Background
Zika virus (ZIKV) is transmitted by
Aedes aegypti and
Aedes albopictus mosquitoes. Infection by ZIKV most often results in mild symptoms such as fever, maculopapular rash, arthralgia, cephalgia and conjunctivitis [
1]. However, the infection may cause severe complications including neurological sequelae and Guillain-Barré syndrome [
2]. In addition, ZIKV-related congenital microcephaly, ventriculomegaly and intracranial calcification have been identified in infants born to ZIKV-positive mothers [
3]. There is a strong association between congenital ZIKV infection and microcephaly; one study estimates the odds of microcephaly to be 73.1 times higher among those with ZIKV infection [
4]. Multiple outbreaks of microcephaly-associated with Zika cases have been reported since reemerge [
5‐
9]. In Brazil for example, during two Zika outbreaks in 2015 and 2016, more than 1.6 million cases were reported and during this period, 1950 cases of ZIKV infection-related microcephaly were confirmed [
9]. This devastating complication was one factor that led the WHO to declare ZIKV infection as a Public Health Emergency of International Concern (PHEIC) and as an ongoing challenge in 2016 [
10]. Microcephaly associated with ZIKV infection has been also reported in Asian countries [
11‐
13].
ZIKV was first found in Africa over 70 years ago when it was identified in a monkey in 1947 [
14] and in humans in 1954 [
15]. After local outbreaks in various Pacific Islands [
16], the virus reached the Americas (Brazil) in 2015 [
17], and has since continued to spread and has been reported in 86 countries in the Americas, Africa, and Southeast Asia [
18]. Globally, it is predicted that over 2.17 billion people live in areas that are environmentally suitable for ZIKV transmission, and 1.42 billion of them live in Asia [
19]. Asia is susceptible to epidemic ZIKV transmission because of widespread distribution of the mosquito vectors for ZIKV, the large amount of travel to and from Zika-affected areas, conducive conditions for ZIKV transmission, and limited health resources [
20‐
23].
A recent modeling study ranked Indonesia as the third country most at risk for ZIKV exposure due to the monthly volume of airline travelers [
21]. Indonesia has not yet had a Zika outbreak, but there is evidence of ZIKV transmission in the country. Studies using serum samples from 1978 and 1983 found evidence of anti-ZIKV antibodies in Central Java and Lombok [
24,
25]. In 2014, 9.1% of serum samples from children 1–4 years old were ZIKV seropositive [
26]. In 2013 and 2014, two travelers visiting Indonesia acquired ZIKV infection and were diagnosed after returning to Australia [
27,
28]. In 2015, an individual with no history of traveling abroad was diagnosed with Zika [
29]. Zika cases may be underestimated in Indonesia for three major reasons: (1) the clinical presentation of Zika and dengue is similar; (2) the availability of Zika diagnostic tests is limited in Indonesia; and (3) Zika reports are based on passive case-based surveillance [
30,
31].
In order to mitigate Zika complications, in particular pregnancy-related complications, it is important to diagnose the disease in its early stages and implement prevention programmes. Assessment of the knowledge about ZIKV infection among healthcare workers (HCWs) can identify problems that HCWs may face in reaching this diagnosis. Zika-related knowledge is important since knowledge gaps may lead to attitudes and practices that hamper ZIKV infection diagnosis, management, and risk reduction [
32].
Studies related to knowledge and attitude towards ZIKV infection have been conducted in various community groups. At least 21 studies related to knowledge of ZIKV infection have been conducted [
1,
33‐
52], in the general population [
33‐
37] or specific groups such as reproductive-age women [
38,
39], pregnant women [
40‐
43], construction workers [
44], and medical [
1,
39,
45‐
49,
52] and non-medical university students [
33,
52]. Five of these studies were conducted among HCWs [
1,
39,
45,
50,
51]. Ten studies related to attitude towards ZIKV infection have been conducted [
34,
35,
37,
41,
48,
52‐
55], but only one of these among HCWs [
56]. These figures indicate that information about knowledge and attitude towards ZIKV infection among HCWs is limited. Given the fact that HCWs have critical roles in the prevention and management of Zika disease, studies to fill this gap in the literature are required.
In Indonesia, general practitioners (GPs) are the frontline HCWs who are responsible for the early diagnosis, treatment, and prevention of diseases including ZIKV infection. Thus, GPs in Indonesia should have some knowledge to treat ZIKV infection because it has the general manifestation of fever, which is included in the competency list of general medical practice [
57]. In addition, the symptoms of ZIKV infection are similar to those of other mosquito-borne infections such as dengue fever or chikungunya fever [
58]. It is important for GPs to recognize symptoms of ZIKV infection in order to detect or prevent complications. Most Zika prevention measures, including the strategic responses set out by the WHO, are also within the GPs’ competency list. These circumstances indicate that GPs play a pivotal role in the early detection and prevention of ZIKV infection in Indonesia.
Previously, our group conducted a project to assess the knowledge and attitude towards ZIKV infection among doctors in Aceh province of Indonesia [
51,
56]. Both specialist doctors and GPs were included, and multiple stratified analyses indicated that specialists had a lower knowledge and a less positive attitude compared to GPs. To generalize these results in the national context, an expanded survey that included other regions of Indonesia was conducted. As GPs are the frontline HCWs in Indonesia, and because one of the most important issues related to ZIKV infection is congenital microcephaly, the survey sampled GPs and focused on the pregnancy-related issues of ZIKV infection. Thus, this study sought to provide a comprehensive picture of the knowledge and attitude towards pregnancy-related issues of ZIKV infection among GPs in Indonesia.
Discussion
General practitioners are frontline HCWs in Indonesia and other countries, and their ability to comprehensively react to cases of Zika disease in their communities is, in part, limited by the knowledge and attitudes that they hold. Studies on knowledge and attitude towards ZIKV infection among GPs are limited. Given the fact that HCWs have critical roles in the prevention and management of ZIKV infection, this study was conducted to fill this gap in the literature. We found that almost 40% of the participating GPs had a poor knowledge of pregnancy-related issues of ZIKV infection. For example, 73.9% of respondents mentioned that ZIKV could be passed through breastfeeding. In fact, there are no reports to suggest that a ventricular septal defect was associated with ZIKV infection, and the U.S. CDC stated that there are no reports of infants getting ZIKV through breastfeeding, and mothers are encouraged to breastfeed even in areas with risk of Zika [
67]. One of the plausible explanations of this finding is that ZIKV infection has not been a subject taught in Indonesia. For instance, Zika was not listed in the 2006 National General Practitioner Competence List of the Republic of Indonesia [
68]. Therefore, while a few medical schools in Indonesia have incorporated the subject into their curriculum, this knowledge is not a mandatory subject for medical doctor graduates in Indonesia [
69]. In addition, we found no independent factor that was significantly associated with knowledge among GPs. Previously, our study in Aceh province found that specialists had significantly lower knowledge compared to GPs, and some determinants relating to specialists were associated with lower knowledge [
51]. For example, doctors whose workplace had access to medical journals (which was the case for most of the specialists) had lower knowledge compared to doctors whose workplace had restricted access to journals (e.g., in primary health service). In addition, doctors who worked in community health centres had greater knowledge compared to doctors who were working in private clinics or private hospitals and government hospitals, where most doctors were specialists. Therefore, it is not surprising that none of the independent variables were associated with knowledge in this survey because all of the respondents were GPs with a homogenous knowledge base. All of the respondents of this study received their medical education from the national curricula based on the 2006 National General Practitioner Competence List [
68], where Zika was not listed as a compulsory disease.
We found that 66.3% of the participants had a medical practice experience of less than 5 years, and only 7.9% of the total participants stated that they had been contacted by a patient presenting signs and symptoms of ZIKV infection. These characteristics suggest that most of our participants could be considered to be at an intermediate level of expertise instead of an expert level [
70]. Doctors at an intermediate level of expertise are better at recalling more signs and symptoms because they are able to focus on isolated signs and symptoms, and connect them to a pathophysiology mechanism [
70]. In contrast, experts commonly use encapsulated knowledge or short-cut knowledge which is constructed from the memories of previous patients, which creates illness scripts. As a consequence, the expert may be inhibited in recalling signs and symptoms [
70]. This could explain why most of our participants had relatively good knowledge about ZIKV infection compared to the specialist doctors in our previous survey [
51]. Yet, the GPs could also be categorized as having incomprehensive knowledge about ZIKV infection since there were misperceptions about several aspects of the infection (i.e., that ZIKV could be transmitted via breastfeeding and that ventricular septal defect could be caused by the infection).
This incomprehensive knowledge, interestingly, was not adequate to improve GPs’ attitude towards ZIKV infection management because attitude change requires more than merely cognitive or knowledge transformation but also relies on affective and behavioural dimensions of change [
71]. Attitude is a summary evaluation of an object of thought that is constructed in a particular situation; it is context-dependent [
71]. To improve GPs’ attitude towards ZIKV infection, more exposure to cases of ZIKV infection is therefore required, to provide some experience enabling them to acquire diagnostic and management knowledge and to apply their knowledge in a practical setting [
72]. The lack of exposure of real cases of ZIKV infection produces fewer opportunities for the GPs to apply their relatively good knowledge on ZIKV infection, and as a result the knowledge generates less of an impact on their attitudes. This might, in part, explain the lack of an association between knowledge and attitude among GPs.
This study revealed that GPs who had had contact with patient(s) presenting signs and symptoms of ZIKV infection were three times more likely to have a positive attitude. This finding could be explained by the experiential learning theory, in which learners will have better perception and cognition towards a disease if they are directly exposed to actual cases [
73].
In general, our present study together with our previous survey [
51] indicates that knowledge of ZIKV infection in HCWs in Indonesia is relatively low. Therefore, strategies for enhancing the capacity of HCWs (including GPs and other healthcare staffs) to respond to ZIKV infection may be needed. Scholars in the field of knowledge management have focused on knowledge seeking behavior of GPs at the global level. One study described a preference of GPs for local knowledge, for example, transfers from their own experiences or colleagues’ experiences and communication with leaders in their institution, as a reaction to the overwhelming information overload from 400.000 medical articles published each year [
74]. In addition, GPs preferred interactive sessions in workshops and conferences over didactic lectures to improve their performance in clinical decision making [
75,
76]. Therefore, efforts to increase GPs’ knowledge on ZIKV infection should be supported by incorporating relevant information regarding ZIKV infection in continuing medical education (CME) programmes in collaboration with the Indonesian Medical Council which regulates future GPs’ competence and certification.
Online survey research has advantages which include time and cost benefits, however, this study is not without limitations. The results from this study, therefore, should be interpreted with caution. First, the incomplete response rate in this survey is high (46.3%) if compared to our previous survey [
51,
56]. Second, there is potential for biased geographical selection of respondents because certain localities in Indonesia are less likely to have internet access than others. Third, we did not collect the exact location of the respondents making it not possible to create a map showing spatial heterogeneity. However, our study is still able to show the distribution of the respondents between rural (district) and urban (regency) areas. In addition, we also analyzed respondents based on type of workplace, which is one of the most important heterogeneity analysis in medical setting because it reflects facility characteristics. Finally, dishonesty can be an issue in the sense that some respondents may not have been fully truthful with their answers, or may have looked up the correct response to answers. To minimize this last issue, a clear introduction on the first page of the survey was provided asking participants to respond based on their current knowledge and beliefs without trying to find the correct answer from other resources.
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