Knowledge, attitude and preventive practices regardingdengue fever in rural areas of Yemen

Khaled G. Saieda,*, Abdullah Al-Taiarb, Abdulrahman Altairea, Ala Alqadsia,Enas F. Alariqia and Maha Hassaana

aDepartment of Community Medicine, Faculty of Medicine and Health Sciences, Sana’a University, P.O. Box 2583 Al-Tahreer Post Office,Sana’a, Yemen; bDepartment Community Medicine and Behavioural Sciences, Faculty of Medicine, Kuwait University, Box 24923 Safat,

13110 Kuwait, Kuwait

*Corresponding author: Tel: +967 713262611; E-mail: kghilan@yahoo.co.uk

Received 12 October 2014; revised 20 February 2015; accepted 16 March 2015

Background: In recent years there have been several reports of outbreaks of dengue fever (DF) in Yemen. Thisstudy aimed to describe the prevailing knowledge, attitude and preventive practices regarding DF, and to inves-tigate the factors associated with poor preventive practices in rural areas of Yemen.

Methods: A population-based, cross-sectional study was conducted on 804 randomly selected heads of house-hold. A pretested, structured questionnaire was administered through face-to-face interviews. Logistic regressionwas used to investigate factors independently associated with poor practice.

Results: Out of 804 participants, 753 (93.7%) were aware of the symptoms of DF and 671 (83.4%) knew that DFwas transmitted by mosquito bites. Only 420 (52.2%) knew that direct person-to-person transmission was notpossible. Furthermore, 205 (25.5%) thought that someone with DF should be avoided and 460 (57.2%)thought the elimination of breeding sites was the responsibility of health authorities. Poor knowledge of DFand a low level of education were significantly associated with poor preventive practices.

Conclusions: In rural areas of Yemen, people have a vague understanding of DF transmission and a negativeattitude towards preventative practices. Efforts should be made to correct misconceptions about transmissionof the disease and to highlight the importance of community participation in control activities.

Keywords: Attitude, Dengue, Knowledge, Practices, Yemen

IntroductionDengue fever (DF) is amosquito-borne viral infection that has recentlybecome a major international public health concern. Over the pastfive decades, there has been a dramatic global increase in the inci-dence of DF1 and the disease has become now endemic in morethan 125 countries.2 It has been estimated that annually 96million new apparent infections occur worldwide, with 294 millioninapparent infections.3 These unobservable infections create enor-mous difficulty in terms of understanding the true economicburden of the disease and the dynamics of the infection. Despitesome progress in vaccine development, there are none readily avail-able on themarket as well as no specific treatment for DF. Thus, themost effective way to prevent dengue virus transmission is tocombat disease-carrying mosquitoes, particularly Aedes aegyptiand A. albopictus.

Recent DF outbreaks have been reported from within WHO’seastern Mediterranean Region in Sudan, Saudi Arabia and Yemen.Unlike its oil-rich neighbouring countries, Yemen has weaker

healthcare and surveillance systems. Recently, frequent DF out-breaks have been reported in the media, few of which have beenproperly documented.4,5 During these outbreaks, the predominantserotype was type 2 in the west6 and type 3 in the southeast.4,5

Mostly young adults were affected. Among the suspected cases inthe southeast, studies have reported a high prevalence of dengueIgG suggesting previous exposure and background endemicity pre-ceding these outbreaks.4 Overall, the true burden of the disease inYemen remains unknown, but is anticipated to be high.

The knowledge and attitude of the general public towards DFhave been recently described in various settings,7–14 but little isknown about them in Yemen or the Middle East. Previously, wedemonstrated that people in Yemen have a vague understandingof the causes of malaria. While the majority of people know thatmalaria is caused by mosquito bites, most believe that malariacan also be caused or transmitted by a range of factors, includingflies, eating uncovered food, not having breakfast and breastfeed-ing.15 In this study, we aimed to describe the knowledge, attitudeand preventive practices regarding DF, using a population-based

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survey in one rural district of Yemen, and to investigate the factorsassociated with poor preventive practices.

MethodsA cross-sectional studywas conducted in the Beit Al-fakieh districtof Hodeidah province, which is located along the west coast ofYemen on the Red Sea. The area comprises eight sub-districts. Ithas two rainy seasons (November-March and June-October)and had a high occurrence of DF in 2011.16 The study populationcomprised the heads of households who had lived in the districtfor at least 1 year. Those who were not able to communicatebecause of mental illness or severe hearing defects wereexcluded. We used a multistage random sampling to select thestudy group. First, we randomly selected two sub-districts fromthe eight sub-districts. We then randomly selected five villagesfrom the two selected sub-districts according to the relative sizeof the population in the sub-district. In each village, the house-holds were selected in a systematic random sampling methodtaking the first house in the centre of the village as a random start.

Data were collected through face-to-face interviews, with theheads of the households using a structured, pretested question-naire. This included questions on socio-demographic characteris-tics such as age, gender, marital status and educational level inaddition to questions on knowledge about DF. This part of thequestionnaire included 14 questions (requiring ‘yes’, ‘no’ or ‘donot know’ answers) related to signs and symptoms, transmission,treatment and prevention. Attitudes towards DF were measuredusing 12 statements (requiring ‘agree’, ‘disagree’ or ‘not sure/donot know’ answers), which covered susceptibility, seriousnessand threat. Practices regarding DFwere assessed by 12 items cov-ering various aspects of prevention. The questionnaire was pilotedon 30 participants who were not included in the study.

The data were entered and analysed using SPSS softwareversion 20 (SPSS Inc., Chicago, IL, USA). The total score of knowl-edge about DF was calculated by assigning one score for eachcorrect answer and zero score for each wrong answer. These

were then summed up to calculate the total score of knowledge.Similarly, in order to calculate the attitude score, the answers‘agree’, ‘not sure’ and ‘disagree’ were given scores of 3, 2 and 1,respectively (the scores were reversed for negative attitudeitems) and these were added to calculate the total score. Asimilar approach was used to calculate the practice score, withzero score assigned to eachwrong practice and one score assignedto each correct practice. Respondents who scored more than themedian value (11 for knowledge, 29 for attitudes, 6 for practice)were considered to have good levels of knowledge, attitude andpractices, while those who scored the median value or less wereconsidered to have poor levels. Spearman’s correlation coefficientwas used to assess the strength and direction of the bivariate rela-tionship between knowledge, attitude and practices dealing withscores as a continuous variable. Logistic regression was used to in-vestigate the independent factors associated with poor preventivepractices. The significance of each variable was determined using alikelihood ratio test that compared themodel with andwithout thevariable.

The study was approved by the Faculty of Medicine and HealthSciences of Sana’a University, and verbal consent was obtainedfrom each participant after adequate explanation of the natureof the study.

ResultsOf the 820 heads of household approached, 16 (1.9%) refused toparticipate. Table 1 shows the characteristics of the study group.The median (interquartile range [IQR]) age was 39 (IQR 30–50)years. Of the participants, 741 (92.2%) were men and 665(82.7%) were married. More than half of the members of studygroup were illiterate (54.9%; 442/804) and 3.9% had a universitydegree (31/804).

The number of those demonstrating the correct knowledgeabout DF among the study group is shown in Table 2. Of 804heads of household, 753 (93.7%; 95% CI 91.7–95.2%) knewthat the main symptoms of DF are fever, headache, pain behindthe eyes, joint pain, muscle pain and skin rash. Six hundred andfive (75.2%; 95% CI 72.1–78.2%) knew that abdominal pain,vomiting blood, bloody stools and bleeding from the nose weresigns of severe DF. More than three quarters, 671 (83.4%; 95%CI 80.7–86.0%), knew that DF was transmitted by mosquitobites, but only 420 (52.2%; 95% CI 48.7–55.7%) knew that DFcannot be transmitted from an infected person to a healthyperson through direct contact.

Positive and negative attitudes towards DFare shown in Table 3.Of the study participants, 528 (65.7%; 95% CI 62.3–69.0%) agreedthat DF is a serious and sometimes life-threatening disease, and685 (85.2%; 95% CI 82.6–87.6%) agreed that sleeping under abed net can help to prevent it. Of 804 heads of household, 205(25.5%; 95% CI 22.5–28.6%) thought that close contact with aperson with DF should be avoided. Of even more concern was thefact that 460 (57.2%; 95% CI 53.7–60.7%) thought the eliminationof breeding sites should be the responsibility of health authoritystaff only. Surprisingly, more than 41.0% either agreed that DFcannot be prevented, or were not surewhether it can be prevented.

Those among the study group who reported correct DF prevent-ive practices are shown in Table 4. Of 780 participantswho reportedowning water tanks, 730 (93.5%; 95% CI 91.6–95.2%) had covers

Table 1. Socio-demographic characteristics of 804 head ofhouseholds in Hodeidah, Yemen

Characteristics n (%)

Age, median (IQR) years 39 (30–50)Gender, male 741 (92.2)Marital statusMarried 665 (82.7)Single 104 (12.9)Widowed/divorced 35 (4.4)

Working in paid job 386 (48.0)Educational levelIlliterate 442 (54.9)Able to read and write 80 (10.0)Completed primary school 100 (12.4)Completed intermediate school 71 (8.8)Completed secondary school 80 (10.0)Completed university degree or more 31 (3.9)

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for them, and almost all said that they covered them immediatelyafter use. Only a minority reported using preventive measuresagainst mosquitoes, such as mosquito nets (131/804; 16.3%;95% CI 13.8–19.0%), window screens (59/804; 7.3%; 95% CI5.6–9.4%) or door screens (65/804; 8.1%; 95% CI 6.3–10.2%),but more than one-third said that they spray insecticide indoorsor use repellent to prevent mosquito bites. Approximately 94%(755/804) said that they sought medical help when they felt sick.

Logistic regressionwas used to investigate the factors significant-ly associated with poor DF preventive practices. The binary outcomefor this analysis was created bydichotomising the practice score intogood (> median) and poor (≤ median). Tables 5 and 6 show theassociation between different factors and poor preventive practices

using univariate and multivariate analyses. Factors that showed asignificant association with poor practice in the univariate analysiswere older age, low educational level, not working in a paid job,fewer people in the house and poor knowledge of and attitudestowards DF. In the multivariate analysis, only low educational leveland poor knowledge of DFwere significantly related to poor prevent-ive practices. A Spearman’s rank order correlationwas used to inves-tigate the link between the knowledge, attitude and preventivepractices scores. There was a weak positive correlation betweenthe knowledge and attitude scores, between the knowledge andpreventive practices scores and between the attitude and preventivepractices scores (the Spearman’s correlation coefficient was 0.234[p<0.001], 0.192 [p<0.001] and 0.150 [p<0.001], respectively).

Table 3. Distribution of the respondent’s attitudes towards dengue fever (n=804)

The statements Agree Disagree Not suren (%) n (%) n (%)

Dengue fever is a serious and sometimes life-threatening diseasea 528 (65.7) 71 (8.8) 205 (25.5)Everybody can be infected with dengue fevera 726 (90.3) 26 (3.2) 52 (6.5)Sleeping under a bed net can help prevent dengue fevera 685 (85.2) 32 (4.0) 87 (10.8)You have an important role in the prevention of dengue fevera 604 (75.1) 132 (16.4) 68 (8.5)The best way to prevent people from getting dengue fever is to control mosquitoesa 676 (84.1) 23 (2.9) 105 (13.1)If someone gets dengue fever, she/he should seek treatmenta 678 (84.3) 19 (2.4) 107 (13.3)The risk of getting dengue fever among men and women is not the sameb 169 (21.0) 449 (55.8) 186 (23.1)A person who once had dengue fever cannot get it againb 137 (17.0) 474 (59.0) 193 (24.0)Close contact with people with dengue fever should be avoidedb 205 (25.5) 492 (61.2) 107 (13.3)Strong, healthy people do not get dengue feverb 170 (21.1) 499 (62.1) 135 (16.8)Dengue fever is a disease that cannot be preventedb 157 (19.5) 473 (58.8) 174 (21.6)Elimination of breeding places is the responsibility of public health staff onlyb 460 (57.2) 274 (34.1) 70 (8.7)

a Positive statement where agree is the correct answer.b Negative statement where disagree is the correct answer.

Table 2. Correct knowledge about dengue fever among 804 head of households in Hodeidah, Yemen

Correct knowledge answers n (%)

Patient with dengue fever usually has fever, headache, pain behind the eyes,joint pain, muscle pain and skin rash 753 (93.7)Abdominal pain, vomiting blood, bloody stools, bleeding from nose are signs of danger in dengue fever 605 (75.2)Dengue fever may affect children and adults 766 (95.3)Dengue fever is transmitted by mosquito bites 671 (83.5)Mosquitoes that transmit dengue fever bite mainly during the daytime 270 (33.6)Dengue fever is not transmitted from an infected person to a healthy person through direct contact 420 (52.2)The main method of controlling dengue fever is to combat mosquitoes 638 (79.4)Stagnant water in old tyres and trash cans can be breeding places for mosquitoes 692 (86.1)Dengue fever is more common in the rainy season 683 (85.0)Uncovered water containers should be cleaned every week 654 (81.3)Water containers in the house are the most common breeding sites of mosquitoes 611 (76.0)Discarded tyres and tin cans should be eliminated to prevent dengue fever 617 (76.7)Covering water collections around the house with sand is one ways to combat mosquitoes 633 (78.7)There is no specific treatment for dengue fever 347 (43.2)

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DiscussionEven before the current social upheaval, the healthcare system inYemen was unable to detect and respond to outbreaks of infec-tious diseases such as DF. As the current social unrest will com-pound the difficulty in preparedness and response to epidemics,and it would therefore seem sensible for public health initiativesto capitalise on the knowledge and behaviour of the general popu-lation in order to prevent the disease, rather than to rely on govern-mental responses. However, despite many reports of recent DFepidemics, the general population’s knowledge, attitude and pre-ventive practices regarding DF remain mostly unknown in Yemenand the broader Middle East. We have demonstrated that peoplein rural areas of Yemen have a vague understanding of DF trans-mission and many of them believe the health authority to beresponsible for controlling mosquitoes. We have also demon-strated that knowledge and preventive practices are linked.

The majority of participants in the study were aware of thesymptoms of DF, which include fever, headache, pain behind theeyes, joint pain, muscle pain and skin rash. These findings aresimilar to those reported in a study in Nepal, although that studyfound knowledge levels to be lower in highland areas.8 More thanthree-quarters of the participants in the present study agreedthat abdominal pain, vomiting blood, bloody stools and bleedingfrom the nosewere signs of severe DF. People becomemore knowl-edgeable about the signs and symptoms of the disease when theylive in communities with a high prevalence,17 and this may explainthe good levels of knowledge about the signs and symptoms of DFin our setting. Such good knowledge about the symptoms of DF islikely to be useful in health-seeking behaviour.

In this study, the majority of the participants (83%) agreedthat DF is transmitted by mosquito bites. This is a similar resultto that reported among people visiting tertiary care hospitals inPakistan.18 However, only one-third of the study participantsthought that transmission can occur during the daytime. This isprobably because the study area is endemic with malaria andthus people are more familiar with the A. arabiensis vector that

Table 4. Distribution of reported correct preventive practices against dengue fever among 804 heads of households in Hodeidah, Yemen

Correct practices n (%)

Do you have a cover for all your water tanks (water containers)? 730a (93.5)Do you cover your water tank immediately after using it? 728a (93.3)Do you eliminate stagnant water around your house to reduce mosquitoes? 536 (66.7)Do you get rid of discarded tyres and tin cans which contain stagnant water? 505 (62.8)Do you use mosquito nets to prevent mosquito bites? 131 (16.3)Do you have window screens to reduce mosquitoes? 59 (7.3)Do you have a door screen to reduce mosquitoes? 65 (8.1)Do you spray insecticides indoor to reduce mosquitoes? 290 (36.1)Do you use repellent for mosquitoes? 320 (39.8)Do you cut the trees/vegetation surrounding your house to reduce mosquitoes? 400 (49.8)Do you participate in campaigns to help prevent dengue fever in your community? 336 (41.8)Do you usually go to the health centre/unit when you feel ill? 755 (93.9)

a Of 804 participants, 24 (3.0%) did not store water at home (those without water tanks).

Table 5. Socio-demographic factors, knowledge and attitudesregarding dengue fever in relation to poor preventive practices (≤the median score) using univariate analysis

n OR 95% CI p-value

Age in years 804 1.02 1.01–1.03 <0.001GenderMale 741 1.22 0.72–2.07 0.451

Marital status 0.095Married 665 1.18 0.77–1.80Divorced/widowed 35 2.60 1.04–6.51Single 104 1.00 NAa

Education level <0.001Illiterate 442 3.77 2.45–5.81Able to read and write 80 2.63 1.44–4.78Primary/intermediate 171 1.28 0.79–2.07High school or above 111 1.00 NAa

Working 0.006No 418 1.50 1.12–2.01

Number of people in house 0.050<6 262 1.64 1.05–2.567–10 421 1.64 1.08–2.49>10 117 1.00 NAa

Knowledge score <0.001Poorb 549 1.76 1.30–2.39Goodc 255 1.00 NAa

Attitude score 0.006Poorb 482 1.51 1.12–2.02Goodc 322 1.00 NAa

a NA: not applicable, reference group.b Less than or equal to the median.c More than the median.

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is generally active during the night, whereas the dengue vectorsare generally active before dusk.19,20 We have previously demon-strated that, although the majority of people link malaria to mos-quitoes, the quality of their knowledge of the disease transmissionis undermined by various misconceptions, such as the belief intransmission of the disease by flies, breast milk or throughperson-to-person contact.15 In the present study, half of thestudy group thought the disease can be transmitted from aninfected person to a healthy person through direct contact(Table 2). A recent study in Nepal reported that, of 589 partici-pants, 32% believe DF to be transmitted by flies, 42% by ticks,51% through food and water and 56% through person-to-personcontact.8 Similar findings have been reported from Jamaica,where, of 188 residents, 33% and 28% believe DF to be transmit-ted by flies and ticks, respectively.21 Such misconceptions maylead to the assumption that DF is an unavoidable disease forlocal people because, as from the local perspective, avoidanceof mosquitoes alone is not sufficient to prevent the disease. Thismight explain why more than 40% of the participants in ourstudy reported believing that DF is a disease that cannot be pre-vented, or were not sure whether it can be prevented (Table 3).In Nepal, however, despite these prevalent misconceptions,95% of the participants agreed that DF can be prevented,although the authors attribute this to the cultural context thatmean that people in that area have a tendency to agree withthe statements that investigators use to measure attitude.8

Overall, the majority of participants had an unfavourable atti-tude towards various aspects of the disease, and a large numberhad a negative attitude towards disease prevention in comparisonwith those in Asian settings.8,22,23 As mentioned above, such vari-ancemay be attributed to differing cultural contexts, but this doesnot preclude the public health implications of the results. It is amajor concern that 57%of the participants thought that the elim-ination of breeding sites is the sole responsibility of the healthauthorities. Given the current social unrest in the country, healthauthorities are unlikely to be able to eliminate breeding sites,and educational campaigns should therefore stress the import-ance of community participation and promote the role of indivi-duals in controlling DF by reducing breeding sites in and around

their homes. As mentioned above, 40% of the study groupthought the disease cannot be prevented or were not surewhether it can be prevented. While such beliefs may be attributedto localmisconceptions about themultiple causes of DF, theymayalso be due to experience of frequent outbreaks of the disease. Astudy in Malaysia has demonstrated that communities with highIgG seropositivity (which reflects high frequency of DF) usuallyreport a general lack of self-efficacy in taking preventivemeasuresagainst DF.7 Such communities are also highly likely to report alack of preventive measures at the community and authoritylevel.7

A lack of tap water forces people to store water in their house-holds, which increases the risk of DF.7 In the study area, there isno tap water supply and 97% of households have water tanks.Although most participants reported covering their water tanksafter use, this situation makes community engagement in elimin-ation of mosquito breeding sites in water containers highlyimportant. As in other areas of Yemen, the use of mosquito netsseems to be a rare practice;24 when they are used, it is generallyonly to help babies sleep without being disturbed by flies.15 Itappears that mosquito nets, window and door screens andother preventive measures are used less in rural areas of Yementhan in other settings.8,21

In this study, both univariate and multivariate analysesrevealed an association between knowledge and preventive prac-tices. These results are similar to those reported from Laos22 andNepal,8 but differ from those reported in Malaysia,23 Jamaica21

and Thailand,17 where good knowledge levels did not lead togood preventive practices. However, the association in our studywas not strong, which may support the notion that knowledgedoes not necessarily correspond to preventive measures. It isalso not clear from this study whether self-reported practices cor-respondwith actual preventive practices. In Thailand, for instance,respondents with a good knowledge of preventive measures aremore likely to have a higher number of unprotected containersin and around their houses;17 while in Malaysia self-reported prac-tices are significantly associated with seropositivity in univariatebut not in multivariate analyses.7 In our setting, low educationallevels and poor knowledge of the disease were the main predic-tors of poor preventive practices against DF (Table 6). A study ona convenient sample of people attending tertiary care hospitalsin Pakistan, showed income as the only predictor of good knowl-edge about DF in multivariate analysis.18 In our setting, incomedata was not collected because less than half of the participantswere in paid work, and education, independent of knowledge, wasfound to be significantly related to preventive practices. In fact noassociation was found between the knowledge score and theeducational level (data not shown).

This is the first study that has systematically investigated theknowledge, attitude and preventive practices regarding DF inYemen, from where WHO has received reports of several recentoutbreaks. We chose to conduct a household survey via personalinterviews because of the high illiteracy rate. The response ratewas high and the findings are thus critical to guiding publichealth initiatives and encouraging community participation. Oneof the weaknesses of our study was that we did not inspect thebreeding sites around the houses. However, it would have beendifficult to standardise such an observation, which, in any case,may only have provided a snap-shot of the situation. The targetpopulation (heads of households) were primarily men with

Table 6. Factors associated with poor preventive practices againstdengue fever (≤ the median score) using multivariate analysis

OR 95% CI p-value

Education level <0.001Illiterate 3.80 2.45–5.86Able to read and write 2.78 1.52–5.10Primary/intermediate 1.32 0.81–2.14High school or above 1.00 NAa

Knowledge score <0.001Poorb 1.73 1.26–2.38Goodc 1.00 NAa

a NA: not applicable, reference group.b Less than or equal to the median.c More than the median.

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whom decisions about taking preventive measures were likely torest, and so our findings cannot be extrapolated to other groupsin the community, such as mothers. Finally, this type of study isuseful for gathering information on knowledge, attitude and prac-tices pertaining to a health issue but the interpretation of theresults should take into account the cultural context of the localpopulation, an understanding of which could be acquiredthrough qualitative research.

ConclusionsIn summary, we have demonstrated that people in rural areas ofYemen have a vague understanding of the transmission of DF,their attitudes towards various aspects of the disease are negativeand they rarely undertake preventive practices against thedisease. Public education is needed to correct the misconceptionsthat there are other methods of transmission, such as directcontact with an infected person, so that it becomes clear that pre-venting mosquito bites is sufficient to prevent DF. The educationalmessage should be simple in order to accommodate the highrates of illiteracy in the community. Efforts should be made toencourage the use of bed nets, which is strikingly low. Educationalcampaigns should also focus on the role of the community partici-pation in order to correct the belief that the elimination of DF is thesole responsibility of health authorities. Community participationis critical given the current social unrest in the country and inthe light of the fact that frontline health services are fairly poorand unlikely to distinguish DF from other infectious diseases.

Authors’ contributions: KGS, AAT conceived the study, analysed the dataand drafted the manuscript; AAL, AAQ, EAL, MHA collected the data andrevised the manuscript for intellectual content. All authors read andapproved the final manuscript. KGS is the guarantor of the paper.

Acknowledgments:We are grateful to all the participants in the study. Weare grateful to Manal Q. Alariqi, Ahmed Almaasali, Solaf Alwadhi, HashemAlkibsi, Yehya Alsabri and Areej Alsiaghy for their contributions to thisstudy. We are also grateful to Professor Saeed Akhtar, Dr Lukman Thaliband Dr Reem Al-Sabah for their comments on the draft of this manuscript.

Funding: None.

Competing interests: None declared.

Ethical approval: The study was approved by the Faculty of Medicine andHealth Sciences of Sana’a University.

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