Jehan I: Knowledge, awareness and practices regarding dengue fever among the adult population of dengue Hit cosmopolitan. PLoS ONE 2008, Financial support 3:1–6. The Nossal Institute for Global Health, University of Melbourne, Australia. 19. Syed M, Saleem T, Syeda UR, Habib M, Zahid R, Bashir A, Rabbani M, Khalid M, Iqbal A, Rao EZ, Shujja Ur R, Saleem S: Knowledge, attitudes and Author details practices regarding dengue fever among adults of high and low Faculty of Postgraduate Studies, University of Health Sciences, socioeconomic groups. J Pak Med Assoc 2010, 60:243–247. Vientiane, Lao PDR. Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Mahosot Hospital, Vientiane, Lao PDR. Centre for Clinical 20. Haldar A, Gupta UD, Majumdar KK, Laskar K, Ghosh S, Sen S: Community Vaccinology and Tropical Medicine, Churchill Hospital, University of Oxford, perception of dengue in slum areas of metropolitan of West Bengal. Oxford, UK. Nossal Institute for Global Health, The University of Melbourne, J Commun Dis 2008, 40:205–2010. Melbourne, Australia. Pak-Ngum District Health Office, Vientiane Capital, Lao 21. van Benthem BHB, Khantikul N, Panart K, Kessels PJ, Somboon P, Oskam L: PDR. Knowledge and use of prevention measures related to dengue in northern Thailand. Trop Med Int Health 2002, 7:993–1000. Received: 2 January 2013 Accepted: 22 April 2013 22. Phuanukoonnon S, Brough M, Bryan JH: Folk knowledge about dengue Published: 3 May 2013 mosquitoes and contributions of health belief model in dengue control promotion in Northeast Thailand. Acta Trop 2006, 99:6–14. References 23. Hairi F, Ong CH, Suhaimi A, Tsung T-W, Ahmad MAA, Sundaraj C, Soe MM: 1. WHO T: WHO report on global surveillance of epidemic-prone infectious A knowledge, attitude and practices (KAP) study on dengue among diseases - dengue and dengue haemorrhagic fever. Geneva: WHO; 2009. http:// selected rural communities in the Kuala Kangsar district. Asia Pac J Public www.who.int/csr/resources/publications/dengue/CSR_ISR_2000_1/en/. Health 2003, 15:37–43. Mayxay et al. BMC Public Health 2013, 13:434 Page 8 of 8 http://www.biomedcentral.com/1471-2458/13/434 24. Pérez-Guerra CL, Zielinski-Gutierrez E, Vargas-Torres D, Clark GG: Community beliefs and practices about dengue in Puerto Rico. Rev Panam Salud Publica 2009, 25:218–226. 25. Matta S, Bhalla S, Singh D, Rasania SK, Singh S: Knowledge, attitude and practice (KAP) on dengue fever: a hospital based study. Indian J Community Med 2006, 31:185–186. 26. Jennings CD, Phommasack B, Sourignadeth B, Kay BH: Aedes aegypti control in the Lao People’s Democratic Republic, with reference to copepods. Am J Trop Med Hyg 1995, 53:324–330. 27. Pai H-H, Hong Y-J, Hsu E-L: Impact of a short-term community-based cleanliness campaign on the sources of dengue vectors: an entomological and human behavior study. J Environ Health 2006, 68:35–39. 28. Espinoza-Gomez F, Moises Hernandez-Suarez C, Coll-Cardenas R: Educational campaign vs malathion spraying for the control of Aedes aegypti in Colima, Mexico. J Epidemiol Community Health 2002, 56:148–153. doi:10.1186/1471-2458-13-434 Cite this article as: Mayxay et al.: Dengue in peri-urban Pak-Ngum district, Vientiane capital of Laos: a community survey on knowledge, attitudes and practices. BMC Public Health 2013 13:434. 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Dengue in peri-urban Pak-Ngum district, Vientiane capital of Laos: a community survey on knowledge, attitudes and practices

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Copyright © 2013 by Mayxay et al.; licensee BioMed Central Ltd.
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Medicine & Public Health; Public Health; Medicine/Public Health, general; Epidemiology; Environmental Health; Biostatistics; Vaccine
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Abstract

Background: Dengue remains an important cause of morbidity in Laos. Good knowledge, attitudes and practices (KAP) among the public regarding dengue prevention are required for the success of disease control. Very little is known about dengue KAP among the Lao general population. Methods: This was a KAP household survey on dengue conducted in a peri-urban Pak-Ngum district of Vientiane capital, Laos. A two-stage cluster sampling method was used to select a sample of participants to represent the general community. Participants from 231 households were surveyed using an interviewer-administered questionnaire. Results: Although 97% of the participants heard of dengue, there was a lack of depth of knowledge on dengue: 33% of them did not know that malaria and dengue were different diseases, 32% incorrectly believed that Aedes mosquito transmits malaria, 36% could not correctly report that Aedes mosquitoes bite most frequently at sunrise and sunset; and < 10% of them recognized that indoor water containers could be Aedes mosquito breeding sites. Attitude levels were moderately good with a high proportion (96%) of participants recognizing that dengue was a severe yet preventable disease. Self reported prevention methods were quite high yet observation of the participants’ yards showed use of prevention methods to be only moderate. The majority (93%) of the interviewees did not believe that they had enough information on dengue. There was an association between good knowledge and better practices, but good knowledge was associated with worse attitudes. Conclusions: There is a lack of depth of knowledge regarding dengue in Pak-Ngum community and observation methods revealed that more needs to be done by community members themselves to prevent the spread of Aedes mosquitoes. Keywords: Dengue, Knowledge, Attitude, Practice, Vientiane, Laos Background [3]. Annually, there are approximately 50 to 100 million Dengue - an Aedes mosquito-borne, viral and prevent- cases of dengue infection with 500,000 severe cases re- able disease – remains an important public health prob- quiring hospitalization which result in approximately lem in the tropical and subtropical world [1,2]. It is 24,000 deaths, mainly among children [2]. estimated that ~2.5 billion people globally are at risk of In Lao PDR (Laos), dengue is still an important cause dengue infection, of which 52% reside in Southeast Asia of morbidity particularly in urban areas. The disease is endemic in nine out of seventeen provinces and 3.9 mil- lion residents are presently at risk of infection [4]. Over * Correspondence: [email protected] the past decade, the burden of dengue has increased dra- Faculty of Postgraduate Studies, University of Health Sciences, matically and in 2006 it was ranked one of the top ten Vientiane, Lao PDR Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), causes of death in Laos [5]. It is observed that dengue Mahosot Hospital, Vientiane, Lao PDR epidemics occur cyclically, every few years [6,7]. The Full list of author information is available at the end of the article © 2013 Mayxay et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Mayxay et al. BMC Public Health 2013, 13:434 Page 2 of 8 http://www.biomedcentral.com/1471-2458/13/434 first reported dengue outbreak in Lao PDR was in the Capital of Laos. Ethical clearance for the study was capital of Vientiane in 1983, where there were 1,759 granted by the Ethics Committee of the University of cases of dengue hemorrhagic fever or DHF [8]. Since Health Sciences, Ministry of Health, Laos. then, there have been multiple reports of outbreaks, Pak-Ngum District is approximately 60 Km south of which are now no longer restricted to just the capital. the center of Vientiane Capital and is inhabited predom- The largest of these outbreaks was in 1987, where there inantly by rice farmers of the Lao Loom ethnic group were 9,699 cases and 295 deaths, mostly in children (~98%) with a GDP of ~1,039 $US. It is home to 53 vil- under fifteen years of age [8]. In 2009, 7,835 dengue lages with 9,403 households and a total population of cases and 19 deaths were reported to the national sur- 50,265. There is one district hospital, 9 health centers veillance system (facility-based), which increased to and 11 private pharmacies in the district. The climate in more than 22,000 dengue cases and 45 deaths in the Pak-Ngum is tropical with a distinct monsoon season 2010 epidemic [9]. Although most dengue outbreaks in (April - October) and a dry season (November - March). Laos have occurred in urban areas, an ecological survey The climate tends to be hot and humid throughout the of Aedes mosquitoes conducted in a central province of course of the year. Although the number of dengue Laos suggested that dengue might be more prevalent in cases presented and admitted to Pak-Ngum District rural than urban areas and that peri-urban areas may be Hospital was low in recent years (36 cases in 2009 and the hotspot for dengue infection [10]. Indeed, dengue 54 in 2012), the 2012 Aedes mosquito larvae survey was the leading cause of non-malaria febrile illness found that 91% of households tested positive for Aedes among patients seen at a rural Salavan Province in larvae and there were 125 containers with Aedes larvae southern Laos between 2009–2010 [Mayxay et al., The per 100 households. causes of non-malaria fever in Laos - evidence to inform empirical treatment of fever, submitted]. Sampling procedure and survey Despite its severity, dengue is a preventable disease A two-stage cluster sampling method [11-15] was used [1]. The only method to prevent the transmission of to select a sample of participants to represent the gen- dengue virus is to control the vector mosquito breeding eral community of Pak-Ngum. First, 30 clusters/villages sites. Good knowledge, attitudes and practices (KAP) were randomly selected from 40 accessible villages using among the public are required to successfully prevent or probability proportionate to size cluster sampling (there minimize dengue outbreaks. However, very little is were 13 additional villages in this district which could known about the public’s KAP on dengue and dengue not be accessed). Once the clusters were selected, we used prevention in Laos. Only one KAP study regarding simple random sampling from village household lists to dengue was conducted in Pakse City of southern identify 8 households to survey for each cluster. We calcu- Champasack province of Laos in 2009. Out of 230 inter- lated a desired sample size of 240 households (8 house- viewees, 93.5% knew that dengue was transmitted by holds from each of the 30 clusters). This was based on a mosquitoes and 93.9% recognized water containers as 95% confidence level, a ± 10% margin for error, a response breeding sites for these mosquitoes. The most com- distribution of 50% (which requires the largest sample monly named symptom was fever, which was named by size), and allowance of 10% for non-response and a con- 75.2% of the participants. However, the participants in servatively estimated design effect of two. this study were comprised of people who had been diag- We sought to interview the adult (>18 years of age) nosed with dengue in the past two years by both symp- head of each of the selected households. After written toms and laboratory tests from the hospital – the results consent was obtained, the head of each household was were not able to be generalized to the whole community face-to-face interviewed by two local interviewers (ST in Pakse [5]. and KP) using an interviewer-administered questionnaire Understanding the KAP of the general community on in the local language. dengue and prevention will provide valuable information The questionnaire comprised questions on knowledge, for effective strategic planning and engaging the public attitudes, practices related to dengue and dengue pre- in dengue control. This paper reports on a survey of vention. After completing the questionnaire, the inter- KAP on dengue and dengue prevention among the viewer made an observation of the area around the general community of Pak-Ngum District – a peri-urban participant’s dwelling to assess it with regard to dengue area of Vientiane Capital of Laos. prevention. The questions in the questionnaire were de- termined by reviewing previous KAP studies assessing Methods the levels of knowledge, attitudes and practices regarding Study duration and location dengue. A KAP questionnaire used in Swaziland to test A household survey was conducted in January 2009 in the public’s knowledge on malaria was also used as a Pak-Ngum District - a peri-urban area of Vientiane template for beginning to build our own questionnaire Mayxay et al. BMC Public Health 2013, 13:434 Page 3 of 8 http://www.biomedcentral.com/1471-2458/13/434 Table 1 Socio-demographic characteristics of the [16]. The questionnaire was first translated into Lao and participants in the survey (n = 231) then back translated into English to make sure the first Variable n % translation was accurate. We piloted the questionnaire on students at the University of Health Sciences in Gender Vientiane, Laos. Male 77 33.5 Female 153 66.5 Data analysis Age (years): Data were entered into a Microsoft Excel spreadsheet 18 – 24 9 3.9 and then transferred to Stata version 13.0 for analysis 25 – 34 52 22.6 using survey commands to adjust for the two-stage clus- 35 – 44 74 32.2 ter sampling design. Descriptive statistical analysis was 45 – 54 65 28.3 used to provide estimates of population proportions with 55 – 64 22 9.6 their respective 95% confidence intervals. Cross tabula- 65+ 8 3.5 tions were performed with Chi-square or Fisher’s Exact tests to assess statistical significance (α = 0.05). Education (years): 0 18 7.9 Results 1 – 6 116 50.7 Of the 240 households randomly selected to be sur- 7 – 12 92 40.2 veyed, 231 (96.2%) gave consent and participated in the 12+ 3 1.3 study. Nine households were not surveyed because no Occupation one was at home during the survey despite the third at- Farmer 192 83.1 tempt of visit. The socio-demographic details of the in- Merchant 16 6.9 formants are shown in Table 1. Housewife 8 3.5 Labourer 8 3.5 Dengue knowledge of and dengue information source received by the respondents Gardener 4 1.7 Of all participants, 225 (97.4%, 95% CI = 95.0 - 99.8) had Civil servant 1 0.4 heard of dengue. Most participants could recognize fever Government worker 1 0.4 as a symptom of dengue and a considerable proportion Unemployed 1 0.4 recognized headache and muscle pain but fewer could Religion (Buddhist) 231 100 name bleeding and skin rash as signs of dengue infection Previous family experience with dengue (yes) 38 16.4 (Table 2). We found that 94.1% (n = 209, 95% CI = 89.2- 99.1) knew that mosquitoes were the transmitting vec- tors, and 93.3% (n = 195) of these knew that Aedes n = 202, 95% CI = 84.5-95.9) knew that malaria was aegypti were the specific mosquito that transmitted den- transmitted by a mosquito but there was some confusion gue. Almost all participants [n = 212, (94.2%, 95% CI = between the mosquito vectors for malaria and dengue. 90.6-97.8)] recognized outdoor containers (tyres, river/ Only 28.0% (n = 63, 95% CI = 16.1-39.8) could name the ponds) as breeding sites for Aedes mosquito, but less Anopheles mosquito as the vector for malaria, while than 10% recognized that indoor water containers (forest 31.6% (n = 71) incorrectly believed that Aedes mosqui- areas, sewage, drains, dirty water, and stagnant water) toes transmit malaria. were also potential breeding sites. A small proportion in- correctly believed areas with running water could be breeding sites for Aedes mosquitoes. In addition, 63.6% Table 2 Signs and symptoms of dengue recognized by (n = 143, 95% CI = 51.1-76.0) correctly reported that the respondents in the survey (n = 231) Aedes mosquitoes bite most frequently at sunrise and Symptoms/signs n % (95% C.I.) 93.3% of them (n = 210, 95% CI = 89.2-97.5) correctly Fever 182 80.9% (71.4 - 90.4) identified that rainy season was when Aedes mosquitoes Headache 103 45.8% (30.9 - 60.7) were most prevalent. Muscle pain 70 31.1% (20.9 - 41.2) Two-thirds (67.4%, n = 151, 95% CI = 59.3-75.5) of par- Bleeding 57 25.3% (13.4 - 37.3) ticipants knew that dengue and malaria were different Skin rash 33 14.7% (8.1 - 21.2) diseases, the rest either thought they were the same dis- Nausea 16 7.1% (2.5 - 11.7) ease (22.8%, n = 51, 95% CI = 13.9-31.7), or reported that they did not know if they were different (9.8%, n = 22, Don’t know 32 14.2% (6.9 - 21.5) 95% CI = 5.2-14.5). The majority of interviewees (90.2%, NB: Multiple response options. Mayxay et al. BMC Public Health 2013, 13:434 Page 4 of 8 http://www.biomedcentral.com/1471-2458/13/434 Respondents were asked where they had heard about Thirty-nine percent (n = 88) mentioned that dengue pre- dengue and where they hoped to get more information. vention was the responsibility of health care workers. The results are presented in Table 3. The majority [n = 209 (92.9%), 95% CI = 88.7-97.1] of the interviewees Dengue prevention practice by the respondents did not believe that they had enough information on When the participants were asked on what methods they dengue. Forty-seven percent of them wanted more infor- used to protect themselves from Aedes mosquito bites, mation on control and prevention methods, and 25.3% almost all said they would use mosquito nets (Table 4). wanted to know more about signs and symptoms of Most interviewees recognized that water containers were dengue. a major breeding site for Aedes mosquitoes. Approxi- mately half of the participants reported that they cover their water containers and just less than half reported Attitudes of the respondents on dengue that they clean water containers to prevent breeding. Ninety-six percent (n = 211, 95% CI = 92.0-99.9) of par- One quarter reported that they treat the water in water ticipants believed that dengue was fatal, but only 28.0% containers. From observation of the respondents’ houses (n = 216, 95% CI = 17.7-38.3) would seek treatment there were signs that participants weren’t taking mea- within the first 24 hours. All respondents said they sures to eradicate Aedes breeding sites. There were many would seek treatment at some stages at a health facility. yards containing rubbish, water jars and tanks, as well as Ninety-four percent (n = 211, 95% CI = 88.2-99.3) of discarded tyres. Despite 50.7% of participants reporting them believed that dengue was preventable. More than that they covered their water containers, only 21.5% of half of these participants (64.9%, n = 146) considered water jars and 10.2% of water tanks outside the partici- themselves at least partly responsible for dengue preven- pants’ dwelling were covered on observation (Table 5). tion, leaving approximately one-third believing that they were not in any way responsible for dengue prevention. Comparison between the groups or variables Table 3 Sources of information about dengue received by There were no statistical differences across gender, edu- the respondent in the survey (n = 231) cation, age, and previous experience with dengue infec- Variable n % (95% C.I.) tion between: (1) the respondents who were able to list Where participants have heard about dengue: 0, 1–2, and 3 or more symptoms/signs of dengue; (2) the Television 128 56.9 (46.9 – 66.8) participants who would seek treatment within 24 hours, Friends 125 55.6 (45.0 – 66.1) 2–3 days, and after 4 or more days if they suspected they had dengue; and (3) the interviewees who reported to Health facilities 112 49.8 (37.9 – 61.6) use 1, 2, and 3 or more methods to protect themselves Community meetings 91 40.4 (28.0 – 52.9) from mosquito bites. Health care workers 83 36.9 (24.5 – 49.3) Radio 46 20.4 (13.3 – 27.6) Table 4 Dengue prevention practices reported by the Family 40 17.8 (8.9 – 26.6) respondents in the survey (n = 231) Temple/Church 27 12.0 (6.1 – 17.9) Variable n % (95% C.I.) Poster/pamphlets 5 2.2 (0 – 5.2) Mosquito bite prevention practices: Newspaper 2 0.9 (0 – 2.2) Mosquito nets 223 99.1 (97.8 - 100) School 1 0.4 (0 – 1.3) Mosquito coils, mats and liquid vapourisers 94 41.8 (33.3 - 50.3) Where participants hope to hear about dengue: Indoor insecticide spraying 80 35.6 (24.5 - 46.6) Television 114 50.7 (39.0 – 62.3) Fans 23 10.2 (5.9 - 14.5) Community meetings 107 47.6 (36.9 – 58.1) Clothing 13 5.8 (1.6 – 10.0) Health care workers 94 41.8 (28.6 – 54.9) Personal mosquito repellents 8 3.6 (1.0 - 6.2) Health facilities 78 34.7 (22.9 – 46.3) Window and door screens 1 0.4 (0–1.4) Friends 73 32.4 (17.5 – 47.4) Methods to eradicate Aedes breeding sites: Radio 54 24.0 (15.8 – 32.2) Covering water containers 114 50.7 (37.3 - 64.0) Temple/Church 22 9.8 (4.1 – 15.4) Cleaning water containers regularly 105 46.7 (32.7 - 60.7) Family 22 9.8 (1.4 – 18.1) Treated water in water containers 60 26.7 (15.8 - 37.5) Poster/pamphlets 21 9.3 (3.7 – 14.9) Not store water 52 23.1 (13.3 - 32.9) School 2 0.9 (0 – 2.2) Cut down vegetation around the home 43 19.1 (10.5 - 27.7) Newspapers 1 0.4 (0 – 1.4) Dispose old tyres 25 11.1 (4.1 - 18.1) NB: Multiple response options. NB: Multiple response options. Mayxay et al. BMC Public Health 2013, 13:434 Page 5 of 8 http://www.biomedcentral.com/1471-2458/13/434 Table 5 Dengue prevention practices by the respondents by observing the participants’yards in the survey (n = 231) Yards containing objects Objects filled with water Water collection points that were covered n (%) [95% C.I.] n (%) [95% C.I.] n (%) [95% C.I.] Discarded tyres 63 (27.3%) 7 (11.1%) [13.8 - 40.7] [1.1 - 21.1] Not applicable Cans 46 (19.9%) 2 (4.5%) [10.2 - 29.7] [0–11.3] Not applicable Plastic bottles 47 (20.3%) 0 (0%) [8.6 - 32.1] [0.00-0.00] Not applicable Coconut shells 38 (16.4%) 1 (2.6%) [9.2 - 23.7] [0–8.2] Not applicable Flower vases 9 (3.9%) 2 (22.2%) [0.5 - 7.3] [0–76.9] Not applicable Holes in ground 106 (45.9%) 20 (18.7%) [31.9 - 59.9] [6.3 - 31.0] Not applicable Window/door screens 11 (4.8%) Not applicable [1.1 - 8.4] Not applicable Water jars 190 (82.2%) 41 (21.5%) [74.2 - 90.3] Not applicable [12.5 - 30.4] Water tanks 118 (51.1%) 12 (10.2%) [38.9 - 63.2] Not applicable [2.3 - 18.1] If suspected of having dengue, 65.6% of the respon- There was no significant association between treat- dents who were not able to name any dengue signs/ ment behavior and mosquito bite protection practices. symptoms would seek treatment within 24 hours com- However, there was a significantly negative relationship pared to those who were able to list 1–2 symptoms/signs between good attitudes (people believe they are person- (31.0%), and those who managed to list 3 or more symp- ally at least partly responsible for dengue prevention) toms/signs (15.0%), (p < .01). Seventy-nine percent of the and a higher number of protection methods: the propor- participants who could only name one Aedes aegypti tion of the participants who reported that they used 3 or breeding site held themselves solely responsible for den- more protection methods was significantly lower in the gue prevention as compared to 37.0% of those who group with good attitudes (13.9%) compared with the could name 2, and 37.5% of those who were able to list group with negative attitudes (who does not believe they 3 or more breeding sites (p < .01). These results suggest are responsible for dengue prevention) (29.8%), (p < .01). that attitudes regarding dengue care and prevention are There was also a statistically negative association be- negatively correlated with knowledge. tween good attitudes and incorrect observed practices Those respondents with better knowledge reported bet- (uncovered water jars in yard): the percentage of the in- ter practices. The proportion of respondents who reported terviewees with good attitudes (88.7%) was statistically using three or more methods to protect themselves from higher in the group with observed uncovered water jars mosquito bites was significantly higher in the group who in yard when compared with the group with observed were able to name three or more symptoms/signs of den- covered water jars in yard (11.3%) (p < .01). gue(40.2%)comparedtothe groupwho couldnameonly 1–2 (18.8%) and the group who did not know any dengue Discussion symptoms/signs (9.4%), (p < .01). Forty-four percent of the We conducted a survey to assess the dengue knowledge, interviewees who named 3 or more Aedes aegypti breeding attitudes and practices of the Lao villagers in a peri- sites reported using more methods (3 or more) to eradicate urban area of Vientiane, Laos and found that although Aedes aegypti breeding sites when compared with those almost all of the participants heard of dengue, the depth who named 2 breeding sites (25.3%), and those who named of their knowledge on dengue was still lacking. For ex- one breeding site (5.6%), (p < .01). A higher percentage of ample, approximately one third of interviewees failed to participants with less knowledge of breeding sites (one and differentiate between malaria and dengue and incorrectly two) had uncovered water jars in their yard (90.1% and believed that Aedes mosquito transmits malaria; many 76.1%, respectively) when compared to those with more could not correctly report that Aedes mosquitoes bite knowledge of breeding sites (3 or more – 64.4%), (p < .01). most frequently at sunrise and sunset and few Mayxay et al. BMC Public Health 2013, 13:434 Page 6 of 8 http://www.biomedcentral.com/1471-2458/13/434 recognized that indoor water containers could be Aedes for Aedes breeding. The reasons why people are not mosquito breeding sites. A study in a semi-urban town practicing prevention methods is not due to lack of of Malaysia also found that although 95% of the study knowledge, but other factors which are as yet unknown. participants had heard about dengue, their knowledge In this survey, good knowledge was negatively associ- on dengue transmission and control remained insuffi- ated with good attitudes amongst our study population. cient [17]. Another pilot study among people visiting For example, a higher proportion of participants who tertiary care hospitals in Karachi, Pakistan showed that scored worse in the knowledge section would seek treat- although 90% of the interviewees had heard of dengue, ment immediately. A possible explanation is apprehen- only 38.5% of them were found to have sufficient know- sion towards unfamiliar symptoms, thus prompting the ledge about dengue [18]. Another survey among adults individual to seek medical advice. We also found that a of high and low socio-economic groups in Pakistan higher proportion of those with less knowledge would demonstrated that only 35% of the study sample had ad- take personal responsibility in dengue prevention. equate knowledge about dengue fever and its vector Dengue knowledge and ways to prevent disease is one [19]. Almost all participants in our study appear to want of the crucial aspects in the strategy to improve disease more information about dengue as they believed that prevention, and improving education as a method to they did not have enough dengue information - this is a promote better usage of prevention practices should be very encouraging opportunity to improve the depth of implemented. Insufficient proof to link knowledge as a their knowledge regarding dengue prevention in the determinant for improving practice seems to be a recur- community. ring theme in much of the literature [25]. Community’s This survey confirmed what was found in a previous good knowledge on dengue does not often translate into study conducted in southern Laos that fever was the better practices [5,22,25,26]. For example, participants in most recognized symptom, that most participants recog- Kuala Kangsar of Malaysia had good knowledge of den- nized mosquitoes as the transmitting vector and knew gue prevention practices, yet only half covered their that water containers were a mosquito breeding sites for water containers [23]. However, our study found an asso- dengue [5]. A study in slum areas of metropolitan city of ciation between better knowledge and both better self- West Bengal demonstrated that approximately 69% of reported practices and better-observed practices – the the study subjects recognized fever as the main symp- finding that was consistent with the report from Malaysia tom of dengue but 83% of them were unaware of dengue [17]. This was also seen in Taiwan’s successful application transmission [20]. The survey in northern Thailand of better practices through education and cleanliness pro- showed that fever (81%) and rash (77%) were the most grams [27], as well as the great decrease of Aedes infest- frequently mentioned symptoms by the study partici- ation after education programs in Colima Mexico [28]. pants [21]. Despite the association between better knowledge and Knowledge of the link between mosquitoes and dengue better practice, we found that good attitudes did not lead in the current and previous study [5] in Laos suggests that to better self-reported or observed practices. This trend the mosquito education campaigns across the nation have was not what we expected, as improving attitudes have been effective. However, the respondents in our survey previously been shown in Taiwan to also improve pre- were still confused between dengue and malaria – a find- vention practice use [28]. This shows that having the ing that was also found in Karachi Pakistan [18]. right attitude does not necessarily mean the participant Lack of personal responsibility was found to be prob- will translate it into practice, and be motivated to act lematic in dengue control in many countries such as against dengue infection. This indicates that we need to Thailand [22], Malaysia [23] and Puerto Rico [24]; and promote the utilization of protection strategies through this was also the case in Pakse City of Laos where 22% encouragement of compliance with prevention practices, which will result in more efficient dengue control. This of the study participants held the government solely ac- countable [5]. In our current study, although the major- further highlights that in order to bring about behavioral ity of participants believed that dengue is a severe, yet change we need to implement a multi-factorial ap- proach, which also targets other important facets, such preventable disease; one-third of them do not think they are at least partly responsible for dengue control. as local compliance and the sustainability of disease con- As found in a study in northern Thailand [21], ap- trol programs. Limitations of our study include the exclusion of 13 proximately half of our study participants reported that they cover their water containers in order to minimize inaccessible villages at the time of data collection which the risk of Aedes mosquito breeding. However, from ob- may have introduced selection bias and a possibility that servation, many households had uncovered water jars or a social acceptability bias could have been introduced as tanks in their yard, as well as discarded tyres and rub- the local researchers conducting the surveys were doc- bish that could collect water and provide a possible site tors from the district hospital (participants may have felt Mayxay et al. BMC Public Health 2013, 13:434 Page 7 of 8 http://www.biomedcentral.com/1471-2458/13/434 pressured to give the answers they felt were socially ap- 2. WHO: Dengue and severe dengue, fact sheet No. 117 January 2012. Geneva: WHO; 2012. http://www.who.int/mediacentre/factsheets/fs117/en/. propriate). The study would have been improved by the 3. WHO: Situation of dengue/dengue haemorrhagic fever in South East Asia development of scales with a scoring system to measure region. Geneva: WHO; 2007. http://www.searo.who.int/en/Section10/ knowledge, attitudes and practices – this would have Section332_1098.htm. 4. The Centre of Malariology Parasitology and Entomology (CMPE), Vientiane added greater weight to measures of association between Capital: National vector control policy in Lao PDR, review. Vientiane: CMPE; these three constructs. In addition knowledge and atti- 2008. http://www.actmalaria.net/files/vector_control/vc_policy/vc_laos.pdf. tudes about dengue could differ by important confounders 5. Nalongsack S, Yoshida Y, Morita S, Sosouphanh K, Sakamoto J: Knowledge, like age, gender, education, site of survey, social status and attitude and practice regarding dengue among people in Pakse, Laos. Nagoya J Med Sci 2009, 71:29–37. other relevant characteristics in the population, which 6. Peyerl-Hoffmann G, Schwobel B, Jordan S, Vanisaveth V, Phetsouvanh R, could not be accounted for in this analysis. Further re- Christophel EM, Phompida S, Sonnenburg FV, Jelinek T: Serological search would benefit from adopting a design that would investigation of the prevalence of anti-dengue IgM and IgG antibodies in attapeu province, South Laos. Clin Microbiol Infect 2004, 10:181–184. allow for more detailed multivariate analysis. 7. Mayxay M, Phetsouvanh R, Moore CE, Chansamouth V, Vongsouvath M, Sisouphone S, Vongphachanh P, Thaojaikong T, Thongpaseuth S, Conclusions Phongmany S, Keolouangkhot V, Strobel M, Newton PN: Predictive Good dengue prevention demands the involvement of the diagnostic value of the tourniquet test for the diagnosis of dengue infection in adults. Trop Med Int Health 2010, 16:127–133. community. Better information is required that helps guide 8. Fukunaga T, Tadano M, Shinjo M, Phommasack B, Makino Y, Insisiengmay S: dengue prevention programmes in their efforts to engage Epidemiological situation of dengue infection in Lao PDR. Trop Med 1994, with the community. In summary, in Pak-Ngum district 35:219–227. there is a lack of depth of knowledge regarding dengue in 9. National Center of Laboratory and Epidemiology (NCLE) of Laos: Dengue surveillance data 2010. Ministry of Health; 2010. Unpublished report of the community and observation methods revealed that Ministry of Health. more needs to be done by community members them- 10. Tsuda Y, Kobayashi J, Nambanya S, Miyagi I, Toma T, Phompida S, Manivang selves to prevent the spread of Aedes mosquitoes. Fortu- K: An ecological survey of dengue vector mosquitos in central Lao PDR. Southeast Asian J Trop Med Public Health 2002, 33:63–67. nately, the majority of the community believes they need 11. Singleton Jnr RA, Straits BC: Approaches to social research. 4th edition. more information about dengue. These results will guide Oxford: Oxford University Press; 2005. future research in this area and help to instruct dengue 12. Alecxih L, Corea J, Marker D: Deriving state-level estimates from three national surveys: a statistical assessment and state tabulations, The U.S. Department of prevention programs. health & human services. 1998. http://aspe.hhs.gov/daltcp/reports/derives.htm. 13. Ahmed S: Methods in sample surveys: cluster sampling, John Hopkins Competing interests Bloomberg school of public health. 2009. http://ocw.jhsph.edu/courses/ The authors declare that they have no competing interests. StatMethodsForSampleSurveys/PDFs/Lecture5.pdf. 14. Shackman G: Sample size and design effect. 2009. http://www.ncbi.nlm.nih. Authors’ contributions gov/pubmed?term=Shackman%20G%3A%20Sample%20size%20and% WC, GA, and MM designed the study including the questionnaire and 20design%20effect. two-stage cluster sampling methodology. WC, VV, LI, VS, ST, KK and MM 15. Teck YW: Probability proportional to size (PPS) cluster sampling: application in piloted and refined the questionnaire in the field and implemented the the military setting. 2005. http://www.internationalmta.org/Documents/2005/ sampling methodology. MM wrote the first draft of this manuscript. All 2005134P.pdf. authors have contributed to the further development of the manuscript. All authors read and approved the final manuscript. 16. Hlongwana KW, Mabaso ML, Kunene S, Govender D, Maharaj R: Community knowledge, attitudes and practices (KAP) on malaria in Swaziland: a country earmarked for malaria elimination. Malar J 2009, 8:1–8. Acknowledgements 17. Naing C, Ren WY, Man CY, Fern KP, Qiqi C, Ning CN, Ee CW: Awareness of This study was funded by the Nossal Institute for Global Health, Melbourne, dengue and practice of dengue control among the semi-urban community: Australia. We thank all the participants from Pak-Ngum Districts who kindly a cross-sectional survey. J Community Health 2011, 36:1044–1049. involved in this survey. We are very grateful to Dr. Phouthone and Timothy 18. Itrat A, Khan A, Javaid S, Kamal M, Khan H, Javed S, Kalia S, Khan AH, Sethi Moore for their kind assistance in setting up this survey. MI, Jehan I: Knowledge, awareness and practices regarding dengue fever among the adult population of dengue Hit cosmopolitan. PLoS ONE 2008, Financial support 3:1–6. The Nossal Institute for Global Health, University of Melbourne, Australia. 19. Syed M, Saleem T, Syeda UR, Habib M, Zahid R, Bashir A, Rabbani M, Khalid M, Iqbal A, Rao EZ, Shujja Ur R, Saleem S: Knowledge, attitudes and Author details practices regarding dengue fever among adults of high and low Faculty of Postgraduate Studies, University of Health Sciences, socioeconomic groups. J Pak Med Assoc 2010, 60:243–247. Vientiane, Lao PDR. Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Mahosot Hospital, Vientiane, Lao PDR. Centre for Clinical 20. Haldar A, Gupta UD, Majumdar KK, Laskar K, Ghosh S, Sen S: Community Vaccinology and Tropical Medicine, Churchill Hospital, University of Oxford, perception of dengue in slum areas of metropolitan of West Bengal. Oxford, UK. Nossal Institute for Global Health, The University of Melbourne, J Commun Dis 2008, 40:205–2010. Melbourne, Australia. Pak-Ngum District Health Office, Vientiane Capital, Lao 21. van Benthem BHB, Khantikul N, Panart K, Kessels PJ, Somboon P, Oskam L: PDR. Knowledge and use of prevention measures related to dengue in northern Thailand. Trop Med Int Health 2002, 7:993–1000. Received: 2 January 2013 Accepted: 22 April 2013 22. Phuanukoonnon S, Brough M, Bryan JH: Folk knowledge about dengue Published: 3 May 2013 mosquitoes and contributions of health belief model in dengue control promotion in Northeast Thailand. Acta Trop 2006, 99:6–14. References 23. Hairi F, Ong CH, Suhaimi A, Tsung T-W, Ahmad MAA, Sundaraj C, Soe MM: 1. WHO T: WHO report on global surveillance of epidemic-prone infectious A knowledge, attitude and practices (KAP) study on dengue among diseases - dengue and dengue haemorrhagic fever. Geneva: WHO; 2009. http:// selected rural communities in the Kuala Kangsar district. Asia Pac J Public www.who.int/csr/resources/publications/dengue/CSR_ISR_2000_1/en/. Health 2003, 15:37–43. Mayxay et al. BMC Public Health 2013, 13:434 Page 8 of 8 http://www.biomedcentral.com/1471-2458/13/434 24. Pérez-Guerra CL, Zielinski-Gutierrez E, Vargas-Torres D, Clark GG: Community beliefs and practices about dengue in Puerto Rico. Rev Panam Salud Publica 2009, 25:218–226. 25. Matta S, Bhalla S, Singh D, Rasania SK, Singh S: Knowledge, attitude and practice (KAP) on dengue fever: a hospital based study. Indian J Community Med 2006, 31:185–186. 26. Jennings CD, Phommasack B, Sourignadeth B, Kay BH: Aedes aegypti control in the Lao People’s Democratic Republic, with reference to copepods. Am J Trop Med Hyg 1995, 53:324–330. 27. Pai H-H, Hong Y-J, Hsu E-L: Impact of a short-term community-based cleanliness campaign on the sources of dengue vectors: an entomological and human behavior study. J Environ Health 2006, 68:35–39. 28. Espinoza-Gomez F, Moises Hernandez-Suarez C, Coll-Cardenas R: Educational campaign vs malathion spraying for the control of Aedes aegypti in Colima, Mexico. J Epidemiol Community Health 2002, 56:148–153. doi:10.1186/1471-2458-13-434 Cite this article as: Mayxay et al.: Dengue in peri-urban Pak-Ngum district, Vientiane capital of Laos: a community survey on knowledge, attitudes and practices. BMC Public Health 2013 13:434. 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