International Health Advance Access published April 8, 2015
ORIGINAL ARTICLE
Int Health doi:10.1093/inthealth/ihv021
Knowledge, attitude and preventive practices regarding dengue fever in rural areas of Yemen Khaled G. Saieda,*, Abdullah Al-Taiarb, Abdulrahman Altairea, Ala Alqadsia, Enas F. Alariqia and Maha Hassaana a
Department of Community Medicine, Faculty of Medicine and Health Sciences, Sana’a University, P.O. Box 2583 Al-Tahreer Post Office, Sana’a, Yemen; bDepartment Community Medicine and Behavioural Sciences, Faculty of Medicine, Kuwait University, Box 24923 Safat, 13110 Kuwait, Kuwait
Received 12 October 2014; revised 20 February 2015; accepted 16 March 2015 Background: In recent years there have been several reports of outbreaks of dengue fever (DF) in Yemen. This study aimed to describe the prevailing knowledge, attitude and preventive practices regarding DF, and to investigate the factors associated with poor preventive practices in rural areas of Yemen. Methods: A population-based, cross-sectional study was conducted on 804 randomly selected heads of household. A pretested, structured questionnaire was administered through face-to-face interviews. Logistic regression was used to investigate factors independently associated with poor practice. Results: Out of 804 participants, 753 (93.7%) were aware of the symptoms of DF and 671 (83.4%) knew that DF was transmitted by mosquito bites. Only 420 (52.2%) knew that direct person-to-person transmission was not possible. Furthermore, 205 (25.5%) thought that someone with DF should be avoided and 460 (57.2%) thought the elimination of breeding sites was the responsibility of health authorities. Poor knowledge of DF and a low level of education were significantly associated with poor preventive practices. Conclusions: In rural areas of Yemen, people have a vague understanding of DF transmission and a negative attitude towards preventative practices. Efforts should be made to correct misconceptions about transmission of the disease and to highlight the importance of community participation in control activities. Keywords: Attitude, Dengue, Knowledge, Practices, Yemen
Introduction Dengue fever (DF) is a mosquito-borne viral infection that has recently become a major international public health concern. Over the past five decades, there has been a dramatic global increase in the incidence of DF1 and the disease has become now endemic in more than 125 countries.2 It has been estimated that annually 96 million new apparent infections occur worldwide, with 294 million inapparent infections.3 These unobservable infections create enormous difficulty in terms of understanding the true economic burden of the disease and the dynamics of the infection. Despite some progress in vaccine development, there are none readily available on the market as well as no specific treatment for DF. Thus, the most effective way to prevent dengue virus transmission is to combat disease-carrying mosquitoes, particularly Aedes aegypti and A. albopictus. Recent DF outbreaks have been reported from within WHO’s eastern Mediterranean Region in Sudan, Saudi Arabia and Yemen. Unlike its oil-rich neighbouring countries, Yemen has weaker
healthcare and surveillance systems. Recently, frequent DF outbreaks have been reported in the media, few of which have been properly documented.4,5 During these outbreaks, the predominant serotype was type 2 in the west6 and type 3 in the southeast.4,5 Mostly young adults were affected. Among the suspected cases in the southeast, studies have reported a high prevalence of dengue IgG suggesting previous exposure and background endemicity preceding these outbreaks.4 Overall, the true burden of the disease in Yemen remains unknown, but is anticipated to be high. The knowledge and attitude of the general public towards DF have been recently described in various settings,7–14 but little is known about them in Yemen or the Middle East. Previously, we demonstrated that people in Yemen have a vague understanding of the causes of malaria. While the majority of people know that malaria is caused by mosquito bites, most believe that malaria can also be caused or transmitted by a range of factors, including flies, eating uncovered food, not having breakfast and breastfeeding.15 In this study, we aimed to describe the knowledge, attitude and preventive practices regarding DF, using a population-based
© The Author 2015. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene. All rights reserved. For permissions, please e-mail: [email protected].
1 of 6
Downloaded from http://inthealth.oxfordjournals.org/ at Mount Royal University on June 15, 2015
*Corresponding author: Tel: +967 713262611; E-mail: [email protected]
K. G. Saied et al.
survey in one rural district of Yemen, and to investigate the factors associated with poor preventive practices.
Methods
Table 1. Socio-demographic characteristics of 804 head of households in Hodeidah, Yemen Characteristics
n (%)
Age, median (IQR) years Gender, male Marital status Married Single Widowed/divorced Working in paid job Educational level Illiterate Able to read and write Completed primary school Completed intermediate school Completed secondary school Completed university degree or more
39 (30–50) 741 (92.2)
2 of 6
665 (82.7) 104 (12.9) 35 (4.4) 386 (48.0) 442 (54.9) 80 (10.0) 100 (12.4) 71 (8.8) 80 (10.0) 31 (3.9)
Results Of the 820 heads of household approached, 16 (1.9%) refused to participate. Table 1 shows the characteristics of the study group. The median (interquartile range [IQR]) age was 39 (IQR 30–50) years. Of the participants, 741 (92.2%) were men and 665 (82.7%) were married. More than half of the members of study group were illiterate (54.9%; 442/804) and 3.9% had a university degree (31/804). The number of those demonstrating the correct knowledge about DF among the study group is shown in Table 2. Of 804 heads of household, 753 (93.7%; 95% CI 91.7–95.2%) knew that the main symptoms of DF are fever, headache, pain behind the eyes, joint pain, muscle pain and skin rash. Six hundred and five (75.2%; 95% CI 72.1–78.2%) knew that abdominal pain, vomiting blood, bloody stools and bleeding from the nose were signs of severe DF. More than three quarters, 671 (83.4%; 95% CI 80.7–86.0%), knew that DF was transmitted by mosquito bites, but only 420 (52.2%; 95% CI 48.7–55.7%) knew that DF cannot be transmitted from an infected person to a healthy person through direct contact. Positive and negative attitudes towards DF are shown in Table 3. Of the study participants, 528 (65.7%; 95% CI 62.3–69.0%) agreed that DF is a serious and sometimes life-threatening disease, and 685 (85.2%; 95% CI 82.6–87.6%) agreed that sleeping under a bed net can help to prevent it. Of 804 heads of household, 205 (25.5%; 95% CI 22.5–28.6%) thought that close contact with a person with DF should be avoided. Of even more concern was the fact that 460 (57.2%; 95% CI 53.7–60.7%) thought the elimination of breeding sites should be the responsibility of health authority staff only. Surprisingly, more than 41.0% either agreed that DF cannot be prevented, or were not sure whether it can be prevented. Those among the study group who reported correct DF preventive practices are shown in Table 4. Of 780 participants who reported owning water tanks, 730 (93.5%; 95% CI 91.6–95.2%) had covers
Downloaded from http://inthealth.oxfordjournals.org/ at Mount Royal University on June 15, 2015
A cross-sectional study was conducted in the Beit Al-fakieh district of Hodeidah province, which is located along the west coast of Yemen on the Red Sea. The area comprises eight sub-districts. It has two rainy seasons (November-March and June-October) and had a high occurrence of DF in 2011.16 The study population comprised the heads of households who had lived in the district for at least 1 year. Those who were not able to communicate because of mental illness or severe hearing defects were excluded. We used a multistage random sampling to select the study group. First, we randomly selected two sub-districts from the eight sub-districts. We then randomly selected five villages from the two selected sub-districts according to the relative size of the population in the sub-district. In each village, the households were selected in a systematic random sampling method taking the first house in the centre of the village as a random start. Data were collected through face-to-face interviews, with the heads of the households using a structured, pretested questionnaire. This included questions on socio-demographic characteristics such as age, gender, marital status and educational level in addition to questions on knowledge about DF. This part of the questionnaire included 14 questions (requiring ‘yes’, ‘no’ or ‘do not know’ answers) related to signs and symptoms, transmission, treatment and prevention. Attitudes towards DF were measured using 12 statements (requiring ‘agree’, ‘disagree’ or ‘not sure/do not know’ answers), which covered susceptibility, seriousness and threat. Practices regarding DF were assessed by 12 items covering various aspects of prevention. The questionnaire was piloted on 30 participants who were not included in the study. The data were entered and analysed using SPSS software version 20 (SPSS Inc., Chicago, IL, USA). The total score of knowledge about DF was calculated by assigning one score for each correct answer and zero score for each wrong answer. These
were then summed up to calculate the total score of knowledge. Similarly, in order to calculate the attitude score, the answers ‘agree’, ‘not sure’ and ‘disagree’ were given scores of 3, 2 and 1, respectively (the scores were reversed for negative attitude items) and these were added to calculate the total score. A similar approach was used to calculate the practice score, with zero score assigned to each wrong practice and one score assigned to each correct practice. Respondents who scored more than the median value (11 for knowledge, 29 for attitudes, 6 for practice) were considered to have good levels of knowledge, attitude and practices, while those who scored the median value or less were considered to have poor levels. Spearman’s correlation coefficient was used to assess the strength and direction of the bivariate relationship between knowledge, attitude and practices dealing with scores as a continuous variable. Logistic regression was used to investigate the independent factors associated with poor preventive practices. The significance of each variable was determined using a likelihood ratio test that compared the model with and without the variable. The study was approved by the Faculty of Medicine and Health Sciences of Sana’a University, and verbal consent was obtained from each participant after adequate explanation of the nature of the study.
International Health
Table 2. Correct knowledge about dengue fever among 804 head of households in Hodeidah, Yemen n (%)
Patient with dengue fever usually has fever, headache, pain behind the eyes,joint pain, muscle pain and skin rash Abdominal pain, vomiting blood, bloody stools, bleeding from nose are signs of danger in dengue fever Dengue fever may affect children and adults Dengue fever is transmitted by mosquito bites Mosquitoes that transmit dengue fever bite mainly during the daytime Dengue fever is not transmitted from an infected person to a healthy person through direct contact The main method of controlling dengue fever is to combat mosquitoes Stagnant water in old tyres and trash cans can be breeding places for mosquitoes Dengue fever is more common in the rainy season Uncovered water containers should be cleaned every week Water containers in the house are the most common breeding sites of mosquitoes Discarded tyres and tin cans should be eliminated to prevent dengue fever Covering water collections around the house with sand is one ways to combat mosquitoes There is no specific treatment for dengue fever
753 (93.7) 605 (75.2) 766 (95.3) 671 (83.5) 270 (33.6) 420 (52.2) 638 (79.4) 692 (86.1) 683 (85.0) 654 (81.3) 611 (76.0) 617 (76.7) 633 (78.7) 347 (43.2)
Table 3. Distribution of the respondent’s attitudes towards dengue fever (n=804) The statements
Agree n (%)
Disagree n (%)
Not sure n (%)
Dengue fever is a serious and sometimes life-threatening diseasea Everybody can be infected with dengue fevera Sleeping under a bed net can help prevent dengue fevera You have an important role in the prevention of dengue fevera The best way to prevent people from getting dengue fever is to control mosquitoesa If someone gets dengue fever, she/he should seek treatmenta The risk of getting dengue fever among men and women is not the sameb A person who once had dengue fever cannot get it againb Close contact with people with dengue fever should be avoidedb Strong, healthy people do not get dengue feverb Dengue fever is a disease that cannot be preventedb Elimination of breeding places is the responsibility of public health staff onlyb
528 (65.7) 726 (90.3) 685 (85.2) 604 (75.1) 676 (84.1) 678 (84.3) 169 (21.0) 137 (17.0) 205 (25.5) 170 (21.1) 157 (19.5) 460 (57.2)
71 (8.8) 26 (3.2) 32 (4.0) 132 (16.4) 23 (2.9) 19 (2.4) 449 (55.8) 474 (59.0) 492 (61.2) 499 (62.1) 473 (58.8) 274 (34.1)
205 (25.5) 52 (6.5) 87 (10.8) 68 (8.5) 105 (13.1) 107 (13.3) 186 (23.1) 193 (24.0) 107 (13.3) 135 (16.8) 174 (21.6) 70 (8.7)
a b
Positive statement where agree is the correct answer. Negative statement where disagree is the correct answer.
for them, and almost all said that they covered them immediately after use. Only a minority reported using preventive measures against mosquitoes, such as mosquito nets (131/804; 16.3%; 95% CI 13.8–19.0%), window screens (59/804; 7.3%; 95% CI 5.6–9.4%) or door screens (65/804; 8.1%; 95% CI 6.3–10.2%), but more than one-third said that they spray insecticide indoors or use repellent to prevent mosquito bites. Approximately 94% (755/804) said that they sought medical help when they felt sick. Logistic regression was used to investigate the factors significantly associated with poor DF preventive practices. The binary outcome for this analysis was created by dichotomising the practice score into good (> median) and poor (≤ median). Tables 5 and 6 show the association between different factors and poor preventive practices
using univariate and multivariate analyses. Factors that showed a significant association with poor practice in the univariate analysis were older age, low educational level, not working in a paid job, fewer people in the house and poor knowledge of and attitudes towards DF. In the multivariate analysis, only low educational level and poor knowledge of DF were significantly related to poor preventive practices. A Spearman’s rank order correlation was used to investigate the link between the knowledge, attitude and preventive practices scores. There was a weak positive correlation between the knowledge and attitude scores, between the knowledge and preventive practices scores and between the attitude and preventive practices scores (the Spearman’s correlation coefficient was 0.234 [p< 0.001], 0.192 [p< 0.001] and 0.150 [p< .001], respectively).
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Downloaded from http://inthealth.oxfordjournals.org/ at Mount Royal University on June 15, 2015
Correct knowledge answers
K. G. Saied et al.
Table 4. Distribution of reported correct preventive practices against dengue fever among 804 heads of households in Hodeidah, Yemen n (%)
Do you have a cover for all your water tanks (water containers)? Do you cover your water tank immediately after using it? Do you eliminate stagnant water around your house to reduce mosquitoes? Do you get rid of discarded tyres and tin cans which contain stagnant water? Do you use mosquito nets to prevent mosquito bites? Do you have window screens to reduce mosquitoes? Do you have a door screen to reduce mosquitoes? Do you spray insecticides indoor to reduce mosquitoes? Do you use repellent for mosquitoes? Do you cut the trees/vegetation surrounding your house to reduce mosquitoes? Do you participate in campaigns to help prevent dengue fever in your community? Do you usually go to the health centre/unit when you feel ill?
730a (93.5) 728a (93.3) 536 (66.7) 505 (62.8) 131 (16.3) 59 (7.3) 65 (8.1) 290 (36.1) 320 (39.8) 400 (49.8) 336 (41.8) 755 (93.9)
a
Of 804 participants, 24 (3.0%) did not store water at home (those without water tanks).
Discussion Table 5. Socio-demographic factors, knowledge and attitudes regarding dengue fever in relation to poor preventive practices (≤ the median score) using univariate analysis
Age in years Gender Male Marital status Married Divorced/widowed Single Education level Illiterate Able to read and write Primary/intermediate High school or above Working No Number of people in house 10 Knowledge score Poorb Goodc Attitude score Poorb Goodc a
n
OR
95% CI
p-value
804
1.02
1.01–1.03
ORIGINAL ARTICLE
Int Health doi:10.1093/inthealth/ihv021
Knowledge, attitude and preventive practices regarding dengue fever in rural areas of Yemen Khaled G. Saieda,*, Abdullah Al-Taiarb, Abdulrahman Altairea, Ala Alqadsia, Enas F. Alariqia and Maha Hassaana a
Department of Community Medicine, Faculty of Medicine and Health Sciences, Sana’a University, P.O. Box 2583 Al-Tahreer Post Office, Sana’a, Yemen; bDepartment Community Medicine and Behavioural Sciences, Faculty of Medicine, Kuwait University, Box 24923 Safat, 13110 Kuwait, Kuwait
Received 12 October 2014; revised 20 February 2015; accepted 16 March 2015 Background: In recent years there have been several reports of outbreaks of dengue fever (DF) in Yemen. This study aimed to describe the prevailing knowledge, attitude and preventive practices regarding DF, and to investigate the factors associated with poor preventive practices in rural areas of Yemen. Methods: A population-based, cross-sectional study was conducted on 804 randomly selected heads of household. A pretested, structured questionnaire was administered through face-to-face interviews. Logistic regression was used to investigate factors independently associated with poor practice. Results: Out of 804 participants, 753 (93.7%) were aware of the symptoms of DF and 671 (83.4%) knew that DF was transmitted by mosquito bites. Only 420 (52.2%) knew that direct person-to-person transmission was not possible. Furthermore, 205 (25.5%) thought that someone with DF should be avoided and 460 (57.2%) thought the elimination of breeding sites was the responsibility of health authorities. Poor knowledge of DF and a low level of education were significantly associated with poor preventive practices. Conclusions: In rural areas of Yemen, people have a vague understanding of DF transmission and a negative attitude towards preventative practices. Efforts should be made to correct misconceptions about transmission of the disease and to highlight the importance of community participation in control activities. Keywords: Attitude, Dengue, Knowledge, Practices, Yemen
Introduction Dengue fever (DF) is a mosquito-borne viral infection that has recently become a major international public health concern. Over the past five decades, there has been a dramatic global increase in the incidence of DF1 and the disease has become now endemic in more than 125 countries.2 It has been estimated that annually 96 million new apparent infections occur worldwide, with 294 million inapparent infections.3 These unobservable infections create enormous difficulty in terms of understanding the true economic burden of the disease and the dynamics of the infection. Despite some progress in vaccine development, there are none readily available on the market as well as no specific treatment for DF. Thus, the most effective way to prevent dengue virus transmission is to combat disease-carrying mosquitoes, particularly Aedes aegypti and A. albopictus. Recent DF outbreaks have been reported from within WHO’s eastern Mediterranean Region in Sudan, Saudi Arabia and Yemen. Unlike its oil-rich neighbouring countries, Yemen has weaker
healthcare and surveillance systems. Recently, frequent DF outbreaks have been reported in the media, few of which have been properly documented.4,5 During these outbreaks, the predominant serotype was type 2 in the west6 and type 3 in the southeast.4,5 Mostly young adults were affected. Among the suspected cases in the southeast, studies have reported a high prevalence of dengue IgG suggesting previous exposure and background endemicity preceding these outbreaks.4 Overall, the true burden of the disease in Yemen remains unknown, but is anticipated to be high. The knowledge and attitude of the general public towards DF have been recently described in various settings,7–14 but little is known about them in Yemen or the Middle East. Previously, we demonstrated that people in Yemen have a vague understanding of the causes of malaria. While the majority of people know that malaria is caused by mosquito bites, most believe that malaria can also be caused or transmitted by a range of factors, including flies, eating uncovered food, not having breakfast and breastfeeding.15 In this study, we aimed to describe the knowledge, attitude and preventive practices regarding DF, using a population-based
© The Author 2015. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene. All rights reserved. For permissions, please e-mail: [email protected].
1 of 6
Downloaded from http://inthealth.oxfordjournals.org/ at Mount Royal University on June 15, 2015
*Corresponding author: Tel: +967 713262611; E-mail: [email protected]
K. G. Saied et al.
survey in one rural district of Yemen, and to investigate the factors associated with poor preventive practices.
Methods
Table 1. Socio-demographic characteristics of 804 head of households in Hodeidah, Yemen Characteristics
n (%)
Age, median (IQR) years Gender, male Marital status Married Single Widowed/divorced Working in paid job Educational level Illiterate Able to read and write Completed primary school Completed intermediate school Completed secondary school Completed university degree or more
39 (30–50) 741 (92.2)
2 of 6
665 (82.7) 104 (12.9) 35 (4.4) 386 (48.0) 442 (54.9) 80 (10.0) 100 (12.4) 71 (8.8) 80 (10.0) 31 (3.9)
Results Of the 820 heads of household approached, 16 (1.9%) refused to participate. Table 1 shows the characteristics of the study group. The median (interquartile range [IQR]) age was 39 (IQR 30–50) years. Of the participants, 741 (92.2%) were men and 665 (82.7%) were married. More than half of the members of study group were illiterate (54.9%; 442/804) and 3.9% had a university degree (31/804). The number of those demonstrating the correct knowledge about DF among the study group is shown in Table 2. Of 804 heads of household, 753 (93.7%; 95% CI 91.7–95.2%) knew that the main symptoms of DF are fever, headache, pain behind the eyes, joint pain, muscle pain and skin rash. Six hundred and five (75.2%; 95% CI 72.1–78.2%) knew that abdominal pain, vomiting blood, bloody stools and bleeding from the nose were signs of severe DF. More than three quarters, 671 (83.4%; 95% CI 80.7–86.0%), knew that DF was transmitted by mosquito bites, but only 420 (52.2%; 95% CI 48.7–55.7%) knew that DF cannot be transmitted from an infected person to a healthy person through direct contact. Positive and negative attitudes towards DF are shown in Table 3. Of the study participants, 528 (65.7%; 95% CI 62.3–69.0%) agreed that DF is a serious and sometimes life-threatening disease, and 685 (85.2%; 95% CI 82.6–87.6%) agreed that sleeping under a bed net can help to prevent it. Of 804 heads of household, 205 (25.5%; 95% CI 22.5–28.6%) thought that close contact with a person with DF should be avoided. Of even more concern was the fact that 460 (57.2%; 95% CI 53.7–60.7%) thought the elimination of breeding sites should be the responsibility of health authority staff only. Surprisingly, more than 41.0% either agreed that DF cannot be prevented, or were not sure whether it can be prevented. Those among the study group who reported correct DF preventive practices are shown in Table 4. Of 780 participants who reported owning water tanks, 730 (93.5%; 95% CI 91.6–95.2%) had covers
Downloaded from http://inthealth.oxfordjournals.org/ at Mount Royal University on June 15, 2015
A cross-sectional study was conducted in the Beit Al-fakieh district of Hodeidah province, which is located along the west coast of Yemen on the Red Sea. The area comprises eight sub-districts. It has two rainy seasons (November-March and June-October) and had a high occurrence of DF in 2011.16 The study population comprised the heads of households who had lived in the district for at least 1 year. Those who were not able to communicate because of mental illness or severe hearing defects were excluded. We used a multistage random sampling to select the study group. First, we randomly selected two sub-districts from the eight sub-districts. We then randomly selected five villages from the two selected sub-districts according to the relative size of the population in the sub-district. In each village, the households were selected in a systematic random sampling method taking the first house in the centre of the village as a random start. Data were collected through face-to-face interviews, with the heads of the households using a structured, pretested questionnaire. This included questions on socio-demographic characteristics such as age, gender, marital status and educational level in addition to questions on knowledge about DF. This part of the questionnaire included 14 questions (requiring ‘yes’, ‘no’ or ‘do not know’ answers) related to signs and symptoms, transmission, treatment and prevention. Attitudes towards DF were measured using 12 statements (requiring ‘agree’, ‘disagree’ or ‘not sure/do not know’ answers), which covered susceptibility, seriousness and threat. Practices regarding DF were assessed by 12 items covering various aspects of prevention. The questionnaire was piloted on 30 participants who were not included in the study. The data were entered and analysed using SPSS software version 20 (SPSS Inc., Chicago, IL, USA). The total score of knowledge about DF was calculated by assigning one score for each correct answer and zero score for each wrong answer. These
were then summed up to calculate the total score of knowledge. Similarly, in order to calculate the attitude score, the answers ‘agree’, ‘not sure’ and ‘disagree’ were given scores of 3, 2 and 1, respectively (the scores were reversed for negative attitude items) and these were added to calculate the total score. A similar approach was used to calculate the practice score, with zero score assigned to each wrong practice and one score assigned to each correct practice. Respondents who scored more than the median value (11 for knowledge, 29 for attitudes, 6 for practice) were considered to have good levels of knowledge, attitude and practices, while those who scored the median value or less were considered to have poor levels. Spearman’s correlation coefficient was used to assess the strength and direction of the bivariate relationship between knowledge, attitude and practices dealing with scores as a continuous variable. Logistic regression was used to investigate the independent factors associated with poor preventive practices. The significance of each variable was determined using a likelihood ratio test that compared the model with and without the variable. The study was approved by the Faculty of Medicine and Health Sciences of Sana’a University, and verbal consent was obtained from each participant after adequate explanation of the nature of the study.
International Health
Table 2. Correct knowledge about dengue fever among 804 head of households in Hodeidah, Yemen n (%)
Patient with dengue fever usually has fever, headache, pain behind the eyes,joint pain, muscle pain and skin rash Abdominal pain, vomiting blood, bloody stools, bleeding from nose are signs of danger in dengue fever Dengue fever may affect children and adults Dengue fever is transmitted by mosquito bites Mosquitoes that transmit dengue fever bite mainly during the daytime Dengue fever is not transmitted from an infected person to a healthy person through direct contact The main method of controlling dengue fever is to combat mosquitoes Stagnant water in old tyres and trash cans can be breeding places for mosquitoes Dengue fever is more common in the rainy season Uncovered water containers should be cleaned every week Water containers in the house are the most common breeding sites of mosquitoes Discarded tyres and tin cans should be eliminated to prevent dengue fever Covering water collections around the house with sand is one ways to combat mosquitoes There is no specific treatment for dengue fever
753 (93.7) 605 (75.2) 766 (95.3) 671 (83.5) 270 (33.6) 420 (52.2) 638 (79.4) 692 (86.1) 683 (85.0) 654 (81.3) 611 (76.0) 617 (76.7) 633 (78.7) 347 (43.2)
Table 3. Distribution of the respondent’s attitudes towards dengue fever (n=804) The statements
Agree n (%)
Disagree n (%)
Not sure n (%)
Dengue fever is a serious and sometimes life-threatening diseasea Everybody can be infected with dengue fevera Sleeping under a bed net can help prevent dengue fevera You have an important role in the prevention of dengue fevera The best way to prevent people from getting dengue fever is to control mosquitoesa If someone gets dengue fever, she/he should seek treatmenta The risk of getting dengue fever among men and women is not the sameb A person who once had dengue fever cannot get it againb Close contact with people with dengue fever should be avoidedb Strong, healthy people do not get dengue feverb Dengue fever is a disease that cannot be preventedb Elimination of breeding places is the responsibility of public health staff onlyb
528 (65.7) 726 (90.3) 685 (85.2) 604 (75.1) 676 (84.1) 678 (84.3) 169 (21.0) 137 (17.0) 205 (25.5) 170 (21.1) 157 (19.5) 460 (57.2)
71 (8.8) 26 (3.2) 32 (4.0) 132 (16.4) 23 (2.9) 19 (2.4) 449 (55.8) 474 (59.0) 492 (61.2) 499 (62.1) 473 (58.8) 274 (34.1)
205 (25.5) 52 (6.5) 87 (10.8) 68 (8.5) 105 (13.1) 107 (13.3) 186 (23.1) 193 (24.0) 107 (13.3) 135 (16.8) 174 (21.6) 70 (8.7)
a b
Positive statement where agree is the correct answer. Negative statement where disagree is the correct answer.
for them, and almost all said that they covered them immediately after use. Only a minority reported using preventive measures against mosquitoes, such as mosquito nets (131/804; 16.3%; 95% CI 13.8–19.0%), window screens (59/804; 7.3%; 95% CI 5.6–9.4%) or door screens (65/804; 8.1%; 95% CI 6.3–10.2%), but more than one-third said that they spray insecticide indoors or use repellent to prevent mosquito bites. Approximately 94% (755/804) said that they sought medical help when they felt sick. Logistic regression was used to investigate the factors significantly associated with poor DF preventive practices. The binary outcome for this analysis was created by dichotomising the practice score into good (> median) and poor (≤ median). Tables 5 and 6 show the association between different factors and poor preventive practices
using univariate and multivariate analyses. Factors that showed a significant association with poor practice in the univariate analysis were older age, low educational level, not working in a paid job, fewer people in the house and poor knowledge of and attitudes towards DF. In the multivariate analysis, only low educational level and poor knowledge of DF were significantly related to poor preventive practices. A Spearman’s rank order correlation was used to investigate the link between the knowledge, attitude and preventive practices scores. There was a weak positive correlation between the knowledge and attitude scores, between the knowledge and preventive practices scores and between the attitude and preventive practices scores (the Spearman’s correlation coefficient was 0.234 [p< 0.001], 0.192 [p< 0.001] and 0.150 [p< .001], respectively).
3 of 6
Downloaded from http://inthealth.oxfordjournals.org/ at Mount Royal University on June 15, 2015
Correct knowledge answers
K. G. Saied et al.
Table 4. Distribution of reported correct preventive practices against dengue fever among 804 heads of households in Hodeidah, Yemen n (%)
Do you have a cover for all your water tanks (water containers)? Do you cover your water tank immediately after using it? Do you eliminate stagnant water around your house to reduce mosquitoes? Do you get rid of discarded tyres and tin cans which contain stagnant water? Do you use mosquito nets to prevent mosquito bites? Do you have window screens to reduce mosquitoes? Do you have a door screen to reduce mosquitoes? Do you spray insecticides indoor to reduce mosquitoes? Do you use repellent for mosquitoes? Do you cut the trees/vegetation surrounding your house to reduce mosquitoes? Do you participate in campaigns to help prevent dengue fever in your community? Do you usually go to the health centre/unit when you feel ill?
730a (93.5) 728a (93.3) 536 (66.7) 505 (62.8) 131 (16.3) 59 (7.3) 65 (8.1) 290 (36.1) 320 (39.8) 400 (49.8) 336 (41.8) 755 (93.9)
a
Of 804 participants, 24 (3.0%) did not store water at home (those without water tanks).
Discussion Table 5. Socio-demographic factors, knowledge and attitudes regarding dengue fever in relation to poor preventive practices (≤ the median score) using univariate analysis
Age in years Gender Male Marital status Married Divorced/widowed Single Education level Illiterate Able to read and write Primary/intermediate High school or above Working No Number of people in house 10 Knowledge score Poorb Goodc Attitude score Poorb Goodc a
n
OR
95% CI
p-value
804
1.02
1.01–1.03
