Dengue is the common and rapidly spreading mosquito-borne

ORIGINAL ARTICLE - COMMUNITY MEDICINE A cross sectional study to assess the knowledge, attitude and practice of dengue fever in urban field practice area R.Tamilarasi (1), Latha Maheshwari. S (2), Ahimth.J.A. (3), Jonathan Abish David (4), Jeevananthan.D (5), Goudaperu Naveen (6), Kerena Epsiba (7) Abstract Introduction:Dengue is the common and rapidly spreading mosquito-borne viral disease in the world. Dengue/dengue haemorrhagic fever (DHF) is an emergent disease in India. The relationship of this country with dengue has been long and intense. Thus the present study was taken up to assess the awareness and practice towards the prevention of dengue fever.methods and Material:This Cross-sectional study was done from June 2016 - October 2016 in Sanjeeevirayanpet, the urban field practice area of Stanley medical college. All people who are above 18 of both sexes and who gave consent were included in the study by Random sampling technique. Total of 25o participants were interviewed by by using a semi structured pre formed questionnaire.statistical analysis used: The data was entered in MS Excel and appropriate simple frequencies and statistical were used for data analysis.results:out of the 250 people involved in this study, most of them (43.2%) were in the age group of 30-50 years and 61.2% were males and 83.6% were married. 237 (97.53%) have correctly answered that the mode of transmission was through mosquto bite. Regarding the common symptoms of dengue fever was the most consistent response (92.59%) followed by muscular pain (73.25%) and head ache (72.84%). With regards to knowledge of preventive measures, only 86.83% responders were generally aware of preventing water stagnation. Common breeding sites for mosquitoes was correctly recognized by 81.48% but only 2% have agreed that prevention of dengue is not the mere responsibility of government and everyone have the responsibility in preventing dengue. Conclusions: This study concludes, that the study participants have a reasonable knowledge about dengue. But proper measures like health education can be given to improve their knowledge which can improve their practice.key-words: Dengue, awareness, attitude, practice 8 INTRODUCTION Dengue is the common and rapidly spreading mosquito-borne viral disease in the world. Dengue is a mosquito borne infection that in recent decades has become a major international public health concern. Dengue causes a severe flu like illness and sometimes potentially lethal complications called as Dengue haemorrhagic fever and Dengue shock syndrome. Dengue is found in tropical and subtropical regions around the world, predominantly in urban and semi urban areas 1.Dengue/dengue haemorrhagic fever (DHF) is an emergent disease in India. The relationship of this country with dengue has been long and intense. The first recorded epidemic of clinically dengue- like illness occurred at Madras in 1 780 and the dengue virus was isolated for the first time almost simultaneously in Japan and Calcutta in 1943-1944. After the first virologically proved epidemic of dengue fever along the East Coast of India in 1963-1964, it spread to all over the country. The first full-blown epidemic of the severe form of the illness, the dengue haemorrhagic fever/ dengue shock syndrome occurred in North India in 1996. It is endemic in 31 states and union territories of the country and contributes annual outbreaks of dengue/ DHF.2-4.During 2013 about 74168 cases were reported with 168 deaths, the highest number of cases were reported from Kerala, followed by Odisha, Karnataka, Tamil Nadu and Delhi.5 Dengue is been urban disease but has spread to rural areas in recent years due to development activities, water storage practices. 6-9.To tackle increasing dengue cases in urban, peri-urban and rural areas because of expanding urbanization, deficient water and solid waste management, the emphasis is on avoidance of mosquito breeding conditions in homes, workplaces and minimizing the man-mosquito contact. Improved surveillance, case management and community participation, inter-sectoral collaboration, enactment and enforcement of civic bye laws and building bye laws are emphasized for this vector borne disease.looking at the cost-effectiveness of the preventive measures over Please Scan this QR Code to View this Article Online Article ID: 2017:04:01:02 1,2,3,4,5,6,7.Department of community medicine, Stanley Medical College.

the treatment charges for Dengue fever in private hospitals, there is an urgent need to bring about awareness in people regarding the preventive measures in controlling dengue fever. Thus the present study was taken up to assess the awareness and practice towards the prevention of dengue fever, which serve as an educational diagnosis of a population. This information helps programs set communication objectives linked to increased community engagement and demand for services and develop strategies appropriate for the social, cultural and political contexts of at-risk communities. AIM AND OBJECTIVES To assess the knowledge, attitude and practices of dengue fever of people in Sanjeevirayanpet, the urban field practice area of Stanley medical college. Subjects and Methods: STUDY POPULATION Household population in Sanjeevirayanpet urban field practice area of Stanley medical college. INCLUSION CRITERIA: - Age above 18 of both sexes. - Those who gave consent. EXCLUSION CRITERIA: -People who did not cooperate with the study. -Those who did not know Tamil and English. -Those who were sick and unable to answer. STUDYDESIGN: Cross-sectional study. STUDY AREA : Sanjeeevirayanpet, the urban field practice area of Stanley medical college. SAMPLE SIZE : Based on a previous study done in Guntur P=10.27 q=100-10.27=89.73 d=4 Sample size=4pq/d2 =250 SAMPLING TECHNIQUE: Random sampling technique. Data collection was started from the first house of sanjeevirayan kovil street, randomly selected 1 member of above 18 years age group was interviewed from each family. STUDY TOOL: The questionnaire was framed based on previous literatures and text books. METHOD OF DATA COLLECION: After getting the permission from the Institutional ethical committee, Respected Dean and Head of the Department of community medicine, the data collection procedure was started. The people who were involved in the study were explained everything about the study in English or Tamil and the reason of doing the study was explained. A proper informed consent was obtained in English or Tamil. The data was collected with the help of a preformed questionnaire by interview technique. STATISTICAL ANALYSIS: The data collected was entered in the Microsoft Excel computer program and checked for any inconsistency. Descriptive statistics for the collected data were recorded and results were shown in percentages. RESULTS Out of the 250 people involved in this study, 243 (97.2%) of our study population have heard about the disease dengue and 7 have not heard about the disease dengue. So the rest of the questions were asked only to the 243 who have heard about dengue. The rest 7 were not questioned from here on. TABLE:I Characteristics of participants: DETAILS OF STUDY PARTICIPANTS Frequency Percent SEX FEMALE 97 38.80% A total of 250 were visited out of which 243 were asked about dengue in the study. Majority of the respondents (43.2%) were in the age group of 30-50 years with 61.2% of them being males. As per their marital status, 83.6% were married. As per Modified Kuppusamy classification of socio-economic status, those belonging to high class and lower middle class of socio-economic status were 10.8% and 15.6% respectively. MALE 153 61.20% AGE (years) 20-30 53 21.20% 31-40 85 34.00% 41-50 66 26.40% 51-60 46 18.40% MARITAL STATUS UNMARRIED 38 15.20% SOCIO ECONOMIC STATUS MARRIED 209 83.60% DIVORCED 1 0.40% WIDOW 2 0.80% UPPER 27 10.80% UPPER DLE LOWER DLE MID- MID- 166 66.40% 39 15.60% UPPER LOWER 16 6.40% LOWER 2 0.80% Total 250 100% 9

10 TABLE II: Response to knowledge based questions: 144 have answered that transmission does not happens KNOWLEDGE QUESTIONS Frequency (%) through direct contact. Regarding the common MODE OF TRANSMISSION MOSQUITO BITE 237 (97.53%) symptoms of dengue fever was the most consistent response DIRTY DRINKING 0 which is about 92.59% followed by muscular pain WATER (73.25%) and head ache (72.84%).With regards to knowledge UNHYGIENIC FOOD 0 of preventive measures, responders were gener- HOUSEFLIES 0 ally aware of cleaning house (90.12%), preventing water DON T KNOW 6 (2.47%) stagnation (86.83%), cleaning of garbage (83.95%) and HUMAN TO HUMAN YES 69 (28.40%) mosquito mats/ (75.72%). Regarding the knowledge of SPREAD NO 144 (59.26%) bite time of mosquito only 23.05% were aware that Aedes DON T KNOW 30 (12.35%) Aegypti bites during day time. SYMPTOMS FEVER 225 (92.59%) NAUSEA/ VOMITING 147 (60.49%) TABLE III: Knowledge on breeding sites of dengue vectors: BLEEDING 41 (16.81%) Site Breeding Yes No D o n t MUSCULAR PAIN 178 (73.25%) Know HEADACHE 177 (72.84%) WATER STORAGE 198 (81.48%) 38 (15.64%) 1 PREVENTIVE MEASURES THEY WILL TAKE MOSQUITO SPRAY 74 (30.45%) JARS/ CONTAIN- MOSQUITO MAT/ 184 (75.72%) COIL/ VAPOURIZER MOSQUITO NET 132 (54.32%) WINDOW AND 118 (48.56%) DOOR SCREEN CLEANING HOUSE 219 (90.12%) CLEANING OF GAR- 204 (83.95%) BAGE/ TRASH USE OF SMOKE TO 128 (52.67%) DRIVE AWAY MOS- QUITOES ERS COOLERS, TYRE 129 (53.09%) 107 (44.03%) 1 AND POTS DIRTY WATER 158 (65.02%) 78 (32.1%) 1 GARBAGE/ TRASH 146 (60.08%) 90 (37.04%) 1 PLANTS/ VEGETA- 64 (26.34%) 172 (70.78%) 1 TION PREVENT WATER 211 (86.83%) STAGNATION The most common breeding place for mosquitoes was BITE TIME MORNING 40(16.46%) correctly recognized by most of the participants as water DAY TIME 56(23.05%) storage jars/ containers (81.48%). EVENING 40(16.46%) The attitudes of the respondents were assessed using 5 NIGHT 54(22.22%) questions. Among them 76.13% respondents strongly DON T KNOW 47(19.34%) agreed and 16.46% agreed that dengue is a serious illness. Total 243(100%) Only 16.46 % respondents strongly agreed and 22.63% agreed that they are at risk of getting dengue whereas Out of the 243 participants, 237 (97.53%) have correctly answered 14.81% were not sure about the risk. 53.50% respondents that the mode of transmission was through MOSQUITO BITE, strongly agreed, 39.09% agreed about Dengue fever can none have answered that the transmission was through DIRTY be prevented and 4.94% were unsure.83.13% respondents DRINKING WATER, UNHYGIENIC FOOD, HOUSEFLIES and 6 strongly agreed, 13.99% agreed about need for treatment have answered that they DONOT KNOW the mode of transmission. and hospitalization for Dengue fever and 2.06% were not sure. For the 6 persons who did not know the mode of transmission Prevention of dengue cannot be done not only by government further questions regarding the knowledge attitude and practices alone but also every individual should have respon- regarding the vector were not asked. Out of the 243, 69 persons sibility to prevent dengue, they should take measures has answered that transmission happens through direct contact, such as source reduction, keeping their own environment

TABLE IV: Response to attitude based questions: Attitude Questions (N=243) S t r o n g l y Agree Agree Disagree Strongly Disagree Not Sure Dengue a serious illness? 185 (76.13%) 40 (16.46%) 10 (4.12%) 4 (1.65%) 4 (1.65%) I have risk of getting dengue 40 (16.46%) 55 (22.63%) 72 (29.63%) 40 (16.46%) 36 (14.81%) Dengue can be prevented 130 (53.50%) 95 (39.09%) 3 (1.23%) 3 (1.23%) 12 (4.94%) Need for treatment and hospitalization 202 (83.13%) 34 (13.99%) 2 (0.82%) 0 (0%) 5 (2.06%) Preventing dengue is responsibility of government 170 (69.96%) 61 (25.10%) 6 (2.47%) 5 (2.06%) 1 free from mosquito breeding. But almost majority of the (95.06%) respondents had a consensus that the government has the prime responsibility to control mosquito breeding. Only 2% have agreed that prevention of dengue is not the mere responsibility of government and everyone have the responsibility in preventing dengue. When asked about the mode of management of dengue fever they will adopt while they get dengue 94.65% of the respondents replied hospital care as the first measure, 33.33% of respondents responded to do home treatment and 31.69% of them responded of doing preventive measures to prevent further spread of disease. But all modes of treatment are equally important for the treatment of dengue. TABLE V: Practice of preventive measures of dengue among participants: PREVENTIVE MEASURES YES NO THEY TOOK Mosquito Spray 54 (22.22%) 183 (75.31%) Mosquito Mat/ Coil/ Vaporizer 176 (72.43%) 61 (25.10%) Mosquito Net 99 (40.74%) 138 (56.79%) Window And Door Screen 84 (34.57%) 153 (62.96%) Cleaning House 215 (88.48%) 22 (9.05%) Cleaning Of Garbage/ Trash 194 (79.84%) 43 (17.70%) Use Of Smoke To Drive Away 103 (42.39%) 134 (55.14%) Mosquitoes Prevent Water Stagnation 196 (80.66%) 41 (16.87%) Preventive practices regarding dengue were consistent with the knowledge about these practices, with majority of the respondents relying on cleaning house (88.48%) and followed by preventing water stagnation (80.66%). Regarding the source of information on Dengue Fever, 79.01% came to know about Dengue fever through television followed by Newspapers/magazines (51.44%) DISCUSSION Today, dengue ranks as the most important mosquito-borne viral disease in the world. In the last 50 years, incidence has increased 30 fold. The study done by Hairi F et al done in kualakangsar district 10 found that 78 % subjects knew about dengue but in our study about 97.20% knew about dengue. The possible reasons for better awareness could be repeated exposure to health education messages on dengue and other mosquito-borne diseases. Mosquito bite was cited as a cause of dengue in this study by 97.53 % respondents, which is similar to a study done in Brazil.11 Whereas, 2.47% were not aware of the cause. Swaddiwudhipong et al 12 reported that > 90 % respondents knew that the disease is transmitted by Aedes mosquitoes. In our study we found that 97.53 % respondents mentioned mosquito bite as cause of dengue and only 28.40 % believed that the human to human spread occurs in dengue. This indicates their inadequate knowledge and a need for more health education programme. Whereas 12.35 % people were not sure whether it has human to human transmission. These findings are consistent with similar studies done by Hairi F et al 10 and Acharya A et al.13 The common symptoms of Dengue fever are high fever, severe headache, severe pain behind the eyes, joint pain, muscle and bone pain, rash, and mild bleeding. Degallier N et al 11 and Acharya A et al 13 reported the adequate knowledge on dengue symptoms. Gupta et al 14 reported that fe- 11

12 ver was the commonest symptom of the disease followed by symptoms of bleeding and headache. Our respondents showed considerably good knowledge about the symptoms with fever (92.59 %) being correctly accounted as the most common. Benthem et al 15 found that rash or bleeding is a specific symptom of dengue infection indicating to dis-tinguish dengue infection from other diseases. The study done by Gupta et al 14 reported 92 % knew about fever followed by headache as a symptom of dengue whereas Degallier N et al found, 73.1 % respondents knew about fever which was similar to our finding. 11 Most respondents were aware of measures to protect themselves against contact with mosquitoes through window screening, mosquito coil/mats, use of bed nets, covering standing water and removal of standing water. Previous studies have reported these methods to be most effective means of prevention.16,17 Measures aimed at keeping the house clean (90.12%) and preventing water stagnation (86.83%),which serves as local breeding sites were the most popular techniques which respondents knew. Cleaning of garbage/ trash (83.95%) was also a popular method of vector control. Matta et al 18 found that, 79.8 % respondents knew about breeding places of mosquitoes. The Aedes aegypti mosquito typically bites during the day. But large number of respondent doesn t know the biting time of the mosquito. The attitudes of the respondents were such that 76.13% respondents strongly agreed and 16.46% agreed that dengue is a serious illness. Only 16.46 % respondents strongly agreed and 22.63% agreed that they are at risk of getting dengue whereas 14.81% were not sure about the risk. 53.50% respondents strongly agreed, 39.09% agreed about DF can be prevented and 4.94% were unsure. 83.13% respondents strongly agreed,13.99% agreed about need for treatment and hospitalization for Dengue fever and 2.06% were not sure. 95.06% respondents had a consensus that the government has the prime responsibility to control mosquito breeding. Regarding the attitude of the management of dengue 94.65% of the respondents seek hospital care as the first measure, 33.33% of respondents do home treatment and 31.69% of them responded of doing preventive measures to prevent further spread of disease. Our findings run similar to findings in a study done by 19 where strong positive attitude was associated with knowledge about DF. Hairi et al 10 found that there was no significant association seen between knowledge and practice. However, there was a significant association seen between knowledge and attitude towards Aedes control. Preventive practices regarding dengue were consistent with the knowledge about these practices, with majority of the respondents relying on cleaning house (88.48%) and followed by preventing water stagnation (80.66%). Snehalatha KS et al 20 reported that in Pondicherry south India, 99.3 % used some personal protection measures. This is higher than the pre-sent study (86.82 %) most probably due to socioeconomic differences. Most important role seemed to be played by media including television and newspaper. In the present study, television was the most important source of information (79.01 %), similar to a study done by Swaddiwudhipong W.12 Conclusion So this study concludes, that the study participants have a reasonable knowledge about dengue and practice of preventive measures of dengue is found to be consistent with their knowledge level. But still they need still more knowledge about dengue. So proper measures like health education can be given to improve their knowledge which can improve their practice. Health education can be conveyed using Medias like television, newspaper, radio. REFERENCES 1. WHO. Media centre Fact sheet, Dengue and dengue haemorrhagic fever. May 2016. (last cited on may 2016) Available at http://www.who.int/mediacentre/factsheets/ fs117/en/ 2. Sharma SN, Raina VK, Kumar A. Dengue/DHF: an emerging disease in India. J Commun Dis.2000;32(3):175-9. 3. Chaturvedi UC, Nagar R. Dengue and dengue hemorrhagic fever: Indian perspective. J Biosci.2008;33(4):429-41. 4. Park K. Park s Textbook of Preventive and Social Medicine. 23rd ed. Jabalpur: Banarasidas BhanotPublishers;2015. 5. Govt. of India (2015). National Health Profile 2015, DGHS, Ministry of Health and Family Welfare,NewDelhi. 6. Mehendale SM, Risbud AR, Rao JA, Banerjee K. Outbreak of dengue fever in rural areas of Parbhani district of Maharashtra (India). Indian J Med Res. 1991;93:6-11. 7. Arunachalam N, Murty US, Kabilan L, Balasubramanian A, Thenmozhi V, Narahari D, Ravi A, Satyanarayana K. Studies on dengue in rural areas of Kurnool District, Andhra Pradesh, India. J Am Mosq Control Assoc. 2004;20(1):87-90. 8. Paramasivan R, Dhananjeyan KJ, Leo SV, et al. Dengue fever caused by dengue virus serotype-3 (subtype-iii) in a rural area of Madurai district, Tamil Nadu. Indian J Med

Res. 2010;132:339-42. 9. Hati AK. Studies on dengue and dengue haemorrhagic fever (DHF) in West Bengal State, India. J Commun Dis. 2006;38(2):124-9. 10.Hairi F, Ong CHS, Suhaimi A, Tsung TW, bin Anis Ahmad MA, Sundaraj C, et al. A knowledge, attitude and practices (KAP) study on dengue among selected rural communities in the Kuala Kangsar district. Asia-Pacific Journal of Public Health. 2003;15(1):37-43. 11. Dégallier N, Vilarinhos P, De Carvalho M, Knox M, Caetano Jr J. People s knowledge and practice about dengue, its vectors, and control means in Brasilia (DF), Brazil: its relevance with entomological factors. Journal of the American Mosquito Control Association. 2000;16(2):114-23. 12. Swaddiwudhipong W, Lerdlukanavonge P, Khumklam P, Koonchote S, Nguntra P, Chaovakiratipong C. A survey of knowledge, attitude and practice of the prevention of dengue hemorrhagic fever in an urban community of Thailand. The Southeast Asian journal of tropical medicine and public health. 1992;23(2):207. 13. Acharya A, Goswami K, Srinath S, Goswami A. Awareness about dengue syndrome and related preventive practices amongst residents of an urban resettlement colony of south Delhi. Journal of vector borne diseases. 2005;42(3):122. 14. Gupta P, Kumar P, Aggarwal O. Knowledge, attitude and practices related to dengue in rural and slum areas of Delhi after the dengue epidemic of 1996. Journal of communicable diseases. 1998;30(2):107-12. 15.Van Benthem BH, Khantikul N, Panart K et.al. Knowledge and use of prevention measures related to dengue in northern Thailand.lTrop Med Int Health. 2002 Nov;7(11): page 993-1000. 16. Jelinek T. Dengue fever in international travelers. Clinical Infectious Diseases. 2000;31(1):144-7. 17. Fradin MS, Day JF. Comparative efficacy of insect repellents against mosquito bites. New England Journal of Medicine. 2002;347(1):13-8. 18. Matta S, Bhalla S, Singh D, Rasania S, Singh S. Knowledge, Attitude and Practice (KAP) on Dengue fever: A Hospital Based Study. Indian Journal of Community Medicine. 2006;31(3):185-6. 19. Donalisio MR, Alves MJCP, Visockas A. A survey of knowledge and attitudes in a population about dengue transmission-region of Campinas São Paulo, Brasil-1998. Revista da Sociedade Brasileira de Medicina Tropical. 2001;34(2):197-201. 20. Snehalatha K, Ramaiah K, Vijay Kumar K, Das P. The mosquito problem and type and costs of personal protection measures used in rural and urban communities in Pondicherry region, South India. Acta tropica. 2003;88(1):3-9. ACKNOWLEDGEMENT Authors would like to thank the department of Community Medicine, for supporting us in doing this work. We also thank our colleagues for their valuable inputs. And our sincere thanks to all population who participated in this study and without whom the study wouldn t have been possible 13