The knowledge, attitude and practice of community people on dengue fever in Central Nepal: a cross-sectional study

Dengue fever (DF) is a mosquito-borne viral disease caused by four serotypes of the dengue virus (DENV-1, DENV-2, DENV-3, and DENV-4) [1]. DF has become a major international public health concern with an estimated 10,000 deaths and 100 million symptomatic infections per year in over 128 countries, predominantly in Asia, followed by Latin America and Africa [2‐5]. It is mainly transmitted to humans by the mosquito vectors Aedes aegypti and Aedes albopictus, which have spread to tropical and sub-tropical regions around the globe, predominantly in urban and semi-urban areas [6]. The distribution of such vector-borne diseases is determined by a complex set of environmental and social-demographic factors [7, 8]. Climate change along with rapid landscape and demographic changes is already changing the environment of Himalayan countries, such as Nepal, causing the shifting of disease vectors and disease transmission from tropical to temperate and highland areas [9, 10]. Furthermore, warming in the Himalayas is reported to be greater than the global average temperature rise (0.06 °C/year) indicating that the Himalayas are more sensitive and vulnerable to climate change [11]. Accordingly, the expansion of dengue and chikungunya cases and their vectors in the countries of the Hindu Kush Himalayan region, including Nepal, has been documented [12].

The first DF case in Nepal was reported in 2004 [13], while the first dengue outbreak was reported from the lowland areas in 2006 [14] with circulation of all four dengue serotypes [15]. Since 2006, Nepal has continued to experience DF outbreaks with increasing cases from the lower altitudes up to the hilly regions, with a significant impact on public health [12, 15‐24]. In 2019, Nepal experienced a large dengue outbreak with more than 17,000 reported cases from the lowland areas [< 1500 m above mean sea level (amsl)] to the highland areas (> 1500 m amsl) including some areas which were not previously reported as being dengue-endemic [16, 25]. However, the majority of cases until 2018 have been reported from the lowland areas (< 1500 m) which are densely populated [12, 16, 20] with known distribution of Aedes vectors, i.e., Aedes albopictus and Aedes aegypti [20, 26]. The frequent outbreaks of DF and the rising number of dengue cases in Nepal suggest that the vector control efforts are probably ineffective or insufficient and are conducted exclusively only as part of an emergency response to outbreaks [27]. In the meantime, the vaccine development against DF has made remarkable progress in recent years, however, the vaccines are unavailable in Nepal and also do not protect against all serotypes of DF [5, 28, 29]. Furthermore, an individual can be infected with dengue several times, which eventually increases the risk of severe dengue infection [30]. In the absence of an efficacious vaccine and specific antiviral treatment, vector prevention and control strategies have helped to minimize the increase in dengue frequency and the severity of dengue epidemics [31]. Community participation may offer a more cost-effective approach and, therefore, provide more sustainable dengue reduction interventions [32]. Meanwhile, in general human behavior change communication (BCC) is one of the strategies currently adopted for reducing the vector population and dengue virus transmission [33, 34]. However, it is important to consider that the diverse ethnic groups from distinct socio-economic and cultural backgrounds reside in the different altitudinal gradients of Nepal [35]. Prior to 2019, several sporadic outbreaks of DF were only reported from the lowlands, while the highland regions were considered as non-dengue endemic areas [16, 21, 36‐38]. Thus, in order to improve and design sustainable public health interventions for dengue throughout the different altitudinal regions of Nepal, with people having different socio-economic and cultural backgrounds, it is essential to recognize and understand the people’s knowledge, attitude and practices (KAP) on dengue virus and its vectors [39, 40]. While several KAP studies have been conducted in Nepal, these were limited to specific dengue-endemic areas [41, 42] or only focused on dengue-infected people [43]. Furthermore, none of the previous studies were conducted in both the highland and lowland areas except for one study by Dhimal et al. [40] which was focused on quantitative data only. Thus, this present mixed-method study aimed to assess and compare the KAP among community groups residing in lowland and highland areas, applying both quantitative and qualitative methods. The purpose of using both methods was to triangulate the study outcomes, gaining an in-depth understanding of the general community and the public health professionals who were presumed to be in better receipt of health information.

In the present study, both qualitative and quantitative findings provide similar information regarding the knowledge, attitude and practice of people residing in the highland and lowland areas of Central Nepal. According to our present study, only a small proportion of the HHS (2.3%) achieved a high knowledge score and high proportion achieved low (37.9%) and no (59.8%) knowledge score, while a large proportion (74.1%) achieved high attitude scores and a fairly-high proportion (21.2%) achieved high practice score regarding DF. Furthermore, both the qualitative (FGDs, IDIs) and quantitative (HHS) results indicate that people living in the lowland areas had better knowledge on DF than people living in highland areas, however no significant differences were found in the attitude and practice categories. Results from the HHS and FGDs illustrate, that while the majority of participants obtained high attitude scores towards DF, they had no adequate knowledge on DF and were not completely adopting the preventive practices in order to reduce the breeding sites of the dengue vectors. This lack in knowledge and practice behavior reveals the urgent need for massive dengue awareness campaigns in both areas. Moreover, providing health education about the disease should be compulsory to ensure that the Nepalese people can better understand DF, improve their knowledge on dengue transmission and on the preventive and control measures in order to reduce future dengue epidemics.

The qualitative data revealed that almost all of the IDI participants, except FGD participants in our study had heard and had knowledge of DF. However, only 40.6% of the HHS participants had previously heard about DF, with significantly more of these participants being from the lowland areas. This finding is consistent with a previous study conducted in Eastern Nepal [41]. However, in similar studies conducted in Australia, India and Pakistan, the majority of people (> 80%) had heard about DF [67‐69] which is relatively higher than in Nepal. DF epidemics in those countries were reported much earlier, in the 1980 [12, 70], whereas in Nepal, the first DF outbreak was reported in 2006 [15], this may be the reason for why Nepalese people are less familiar with DF. Fever and headache were the most quoted symptoms in our study which are comparable with similar studies conducted in Sri Lanka, India, Yemen, Vientiane, Australia and Malaysia [67, 68, 71‐73]. The major clinical features reported during the 2016 DF outbreak in Nepal were fever (100%), headache (71.3%), rashes (11.3%), retro-orbital pain (23.5%), vomiting (23.4%), joint pain (32.1%), and thrombocytopenia (85.7%), and minor symptoms were comprised abdominal pain and a feeling of restlessness [18]. However, most of the community people were unable to relate other common signs and symptoms of DF except for fever and headache, while the public health officers and FCHVs were aware of the other symptoms such as skin rashes, joint pain, eye pain and fatigue. The different perceptions and experiences of people with fever in relation to other illness, such as malaria, typhoid fever and seasonal flu may sometimes create confusion with the actual disease symptoms [74]. We found high knowledge level on the signs and symptoms of DF in the lowland community compared to the highland community; this may be due to the frequent DF outbreaks that have occurred in the lowland areas [12], while the participants in the highland neither personally experienced the disease nor witnessed a case from a close relative, friend or neighbor.

Ae. aegypti and Ae. albopictus are the most common vectors responsible for transmitting DF to humans [75]. Most of the HHS participants in our study thought that flies, ticks and all types of mosquitoes cannot transmit dengue but unfortunately, very few participants could state the Aedes mosquitoes as the major, responsible vector to transmit DF. A few lowland FGD participants were able to describe Aedes, but they could not name the vector. Conversely, the highland community, except teachers and health workers, did not even know that the mosquito’s bite could transmit dengue. The presence of fewer numbers of the mosquito vectors in the highland areas [20] might also be the plausible reason behind the ignorance of the highland dwellers towards mosquito vectors. In contrast to our study, a study from Malaysia showed that 97% of the participants knew that Ae. aegypti was the specific mosquito that causes DF [76]. Dengue was reported quite earlier in Malaysia (1901) than in Nepal, followed by more frequent outbreaks [77]. This may have influenced the population’s knowledge about the dengue vector and caused this to be handled down the generations in Malaysia than in Nepal. Regarding the feeding behavior of the dengue vectors, the dengue vector’s bite occurs mostly after sunshine and before sunset [78]. Meanwhile, more than half of the HHS participants as well as public health professionals, health workers, teachers and FCHVs, were aware about the daytime biting habit of the dengue vectors. This finding is comparable with other studies carried out in Thailand [64] and Sri Lanka [71]. There is also increasing evidence of DENV transmission by blood and organ transplantation [79‐82], suggesting the increasing threat to blood supplies, especially in endemic regions. Interestingly, 70.5% of the HHS participants in our study stated that DF could be transmitted by blood transfusion, thus the negative image associated with blood transfusion as a risk of transmitting diseases in general might influence people’s perceptions [83]. Hence, the provision of adequate and relevant information should be made readily available to all layers of the communities [84]. However, most participants in our study mentioned radio and television as their main sources of information regarding DF, followed by health professionals and neighbors. Similar findings were reported from Jamaica, India, Vientiane and Malaysia [68, 76, 85, 86]. Surprisingly, very few participants had received DF information through teachers and children, indicating the lack of an updated health education in the educational institutions. Thus, the development of school-based educational programs is very important in order to enhance the knowledge of DF for both teachers and students; this could motivate all actors towards dengue prevention and control. Furthermore, school-based dengue prevention and control programs could provide a sustainable practice for community awareness through the involvement of children. Thus, this could help to prevent the disease spread in endemic areas, and control future dengue epidemics [87] in non-dengue endemic regions. Health professionals compared to highland areas better informed participants from lowland areas about dengue. The difficult geographical landscape of the highland regions, linked with rough and poor maintained roads [88], presumably reduces the mobilization of health workers in the highland areas. Meanwhile, the higher frequency of DF outbreaks in the lowlands may lead the health professionals to talk more about DF in the lowland areas than in the highland areas. Thus, this suggests that the health authorities of each area could customize their channels of information by emphasizing the collaboration between communities, community leaders, FCHVs, local political leaders including religious bodies, local non-governmental organizations, local youth clubs and local educational institutions. This could help to establish a cordial relationship between the communities and the stakeholders, including health professionals, which would also help to enhance the knowledge of DF among different communities and motivate themselves to improve their DF preventive and control practices.

The high attitude scores acquired by the majority of the HHS participants in our study (74.1%) showed a greater concern of the people towards DF; similar findings, i.e., high attitude, were reported in Pakistan [69, 89] and Yemen [90]. The majority of the people perceived DF as a serious disease and seemed supportive towards dengue prevention and control. However, most of them did not consider themselves to be at risk of having DENV infection; we believe that, these participants did not have previous communication with dengue-infected persons in their neighborhood or that, in the community, there had scarcely been any reports of severe dengue infection. Nonetheless, our qualitative findings revealed that the people from both the highland and lowland areas working in the health management sectors believed that the lowland and highland areas are at risk of increasing dengue outbreaks due to increasing temperature and mobility of people from dengue-endemic regions to non-endemic regions. Recent DF outbreaks, with reported cases from the lowlands to the middle and high, mountainous regions of Nepal, are clear evidence of the growing threat of DF epidemics with the changing climate [17]. Discarded tires, mud pots, ditches, plastic buckets, cement tanks, tree holes, rocks and other plastic containers in indoor and outdoor locations have been investigated as major breeding sites for Aedes mosquitoes as described in various studies [91‐94]. In addition, the control of the dengue vectors has mainly been approached by source reduction, such as the elimination and management of water-holding containers and discarded tires [95, 96]. The most promising thing is that more than 80% of the participants from both the highland and lowland areas were positive towards the fact that stagnant water in discarded tires, broken pots and bottles are the breeding sites of those mosquitoes and are aware that controlling the breeding places of mosquitoes is a good strategy to prevent dengue. This finding is consistent with a similar study conducted in Nepal between 2011 and 2012 [40].

More people in our study were found to obtain high practice score than overall knowledge score. Similar findings were reported in studies from Sri Lanka [97], Vietnam [98, 99] and Malaysia [100] but contrary to other studies of Philippines [101] and Jamaica [85], which reported high levels of knowledge but low level of practices. Despite having a poor knowledge of the symptoms and transmission modes regarding DF, most of the highland and lowland dwellers (< 70%) had a very good knowledge on preventive measures. This might be because the questions asked at the practice level were linked with the people’s daily practices in order to control other mosquitoes and were not DF-specific [40]. The translation of this knowledge regarding preventive practices was partially observed in our study. HHS participants stated that they were covering water containers in the home, focusing on cleaning of garbage/trash, cutting down bushes in the yard, turning containers upside down, and preventing water stagnation in order to eliminate mosquito-breeding sites and to reduce the mosquitoes. The other common practices mentioned by the HHS, FGDs and IDIs were the use of nets in doors and windows, fans, mosquito coils and covering the body with clothes. These preventive practices were reported less frequently in the highland areas as the people there reported a lower presence of mosquitoes. Nevertheless, it is a little discouraging that only a small proportion of the lowland participants considered the use of mosquito-repellent cream, insecticides sprays and professional pest control as methods of protection. Overall, only 21% participants of our study reported a high practices score; this is consistent with the studies in Jamaica [85] and Indonesia [62]. This may have been attributed by the people’s attitudes, where most of the participants in our study did not consider themselves to be at risk of DF. Besides, it is difficult to change a person’s behavior deeply embedded in structural factors and social determination [102], such as sleeping outdoors due to load shedding, affordability and the lack of resources including professional pest control, mosquito coils, mosquito repellent cream, etc.

In contrast to the study of Dhimal et al. [40], our study found a statistically significantly difference between the knowledge level of the highland and lowland dwellers. However, we could not observe any statistically significant difference in their attitudes and practice levels. Among the socio-demographic variables, the overall knowledge of the participants was associated with the area of residence (highland/lowland), age, educational level, monthly income, SES and occupation. People from the lowland areas if compared to the highland areas were less likely to have a low knowledge score. Frequent DF outbreaks and ongoing DF control programs during outbreak period might tend the people of lowland areas to gain at least some knowledge on DF. Similarly, participants with secondary or higher secondary education level were less likely to achieve low knowledge score on DF if compared to illiterate people. However, there was no significant association of the knowledge level with gender consistent with a study conducted in Indonesia [62]. Similarly, no significant association was found between preventive practices and socio-demographic characteristics including education level; this is consistent with a study conducted in Jamaica [85]. This implies that those demographic variables do not have significant bearings nor influence on how they behave to prevent dengue infection. One possible cause might be the lack of health education in the curricula regarding DF in each academic level [40]. Furthermore, the lack of school-based awareness programs regarding DF preventive and control measures might be the reason why the educational qualification of study’s participants did not contribute to the adoption of better preventive practices. Attitude was found to be positively associated with the educational level, a finding consistent with the results from Malaysia [76]. Literate participants were found to obtain high attitude scores if compared to illiterate people, indicating the role of education for changing the attitudes of people [40].

Our study shows a complete lack of high knowledge scores, and more participants with no knowledge scores in the highland areas regarding DF. However, in the lowland, at least 3.5% of the researched participants had acquired high knowledge scores on the signs, and symptoms and transmission of DF as well as the effective preventive and control measures against DF. Due to occurrence of frequent DF outbreaks and the DF burden in the lowlands of Nepal in recent years [17, 26, 35‐37, 90] and accordingly, due to the awareness programs conducted in lowland during the outbreak periods might tend people of lowland to gain more knowledge on DF if compared to highland. Although the study of Shrestha et al. [106] reported the implementation of effective vector control strategies as a definite reason beside the reduction of dengue cases in Nepal up to 2016, the low level of DF-related knowledge and practices in this study raise a big question regarding the adoption of effective health educational programs in the communities. In the meantime, the huge dengue outbreak in 2019 [17] indicates that the ongoing dengue prevention and control programs in Nepal are not sufficient and need to be improve in order to prevent the increasing DF incidence in Nepal.

The Nepalese people have a very high attitude level regarding DF. However, their knowledge and awareness sensitivity on DF and preventive practices regarding vector control remains at low level in both highland (> 1500 m amsl) and lowland (< 1500 m amsl) areas. Compared to people in the highland, the lowland people have more knowledge on DF but this knowledge is not adequate to prevent and control future dengue epidemics. For the effective prevention of future dengue epidemics, it is recommended to broaden the use and scope of mass media such as radio and television, to share DF information on a timely basis and with content that, potentially, could lead to behavioral changes in the people. The health authorities should highly customize their channels of information by emphasizing the collaboration required between communities and various stakeholders. However, the development of sufficiently and easily understandable IEC/BCC materials on DF is most important in order to bring awareness to the community people having different educational levels. Most importantly, the inclusion of health education in school and university curricula, as well as school-based preventive programs regarding DF is highly recommended to establish a sustainable chain of awareness especially in highland areas that lack quality health services as well as adequate health education.