ABSTRACT

Objective.

To describe the knowledge, attitudes, practices, and perceptions about Zika in women of childbearing age (WCA) in the department of Amazonas in Peru, following a Zika outbreak.

Materials and methods.

Descriptive study with a mixed quantitative-qualitative approach. We carried out stratified sampling, by applying a survey to a sample of 723 WCA aged 15 to 49 years in the district of Bagua, department of Amazonas, then we carried out four focus groups with 35 WCA in each group. Frequencies and the grounded theory were used for quantitative and qualitative analysis respectively. Interpretation of both methods was integrated using a narrative approach.

Results.

We found that 86.3% of WCA knew that it is possible to get sick with Zika, 10.1% knew that it is transmitted through sexual intercourse, 2.2% knew that it can be transmitted during pregnancy and 68.5% consider that the information is insufficient. In practice, 60% (n=434) used mosquito nets, 53.4% (n=386) covered water containers and 7.3% (n=4) perceived local government involvement. Qualitative data showed distrust of vector control and expressed the need for psychological support for pregnant women and their families.

Conclusions.

There are gaps in the knowledge and practices of WCA regarding the prevention of sexual and vertical transmission of Zika; WCA distrust vector control, do not perceive local government involvement, suggest psychological support should be provided to pregnant women with Zika, as well as to mothers with disabled children, and wish to access more information about Zika.

Keywords:
Knowledge; Attitudes; Practices; Prevention; Zika; Women of reproductive age

INTRODUCTION

Zika is an arbovirus associated with severe sequelae such as congenital brain anomalies ¹1. Nuñez E, Vasquez M, Beltran B, Padgett D. Virus zika en Centroamérica y sus complicaciones. Acta Medica. 2016;33 (1):42-9. or Guillain-Barré syndrome ²2. Cao-Lormeau V-M, Blake A, Mons S, Lastère S, Roche C, Vanhomwegen J, et al. Guillain-Barré Syndrome outbreak associated with Zika virus infection in French Polynesia: a case-control study. The Lancet. 2016;387(10027):1531-9. doi: 10.016/s0140-6736(16)00562-6.
https://doi.org/10.016/s0140-6736(16)005... . It is considered that the cost of the Zika epidemic in Latin America, in three years, was 7 to 18 billion dollars and that the long-term costs will be associated with the sequelae ³3. Programa de las Naciones Unidad para el Desarrollo. Evaluación del impacto socioeconómico del virus del zika en América Latina y el Caribe: Brasil, Colombia y Surinam como estudios de caso [Internet]. EEUU: Programa de las Naciones Unidad para el Desarrollo; 2017 [citado el 9 junio del 2019]. Disponible en: https://www.undp.org/content/undp/es/home/librarypage/hiv-aids/a-socio-economic-impact-assessment-of-the-zika-virus-in-latin-am.html.
https://www.undp.org/content/undp/es/hom... . Furthermore, since its arrival into the continent, there has been an ongoing debate on reproductive rights versus the option of abortion, due to the potential sequelae in newborns⁴4. Carabali M, Austin N, King NB, Kaufman JS. The Zika epidemic and abortion in Latin America: a scoping review. Glob Health Res Policy. 2018;3:15. doi: 0.1186/s41256-018-0069-8.
https://doi.org/0.1186/s41256-018-0069-8... .

The first native cases of Zika in Peru were documented in 2016. Sustained transmission has been observed in the department of Amazonas since the report of the first outbreak between 2017 and 2018 with cases in pregnant women and women of childbearing age (WCA) ⁵5. Mateo S, Cáceres MB, Turpo MG. Situación epidemiológica del zika en el Perú al I semestre del año 2019 [Internet]. Lima: Centro Nacional de Prevención y Control de Enfermedades Ministerio de Salud; 2019 [citado el 16 de septiembre del 2020]. Boletín Epidemiológico del Perú. Disponible en: https://www.dge.gob.pe/portalnuevo/publicaciones/boletines-epidemiologicos/.
https://www.dge.gob.pe/portalnuevo/publi... ^,66. Cabrera R. Situación epidemiológica del zika en el Perú 2016-2018 [Internet]. Lima: Centro Nacional de Epidemiología Prevención y Control de Enfermedades Ministerio de Salud; 2019 [citado el 19 de septiembre del 2020]. Boletín Epidemiológico del Perú. Disponible en: https://www.dge.gob.pe/portalnuevo/publicaciones/boletines-epidemiologicos/.
https://www.dge.gob.pe/portalnuevo/publi... . The main response interventions focused on intensifying actions against the Aedes aegypti vector ⁷7. Ministerio de Salud. AE-UFVE N° 005-2017 Alerta epidemiológica de riesgo de transmisión de zika en Lima y Callao [Internet]. Lima: Centro Nacional de Epidemiología Prevención y Control de Enfermedades Ministerio de Salud; 2017 [citado el 19 de setiembre del 2020]. Disponible en: https://www.dge.gob.pe/portalnuevo/publicaciones/alertas-epidemiologicas/.
https://www.dge.gob.pe/portalnuevo/publi... ⁾ and recommended condom use and delaying pregnancy ⁸8. Ministerio de Salud. AE-CDC-006-2017. Alerta epidemiológica de riesgo de transmision congénita por Zika en el Perú [Internet]. Lima: Centro Nacional de Epidemiología Prevención y Control de Enfermedades Ministerio de Salud; 2017 [citado el 19 de septiembre del 2020]. Disponible en: https://www.dge.gob.pe/portalnuevo/publicaciones/alertas-epidemiologicas/.
https://www.dge.gob.pe/portalnuevo/publi... . Given this type of measures, it is essential to know the perception, knowledge, attitudes and practices (KAP) of the community, especially of WCA, in order to identify whether the recommendations were understood, accepted and practiced in this population and to allow rethinking strategies with scientific evidence.

Some studies describe the lack of knowledge regarding sexual transmission ⁽⁹9. Heitzinger K, Thoroughman DA, Porter KA. Knowledge, attitudes, and practices of women of childbearing age testing negative for Zika virus in Kentucky, 2016. Prev Med Rep. 2018;10:20-3. doi: 10.1016/j.pmedr.2018.01.002.
https://doi.org/10.1016/j.pmedr.2018.01.... ^,1010. Sharma S, Tyagi A, Ramachandra S, Bhuyan L, Dash KC, Raghuvanshi M. Knowledge, Attitudes, and Practices among Health-Care Providers Regarding Zika Virus Infection. J Int Soc Prev Community Dent. 2018;8(1):41-7. doi: 10.4103/jispcd.JISPCD_371_17.
https://doi.org/10.4103/jispcd.JISPCD_37... , age and schooling¹¹11. Zamora C, Taminche R, Salazar B. Variables asociadas a la prevención del zika en personas adultas atendidas en el centro de salud 9 de octubre, Iquitos-2017 [Tesis Bachiller]. Loreto: Facultad de Enfermería, Universidad Nacional de la Amazonia Peruana; 2017. Disponible en: https://repositorio.unapiquitos.edu.pe/handle/20.500.12737/5276.
https://repositorio.unapiquitos.edu.pe/h... as factors that could represent barriers to the prevention of Zika. Although low risk perception among pregnant women has been reported ¹²12. Arce N, Michuy K, Del Aguila C. Conocimiento y percepcion de riesgo de enfermar con zika en gestantes atendidas en la institución prestadora de servicios de salud "Moronacocha", Iquitos - 2017. [Tesis Bachiller]. Loreto: Facultad de Enfermería, Universidad Nacional de la Amazonia Peruana; 2017. Disponible en: https://repositorio.unapiquitos.edu.pe/handle/20.500.12737/5376.
https://repositorio.unapiquitos.edu.pe/h... , there is limited information on the perceptions of WCA about the risk of disease and their attitudes regarding prevention measures implemented by the health sector and local governments. Therefore, our study aimed to determine the knowledge, attitudes, practices and perceptions of WCA about the disease, complications, interventions and recommendations implemented after a Zika outbreak in the department of Amazonas.

MATERIALS AND METHODS

Study design and population

Descriptive study, with a mixed quantitative-qualitative approach. It was conducted between November and December 2018 on WCA aged 15 to 49 years, residents of the district of Bagua, department of Amazonas. The district of Bagua is located in the northern jungle of Peru, at an altitude of 420 meters and has environmental characteristics that favor the presence of the Aedes aegypti vector ¹³13. Ministerio del Ambiente. Indicadores ambientales Amazonas [Internet]. Lima: Ministerio del Ambiente; 2009 [citado el 23 de setiembre del 2020]. Boletín: Serie Indicadores Ambientales N° 12. Disponible en: https://sinia.minam.gob.pe/documentos/serie-indicadores-ndeg12-boletin-indicadores-ambientales-region.
https://sinia.minam.gob.pe/documentos/se... .

For the quantitative approach, we developed a questionnaire based on the KAP survey on Zika and its complications for community settings by a multidisciplinary team of the World Health Organization (WHO) ¹⁴14. Organización Mundial de la Salud. Encuestas de conocimientos, actitudes y prácticas: enfermedad viral de Zika y sus posibles complicaciones [Internet]. Ginebra: OMS; 2016 [citado el 9 junio de 2019]. Disponible en: http://www.who.int/csr/resources/publications/zika/kap-surveys/es/.
http://www.who.int/csr/resources/publica... , which was made available for use in member countries. Since it is an instrument that has not been tested in the field, the WHO recommends the application of a pilot test. For our study, questions were selected according to the research objectives. The instrument was validated by four experts with experience in field epidemiology, epidemiological surveillance of congenital diseases and research. The review process included the evaluation of the questionnaire by using a rating card with six categories: sufficiency, congruence, wording, clarity-precision, relevance and pertinence of the items. A pilot test was also conducted in the city of Bagua Grande in the province of Utcubamba-Amazonas, with a non-probabilistic sample of 5% of the study sample (36 WCA), to adapt it to the context, improve the structure of the questions and determine the time required to fill out the instrument. At the beginning of the study, 40 questions were selected from the WHO survey that addressed the research objective. After review by the experts, five questions were ordered and reformulated. As a result of the implementation of the pilot test, three questions were removed, one question was added and the structure of question 19 was modified for better understanding. The final survey consisted of 38 questions, divided into four sections: sociodemographic data, knowledge, attitudes and practices; the average time to complete the survey was 15 to 30 minutes.

Subsequently, four focus groups were formed, using a semi-structured guide with 17 open-ended questions on perceptions of Zika. The average duration of each focus group was 60 to 120 min and was moderated by a professional with experience in qualitative research. The instrument was validated by expert judgment.

Sample and sampling

For the quantitative phase, we considered the estimated population of women aged 15-49 years in 2018 (6,862 WCA), published in the National Institute of Statistics and Informatics. An expected proportion of 50% (proportion of correct answers of knowledge and practices) was considered to obtain the maximum sample size, reliability level of 95%, margin of error of 5%, rejection rate of 0.1 and design effect of 1.8. The resulting sample of 721 women was calculated using Epidat 4.1 software (Xunta de Galicia- OPS).

The sampling was stratified by two-stage clusters, so a sample of subjects was selected for each sector of the district of Bagua (19 sectors). The first level unit was a random selection of blocks in each sector using the 2018 cadastral sketch of the District Municipality, proportional to the size of each cluster. The second level unit was the dwellings within each block and we randomly selected four dwellings per block. In each dwelling we sought for a WCA aged 15 to 49, if the subject was not found in the selected address, the next dwelling to the right was chosen.

For the qualitative approach, a non-probabilistic purposive sample of WCA who voluntarily agreed to participate in the focus groups was selected and the invitation was extended to all WCA during the application of the survey. The focus groups were formed according to their arrival; four groups were formed with a minimum of eight and a maximum of eleven WCA.

Data collection

The questionnaires were applied from November 26 to December 31, 2018. Previously, enumerators and supervisors were trained, in order to ensure the correct application of the instrument. There were twenty enumerators, distributed in each sector, and three supervisors who monitored six to seven enumerators in order to ensure the quality of the information collected. The survey was administered to WCA who were at home and who wished to participate in the study.

During the application of the survey each enumerator in charge of a sector made the invitation for the focus groups, seeking to include the entire rural and urban socioeconomic spectrum. From the 4th to the 7th of December 2018, four focus groups were carried out, each group had a moderator who used the semi-structured guide and led the focus groups. Likewise, there were two observers who recorded the field notes and the participants’ responses through a voice recorder.

Study variables

The quantitative survey included, in addition to the sociodemographic variables, 16 questions on knowledge, 9 questions on attitudes and 15 on practices. For the collection of qualitative data, stimulation questions were used for five topics: dissemination of information about Zika, knowledge about the disease, prevention of the disease, consequences for the pregnant woman and complications of the disease.

Analysis plan

For the descriptive quantitative analysis, we used absolute and relative frequencies and measures of central tendency and dispersion (mean and standard deviation) for the categorical and numerical variables, respectively. The statistical software Stata version 12 (Stata Corp LLC, USA) was used.

The qualitative analysis included the extraction of key quotes that were coded and grouped into five sections: Dissemination of information, knowledge about the disease, prevention of the disease, consequences in pregnant women and complications due to Zika. For the analysis, we used the grounded theory methodology, based on the analysis of the content of the responses, seeking to elaborate an integrating theory to explain the perception of each topic.

The quantitative-qualitative integration was carried out in the data interpretation phase, by using narrative integration with a constructive approach (weaving approach) ¹⁵15. Fetters MD, Curry LA, Creswell JW. Achieving integration in mixed methods designs-principles and practices. Health Serv Res. 2013;48(6 Pt 2):2134-56. doi: 10.1111/475-6773.12117.
https://doi.org/10.1111/475-6773.12117... . The integration followed the interpretation of the five sections, allowing to broaden, deepen and contextualize the study findings.

Ethical aspects

The study was approved by the Ethics Committee of the Hospital Nacional Dos de Mayo- Lima (evaluation 093-2018-CEIB- HNDM). All participants signed an informed consent form before the application of the survey and the focus group, after being informed of the purpose, risks and benefits of the research. Likewise, an informed consent form was used for underage participants. The data recorded in the instruments were anonymous in order to protect the participant’s identity and privacy.

RESULTS

A total of 723 WCA were surveyed, the mean age was 31.8 years with a standard deviation (SD) of 8.9 years; 75.8% (n=548) were housewives, 45.8% (n=331) completed at least secondary school, 53.9% (n=389) were cohabitants, 62.5% (n=449) were Catholic and 87.4% (n=632) were from urban areas. From the total WCA surveyed, 4.4% (n=32) were pregnant women and the average monthly income was 781 soles (Table 1). The four focus groups included 35 WCA between 17 and 49 years of age (three groups of eight and one group of eleven) from the district of Bagua, none of whom reported being pregnant.

Knowledge about the disease

Regarding knowledge, 86.3% (n=624) considered that it is possible to become ill with Zika; 35.6% (n=257) believed that it can cause a rash; 10.1% (n=73) that it can be transmitted through sexual intercourse and 2.2% (n=16) that it can be transmitted during pregnancy. A total of 97.1% (n=702) of the WCA would advise a patient with Zika to go to a health facility. Regarding practices, 94.2% (n=681) reported that if they had a rash, they would go to the health facility (Table 2).

In the focus groups, we found that Zika is perceived as “similar” to dengue and they consider that it “affects pregnant women”. Most of them relate transmission to the bite of the “mosquito”. However, some recognize transmission during pregnancy (Annex 1).

Dissemination of information about Zika

Regarding information on Zika, 85.8% (n=620) of the WCA received information more than a year ago; 41.1% (n=297) heard it on the radio; 34.3% (n=248) through talks by health personnel and 23.7% (n=171) on television. Of the total of participants, 68.5% (n=495) considered that the information received is still insufficient and would like to obtain more information on prevention 48% (n=347) and treatment 41.1% (n=297) Table 3. In the focus groups, participants indicated that information on Zika was broadcasted “fast” on radio and television. On the other hand, they indicate that other dissemination strategies should be considered (Annex 1).

Disease prevention

WCA believe that Zika can be prevented by using mosquito nets 60% (n=434) and covering water containers 53.4% (n=386); 3.6% (n=26) believe it can be prevented by avoiding sexual intercourse and 1.9% (n=14) by using a condom. Of the participants, 36.1% (n=261) considered that families are responsible for preventing Zika, 27.3% (n=197) that the health sector is responsible, 16.5% (n=119) that local governments and 27% (n=195) believe that everyone is responsible. Regarding practices, 74.4% (n=538) of WCA reported having taken some measure to protect themselves and 81.8% (n=591) to protect their family. Fourteen percent (n=101) reported that they kept the sachet of larvicide in the container and 7.9% (n=57) allowed the health brigades to enter their home. On the other hand, only 4.4% (n=32) used condoms, 1% (n=7) avoided sexual intercourse and 0.6%(n=4) received education within their families; 84.2% (n=609) considered that the health sector had taken preventive measures, 67.6% (n=489) through focal (larval) control. Of the WCA, 7.6% (n=55) consider that the local government has carried out activities, of which 7.3% (n=4) have coordinated with the local healthcare center (Table 4). In the focus groups, they considered that the health sector continues to do the “same thing”, they are suspicious of the impact of the new larvicide for focal control, they believe that spraying does not control the vector and “contaminates”. They perceive that the population is not “aware” of Zika prevention and give importance to education within the family and educational centers (Annex 1).

Consequences of Zika in pregnant women

Of the participants, 60.2% (n=435) believe that Zika causes risk of miscarriage, 30.2% (n=218) that it increases the risk of malformation in the newborn, and 19.2% (n=139) believe that they should not get pregnant in order to prevent Zika. Regarding practices, 31.7% (n=229) would choose to use condoms to prevent pregnancy, 62.8% (n=454) of WCA would go to prenatal controls if they were pregnant and with Zika and 98.3% (n=711) believe that they should be tested for Zika during prenatal controls (Table 5). In the focus groups, WCA believe that abortion would not be a choice. WCA perceive the concern and distress that a pregnant woman with Zika could suffer and the importance of psychological care (Annex 1).

Complications of Zika

Regarding complications, 38.7% (n=280) of WCA have heard of microcephaly, of which 87.1% (n=244) related it to zika; 82.1% (n=230) considered when the baby is born with a small head to be a complication of Zika. On the other hand, 5.5% (n=44) had heard about Guillain Barré, of which 52.5% (n=21) related it to Zika and 42.5% (n=17) considered that it causes difficulty in moving. Of the WCA, 34.7% (n=251) were concerned that Zika could cause disability to their babies; 75.1% (n=543) believed that the mother of a baby with a disability could suffer discrimination. Regarding practices, 58.7% (n=424) would use contraceptive methods to prevent complications; 2.6% (n=19) would take a child with a disability to a specialist or rehabilitation 1.9% (n=14) (Table 6). In the focus groups, WCA perceived that children with Zika are not necessarily born with malformations (Annex 1).

DISCUSSION

The participants did not identify sexual and vertical transmission of Zika as forms of transmission, a situation similar to the study by Nelson E. et al, in which only 2% of women identified sexual intercourse as a route of transmission ¹⁶16. Nelson EJ, Luetke MC, Kianersi S, Willis E, Rosenberg M. Knowledge and perceptions of Zika virus transmission in the community of Puerto Plata, Dominican Republic. BMC Infect Dis. 2019;19(1):339. doi: 10.1186/s12879-019-3952-0.
https://doi.org/10.1186/s12879-019-3952-... . On the other hand, exanthema was one of the clinical manifestations least recognized as characteristic of the disease; similar findings were also described in the dengue and Zika endemic areas of the Dominican Republic, where only 8% of the population recognized this manifestation as the main sign of Zika ¹⁶16. Nelson EJ, Luetke MC, Kianersi S, Willis E, Rosenberg M. Knowledge and perceptions of Zika virus transmission in the community of Puerto Plata, Dominican Republic. BMC Infect Dis. 2019;19(1):339. doi: 10.1186/s12879-019-3952-0.
https://doi.org/10.1186/s12879-019-3952-... , despite being a frequent characteristic of the disease ¹⁷17. Ministerio de salud. Norma Técnica N° 125/MINSA CDC-INS, Norma técnica de salud para la vigilancia epidemiológica y diagnóstico de laboratorio de dengue, chikungunya, zika y otras arbovirosis en el Perú [Internet]. Lima: Centro Nacional de Epidemiología Prevención y Control de Enfermedades Ministerio de Salud; 2016 [ citado el 1 de febrero de 2019]. Disponible en: http://www.dge.gob.pe/portal/docs/tools/dengue/RM982-2016-MINSA.pdf.
http://www.dge.gob.pe/portal/docs/tools/... .

In addition, the most frequently recognized symptoms of Zika were fever, headache, and malaise, characteristic manifestations of dengue, which would reflect not only lack of knowledge, but also confusion between the two arboviruses. These findings have also been described in Iquitos ¹⁸18. Weldon CT, Riley-Powell AR, Aguerre IM, Celis Nacimento RA, Morrison AC, Oberhelman RA, et al. "Zika is everywhere": A qualitative exploration of knowledge, attitudes and practices towards Zika virus among women of reproductive age in Iquitos, Peru. PLoS Negl Trop Dis. 2018;12(8):e0006708. doi: 10.1371/journal.pntd.
https://doi.org/10.1371/journal.pntd... ⁾ and could be related to the greater public health impact (fatal cases) and greater media coverage given to dengue. The influence of media coverage, in addition to risk communication by official media, on the knowledge, practices and familiarity of the population with the disease has been described ¹⁹19. Ophir Y, Jamieson KH. The Effects of Zika Virus Risk Coverage on Familiarity, Knowledge and Behavior in the U.S. - A Time Series Analysis Combining Content Analysis and a Nationally Representative Survey. Health Commun. 2020;35(1):35-45. doi: 10.1080/10410236.2018.1536958.
https://doi.org/10.1080/10410236.2018.15... , which is key to improving adherence to preventive measures.

Radio, talks by health personnel, and television were the mostly reported sources of information about the disease, reflecting mass dissemination efforts during the Zika outbreak in Bagua ²⁰20. Mateo S, Caceres B. Situación epidemiológica de zika en el Perú [Internet]. Lima: Centro Nacional de Epidemiológia, Prevención y Control de Enfermedades Ministerio de Salud; 2018; 27(52):1249-1254 [ citado el 16 de octubre del 2020]. Boletín Epidemiológico del Perú. Disponible en: https://www.dge.gob.pe/portalnuevo/publicaciones/boletines-epidemiologicos/.
https://www.dge.gob.pe/portalnuevo/publi... . However, in the focus groups, the perception was that information via radio and television is brief and they suggest that health personnel should conduct more educational talks. Delet J. et al., in a study conducted in Martinique, reported that 64.3% of pregnant women suggested dissemination strategies other than radio and television ²¹21. Delet J, Cabie A, Merle S, Volumenie JL, Monthieux A. Knowledge, attitudes and practices of pregnant women in Martinique in the immediate aftermath of the Zika virus outbreak. Eur J Obstet Gynecol Reprod Biol. 2018;222:70-4. doi: 10.1016/j.ejogrb.2018.01.010.
https://doi.org/10.1016/j.ejogrb.2018.01... . In addition, the focus groups participants considered it necessary to have access to more information on prevention, treatment and less repetitive messages; therefore, not only the media should consider the interests of the population ²²22. Alarcon L. Estudio cualitativo para el fortalecimiento de medios de comunicación públicos-estatales de Lambayeque, La Libertad, Piura y Cajamarca. Rev Tzhoecoen [Internet]. 2014 [citado el 11 de junio de 2019]; 6(1). Disponible en: http://revistas.uss.edu.pe/index.php/tzh/article/view/19.
http://revistas.uss.edu.pe/index.php/tzh... , but also the quantity and quality of the information.

The low percentage of condom use or sexual abstinence to prevent Zika is compatible with similar findings in other countries in the region. D’Angelo DV. et al. found, in Puerto Rico, that these preventive measures were not common practice among pregnant women ²³23. D'Angelo DV, Salvesen von Essen B, Lamias MJ, Shulman H, Hernandez-Virella WI, Taraporewalla AJ, et al. Measures Taken to Prevent Zika Virus Infection During Pregnancy - Puerto Rico, 2016. MMWR Morb Mortal Wkly Rep. 2017;66(22):574-8. doi: 10.15585/mmwr.mm6622a2.
https://doi.org/10.15585/mmwr.mm6622a2... . Although no details of perceptions of these preventive measures were collected in the focus groups, the study by Weldon C. describes cultural barriers ¹⁸18. Weldon CT, Riley-Powell AR, Aguerre IM, Celis Nacimento RA, Morrison AC, Oberhelman RA, et al. "Zika is everywhere": A qualitative exploration of knowledge, attitudes and practices towards Zika virus among women of reproductive age in Iquitos, Peru. PLoS Negl Trop Dis. 2018;12(8):e0006708. doi: 10.1371/journal.pntd.
https://doi.org/10.1371/journal.pntd... ⁾ and may be related to reluctance by the partner or low frequency of use in the context of a conjugal relationship.

Similar results have been described in other regions of Peru; for example, Palma H. et al. found, in Piura, that the population justified their reluctance to vector control because they did not perceive the desired effect ²⁴24. Palma-Pinedo H, Cabrera R, Yagui-Moscoso M. Factores detrás de la renuencia al control vectorial del Dengue en tres distritos del Norte del Perú. Rev Peru Med Exp Salud Publica. 2016;33(1):13-20. doi: 10.17843/rpmesp.2016.331.1900.
https://doi.org/10.17843/rpmesp.2016.331... . Although the focus group participants recognized the work of the health sector, they reported that the lack of coordination between the local government and the health sector is an important limitation. The study by Weldon C., et al. suggested complementing vector control with short informative talks on prevention ¹⁸18. Weldon CT, Riley-Powell AR, Aguerre IM, Celis Nacimento RA, Morrison AC, Oberhelman RA, et al. "Zika is everywhere": A qualitative exploration of knowledge, attitudes and practices towards Zika virus among women of reproductive age in Iquitos, Peru. PLoS Negl Trop Dis. 2018;12(8):e0006708. doi: 10.1371/journal.pntd.
https://doi.org/10.1371/journal.pntd... , which, together with the participation of community agents and local government, could represent an alternative to optimize interventions. Pérez-Guerra C. et al. found that the population considers that local governments should participate actively and sustainably ²⁵25. Perez-Guerra CL, Zielinski-Gutierrez E, Vargas-Torres D, Clark GG. Community beliefs and practices about dengue in Puerto Rico. Rev Panam Salud Publica. 2009;25(3):218-26. doi: 10.1590/s020-49892009000300005.
https://doi.org/10.1590/s020-49892009000... .

Regarding education within the family, educational centers were also considered important spaces for the transmission of preventive messages. Guber DJ. et al. considered that health behavior modifications in the community can take years, so it is important to initiate programs based on the family and community ²⁶26. Gubler DJ, Clark GG. Community involvement in the control of Aedes aegypti. Acta Tropica. 1996;61(2):169-79. doi: 10.1016/0001-706x(95)00103-l.
https://doi.org/10.1016/0001-706x(95)001... . Previous evidence reports that the insertion of health programs in schools significantly increases the knowledge of students ²⁷27. Usman HB, AlSahafi A, Abdulrashid O, Mandoura N, Al Sharif K, Ibrahim A, et al. Effect of Health Education on Dengue Fever: A Comparison of Knowledge, Attitude, and Practices in Public and Private High School Children of Jeddah. Cureus. 2018;10(12):e3809. doi: 10.7759/cureus.3809.
https://doi.org/10.7759/cureus.3809... , who, in turn, deliver information to their homes ²⁵25. Perez-Guerra CL, Zielinski-Gutierrez E, Vargas-Torres D, Clark GG. Community beliefs and practices about dengue in Puerto Rico. Rev Panam Salud Publica. 2009;25(3):218-26. doi: 10.1590/s020-49892009000300005.
https://doi.org/10.1590/s020-49892009000... .

The majority of the WCA considered that Zika can cause miscarriage, a finding similar to that reported by Burgos S., et al. in Lambayeque-Peru, where 50% of participants recognized the risk of miscarriage during pregnancy ²⁸28. Burgos-Munoz SJ, Toro-Huamanchumo CJ. Zika knowledge and preventive practices among reproductive-age women from Lambayeque, Peru. Eur J Obstet Gynecol Reprod Biol. 2018;228:255-60. doi: 10.1016/j.ejogrb.2018.07.017.
https://doi.org/10.1016/j.ejogrb.2018.07... ; they also considered that pregnant women at risk should attend scheduled prenatal controls, as well as being tested for Zika. Pooransingh S. et al. in Trinidad and Tobago found that 88% of pregnant women considered that they should be tested for Zika and 76.9% considered that pregnant women with Zika should see a doctor ²⁹29. Pooransingh S, Parasram R, Nandram N, Bhagwandeen B, Dialsingh I. Zika virus disease-knowledge, attitudes and practices among pregnant women-implications for public health practice. Public Health. 2018;165:146-51. doi: 10.1016/j.puhe.2018.09.025.
https://doi.org/10.1016/j.puhe.2018.09.0... .

Qualitative results suggest that participants do not consider abortion as a preventive measure. Pooransingh S. et al. reported that 62% of pregnant women did not agree that women with Zika should have abortions ²⁹29. Pooransingh S, Parasram R, Nandram N, Bhagwandeen B, Dialsingh I. Zika virus disease-knowledge, attitudes and practices among pregnant women-implications for public health practice. Public Health. 2018;165:146-51. doi: 10.1016/j.puhe.2018.09.025.
https://doi.org/10.1016/j.puhe.2018.09.0... . However, they perceived that the distress suffered by pregnant women with Zika, or by mothers of children with sequelae, requires psychological care. The WHO mentions that pregnant women with Zika are highly likely to develop symptoms of distress ³⁰30. Organización Mundial de la Salud. Apoyo psicosocial para las embarazadas y las familias afectadas por la microcefalia y otras complicaciones neurológicas en el contexto del virus de Zika [Internet]. Ginebra: OMS; 2016 [citado el 20 de julio del 2019]. Disponible en: https://apps.who.int/iris/bitstream/handle/10665/204590/WHO_ZIKV_MOC_16.6_spa.pdf;jsessionid=B81AB1AD31231604F0462A434B64AD43?sequence=1.; therefore, it is important to guarantee their specialized care.

The proportion of WCA who have heard about microcephaly, Guillain-Barré syndrome and its relationship to Zika is low. Similar findings were observed in the study by Pooransingh S. et al. who found that 37.4% of pregnant women considered that there was a link between Zika and Guillain Barré syndrome²⁹29. Pooransingh S, Parasram R, Nandram N, Bhagwandeen B, Dialsingh I. Zika virus disease-knowledge, attitudes and practices among pregnant women-implications for public health practice. Public Health. 2018;165:146-51. doi: 10.1016/j.puhe.2018.09.025.
https://doi.org/10.1016/j.puhe.2018.09.0... ; Nelson E. et al. found that 10.4% of the population of women considered microcephaly as a risk for their babies ¹⁶16. Nelson EJ, Luetke MC, Kianersi S, Willis E, Rosenberg M. Knowledge and perceptions of Zika virus transmission in the community of Puerto Plata, Dominican Republic. BMC Infect Dis. 2019;19(1):339. doi: 10.1186/s12879-019-3952-0.
https://doi.org/10.1186/s12879-019-3952-... .

Our study had limitations that may affect the conclusions, the first being that the answers may have been affected by recall bias and social desirability bias. However, the integration of quantitative and qualitative findings allowed us to go deeper into some aspects that would not have been possible to clarify with either of the two individual approaches. In addition, the study used the WHO survey as a basis and was validated by expert judgment and pilot testing in a similar jurisdiction, which improved the understanding of the questions in the questionnaire. On the other hand, the focus groups did not include pregnant women; the participants were the WCA who had the time and perhaps greater concern about the subject. Likewise, the study was conducted in urban and peri-urban areas of the city of Bagua, so WCA from native communities were not included. However, the invitation was extended to all sectors and those responsible for the fieldwork sought to include participants from most sectors.

In conclusion, the results show gaps in knowledge and prevention practices for sexually transmitted Zika. There are important perception barriers about vector control activities, lack of coordination between local government and health services, and there is a need for more and better information about Zika. The role of the family and educational centers is considered very important and underutilized, as well as the need to optimize prenatal control, screening and psychological support for pregnant women with Zika and mothers of children with sequelae. It is recommended that authorities responsible for prevention and control interventions, at all levels of government, should contextualize intervention strategies according to local conditions. This type of research is very useful to support the evaluation of interventions before, during and after an outbreak.

Acknowledgments:

Yliana Margot Rojas Medina, psychologist at the National Center for Epidemiology, Disease Prevention and Control, for her support at the beginning of the study.

References

Publication Dates

History