Knowledge, attitude, and practice regarding dengue virus infection among inhabitants of Aceh, Indonesia: a cross-sectional study

Dengue fever (DF), caused by infection with any of the four dengue virus (DENV) serotypes, has become the most important mosquito-borne viral disease in humans [1]. Dengue fever is associated with significant morbidity, mortality, and economic cost, particularly in developing countries [2]. Since DF was first documented in Indonesia’s capital Jakarta in 1968, it has become prevalent in all provinces of the country and is now a major public health problem [3]. Nearly 60% of the Indonesian population (240 million) live in areas where DENV is known to be circulating. In 2016 there were 201,885 notified cases of DENV infections (77.96 per 100,000 population) and 1585 deaths due to DF [4].

Aceh, located at the northern end of Indonesia’s Sumatra Island, was the most severely affected area by the earthquake and tsunami disaster of 26 December 2004. In 2005, the WHO warned of an increased DF risk in tsunami-affected areas [5]. Reports issued between 2003 and 2011 showed an upward trend of reported DF cases in Aceh [6]. In 2003, before the earthquake and tsunami, the incidence of DF was 2.76 per 100,000. It increased significantly to 35.36 per 100,000 in 2009, and again to 56.40 per 100.000 in 2011 [6]. Recently, in 2016, a total of 2651 DF cases were reported in Aceh (52.02 per 100,000 population) [4].

Dengue prevention and control programme has been placed in national scale by Ministry of Health of Indonesia through Directorate General for Communicable Diseases Control since 1968 with the main objective is to prevent and reduce dengue morbidity and mortality at family and community levels [7]. In 1970s, Indonesia started to implement the peri-focal spraying strategy and health education in a limited area and in 1980, in addition to peri-focal spraying, mass larviciding was adopted [7]. In 1992, organized community efforts were conducted at the village level through the Dengue Hemorrhagic Fever Working Group. This group included one member from Women Empowerment Welfare Group. In the same year, a series of law and legislations of Dengue Prevention and Control Programme were issued. Since 2000, the strategy of dengue control programme has been focused on community participation in source reduction of breeding places [7].

Despite the increasing incidence of DF in Aceh there has been no study to assess the knowledge, attitude and practice (KAP) of Aceh communities regarding DENV transmission and its prevention. Therefore, the aim of the present study was to assess and compare the KAP among community groups in Aceh, in order to design intervention strategies for an effective dengue prevention program.

This study provides the first description of KAP regarding DENV transmission and its prevention in Aceh, Indonesia, where an upward trend in DF incidence has been recorded in the aftermath of the 2004 earthquake and tsunami. These findings may contribute to the identification of intervention groups for DF prevention programs and to the design and development of intervention programs to protect the health of vulnerable groups in the community.

This study found more than 50% of the participants to have poor knowledge regarding DF. The lowest average scores of knowledge regarding DF were obtained in Aceh Tengah, a regency located in the central region of Aceh at approximately 1200 m above sea level. The regency experiences the coolest temperatures in Aceh and has a very low DF incidence due to the low number of competent vectors for DF. In 2012 there were no recorded fatalities due to DF in Aceh Tengah. In contrast, the regency of Aceh Timur (mainly lowland) was among those with the highest knowledge scores; the DF case fatality rate in this regency was 5.9% in 2012 [21], indicating that knowledge regarding DF is closely related to the occurrence and mortality of DF. This finding is consistent with those of a previous study in Nepal showing that the knowledge regarding DF was lower among highland community members, as consequence of lower exposure to the vectors and the diseases, when compared to lowland communities [11].

In univariate analysis, factors associated with good knowledge regarding DF were higher levels of education, occupation (civil servants, private sector employees, entrepreneurs, students), unmarried status, high monthly family income, high SES, and living in the city. There was a robust association between formal education and knowledge regarding DF in the present study. For example, a person with a diploma was almost seven times more likely to have good knowledge compared to a person who was illiterate. This association increased significantly, to almost 14 times more likely, among persons who graduated from a university with a degree. One of the reasons for this may be that school and university curricula of different countries vary in their content on DF which in turn may affect the knowledge level among literate people. In addition, a strong association between income and knowledge level was found in the univariate analysis. However, our multivariate regression analysis revealed that monthly income and other factors (education and occupation) were confounding factors for the SES, and SES was the only strong independent predictor for the knowledge domain regarding DF. One of the possible reasons for the association between SES and better knowledge regarding DF is that people with higher economic status might have better access to information sources on DF [22]. Castro et al. [22] postulated that the combination of better access to information about DF and higher education level might assure a better understanding and comprehension of information on DF when accessed; therefore, better knowledge regarding DF could be achieved.

We found a weak association between knowledge of DF and preventive practice. Although more than 45% of the participants had good knowledge regarding DF (based on the 80% cut-off point), only 32% had good preventive practice. For example, 94% of the participants understood that windows screens and bed nets reduce mosquito biting, but only 74% actually used window screens. In addition, although 91% of the participants understood that DENV vectors breed in standing water, only 73% changed the water in flower containers regularly. Less than half of the participants with good knowledge regarding DF had good preventive practice. Our results indicate that translation from knowledge to practice among participants was poor, as has been reported elsewhere [11, 23‐25]. Although the exact factor that inhibits the translation from knowledge regarding DF into preventive practice is unknown, we suspect that SES could be one of the major factors among the participants of our study. This is based on the following rationale: Firstly, our analysis found that low education and working as a farmer were associated with low preventive practice. As mentioned before, education and occupation were confounding factors for SES. Secondly, living in the suburbs was also associated with low preventive practice, and the majority of residents in the suburbs had a lower education level and were poorer (their main occupation being farming) compared to their counterparts in the cities. We see a major problem in the time allocation for farmers, who have to work every day whereas civil servants or those working in private sector employment have a holiday within the weekend. Less time available could be the main reason for less knowledge regarding DF among suburban participants, and this reason could be a major obstacle for the translation of knowledge into preventive practice among people with low SES. Persons who can spare time during weekends might have used part of that time for translating their knowledge of DF into preventive practices.

As predicted, this study found a strong association between good attitude regarding DF and good practice, indicating that the translation of attitudes into practice was good. Therefore, appropriate preventive programs should be designed to increase not only the knowledge of people but also to improve their attitude regarding DF.

To tackle low knowledge among inhabitants of the suburbs and a lack of translation of knowledge into practice at the same time, the role of religion in the community should be better appreciated. Approximately 98% of the inhabitants of Aceh are Muslim and a male adult is compulsory to pray five times a day especially every Friday afternoon in the mosque. This occasion could be used in close cooperation with mosque management staff to spread educational materials on DF and its prevention, such as brochures and fact sheets. In addition, the preachers should be encouraged to include health and environmental topics, including DF, in the materials used during speech session after praying. To expand this, mosque management could include healthcare providers to provide DF-related speeches in formal or non-formal religious lecture sessions. Furthermore, to increase DF prevention practices, mosque management staff could request the community members to do voluntary communal works to clean and bury of water containers around dwellings, clear the neighborhood of ponds and pits and clean the gutters and surface water drains, especially before and during raining season. Up to now, such opportunities have never been used in Aceh. Engaging local religious leaders and mosques would have at least two advantages: First, it could be more convenient (in terms of time spent) for people to receive information at or near the mosque compared to seminars conducted either in Puskesmas or the town hall (where attendance is usually very low). Second, most of the Acehnese are very observant Muslims and more likely to follow their religious leader in the mosque compared to HCWs. Therefore, it might be easier and more effective to disseminate information on DF and its prevention in this setting. In addition, Aceh is the only province in Indonesia that is implementing Islamic Sharia Law and therefore the religion-related approach will be easier to be implemented in Aceh context. However, it should be kept in mind that people’s attention to such topics is not very high when there is no DF case in the community.

In order to specifically improve the translation of knowledge and attitude into real preventive practice, the most appropriate target groups are hospitalized DF patients and their family members visiting the hospital. The rationale behind this is: (i) we found that the knowledge regarding DF of these groups was not significantly increased compared to participants who had never suffered from DF and had no family history of DF, indicating that the existing DF prevention program did not educate them enough; (ii) we also found that these groups had better attitude regarding DF indicating higher awareness; and (iii) patients’ family members could be more easily interested due to their perceived susceptibility of contracting DF because they are living together with the patient. Increased perceived susceptibility is an important driver of DF prevention practices [26].

In our study context, the status of previous dengue infection of participants (i.e the presence of the antibody anti-dengue) is not relevant. As a country with hyperendemic for dengue, almost 90% of the inhabitants aged 15–18-year-olds in Indonesia are seropositive for dengue and most of the inhabitants with seropositive are never symptomatic [27]. What we are interested is the inhabitants who experienced symptomatic dengue previously (i.e experienced symptomatic dengue). This history is important because, in nature, such experience will associate with awareness and attitude towards disease. In this study, we did record the information of symptomatic dengue history in respondents. We observed a higher use of the internet as a source of information on DF among participants who had experienced DF personally or in their family. This indicates that they might have tried to get more information regarding DF from the internet during and/or after the DF episode reflection awareness of the disease. Therefore, both of these groups (patients and their families) appear most suitable for DF education during visits to Puskesmas or hospitals. Dengue fever education materials could be delivered directly by HCWs to the patients or by providing family members with posters, brochures, or booklets while in hospital. This strategy could be particularly effective in Aceh where a cultural practice exists in which patients in hospital are visited not only by members of the core family but also by the extended family and neighbors. All of these should be educated on such opportunities, improving their knowledge as well as attitude and preventive practice regarding DF. In addition, they should be tasked with spreading DF education materials among their neighbors (e.g., one person should spread the education materials to at least five relatives or neighbors). By adopting a “one for five” strategy, dissemination of the information could be effective. Beyond the mere dissemination of information materials on DF, the “one for five” strategy can also deliver “blue messages” from persons who visited the DF patient in hospital. As Acehnese people tend to explain the condition of their family members in hyperbolic phrases, it is very likely that this could drive the awareness of interlocutors. However, further study should be conducted to assess the effectiveness of such a “one for five” strategy in increasing the KAP regarding DF in Aceh.

As expected, this study found a negative association between receiving information from HCWs in Puskesmas and personal history of DF. In Indonesia, the main role of Puskesmas is to implement preventive programs while the major role of hospitals is curative. Therefore, Puskesmas might be one of the most suitable places for implementing a DF prevention program in order to improve preventive practices among local residents. To achieve this in the future, the government should encourage HCWs in Puskesmas to better educate DF patients and their family members and neighbors, also applying community outreach methods like the “one for five” strategy.

Inevitably, there are some limitations of the present study. First, this study could not determine how all the reported practices were translated into actual practice because the interviewers did not directly inspect the houses inhabited by participants. Second, a desirability bias might exist in some questions within the attitude domain. This latter issue has also been reported from similar study in Nepal [11].

In Aceh, Indonesia, the knowledge regarding DF is low among inhabitants. Only one-third of the participants had good attitude towards DF and reported good preventive practices. Although SES was the only independent predictor factor for KAP domains in this study, some of the intervention groups that should be considered for a DF prevention program are inhabitants with low SES, inhabitants with low education level, those living in the suburbs, and farmers. There was a strong association between knowledge and attitude regarding DF, and between attitude and preventive practice. However, there was a poor translation of knowledge into preventive practice. To achieve success in DF prevention, programs should be designed to increase not only knowledge and attitude domains but also the translation of these domains into real preventive measures. To disseminate DF information and increase the translation of knowledge into preventive measures, a religion-based approach might be considered as part of preventive programs in Aceh. In this study we found that having a personal or family history of DF was not associated with an increased knowledge regarding DF. The most likely explanation for this worrying result could be insufficient information on DF given by HCWs during the treatment of patients in Puskesmas or hospital. In addition, we found a negative association between personal history of DF and receiving information from HCW in Puskesmas. To address these problems, the critical role of Puskesmas as the frontline facility in disease prevention should be optimized using two strategies. First, HCWs should be empowered and encouraged to better educate DF patients, their families and neighbors during their visits to the Puskesmas. Second, Puskesmas and hospital should provide DF patients, their families and visiting neighbors with adequate health education materials, applying outreach strategies that use these groups of persons as multipliers in their communities. In addition, to disseminate DF information to the broader community, posters, booklets and brochures must also be distributed to schools, universities and other various public administrative offices. To enhance the awareness, simple and educating DF posters could be posted in public areas that everyone from different educational levels can understand.