Abstract

Recognition of the determinants of knowledge, attitudes and practices (KAP), which could be conditioned by the experiences and perceptions of the population at risk, is essential for the control of dengue. The scope of this article is to estimate the relationship between the risk perception and dengue diagnosis experiences with KAPs on dengue in an endemic Colombian population. A cross-sectional study with multi-stage random sampling was conducted. Adjusted prevalence ratios (aPR) were estimated using regression models as measures of association. Of the 206 families interviewed, 7% know dengue is caused by a virus and less than 40% recognize other symptoms besides fever. As control strategies, 31% eliminate hatchery sites and 58% use fumigation, though 73% perceive the risk of dengue. The association was identified between the perception of the risk of dengue and knowledge about the vector (aPR = 3.32 CI95% 1.06-10.36), and the experience of diagnosis of dengue with the attitude towards dengue control (aPR = 1.61 CI95% 1.09-2.37). Risk perception and experience with dengue could become determinants of KAPs in relation to this disease.

Key words
Knowledge; attitudes and practices (KAP) in health; Dengue; Perception; Risk

Introduction

Dengue is a viral disease transmitted through the Aedes mosquito bite. These mosquitoes also participate in the transmission of other diseases, such as Yellow Fever, Chikungunya, and Zika¹1 Lima-Camara TN. Emerging arboviruses and public health challenges in Brazil. Rev Saude Publica 2016; 50:36.. No specific antiviral therapy is currently available. Therefore, action taken against the reproduction of the vector, and to avoid the mosquito bite is a crucial strategic approach²2 Fusco DN, Chung RT. Review of Current Dengue Treatment and Therapeutics in Development. J Bioanal Biomed 2014; S8:002.. Nonetheless, its management and implementation require the involvement of numerous public sectors³3 Padilla JC, Rojas DP, Sáenz-Gómez R. Dengue en Colombia. Epidemiología de la reemergencia a la hiperendemia. Bogotá: Guías de Impresión Ltda.; 2012., where the community plays a leading role⁴4 Parks W, Lloyd L, UNDP/World Bank/World Health Organization (WHO) Special Programme for Research and Training in Tropical Diseases. Planificación de la movilización y comunicación social para la prevención y el control del dengue. Guía paso a paso. Ginebra: WHO; 2004..

The occurrence of dengue cases globally has shown an upward trend in the last decades. By 2008, a little over 1,2 million cases were registered in the Americas, South East Asia, and the Western Pacific. By 2013, these cases doubled. Moreover, by 2015, 2,35 million cases had been notified only in the Americas Region⁵5 Organización Mundial de la Salud (OMS). Dengue y dengue grave. [cited 2017 Apr 8]. Available from: http://www.who.int/mediacentre/factsheets/fs117/es/
http://www.who.int/mediacentre/factsheet... . This increase has been accompanied by an elevated mortality rate in Latin American and Caribbean countries, tripling every ten years⁶6 Díaz-Quijano FA, Waldman EA. Factors Associated with Dengue Mortality in Latin America and the Caribbean, 1995-2009: An Ecological Study. Am J Trop Med Hyg 2012; 86(2):328-334..

Dengue is a primary public health issue in Colombia. It is characterized by an endemoepidemic and hyperendemic transmission pattern³3 Padilla JC, Rojas DP, Sáenz-Gómez R. Dengue en Colombia. Epidemiología de la reemergencia a la hiperendemia. Bogotá: Guías de Impresión Ltda.; 2012.. Notably, the department of La Guajira has reported seasonal outbreaks every four years between 1999 and 2010; and 34,7% of the cases were situated in its capital city, Riohacha³3 Padilla JC, Rojas DP, Sáenz-Gómez R. Dengue en Colombia. Epidemiología de la reemergencia a la hiperendemia. Bogotá: Guías de Impresión Ltda.; 2012.. The municipality of Riohacha’s circumstances have favored the permanence of dengue in this population, such as urban overcrowded areas, poor sewerage system and waste disposal, limited control measures against the vector, and inadequate public health infrastructure⁷7 Castrillón JC, Castaño JC, Urcuqui S. Dengue en Colombia: diez años de evolución. Rev Chil Infectol 2015; 32(2):142-149..

The PAHO and the WHO emphasize that the community must commit itself to the control measures. Thus, programs ought to be structured considering the perspectives within the community, identifying the barriers that prevent it from bringing about a change in behavior, and guiding the organization of such programs in consistency with local necessities and realities⁸8 San Martín JL, Prado M. Percepción del riesgo y estrategias de comunicación social sobre el dengue en las Américas. Rev Panam Salud Publica 2004; 15(2):135-139.. For this purpose, an important step is the acquisition of information on Knowledge, Attitudes, and Practices (KAP) concerning the disease⁹9 Holman A. Encuestas de Conocimientos, Actitudes y Prácticas en el ámbito de la Protección de la Infancia. Sierra Leone: Iniciativa de Protección de la Infancia Save the Children; 2012., which will help the community to be strategically involved through participatory research¹⁰10 Organización Panamericana de la Salud (OPAS), Organización Mundial de la Salud (OMS), Ministerio de la Protección Social República de Colombia (MPSRC), Agencia Canadiense para el Desarrollo Internacional (ACDI). Estrategia de Gestión Integrada Nacional Colombia. Bogotá: MPSRC; 2006..

Countless studies have been carried out on dengue KAP in endemic Latin American areas, for instance, Brazil¹¹11 Alves AC, Fabbro AL, Passos AD, Carneiro AT, Jorge TM, Martinez EZ. Knowledge and practices related to dengue and its vector: a community-based study from Southeast Brazil. Rev Soc Bras Med Trop 2016; 49(2):222-226.^,1212 Santos SL, Parra-Henao G, Silva MB, Silva LG. Dengue in Brazil and Colombia: a study of knowledge, attitudes, and practices. Rev. Soc. Bras. Med. Trop 2014; 47(6):783-787., Cuba¹³13 Castro M, Sánchez L, Pérez D, Sebrango C, Shkedy Z, Stuyft PV. The Relationship between Economic Status, Knowledge on Dengue, Risk Perceptions and Practices. PLoS ONE 2013; 12(8):6., Venezuela¹⁴14 Martínez M, Espino C, Moreno N, Rojas E, Mazzarri M, Mijares V, Herrera F. Conocimientos, Actitudes y Prácticas sobre dengue y su relación con hábitats del vector en Aragua-Venezuela. Bol Mal Salud Amb 2015; 55(1):69-85., Puerto Rico¹⁵15 Pérez-Guerra CL, Zielinski-Gutierrez E, Vargas D, Clark G. Community beliefs and practices about dengue in Puerto Rico. Rev Panam Salud Publica 2009; 25(3):218-226., and Peru¹⁶16 Paz-Soldán VA, Morrison AC, López JJ, Lenhart A, Scott TW, Elder JP, Sihuincha M, Kochel TJ, Halsey ES, Astete H, McCall PJ. Dengue Knowledge and Preventive Practices in Iquitos, Peru. Am J Trop Med Hyg 2015; 93(6):1330-1337., as well as in other countries like Malaysia¹⁷17 Wong LP, Shakir SM, Atefi N, AbuBakar A. Factors Affecting Dengue Prevention Practices: Nationwide Survey of the Malaysian Public. PLoS ONE 2015; 10(4):16.

18 Mohamad M, Selamat MI, Ismail Z. Factors Associated with Larval Control Practices in a Dengue Outbreak Prone Area. J Environ Public Health 2014; 2014:459173.^-1919 Wong LP, AbuBakar S, Chinna K. Community Knowledge, Health Beliefs, Practices and Experiences Related to Dengue Fever and Its Association with IgG Seropositivity. PLoS Negl Trop Dis 2014; 8(5):e2789., India²⁰20 Arunachalam N, Tyagi BK, Samuel M, Krishnamoorthi R, Manavalan R, Tewari SC, Ashokkumar V, Kroeger A, Sommerfeld J, Petzold M. Community-based control of Aedes aegypti by adoption of eco-health methods in Chennai City, India. Rev. Pathog Glob Health 2012; 106(8):488-496., Australia²¹21 Gyawali N, Bradbury RS, Taylor-Robinson AW. Knowledge, attitude and recommendations for practice regarding dengue among the resident population of Queensland, Australia. Asian Pac J Trop Biomed 2016; 6(4):360-366., and Pakistan²²22 Siddiqui TR, Ghazal S, Bibi S, Ahmed W, Sajjad SF. Use of the Health Belief Model for the Assessment of Public Knowledge and Household Preventive Practices in Karachi, Pakistan, a Dengue-Endemic City. PLoS Negl Trop Dis 2016; 10(11):15.. Nevertheless, these studies have not assessed how risk perception and the experience of dengue could determine KAP.

Evaluating this type of association could be a valuable contribution to the planning of prevention and control activities. Those mentioned above can provide a way to learn about the community that will be submitted to intervention, as well as beliefs that could facilitate or hinder a change in behavior.

Concerning the above, this research is the first in Colombia which aimed to estimate the association of risk perception and experience with dengue, with factors such as knowledge about the disease and its transmission, the application of practices, and a willing attitude aimed at the control of such arbovirus.

Materials and methods

A cross-sectional analytical study nested in a cohort study was conducted in the department of La Guajira and other departments of the Colombian Caribbean region²³23 Martínez-Vega RA, Rodriguez-Morales AJ, Bracho-Churio YT, Castro-Salas ME, Galvis-Ovallos F, Díaz-Quijano RG, Luna-González ML, Castellanos JE, Ramos-Castañeda J, Diaz-Quijano FA. A prospective cohort study to assess seroprevalence, incidence, knowledge, attitudes and practices, willingness to pay for vaccine and related risk factors in dengue in a high incidence setting. BMC Infectious Diseases 2016; 16(1):9.. Concerning the selection of participants, a cluster and multistage sampling were conducted in which, initially, the city blocks were randomly selected, and for each block, the participant households were then selected randomly. The target population included only adults and permanent residents in the household selected to take part in the study. The participants who were planning to change their household in the following six months were excluded.

In the same visit, two questionnaires were conducted in order to collect data. The first one aimed to evaluate the KAP, validated by Caceres-Manrique et al.²⁴24 Cáceres-Manrique F, Vesga-Gómez C, Perea-Florez X, Ruitort M, Talbot Y. Conocimientos, actitudes y prácticas sobre dengue en dos barrios de Bucaramanga, Colombia. Rev Salud Pública 2009; 11(1):27-38., which contained 21 questions about knowledge and practices, 12 questions about attitudes, and nine questions concerning demographic data. Details on this questionnaire can be found in a previous article, which focused on the association between the educational level and the KAP²⁵25 Diaz-Quijano FA, Martínez-Vega RA, Rodriguez-Morales AJ, Rojas-Calero RA, Luna-González ML, Díaz-Quijano RG. Association between the level of education and knowledge, attitudes and practices regarding dengue in the Caribbean region of Colombia. BMC Public Health 2018; 18(1):143..

The second questionnaire aimed to assess the determinants of perceived demand in dengue vaccines²⁶26 Bracho-Churio YT, Martínez-Vega RA, Rodriguez-Morales AJ, Díaz-Quijano RG, Luna-González ML, Diaz-Quijano FA. Determinants of felt demand for dengue vaccines in the North Caribbean region of Colombia. Ann Clin Microbiol Antimicrob 2017; 16:38.. This last questionnaire was built from a data collection instrument implemented in a multi-country study, carried out in Vietnam, Thailand, and Colombia²⁷27 Lee JS, Mogasale V, Lim JK, Carabali M, Sirivichayakul C, Anh DD, Kang-Sung L, Thiem VD, Limkittikul K, Tho LH, Velez ID, Osorio JE, Chanthavanich P, Silva LJ, Maskery BA. A Multi-country Study of the House hold Willingness-to-Pay for Dengue Vaccines: House hold Surveys in Vietnam, Thailand, and Colombia. PLoS Negl Trop Dis 2015; 9(6):e0003810.. It contains eight questions about the experience with the disease and four questions about dengue risk perception (Table 1). The latter are related to the Health Belief Model by Hochbaum and Rosenstock²⁸28 García del Castillo JA. Concepto de Percepción de Riesgo y su Repercusión en las Adicciones. Salud y drogas 2012; 12(2):133-151.^,2929 Mikulic IM, Cassullo GL, Crespi MC, Caruso AP, Elmasian M, Muiños R. Evaluación de la Percepción de Riesgo en Diferentes Grupos Sociales: Propuesta de un Modelo de Ecuaciones Estructurales. Anuario de Investigaciones 2012; 19(2):37-44.. Thus, elements, such as the perceived susceptibility to becoming ill and the perceived severity in case of falling ill, were combined.

Regarding the collected data storage, an application in Access was employed, where data was double entered. The information was validated with the package Data Compare by Epi-Info. Concerning the description of the population, the absolute and relative frequencies were calculated in the case of the qualitative variables. On the other hand, the median and the interquartile range were calculated for the quantitative variables without a normal distribution.

As dependent variables, the KAP about dengue were considered, referred by the participants of the study. In the case of the open-ended questions, the responses were classified before the analysis. As independent variables, the following were considered: the perceived risk of falling ill; and the experience with dengue cases (diagnosed, hospitalized, and death from dengue) in the personal, family, and neighborhood levels. Moreover, as potentially confounding variables, the demographic variables including age, sex, educational level²⁵25 Diaz-Quijano FA, Martínez-Vega RA, Rodriguez-Morales AJ, Rojas-Calero RA, Luna-González ML, Díaz-Quijano RG. Association between the level of education and knowledge, attitudes and practices regarding dengue in the Caribbean region of Colombia. BMC Public Health 2018; 18(1):143., inhabitants per dwelling, number of working people, and the presence of under 18-years-olds in the place of household were taken into consideration.

Fisher’s exact test and the Mann-Whitney U test were applied in the bivariate analysis depending on the nature of the variable. The associations identified, which p-value was lower than 0.20, were evaluated in a multiple model employing log-binominal regression. In the models, statistically significant variables (p < 0.05) were maintained, including those who modified the estimate of the independent variable of interest by more than 10%. Poisson regression with the robust variance option was employed as an alternative when the log-binomial model did not converge³⁰30 Barros JD, Hirakata VN. Alternatives for logistic regression in cross-sectional studies: an empirical comparison of models that directly estimate the prevalence ratio. BMC Med Res Methodol 2003; 3:21. These models allowed determining the adjusted Prevalence Ratio (aPR), with its 95% Confidence Intervals (CI). The analyses were performed in the statistical software STATA 12.0.

The Research Ethics Committee approved the umbrella project (agreement 019, 2014) of the University of Santander, Bucaramanga, Santander, Colombia. The participants signed an informed consent form. The research complies with the Declaration of Helsinki and does not represent a risk for the participants according to Resolution 008430, 1993 of Colombia.

Results

Two hundred six households from the municipality of Riohacha were invited to participate, from October 31^st to December 19^th, 2015, to apply the two questionnaires. In total, 99,5% (n = 205) of the households participated in the first questionnaire, and 99% (n = 204) in the second one.

Most of the participants were women (80%), and an educational level between primary and secondary education prevailed. Nearly half of the respondents (47%) were aged between 30 and 49 years. The median of the number of inhabitants per dwelling was 4, and minors were found in 81% of the households. Also, 98% were working people, most households had an income of up to 1 Colombian legal minimum wage (SMLV, in Spanish), equivalent to 206.67 USD by 2015 (Table 1).

Concerning dengue risk perception, we observed that 99% of the respondents consider dengue a severe disease, both for adults and children. Furthermore, most of the respondents admitted the probability of contracting dengue themselves (80%) or their children (73%) in the next five years. As for the experience with dengue, more than 20% of the respondents refer to earlier cases in their family and neighbors, including the experience of having had been diagnosed (23%) and hospitalized (21%) (Table 1).

Concerning knowledge about dengue, most (75%) defined it as a disease and 7% related it to a viral etiology. Fever was the most referred symptom (95%). Meanwhile, the other symptoms that were questioned where recognized by less than 50% of the respondents. In what concerns knowledge of the vector, less than 40% of the respondents were aware that the name of the mosquito is Aedes aegypti and that it is identified by the white stripes in its legs. Most indicated their understanding that dengue is transmitted by a mosquito bite, that it reproduces in stagnant water, either clean or due to rainfall; and knew about the mosquito larvae (Table 2).

Regarding practices, 97% indicated seeking medical care if a family member had dengue. Besides, in order to avoid dengue, the most prevalent actions were eliminating breeding areas and fumigating, each with a frequency of 31%. Regarding the measures taken to avoid the mosquito bite, 58% mentioned fumigating, and less than 15% referenced other practices (Table 2).

The dengue control attitude manifested through participation in community actions showed a frequency of less than 40% for most of the respondents (Table 2). Also, 56% of them considered that the lack of information hindered measures against dengue. Concerning the preventive measures for dengue, 62% estimated that the local government is the one responsible for carrying these out, while less than 50% noted that each member of the community shares the responsibility (Table 2).

When evaluating the variables associated with KAP in multiple models, it was gathered that general knowledge about dengue (how it is transmitted, name, and vector’s appearance) was positively associated with risk perception (PR 3.32 95%CI 1.06-10.36) and the educational level (Table 3). As for the practices, measures against the adult stage of the vector were significantly less frequent among respondents who were not aware of whether their neighbors had been diagnosed with dengue (PR 0.57 95%CI 0.35-0.94).

Regarding the attitude towards dengue control, the attendance to meetings arranged by the community was directly associated with the experience of having been diagnosed with dengue (1.61 95%CI 1.09-2.37). This attitude was less frequent among those living with minors (0.56 95%CI 0.37-0.83). A positive association was observed between the experience with the hospitalization of a neighbor due to dengue and the acknowledgment of the responsibility of every person in the control of dengue (PR 1.52 95%CI 1.05-2.19). This attitude was less frequent among male respondents (Table 3).

Discussion

Risk perception of experiencing dengue was a factor associated with the general knowledge of the vector and the knowledge of its breeding areas. This could suggest that recognition of the epidemiological situation can be a determinant in the acquisition of knowledge about dengue. Educational level and age are essential variables of adjustment as they had already been recognized as factors associated with knowledge about dengue and its transmission in the study population²⁵25 Diaz-Quijano FA, Martínez-Vega RA, Rodriguez-Morales AJ, Rojas-Calero RA, Luna-González ML, Díaz-Quijano RG. Association between the level of education and knowledge, attitudes and practices regarding dengue in the Caribbean region of Colombia. BMC Public Health 2018; 18(1):143., as it was observed in Malaysia¹⁷17 Wong LP, Shakir SM, Atefi N, AbuBakar A. Factors Affecting Dengue Prevention Practices: Nationwide Survey of the Malaysian Public. PLoS ONE 2015; 10(4):16. and Brazil¹¹11 Alves AC, Fabbro AL, Passos AD, Carneiro AT, Jorge TM, Martinez EZ. Knowledge and practices related to dengue and its vector: a community-based study from Southeast Brazil. Rev Soc Bras Med Trop 2016; 49(2):222-226..

This suggests that the university community could be a facilitator in the knowledge transference. On a separate note, this also shows that the population with low educational levels would have significant barriers to acquiring knowledge relevant to the prevention of the disease²⁵25 Diaz-Quijano FA, Martínez-Vega RA, Rodriguez-Morales AJ, Rojas-Calero RA, Luna-González ML, Díaz-Quijano RG. Association between the level of education and knowledge, attitudes and practices regarding dengue in the Caribbean region of Colombia. BMC Public Health 2018; 18(1):143..

A study in Puerto Rico evidenced that people who had had a previous diagnosis of dengue were more knowledgeable¹⁵15 Pérez-Guerra CL, Zielinski-Gutierrez E, Vargas D, Clark G. Community beliefs and practices about dengue in Puerto Rico. Rev Panam Salud Publica 2009; 25(3):218-226.. Nevertheless, in this study, experience with dengue was not associated with dengue knowledge. This could be explained partially due to the small number of respondents with a personal history of the disease. Consequently, a study including a larger sample with a history of the disease was required in order to accurately assess this association.

While the study population is endemic to dengue and displayed some knowledge of the topic, this could be insufficient, as described in other cities in Colombia and South America¹²12 Santos SL, Parra-Henao G, Silva MB, Silva LG. Dengue in Brazil and Colombia: a study of knowledge, attitudes, and practices. Rev. Soc. Bras. Med. Trop 2014; 47(6):783-787.^,1616 Paz-Soldán VA, Morrison AC, López JJ, Lenhart A, Scott TW, Elder JP, Sihuincha M, Kochel TJ, Halsey ES, Astete H, McCall PJ. Dengue Knowledge and Preventive Practices in Iquitos, Peru. Am J Trop Med Hyg 2015; 93(6):1330-1337., and Asian countries such as India and Malaysia²⁰20 Arunachalam N, Tyagi BK, Samuel M, Krishnamoorthi R, Manavalan R, Tewari SC, Ashokkumar V, Kroeger A, Sommerfeld J, Petzold M. Community-based control of Aedes aegypti by adoption of eco-health methods in Chennai City, India. Rev. Pathog Glob Health 2012; 106(8):488-496.^,1818 Mohamad M, Selamat MI, Ismail Z. Factors Associated with Larval Control Practices in a Dengue Outbreak Prone Area. J Environ Public Health 2014; 2014:459173.. In this respect, the community itself expressed that the lack of information limits action taken against dengue. This observation is significant since, as stated by the COMBI experience⁴4 Parks W, Lloyd L, UNDP/World Bank/World Health Organization (WHO) Special Programme for Research and Training in Tropical Diseases. Planificación de la movilización y comunicación social para la prevención y el control del dengue. Guía paso a paso. Ginebra: WHO; 2004., the community itself should identify its weaknesses and manage what it needs to improve. Consequently, the comprehensive integration of all the sectors is imperative and relevant to solve this type of issue.

Concerning the practice of preventive measures, the respondents that did not know (or did not answer) whether any neighbor had been diagnosed with dengue showed a lower frequency of measures taken against the adult stage of the vector. This association suggests that unawareness of dengue cases around them could be associated with indifference to the control of this arbovirus. The mentioned above highlights the importance of communication among neighbors as a way of raising public consciousness and preparation in case of an outbreak²¹21 Gyawali N, Bradbury RS, Taylor-Robinson AW. Knowledge, attitude and recommendations for practice regarding dengue among the resident population of Queensland, Australia. Asian Pac J Trop Biomed 2016; 6(4):360-366..

On another note, the study did not find any association between risk perception and practices against dengue, similar to a study carried out in Cuba¹³13 Castro M, Sánchez L, Pérez D, Sebrango C, Shkedy Z, Stuyft PV. The Relationship between Economic Status, Knowledge on Dengue, Risk Perceptions and Practices. PLoS ONE 2013; 12(8):6.. Nonetheless, a study in Karachi, Pakistan²²22 Siddiqui TR, Ghazal S, Bibi S, Ahmed W, Sajjad SF. Use of the Health Belief Model for the Assessment of Public Knowledge and Household Preventive Practices in Karachi, Pakistan, a Dengue-Endemic City. PLoS Negl Trop Dis 2016; 10(11):15., endemic regions for dengue, determined that risk perception are a significant predictor of adequate preventive measures. These results highlight the importance of the regional differences, which must be considered when planning dengue control strategies.

Regarding water storage, it is essential to mention the low proportion of adequate practices observed in the population studied (Table 2), unlike findings in Malaysia¹⁹19 Wong LP, AbuBakar S, Chinna K. Community Knowledge, Health Beliefs, Practices and Experiences Related to Dengue Fever and Its Association with IgG Seropositivity. PLoS Negl Trop Dis 2014; 8(5):e2789. where more than 50% of the respondents had good practices in this regard. The unawareness of the vector’s characteristics in its immature form may explain the findings in the population of La Guajira, as proposed in a study conducted in Venezuela¹⁴14 Martínez M, Espino C, Moreno N, Rojas E, Mazzarri M, Mijares V, Herrera F. Conocimientos, Actitudes y Prácticas sobre dengue y su relación con hábitats del vector en Aragua-Venezuela. Bol Mal Salud Amb 2015; 55(1):69-85.. Therefore, it is recommended that indications given to the community be complemented with information on this aspect.

Attitudes concerning control of dengue manifested in the attendance to meetings arranged by the community were associated positively with a history of diagnosis of dengue in the respondent, family member, or neighbor. Moreover, the experience of their neighbors being hospitalized due to dengue was associated positively with the reasoning that everyone in a community is responsible for taking preventive measures against dengue. Consequently, communication amongst community members is proposed as a cross-cutting element of the health education programs and actions³¹31 Díaz H, Uranga W. Comunicación para la salud en clave cultural y comunitaria. Revista de Comunicación y Salud 2011; 1(1):113-124.. These associations are relevant when planning strategies to accomplish empowerment, understood as “people’s ability to work together, organize themselves, and mobilize resources to solve problems of common concern”³²32 Cáceres-Manrique FM, Vesga-Gómez C, Angulo-Silva ML. Empoderamiento para la prevención y control del Dengue. Rev Salud Pública 2010; 12(5):798-806..

Although the study did not find any association between risk perception and dengue control attitude, there is evidence that carrying out activities to enhance risk perception promotes decision-making towards adopting an expected behavior³³33 Escudero-Támara E, Villarreal-Amaris G. Intervención educativa para el control del dengue en entornos familiares en una comunidad de Colombia. Rev Perú Med Exp salud pública 2015; 32(1):19-25.. It is also worth mentioning that risk perception is a highly polysemous construct, product of a cognitive process based on information that every person possesses from different contexts²⁸28 García del Castillo JA. Concepto de Percepción de Riesgo y su Repercusión en las Adicciones. Salud y drogas 2012; 12(2):133-151.. Also, the acceptability level, benefits associated with the risks, and the level of control intervene in the estimation of the risk. With this in mind, people tend to tolerate risk as long as it is associated with a benefit, or they consider such risk to be under control, which then leads to perceiving the risk to a lesser extent²⁹29 Mikulic IM, Cassullo GL, Crespi MC, Caruso AP, Elmasian M, Muiños R. Evaluación de la Percepción de Riesgo en Diferentes Grupos Sociales: Propuesta de un Modelo de Ecuaciones Estructurales. Anuario de Investigaciones 2012; 19(2):37-44..

Several studies that have analyzed dengue risk perception have suggested that it was not associated with a preventive behavior³⁴34 Daudé E, Mazumdar S, Solanki V. Widespread fear of dengue transmission but poor practices of dengue prevention: A study in the slums of Delhi, India. PLoS One 2017; 12(2):e0171543.. Other papers suggest that people who perceive the risk of catching the disease are more likely to adopt preventive practices²²22 Siddiqui TR, Ghazal S, Bibi S, Ahmed W, Sajjad SF. Use of the Health Belief Model for the Assessment of Public Knowledge and Household Preventive Practices in Karachi, Pakistan, a Dengue-Endemic City. PLoS Negl Trop Dis 2016; 10(11):15.. Furthermore, interactions between experiences, perceptions, and decision-making were evaluated in Madeira Island, Portugal; a learning that lived experience due to an outbreak in the community improved risk perception and practices to some extent. Still, other perceptions and beliefs arose, leading to less preventive practices³⁵35 Nazareth T, Sousa CA, Porto G, Gonçalves L, Seixas G, Antunes L, Teodósio R. Impact of a Dengue Outbreak Experience in the Preventive Perceptions of the Community from a Temperate Region: Madeira Island, Portugal. PLoS Negl Trop Dis 2015; 9(3):e0003395.. Meanwhile, in Sri Lanka, most of the population had a low-risk perception, and control measures were scarce, although it is a dengue endemoepidemic region³⁶36 Banneheke H, Paranavitane S, Jayasuriya V, Banneheka S. Perceived Risk of Dengue in Ones' Living Environment as a Determinant of Behavior Change through Social Mobilization and Communication: Evidence from a High Risk Area in Sri Lanka. J Arthropod Borne Dis 2016; 10(3):392-402..

Due to the above, the complex connection between experience, perception, and KAP justifies carrying out studies in different regions in order to identify barriers and enablers in the acquisition of KAP. This knowledge will allow generating strategies towards social movements, dengue control, as well as other arboviruses.

Among the potential study limitations is the size of the sample, which might be insufficient to explore the associations between some of the variables, such as experience with dengue. Besides that, the cross-sectional design of the study hinders establishing a time connection between experience and dengue risk perception with the KAP. Nevertheless, regardless of those mentioned above, it is likely that experience and perception precede current knowledge, along with the attitudes and practices mentioned by the respondents. Consequently, we consider this study describes relevant associations to recognize communities that require a particular emphasis when carrying out dengue control campaigns.

While KAP descriptions are of a regional nature, the associations found could be useful to develop campaigns that improve KAP about dengue in other endemic countries. This way, it may be plausible to affirm that community campaigns could be mediated and enhanced by integrating the people who have been exposed and have a higher risk perception.

Although the study of KAP is a strategy that has been used for several decades and allows describing characteristics in the study population, it is worth saying that the present is the first study in Colombia that evaluates the associations in risk perception and experience with the KAP about dengue. Besides this, probability sampling, which reduces the risk of selection bias; the use of validated questionnaires and data auditing, which reduces the risk of reporting bias; and the evaluation of other potential confounding variables, are among the strengths of this research.

In conclusion, we observed that risk perception of suffering from dengue was associated with knowledge regarding this arbovirus, and that experience with dengue cases was related to a positive attitude concerning its control. These results show the importance of the individual and collective context in the planning of preventive strategies based on communication and social change.

Acknowledgments

The authors are grateful to the OLFIS technical and administrative team for their valuable contribution to the collection of data.

The current study corresponds to the master’s dissertation in Infectious Disease Research by LBD - (University of Santander, Bucaramanga, Santander, Colombia), which was fostered in the project “Research on the determinants of the burden of dengue and interventions for its reduction in La Guajira, Caribe”.

Research funded by the department of La Guajira in collaboration with the Latin American Organization for the Promotion of Health Research (OLFIS, in Spanish).

References

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