Dengue

Dengue Bulletin Volume 28 (2004)

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Community-based Assessment of Dengue-related Knowledge among Caregivers

Khynn Than Win*^#, Sian Za Nang** and Aye Min***

*Health Systems Research Division, Department of Medical Research (Lower Myanmar), Myanmar
**Health Education Bureau, Department of Health Planning, Myanmar
***Vector Borne Disease Control Programme, Department of Health, Myanmar

Introduction

Dengue haemorrhagic fever (DHF) is endemo-epidemic in 12 out of 14 states and divisions in Myanmar and is transmitted by Aedes aegypti. Most of the reported cases are under 15 years of age^[1]. The Myanmar National Health Plan (NHP) (1996-2001)
termed DHF as one of the diseases under national surveillance. DHF is also listed as the 17^th priority disease in Myanmar. One of the strategies devised in NHP for the prevention and control of DHF is productionofguidelinesforbasic health staff (BHS) as part of the information, education and communication (IEC) programme.

IEC initiatives are based on the concepts of prevention and primary health care. They create awareness, increase knowledge, change attitudes and motivate people to adopt new ideas^[2].

Communication participation appears to be one of the most promising innovative means to prevent and control DHF. Simple elimination of vector-breeding water collections or “source reduction” is the possible answer to the problem. Community activities are identified mainly as reduction of non-essential water containers, protection of water containers from larvae breeding, larviciding and release of larvivorous fish. Community participation needs to be sustained by dissemination of health messages through various channels^[3].

Existing IEC materials in Myanmar included health talks routinely carried out in schools and in the community. Health messages were distributed through radio, television, newspapers and journals before and during the epidemic season. Pamphlets were developed locally in states and divisions. However, it is necessary to find out the most appropriate IEC materials and means that would be relevant for various communities.

This study attempted to improve the existing IEC materials on DHF control based on the knowledge and practice of child-care providers in the Thaketa township of the Yangon division in Myanmar. DHF control will be more effective in the future by strengthening community participation on case information and source reduction.

This research aimed to: (i) explore the extent of dengue-related knowledge among caregivers; (ii) identify the exposure of community members to the existing IEC materials; and (iii) to find out the factors responsible for high knowledge scores.

Methods and materials

This community-based cross-sectional study was based on multistage sampling to identify 405 caregivers in Thaketa township, Yangon. This area was one of the dengue endemic regions in the Yangon division and the case-fatality rate (CFR) was 1.65% in 2002. Both quantitative and qualitative data collection methods, including observation checklist, were used in the study. The study sample included household members aged 18 years and above. The households with children were selected randomly. In these households, we chose one subject from each household, regardless of sex. The respondent was a relative of the child (mother/father/grandfather/grandmother/ brother/sister/uncle/aunt). Mothers were the key persons to be interviewed after taking their consent. The questionnaire was pilot-tested for clarity and validity; all questions were reviewed by epidemiologists, public health experts, health educators and by investigators experienced in conducting community-based surveys in DHF. In order to ensure the accuracy and completeness of data, our surveyors were trained before and after pre-testing.

Ten sessions of Focus Group Discussions (FGDs) were performed among basic health staff (BHS), general practitioners, Maternal and Child Welfare Association (MCWA) members, other volunteers including Ward Law and Order Restoration Council members, voluntary fire brigade members, etc., for recommendation of existing IEC activities (including television, radio, newspapers, local journals and pamphlets). In every FGD, the moderator explained thoroughly the purpose of conducting the discussions. The Township Health Centre, Ward Law and Order Restoration Council offices and homes were chosen for holding FGDs.

Caregivers were those who took care of children at home, or supervised at the health centre or clinic, or advised parents on home care of a child with fever.

Data checking, cleaning and validation were performed using Epi-info 6.0, and data analysis was conducted using SPSS 10.0. P<0.05 was used as the definition of statistical significance. The study period lasted one year starting in June 2002.

Results

About respondents

The sex ratio of the respondents was 7:1 for females and males. The mean age was 35.9±10.3. The majority of the respondents were aged 18-35 years, literate and dependants. About 8.6% of them had received ³ 12 years’ school education. Nearly 40% lived in their own wooden houses. Most of the households (77.8%) had 1 to 2 children under 15 years of age. Only 34 (8.4%) of the households that participated in the interview had a child with history of DHF.

The difference of mean score among males and females was not statistically significant (P=0.271).

Dengue-related knowledge responses

The responses of caregivers are included in Table 1.

Table 1. Dengue-related knowledge responses of caregivers

The total knowledge scores were categorized as low (0-19) and high (20-39). The percentage of the high score group was more than that of the low score group (68.6% vs 31.4%). Signs and symptoms of DHF were fever (57.3%), vomiting (51.6%), purpura (36.3%), drowsiness (28.1%), cold extremities (17%), etc.

Knowledge score of respondents with and without history
of DHF case in their homes

Knowledge scores with and without past history of primary DHF cases at home are given in the Figure.

Figure. Past history of primary DHF cases
at home and knowledge scores

The figure illustrates that the knowledge scores of the caregivers were not statistically different according to the presence of primary DHF case at home (P=0.137).

Prevention of mosquito bites

To prevent and protect children from mosquito bites, the following measures were taken: use of mosquito nets (47.9%), use of repellants (47.2%), wearing of long sleeves (12.6%), others (8.6%), and none (5.2%).

Existing exposure to IEC material in the community

Table 2 contains the responses of the communities to IEC materials.

Table 2. Exposure to IEC materials in the community

The percentage of people watching television was the highest as compared to other types of exposure. Nearly half of the respondents had seen the pamphlets about DHF (48.6%). Exposure to radio talks and information in newspapers and journals was very low. The extent of respondents exposed to any type of IEC was 87%. The facts in those IEC materials were concise and easily recognized (78.3%) (Table 2).

Almost 60% of the interviewees felt that television was the most effective medium for dissemination of knowledge on DHF in the community.

The logistic regression model of knowledge score by the respondents’ characteristics and exposure to health education media is given in Table 3.

Table 3. Logistic regression model of knowledge scores, by respondents’ characteristics and exposure to health education materials

* Significant at P<0.05; ** P<0.01; *** P<0.001; (r) = Reference category

An analysis of the findings suggested that females with over six years of schooling were significantly related to total knowledge scores. Survey respondents with 6-20 years of schooling were more likely to obtain high scores than those with 0-5 years of schooling. Respondents who were exposed to health education media such as pamphlets/posters, television, newspapers and journals obtained higher scores than the unexposed group. The respondents who watched television were more likely to score higher than those who did not (Table 3).

Cross-check by observation checklist

The researchers used an observation checklist to support the findings. Nearly 55% of the households had two to three water containers. Although 46.5% of the water containers had lids, only 19% were covered tightly. Larvae were found in 67% of the water storage tanks and 15.9% of the flower vases at the time of interviews. Gutter blockage was observed in 3.2% of cases. Old tyres, coconut shells and tins were found in the compounds and larvae existed in half of these solid wastes.

Approaches considered for improvement of IEC activities

Many recommendations were extracted from FGDs for the improvement of existing IEC materials. It was suggested that messages should be short and clear. Pamphlets should be widely distributed among the community, especially in schools. The same messages could be published in newspapers and journals once a week before and during the rainy season. Health magazines and magazines on astrology were the most preferred media. They also pointed out the most suitable times for telecast and broadcast of health messages. Regular clearing of gutters should be mentioned in the health message as well as in the book, “Facts for Life”. The fact that “DHF may attack again a previously-infected child” was important to remind mothers of the danger. Cartoons and art competitions and exhibitions on DHF would be the most effective media for schoolchildren and mothers.

Discussion

The mean scores of male and female respondents were not significantly different in the community. Community members knew a lot (more than 80%) about transmission of DHF by mosquito bite, the biting habit of Aedes and the resultant fatality. Nevertheless, only 61.6% correctly identified the main vector of DHF. Nearly 20% answered that Aedes usually bit at nighttime. Some people were still confused that polluted water was also a breeding place. Most of the interviewees responded that the common breeding sites of Aedes were water containers and flower vases. Not more than 30% identified ant traps, broken pots, tins, old tyres and coconut shells as the vector breeding places. The subjects knew little of blocked gutters as possible breeding sites. Nearly 80% thought that DHF could be prevented by immunization. A majority of the interviewees used measures to prevent children from being bitten by mosquitoes. A very small percentage did not use any measure. Some points that require emphasis for community awareness include:

     Aedes is the main vector for DHF.

     Aedes only breeds in clear water, not in polluted water.

     The biting time of Aedes is daytime.

     Blocked gutters should be mentioned as possible breeding sites for Aedes in existing IEC materials.

     There is no vaccine available for the prevention of DHF.

The chance to get high scores was better in females with high education. Caregivers with low educational levels should be targeted for health education. The level of knowledge scores was not related to the history of a previously infected child at home. Knowledge scores may be changed through exposure to various media. Also, sufficient numbers of IEC materials should be distributed in the community. Only a small percentage of the interviewees were not exposed to any type of existing IEC. Ways and means should be found to improve people’s exposure by further discussions with community members and health workers using participatory approaches.

Pamphlets/posters, television, newspapers and journals are still popular media for the public. Television is the most effective medium and various types of programmes, such as songs, comedies, short movies with famous actors, actresses, etc., apart from discussions and health talks can be telecast. However, radio is still a valuable tool in the health education process because of its easy availability ad popular use in semi-urban and rural areas. The effectiveness of various existing IEC materials should be reviewed for further improvement.

Many water containers were not covered tightly to prevent larval breeding. Social mobilization for sustainability of larvae control activities should be implemented. Coordination and cooperation with volunteers and local NGOs should also be strengthened.

Acknowledgement

We express our gratitude to the Township Medical Officer and basic health staff in Thaketa township for their support. We are grateful to volunteers, NGO members and the study area residents for their active participation in the study.

References

1.      Tha NO. A study on the larval control operations for DHF prevention in Sanchaung township, Yangon, Myanmar, 2000-2001 (Unpublished report).

2.      World Health Organization. Information, education and communication. Lessons from the past: perspectives for the future. Department of Reproductive Health and Research, World Health Organization, Geneva, 2001.

3.      Yoon SY. Community participation in the control and prevention of DF/DHF: Is it possible? Dengue Newsletter, 1987, (13): 7-14.