Thesis DF

TABLE OF CONTENTS
Page ABSTRACT ...... iii ACKNOWLEDGEMENTS .... .... iv TABLE OF CONTENTS .... ... v LIST OF TABLES ....... ix LIST OF FIGURES ..... xi ABBREVIATIONS ...... xii CHAPTER I INTRODUCTION ..... 1 1.1 Background and Significance ........ 1 1.1.1 Global burden of Dengue Fever ........2 1.1.2 Dengue in South East Asia Region ...... 2 1.1.3 Dengue in Jayavarman VII.... .... 3 1.1.4 Current Situation ........... 4 1.2 Rationale ....... 4 1.3 Background Information of Jayavarman VII...... 5 1.3.1 Problem Statement ............ 5 1.4 Objectives of the Study .......... 6 1.4.1 General Objective ..............6 1.4.2 Specific Objectives ............6 1.5 Research Question ..............7 1.6 Operational Definitions ..........7 1.6.1 Knowledge ............... 7 1.6.2 Attitude ........ 7 1.6.3 Practice .........7 1.8 Research Variables .........8
CHAPTER II LIETRATURE REVIEW ............. . . 10 2.1 Introduction .......... 10 2.2 KAP Studies on Dengue Fever ........ 10 2.3 Dengue Virus ........... 15 2.4 Mosquito Vector ...... 15 2.5 Human Activities that Influences the spread of Dengue ............ 16 2.6 Manifestation of Dengue Virus Infection .......... 17 2.7 Impact of DF on Health Care System ...... 18 2.8 Summary....... 19 CHAPTER III RESEARCH METHODOLOGY ............. 20 3.1 Study Design ............ 20 3.2 Study Population ........... 20 3.3 Study Area ........... 20 3.4 Study Period ......... 21 3.5 Sample Size ..........21 3.6 Sampling Methods ............ 22 3.7 Research Instrument and Measurement ....... 24 3.8 Validity ........ 27 3.9 Reliability ................. . 2 7 3.10 Data Collection Process .............. 28 3.11 Data Analysis ............ 28 3.12 Limitations of the Study ..............29 3.12.1 Study Design .............. 29 3.12.2 Proportion of the Population ......... 29 3.12.3 Data Collection Tool ......... 30 3.13 Summary ........ 30
CHAPTER IV RESULTS ............. 31 4.1 Demographic Information ....... . 3 1 4.2 Source of Information regarding Dengue Fever ...... 34 4.3 Knowledge on Dengue Fever ............35 4.4 Attitude towards Dengue Fever ....... 38 4.5 Practice about Dengue Fever ............ 41 4.6 Observation Results .............. 45 4.7 Comparison of practice score between grouping variables ..... 46 4.7 Summary ...... 56 CHAPTER V DISCUSSION, CONCLUSION AND RECOMMENDATION ......... 57 5.1 Socio-demographic characteristics of the respondents ... .. 57
5.2 Knowledge about Dengue Fever ... . . . 5 8 5.2.1 Areas of High Knowledge ...... 58 5.2.2 Areas of Knowledge Deficit ........... 59 5.3 Attitude towards Dengue Fever .... ... 60 5.4 Observation .......... 62 5.5 Conclusion .... .... ..63
5.6 Recommendations ... .. 64 5.6.1 Future Research Suggestions ...... 65 REFERENCE .......... ... 66 APPENDICES ......... .. 70 APPENDIX A .... . ... 71 APPENDIX B ..... . .. 76 CURRICULUM VITAE ......... .. . . 79
LIST OF TABLES
Table
Page
1. Research Variables ................... 8 2. Distribution of the respondents by socio-demographic characteristics ... . 32 3. Number and percentages of the sources which the respondents received information regarding dengue fever ..... . 3 5 4. Distribution of knowledge level on dengue fever ... .. 36 5. Number and percentages of the items on the knowledge of dengue fever answered correctly by the respondents ... .. 37 6. Distribution of attitude levels towards dengue fever of the respondents .. 38 7. Percentage of the respondents by the attitude towards dengue fever of each individual item .. 39 8. Number and percentages of items in the households which they have and dont have ... ...41 9. Frequency and percentages of the times in which the respondents drain water in the plates supporting the flower pots ... ..... 42 10. Distribution of practice levels towards dengue fever prevention ... 11. Number and percentages of the respondents by the level of practice about dengue fever prevention ... .44 12. Association between gender and practices on dengue prevention ... .46 13. Association between age and level of practice behaviors against dengue fever prevention ... . 47 .43
x Table 14. Association between marital status and level of practice behaviors against dengue fever prevention ... ..4 7 Page
15. Association between level of education and level of practice behaviors against dengue fever prevention ... 48 16. Association between level of employment and level of practice behaviors against dengue fever prevention ... 17. Association between level of number of family members and level of practice behaviors against dengue fever prevention ... . 50 18. Association between history of DF in the family members in the last 2yrs and level of practice behaviors against dengue fever prevention .... 51 19. Association between received information regarding dengue fever and level of practice behaviors against dengue fever prevention .... 52 20. Association between level of knowledge and level of practice behaviors against dengue fever prevention ... . 53 21. Association between level of attitude and level of practice behaviors against dengue fever prevention ... . 54 22. Correlations of total score of practices of dengue preventive behavior with total knowledge score among the participants .... .. 55 23. Correlations of total score of practices of dengue preventive behavior with total attitude score among the participants .... 55 ..49
xi
LIST OF FIGURES
Figure
Page
1. Conceptual framework for the study......................6 2. Manifestations of Dengue Virus Infections .............................. 17 3. Respondents who received information about DF ... .. 34 4. Ways in which people do perform in preventing mosquito breeding in water tanks ..............................................................................42 5. How often the respondents examine for mosquito larvae in Flower pots ...........................................................................................43 6. The time the respondents use mosquito coils or electric mosquito controllers to prevent from mosquito bites .........................................................................45
xii
LIST OF ABBREVIATIONS
CDC CFR DALYs DF DHF DSS KAP RNA SPSS TV WHO
: : : : : : : : : : :
Centers for Disease Control Case Fatality Rate Disability Adjusted Life Years Dengue Fever Dengue Hemorrhagic Fever Dengue Shock Syndrome Knowledge, Attitude and Practice Ribonucleic Acid Statistical Package for the Social Science Television World Health Organization
CHAPTER I INTRODUCTION
This thesis reports on a descriptive study that investigated the Knowledge, Attitude and Practice level (KAP) of the residents in Male, the capital of Maldives regarding dengue fever prevention. Non-participant observation was used to examine the dengue fever prevention practices followed by the administration of a questionnaire to explore the participants Knowledge, Attitude and Practice level. The purpose of this study was to identify the current level of the Knowledge, Attitude and Practice in people of Male and the areas of deficit. The final report will be provided to the Ministry of Health, Maldives that will assist in the planning of preventive educational programs for the community in a suitable way. This chapter briefly describes the context of the study, the purpose and significance of the study as well as the study question. It concludes with a discussion on the organization of this thesis.
1.1 Background and Significance Dengue is a mosquito-borne infection that had become a major public health concern. It is a disease found in most tropical and subtropical areas of the world and had become the most common arboviral disease of human. Dengue fever and dengue hemorrhagic fever (DHF) are viral diseases transmitted by Aedes mosquitoes, usually Aedes aegypti. The four dengue viruses (DEN-1 through DEN-4) are
immunologically related, but do not provide cross-protective immunity against each other (Center for Disease Control [CDC], 2007). 1.1.1 Global Burden of Dengue Fever Dengue virus is now believed to be the most common arthropod-borne disease in the world. The World Health Organization (WHO) currently estimated there might be 50 million cases of dengue infection worldwide every year. About 250,000 individuals per year manifest the severe forms, which have a mortality rate of about 10 percent. Given the dramatic geographic expansion of epidemic dengue fever (DF) and dengue hemorrhagic fever (DHF), the WHO has classified this disease as a major international public health concern. 1.1.2 Dengue in South East Asia Region The health burden of dengue in South East Asia only is estimated to be 0.42 Disability Adjusted Life Years (DALYs) per 1,000 population (52% due to premature mortality, 48% due to morbidity (Shepard et al., 2004)). The global prevalence of dengue has grown dramatically in recent decades. Not only is the number of cases increasing as the disease is spreading to new areas, but explosive outbreaks are occurring as its epidemiological pattern is changing (Gubler, 1998). In 2003, only eight countries in South East Asia Region reported dengue cases. As of 2006, ten out of the eleven countries in the Region (Bangladesh, Bhutan, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, Thailand and TimorLeste) reported dengue cases. Bhutan reported the first dengue outbreak in 2004. An
outbreak with a high case fatality rate (3.55%) was first reported in Timor-Leste in 2005. The Democratic Peoples Republic of Korea is the only country in this Region of WHO that has no report of indigenous transmission of DF/DHF. In 2006, most
countries reported increase in dengue cases
(Bangladesh, Bhutan, Indonesia,
Thailand, Maldives and Sri Lanka) whereas India, Myanmar and Timor-Leste reported slightly lesser cases than in 2005. Nepal reported dengue cases for the first time in November 2006 (WHO Regional Office for South-East Asia, 2007). 1.1.3 Dengue in Maldives The first Dengue outbreak officially confirmed in Male' (the capital of Maldives) and in Eydhafushi and Dharavandhoo of Baa atoll was in May - June, 1979. Similar outbreaks were reported in Male' in March - April, 1983 and in April, 1988. However, the most serious outbreak occurred in 1988. During this outbreak a total of 2,054 cases with all types of manifestations; Dengue Fever (DF), Dengue Hemorrhagic Fever (DHF) and Dengue Shock Syndrome (DSS) were recorded. Out of the total 2,054 cases, 9 deaths were recorded (Male, Maldives, 2008). After a gap of ten years, outbreaks in 1998 and 1999 were reported with 1,750 and 1,835 cases, respectively. For the first time using commercial diagnostic kits, 81 cases of DF and 15 cases of DHF were detected during the 1998 outbreak, and 59 DF cases and 38 DHF cases were detected in the 1999 outbreak. Since 1979, dengue has become endemic in Maldives. A clinical based surveillance system exists in the country through which dengue situation is monitored daily. Through this daily surveillance, the recent outbreak of dengue was detected in October 2005, which reached a 10-fold increase in the number of cases in January and February, 2006. During October, 2005 to 31st December, 2006, a total of 3,393 cases including 10 deaths were reported with Case Fatality Rate (CFR) of 0.3%. The outbreak peaked in June, 2006 which was laboratory confirmed and dengue virus serotype DEN-1, 2 and 3 were identified to be circulating in the country of which DEN-3 was the most common serotype. Male' was
the most affected island during the outbreak from which 45% of the cases (N=1,262) were reported. 1.1.4 Current Situation In the first two weeks of 2007, a total of 71 cases were reported which is about 33% less compared with the same period of 2006 (141 cases) and about 51% more compared with the same period of 2005 (23 cases). And in the year 2007 no death occurred due to dengue fever. 1.2 Rationale One of the Policy Goal which was mentioned in Health Master Plan 2006 2015 was to ensure people have the appropriate knowledge and behaviors to protect and promote their health. The proportion of people with correct knowledge on dengue: Baseline data available (survey done in December 2007) Target (2010) - increase by 10% Target (2015) - increase by 25% Recently a survey was done to find out the baseline data and still more surveys are needed in order to have enough evidence which will then assist to identify the limitations and can facilitate to promote the health of the people. Dengue fever has emerged as an important public health problem in Maldives as it has become endemic throughout the country. The total number of dengue fever cases recorded, both in Male and Atolls, were 2,768 cases in 2006. So it is very
important to assess the knowledge, attitude and practices of dengue prevention among
people, the shortcomings in this important aspect should be identified and hence it can be worked on to develop appropriate community-oriented prevention programs. Community participation and co-operation has resulted in various degrees of success in disease prevention. This will result in efficient health care in the community level. One of the possible determinants of decrease in dengue illness rate can be increased awareness of the disease, which can be brought about by appropriate dengue prevention programs. Furthermore, studies on this topic are deficient in Maldives and work need to be done to find out the present status regarding dengue prevention and to make efforts to make it worthwhile task. 1.3 Background information of Maldives The Republic of Maldives is a chain of nearly 1,200 tiny coral islands in the Indian Ocean, of which only 200 are inhabited. The Maldives Archipelago contains 26 geographic Atolls that together form a chain 820 kilometers in length and 120 kilometers at the widest point. The 26 geographic atolls are grouped into 20 administrative regions. All islands of Maldives are very low lying, and none exceeds an elevation of three meters. More than 80 percent of the land area is less than 1 meter above mean sea level. The total population of the Maldives in 2006 was 298,698 with a growth rate 1.96%. The population of Male was 103,693 (Ministry of Planning and National Development, 2008). 1.3.1 Problem Statement Maldives is a dengue endemic area with periodic outbreaks during rainy seasons. Every year there is an epidemic and increase in morbidity but not in
mortality. In 2005, the cases had increased but no deaths were reported.
In 2006, the
dengue cases increased to 52% (2,768 cases) and there were 10 deaths (Male, Maldives, 2008). In Maldives Aedes aegypti is the presumed vector. Maldives has received support for their social mobilization activities on dengue vector control from the World Health Organization. Maldives has peaks of dengue cases in the later part of the year from October to December. The dengue cases have remained uncontrolled since October 2005. In 2006, cases doubled and deaths increased from 0 in 2005 to 10 in 2006. In 2007 till October, 1,494 cases have been reported and no deaths. Maldives has potential for frequent outbreaks so the disease and vector surveillance as well as awareness programs should be stepped up and sustained. 1.4 Objectives of the study 1.4.1 General Objective The primary purpose of the study was to identify the current state of knowledge, attitude and practices of the people living in Male fever. 1.4.2 Specific Objectives a. To illustrate the demographic characteristics of people in Male. b. To study the relationship of dengue fever prevention practices with age, gender, education, sources of information and level of knowledge and attitude. regarding dengue
1.5 Research Question What is the knowledge, attitude and practice level of the residents who are living in Male?
1.6 Expected Outcomes and Benefits 1.6.1 The results can be used as a guideline in planning for more effective and reliable solution to health problems in relation to dengue fever. 1.6.2 Results can direct policy makers on health promotion interventions that are more likely to improve in declining the dengue cases in future.
1.7 Operational Definitions 1.7.1 Knowledge: The knowledge that the respondent have regarding the cause, transmission, clinical manifestation and prevention of dengue fever. 1.7.2 Attitude: The feeling and belief of the respondents with regard to dengue fever and its prevention. 1.7.3 Practice: The actions intended to do in order to prevent from dengue fever.
CHAPTER II LITERATURE REVIEW

2.1 Introduction This chapter reviews the International literature on dengue prevention and peoples Knowledge, Attitude and preventive behavior of the disease. It then goes on to examine the mosquito vector, dengue virus, manifestation of dengue virus and the impact of the disease on the health care system. Knowledge of dengue is as an essential component of dengue fever prevention and will be discussed in the light of current literature.
2.2 Knowledge, Attitude and Practice (KAP) studies on Dengue Fever Swaddiwudhipong (1992) conducted a study on Knowledge, Attitude and Practice of the prevention of dengue fever in an urban community in Thailand. 417 households, selected by a systemic cluster sampling method, were interviewed. They found that more than 90% of them know that the disease is transmitted by Aedes mosquitoes and indicated water jars and water retention in the house as the common breeding places. However, the other two common breeding places, and traps and cement baths, were less frequently mentioned. Gupta et al. (1998) conducted a study to assess the knowledge and attitudes about dengue and practice of prevention followed by the residents of a rural area and an urban resettlement colony of East Delhi. It was an interview based cross sectional KAP study which was undertaken in January 1997 to February 1997, a few months
after the dengue epidemic in rural area and urban areas of East Delhi. A pre-structured and pre-tested format containing the relevant questions was administered to the subjects. A total of 687 subjects (334 rural and 353 urban) were interviewed. Nearly four fifth (82.3%) of these were aware of Dengue. Audiovisual media was the most common source of information in both the areas. Knowledge about the disease was fair to good. Fever was the commonest symptom of the disease known to 92% urban and 83% rural respondents followed by symptoms of bleeding and headache. Mosquito was known to spread the disease to 71% rural and 89% urban respondents. More than two third respondents in urban and two fifth in rural areas had used some method of mosquito control or personal protection during the epidemic. Kumar & Gururaj (2000) conducted a study on community perception regarding mosquito-borne diseases in Karnataka, India. The study revealed that more than 90% of the people interviewed perceived mosquitoes as a problem. However, this perception was with regard to the nuisance value of mosquito bites rather than disease-causing potential. Quite a large number of people did not know where the mosquitoes bred. More than one third of the interviewees did not know of any preventive measures against mosquitoes at the community level. Approaches based on social mobilization and communities aimed at bringing behavior change in the communities are stressed. Van Benthem et al. (2002) conducted a study in knowledge and use of prevention measures related to dengue in northern Thailand. They found that of the 1,650 persons, 67% had knowledge of dengue. People with knowledge of dengue reported a significantly higher use of prevention measures than people without knowledge of dengue. In multivariable analyses, knowledge of dengue significantly
12 differed by age, sex, occupation and site (p<0.05). The authors did not give the directions of the associations. Hairi et al. (2003) conducted a study on knowledge, attitude and practices (KAP) on dengue among selected rural communities in the Kuala Kangsar district. The study population was 1511 by simple random sampling method. The data was collected by face-to-face interview of the head of households using a semi-structured questionnaire and found that the knowledge on dengue of community was good. Cross tabulations were done between knowledge and practice, knowledge and attitude, and attitude and practice. There was no significant association seen between knowledge and practice. However, there was a significant association seen between knowledge and attitude towards Aedes control (p=0.047) Matta et al. (2006) conducted a study on Knowledge, Attitude & Practice (KAP) on Dengue fever: A Hospital Based Study. The study was done with the aim of assessing knowledge regarding Dengue fever among general population attending a hospital out-patient department. Another aim was to assess, whether simple preventive measures to check and destroy the breeding sites of mosquito like checking of coolers, discarded tires, flower pots etc. are being practiced in the community. Overall 500 interviews were taken in 28 days (from 1st October to 28th October 2003). Overall 82.4% respondents knew that dengue fever is transmitted by mosquito & 54% associated Dengue with flies/person to person transmission. Regarding knowledge about breeding, 399 (79.8 %) respondents knew about breeding places of mosquitoes. Coolers as the most probable breeding site (for mosquitoes) was named by 42.4% respondents followed by cooler & tires by 24.2%. In this study they
13 concluded that though the knowledge regarding dengue is good in the general population, practice of checking coolers, tires & flower pots is quite poor. Claro et al. (2004) wrote an article on Dengue prevention and control: a review of studies on knowledge, beliefs, and practices. This article aims to contribute to dengue control programs through a review of recent studies on knowledge, beliefs, and practices concerning dengue and dengue prevention. The results show that adequate knowledge of dengue and prevention methods are found in close association with high rates of domiciliary infestation by Aedes aegypti. This suggests that traditional education strategies, although efficient in transmitting information, have failed to change population behavior. Qualitative studies reveal two important issues that appear to explain these attitudes: representations of dengue and risks associated with mosquitoes and difficulties in avoiding infestation of household water recipients due to sanitation problems in communities. Chusongsang (2005) studied factors affecting dengue fever prevention and control behaviors of household leaders and primary school teachers in Khuankhanun District, Phatthalung Province. Logistic regression analysis was used. The results from univariate analysis showed that household leaders with higher level of knowledge had 3.73 times better prevention and control behaviors of DHF (OR=3.73, 95% CI=2.10 - 6.61) Limros (2006) did a cross-sectional analytical study among health leaders of Konkrailat District, Sukhothai Province. He found out that attitude score was positively correlated with knowledge score (p<0.001), but attitude, unlike knowledge, was not associated with elimination of breeding places. For community level cooperation against dengue infection, attitude was associated with campaign
14 (p=0.001), and frequency of information with spray use (p<0.001) and coil use (p=0.022). Koenraadt et al. (2006) conducted a survey on Knowledge, Attitude, and Practice (KAP) in two sub-districts of Kamphaeng Phet province, Thailand, to test the hypothesis that correct dengue knowledge and practice reduce dengue vector populations. They found a negative association between respondents' knowledge of preventive measures and the number of unprotected containers in and around their houses. Knowledge of development sites was positively associated with unprotected containers. No relationships existed between knowledge of dengue and adult mosquito reduction practices. A higher number of unprotected containers increased the likelihood of the house being infested with one or more adult Aedes aegypti. Surprisingly, houses of respondents that used mosquito coils or had screening on doors and windows were significantly more likely to be infested (odds ratio =2.0) with adult Aedes aegypti. They concluded that there is a direct link between knowledge on dengue prevention and container protection practices, whereas measures against adult mosquitoes are used only when people experience a mosquito nuisance problem. Community Awareness Survey on Dengue was done in December, 2007. The survey intended to determine the knowledge, attitude and practices on dengue among the population. A convenient sampling was used for the study and 2000 people participated in the survey. The respondent were from Male, Hulhumale and K.Villingili. Among the respondents, 62.25% were aware of the type of dengue. They have recommended in the study that there is a need of public participation in controlling dengue (Male, Maldives, 2008).
15 In light of the surveys done on dengue fever it showed that knowledge was associated with the preventive behaviors of the people. Koenraadt et al. (2006) concluded in the study that there is a direct link between knowledge on dengue prevention and container protection practices, whereas measures against adult mosquitoes are used only when people experience a mosquito nuisance problem. The study done by Claro et al. (2004) showed that adequate knowledge of dengue and prevention methods are found in close association with high rates of domiciliary infestation by Aedes aegypti. Another study which was done by Van Benthem et al. (2002) showed that people with knowledge of dengue reported a significantly higher use of prevention measures than people without knowledge of dengue. This showed that correct knowledge was needed in order to prevent from dengue fever. Along with all the support we need to provide the community with the precise knowledge regarding the disease and to clarify any doubts they have. 2.3 Dengue Virus It is a RNA virus belonging to Flaviviridae group consists of 4 serotypes, DEN-1 to DEN-4. All are capable of causing disease in humans. Recent trends show an increase prevalence of DEN-3 serotype.
2.4 Mosquito Vector Dengue Fever (DF) is caused by mosquito of Aedes group. The most important one is A. aegypti which is a day biting mosquito, rests indoors and can breed in small collection of water. Rainy season increases risk of DF as it increases larval population; ambient temperature and humidity favor viral propagation.
16 2.5 Human Activities that Influence the Spread of Dengue The phenomena of human population growth in the tropics and dramatic redistribution of the human population into urban centers have greatly influenced the epidemiology of dengue; the density and distribution of its vector. However, in the American region, the urban population exploded during the period 1970 to 1990 and it is in these urban areas that dengue has become a major health problem, while rural populations have been less affected. Insufficient municipal water supplies, necessitating the storage of water for drinking and washing, and poor sanitation (resulting in the great amount of devices that collect rainwater, e.g., bottles, cans, tires, etc) have been responsible for a huge expansion of A. aegypti populations in America. This coupled with a very large supply of susceptible human hosts has created a system ideal for the inexhaustible transmission of dengue viruses.
17 2.6 Manifestations of Dengue Virus infection

Dengue Virus Infection
Asymptomatic
Symptomatic
Dengue Haemorrhagic Fever (plasma leakage) Undifferentiated Fever (viral syndrome) Dengue Fever syndrome
No Shock
Dengue shock syndrome
With haemorrhage
With unusual haemorrhage
Dengue Fever
DHF
Figure 2: Manifestation of dengue virus
18 2.7 Impact of Dengue Fever in the Health Care System Clark et al. (2005) conducted a study on dengue fever and dengue
hemorrhagic fever which constitutes a substantial health burden on the population in Thailand. In this study, the impact of symptomatic dengue virus infection on the families of patients hospitalized at the Kamphaeng Phet Provincial Hospital with laboratory-confirmed dengue in 2001 was assessed, and the disability-adjusted life years (DALYs) lost for fatal and non-fatal cases of dengue were calculated using population level data for Thailand. When they accounted for the direct cost of hospitalization, indirect costs due to loss of productivity, and the average number of persons infected per family, they observed a financial loss of approximately US $61 per family, which is more than the average monthly income in Thailand. The DALYs were calculated using selected results from a family level survey, and resulted in an estimated 427 DALYs/million population in 2001. These results indicate that dengue prevention, control, and research should be considered equally important as that of diseases currently given priority. Harving & Ronsholt (2007) conducted a survey on the economic impact of dengue hemorrhagic fever on family level in Southern Vietnam and this study shows that the average family cost of treating one child is approximately (USD 61) including direct and indirect costs. On average, the largest expenses were those related to the initial visit at a local general practitioner, the hospital bill and lost income for the parents. Dengue hemorrhagic fever is a large expense for a family and can rightly be considered as a substantial socio-economic burden in Southern Vietnam.
19 2.8 Summary This chapter has highlighted why people need to have good knowledge of dengue fever and provided literature from around the world which suggested that peoples knowledge on dengue fever plays an important part in the prevention of the disease. It has described dengue virus, mosquito vector, manifestation of dengue virus and human activities that influence the spread of dengue. It has also provided information on the impact of dengue on health care systems. The following chapter describes the methods used for this research in detail.
CHAPTER III RESEARCH METHODOLOGY
3.1 Study design The study design was a descriptive cross-sectional study concerning Knowledge, Attitudes, and Practices of dengue fever prevention among the people in Male, Maldives.
3.2 Study population The population in this study was residents of Male who were living there for at least one year and are of age between 18 - 60 yrs.
3.3 Study area Male was selected as the study area due to the high population density and availability of adequate data. It is the home of over 103,693 people and data on dengue occurrence is available from 1998 up to 2006. So considering these factors Male was selected as an ideal for this survey. Male has an area of roughly two square kilometers. Administratively Male is divided into four districts. Each district is divided by roads. Henveiru: Maafannu: Galolhu & Machchangolhi: occupies the North-East side occupies the North-West side lie in the centre and to the south.
Majority of the island is not zoned, between residential and commercial areas. It is further divided into blocks and every block has a unique block number assigned by Male Municipality. Each block may enclose several houses, shops, garages and many more. All the houses in Male has a name unlike a numeric address as in other countries. All the roads are paved in Male and the drainage is handled by a system of drains on either side of the roads which connect to underground wells. There has been lot of conjectures about these wells as a source of misquote. However, there has been no survey of mosquito breeding sites undertaken in Male. Other than this, mosquitoes are thought to breed on roof gutters and underground wastewater tanks in Male.
3.4 Study period From February 19, 2008 - March 08, 2008.
3.5 Sample size N = z 2pq d2 Where z = the reliability coefficient at 95% confidence interval (1.96) d = acceptable error (0.05%) p = proportion in the population processing the characteristic of interest q = (p-1) The above formula was used to calculate the sample size. As studies were deficient in this topic in Maldives a pilot study was done and then computed an estimate for the value for p which then was applied to calculate sample size.
22 Standard values which can be used in this formula to calculate the sample size might be either larger or smaller of a better estimate of p. This procedure should be used only if one is unable to arrive at a better estimate of p (Wesson, 2006). Below shows the percentages which have been calculated from the pilot study and the value for p which was used in this study was 68%. Knowledge: Attitude: Practice: 69% 74% 68%
The pilot study was done in another district which was not included in the actual survey. The district selected was Machchangolhi which lie in the center and to the south side of Male and 30 household was selected to participate in the pilot study. N= 1.962 x 0.68 x 0.32 0.05 x 0.05 = = = 334 + 33 (10%) 367 374 sample size
The sample size turned out to be 374 instead of 367 because the 19 blocks which was selected randomly had a total number of 374 houses. Hence all the houses have been included in the survey.
3.6 Sampling Methods Step 1: Purposive sampling method was used and Maafannu was chosen among the four districts. This was because this area was considered to have more
23 people living than the rest of the three districts. Maafannu has a total number of 134 blocks and 2,292 houses. Step 2: Each District is further divided into block and numbers have been assigned to these blocks. Therefore in this step simple random sampling method was used to select the blocks. Each block did not exceed more than 100 houses. A total of 19 blocks were selected randomly and all the houses in those blocks were included in the survey. A total of 374 houses were in the 19 blocks which have been selected. Step 3: After selection of the household, head of each selected household was interviewed.
3.8 Research Instrument and Measurement A standardized questionnaire was developed from questionnaires which have been used in earlier studies and from different articles related to dengue fever and was used for the survey. The questions were directed towards gaining information regarding the peoples knowledge, attitude and practice on dengue fever. It also included the socio-demographic characteristics of the subjects. The questionnaire was translated from English to Dhivehi and was made sure that the original meaning is retained. The questionnaire was divided into 5 core categories and they are:
25 Part I (Socio-demographic): There were 11 questions in this part. The questions include sex, age, etc. Single question which asked about the source of information in which they receive regarding dengue fever have been included in this part. Part II (Knowledge regarding Dengue Fever): There were 14 questions in this part and were asked to know the knowledge of dengue fever which included signs and symptoms, transmission, treatment and prevention. Each question had two choices. A correct answer was given 1 score and 0 score for a wrong answer. The score varied from 0 - 14 points and was classified into 3 levels as follows: Blooms cut off point, 60-80%. High level (80-100%) Moderate level (60%-79%) Low levels (less than 59%) 12-14 scores 09-11 scores 00-08 scores
Part III (Attitudes regarding Dengue Fever): This part includes the attitude of the people towards dengue fever in the aspect of prevention and it was assessed by using Likerts scale. There were 12 statements which included both positive and negative. The rating scale was measured as follows: Positive Statement Choice Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree Scores 5 4 3 2 1 Negative Statement Choice Strongly agree Agree Neither agree nor disagree Strongly disagree Strongly disagree Scores 1 2 3 4 5
26 The scores varied from 12 to 60 and all individual answers were summed up for total scores and calculated for means. The scores were classified into 3 levels (Positive Attitude, Neutral Attitude and Negative Attitude). Positive Attitude Neutral Attitude Negative Attitude 47-60 scores 41-46 scores 12-40 scores
Part IV (Practices regarding Dengue Fever): 13 items have been included in this part. For several items, many respondents answered Do not have. In such items sample sizes were too small to allow meaningful, representative analysis of practice in relation to independent variables. Hence, in this study only 8 items were analyzed (item 1, 7, 8, 9, 10, 11, 12 and 13) and the score in practices regarding dengue prevention of the respondents varied from 0 to 8, and were classified into 3 levels. These 8 items were all assessed as zero-one indicator (dummy) variables. These variables were given value zero for no and value one for yes. They were good practice, fair practice and poor practice (Blooms cut off point, 60-80%). Good Level Fair Level Poor Level Part V (Observation): Observation checklist was included in this part. This was a non-participant observation where the researcher does not get involved in the activities of the group but rather remains as a passive observer. So here the researcher only examine and then draw a conclusion from what have been observed. 07 - 08 scores 05 - 06 scores 00 - 04 scores
27 3.9 Validity Validity is the test which measures the desired performance and appropriate inferences can be drawn from the results (New Horizons for Learning, 2007). The assessment accurately reflects the learning it was designed to measure. Content validity was ensured by taking suggestions from qualified persons. The questionnaire was amended according to the suggestions.
3.10 Reliability Reliability is the measure of consistency for an assessment instrument. The instrument should yield similar results over time with similar populations in similar circumstances (New Horizons for Learning, 2007). To ensure reliability, the questionnaire was pre-tested before the actual data collection began, with 30 people who are living in Male. And the internal consistency was analyzed by using Cronbachs Alpha Coefficient. Upon analysis, the Cronbachs Alpha result was 0.73 for knowledge part, 0.71 for attitude part, and 0.80 for practice part. The overall Cronbachs Alpha Coefficient value was 0.80.
3.12 Data Collection Process After getting the ethical approval from Ministry of Health, Maldives a pilot study was done of 30 households in a different district as the actual survey. The researcher spent 03 days (19/02/2008 - 21/02/2008) for the pilot study. After that the data collection for the actual survey was started. For that the researcher spent 15 days (23/02/2008 - 08/03/2008) every day from morning 10:00 hrs till evening 18:00 hrs in completing the questionnaires. The 374 completed questionnaires were then used for the analysis.
3.13 Data Analysis and Statistic Application
Data was analyzed by using SPSS program, version 15 for windows. The questionnaires were weighed against the database to check the accuracy of the data entry a minimum of two times. Any error found was corrected before the actual analysis. Descriptive statistics (frequency, percentage, mean and standard deviation) were used primarily to summarize and describe the data to make it more graspable. For analytical statistic Chi-square was used where appropriate and correlation coefficient was used to describe the strength and direction of the relationship between two variables. Frequency distribution in terms of: Socio-demographic charactersitics Level of knowledge Attitude towards dengue fever Practice regarding dengue fever prevention Cross-tabulations: Level of practice behaviors of dengue fever prevention with Age, Sex, Marital Status, Education, Occupation, Sources of information about dengue fever, etc Association between: Socio-demographic characteristics and practice Knowledge and practice Attitude and practice
3.14 Limitations of the Study 3.14.1 Study Design: A descriptive study design was used to describe the knowledge, attitude and practices of the study participants in relation to dengue fever prevention. Descriptive designs do not attempt to generalize the findings to populations outside the study participants. Therefore, findings of this study could not be generalized beyond the participants of the study. As this study was done in Male, the capital of Maldives it cannot be generalized to the rest of the community who are living in other small islands.
3.14.2 Proportion of the Population: In this study females proportion is higher than males. The male: female ratio in this study was 1.5 which meant there
were 150 men to every 100 women. Whereas in Maldives, for the whole population the ratio is 1.05 which meant there are 105 men to every 100 women. So the result might not represent the society as a whole. 3.14.3 Data Collection Tool: Another limitation of this study was that it used a structured questionnaire to collect data from the survey population. This limited the responses that the people could choose from and did not have the capacity for indepth answers. Dengue is a vast and very important topic and only some aspects were included in the questionnaire leaving many areas of knowledge not explored. 3.15 Summary This chapter has discussed the research methods used for this descriptive study, with specific focus on sample and setting, questionnaire development, validity and reliability, ethical considerations, methods of data collection and analysis. The next chapter will describe in detail the results or findings of the data analysis.
CHAPTER IV RESULTS
This chapter provides a detailed description of the results obtained from the analysis of the survey and the observation. The variables are described as simple percentages, means, and standard deviations etcetera as appropriate depending on the nature of the variables. It starts with the demographic data followed by the responses for each section of the questionnaire. The level of knowledge, attitude and practice score were then presented followed by the results Chi square test used as appropriate, to see whether there is any association between socio demographic characteristics and Practice scores. Lastly correlation was used to see the relationship between Knowledge and Practice and Attitude and Practice scores among the respondents.
4.1 Demographic Information This study was conducted in Maafannu district of Male, Maldives. Three hundred and seventy four participants (374) completed the survey questionnaire. The majority of the participants were female (60%). The mean age of the participants was 36 years with a standard deviation of 9.63. The age ranged from 20 to 62 years. Table 2 shows that the majority of the respondents (39%) were in the age range of 31 - 40 years, 33% were younger than 31 years, 20% were older than 41 years and only 27 respondents (7.0%) were older than 51 years. More than half of the respondents (86%) were married. Most of them were educated both in primary school (44%) and in secondary school (44%) and most of them were employed (65%). Out of those who
were employed and economically active the common income was above Ruffiyya 3000/month (USD 234/month) (45%). Most of the families had a family size of 1 - 10
people (81%) and most of them (83%) had 0 - 3 kids below 15yrs. 73 (20%) households had the history of dengue fever.
Table 2: Distribution of the respondents by socio-demographic characteristics Characteristics Gender Male Female Age group (years) 21-30 31-40 41-50 51 Mean = 35.89 Marital Status Single Married Widowed/Divorced 15 323 36 4.0 86.4 9.6 SD = 9.63 125 147 76 26 Minimum = 20 33.4 39.3 20.3 7.0 Maximum = 62 149 225 39.8 60.2 Number (n=374) Percentage
Education Level Primary Secondary Graduate/Post graduate 164 164 46 43.9 43.9 12.2
Table 2: (continued) Distribution of the respondents by socio-demographic characteristics Characteristics Employment Status Employed Unemployed Economically Active Income (Rufiyya/month) None 900- 1500 1501-3000 100 26 81 26.7 7.0 21.7 244 100 30 65.2 26.7 8.1 Number (n=374) Percentage
3001
167
44.7
Members in the family 10 11-20 21 Mean = 8.31 SD = 5.37 301 57 16 Minimum = 1 80.5 15.2 4.3 Maximum = 40
Children under 15yrs of age 3 4-6 7 Mean = 2.06 SD = 1.67 312 57 5 Minimum = 0 83.4 15.2 1.3 Maximum = 11
History of dengue in the last 2yrs Yes No 73 301 19.5 80.5
34 4.2 Source of information regarding dengue fever Among the respondents, 90% had received some sort of information regarding dengue fever while 10% hadnt received any as shown in figure 2. Figure 3: Respondents who received information about dengue fever
Respondents were allowed to select more than one source for received information about dengue fever. Among the 90% who received the information, were from both Television (T.V) and Radio (42%) followed by T.V, Radio and other sources (16.6%). Smaller percentages reported receiving from magazines, leaflets, newspapers or friends as shown in Table 3. Those who have mentioned other sources of information comprised of internet, either because of the profession or one of their family members had a history of dengue fever in the past 2 years.
35 Table 3: Number and percentages of the sources which the respondents received information regarding dengue fever. Source of information None T.V and Radio Newspaper Magazines Leaflets Friends Others All of the above Newspaper, Magazines and leaflets T.V, Radio and others Total Number (n = 374) 39 157 7 1 6 7 35 50 10 Percentage 10.4 42 1.9 0.3 1.6 1.9 9.4 13.4 2.7
62 374
16.6 100
4.3 Knowledge on Dengue Fever

Participants answered a total of 14 close ended, multiple choice questions about dengue fever. Each correct response was given one mark with a total of 14 marks. The mean knowledge score for the respondents was 8.60 out of possible 14 points (SD = 2.45). Five of the respondents were able to answer all the questions correctly. The range of knowledge score was 0 - 14 as shown in Table 4.
36 Distribution of knowledge on dengue fever of the respondents showed that 46% of subjects had low knowledge as well as 41% of them had moderate knowledge while 13% had high knowledge. Table 4: Distribution of knowledge level on dengue fever. Level High (12-14 scores) Moderate (9-11 scores) Low ( 0-8 scores) Total Minimum = 0 Number (n=374) 47 155 172 374 Maximum = 14 Mean = 8.60 Percentage 12.6 42.4 46.0 100.0 SD = 2.45
Response for the 14 knowledge part of the questionnaire was summarized in Table 5. 91.4% of the respondents knew that empty stagnant water from old tires, trash cans, and flower pots can be breeding places for mosquitoes (item 7). The questions
with the least number of correctly answered were 29.9% and 31.8%, for the question regarding abates sand (item 11 and 12).
4.4 Attitudes towards Dengue Table 6: Distribution of attitude levels towards dengue fever of the respondents Level Positive (47-60 scores) Neutral (41-46 scores) Negative (12-40 scores) Total Mean = 45.63 SD = 5.66 Number (n=374) 159 158 57 374 Minimum = 26 Percentage 42.5 42.2 15.2 100.0 Maximum = 58
Participants answered a total of 12 questions which had a total score of 60. Distribution of attitudes on dengue fever of the respondents is shown in Table 6. There were 42.5% of respondents who had positive attitude , 42.2% of them had
neutral attitude, while 15.2% had negative attitude. The mean attitude score for all respondents were 45.63 out of a possible 60 points (SD = 5.66). The range of attitude score was 26 and 58 respectively as shown in Table 6.
41 4.5 Practice about dengue fever In the survey questionnaire, there were 13 questions related to practices against dengue fever prevention. For 5 of the 13 items, distributions of responses did not allow a meaningful assessment in relation to independent variables. The responses regarding each of these items are summarized in Table 8.
Out of these five questions and those who have the above items in their household responded in the following ways as shown in Table 9, Figure 4 and Figure 5. Thirty eight percent of the respondents chlorinated their water tanks in order to prevent from mosquito breeding (figure 4). As in figure 5 most of the respondents examined their flower pots for mosquito larvae weekly (38%) and (23%) respondents
42 drained off the water from the plates supporting the flower pots weekly as shown in Table 9.
Table 9: Frequency and percentages of the times in which the respondents drain water in the plates supporting the flower pots (n = 374).
Number None Weekly Alternate days Daily Total 236 86 9 43 374
Percentages 63.1 23.0 2.4 11.5 100
Figure 4: shows the ways in which people do perform in preventing mosquito Gbbbbbbbbbbbreeding in water tanks (n = 374).
Figure 5: shows how often (in percentages) the respondents examine for mosquito jijijijijijijiji larvae in the flower pots (n = 374).
The remaining 8 analyzable items were all assessed as zero-one indicator
variables (dummy variables). Each correct response was given one mark with a total of 8 marks and the score was summed up and set as three levels, poor practice, fair practice and good practice. The mean practice score for the respondents was 4.75 out of possible 8 points (SD = 1.39). As presented in Table 10, majority of the
respondents had fair practice and 43% had low practice, while only 8.8% had good practice. Range of the respondents practices scores was 1- 8.
Table 10: Distribution of practice levels towards dengue fever prevention. Level Good (7-8 scores) Fair (5-6 scores) High (0-4 scores) Total Mean = 4.75 SD = 1.39 Number 33 180 161 374 Minimum = 1 Percentage 8.8 48.1 43.0 100.0 Maximum = 8
44 Table 11: Number and percentages of the items on the practice of dengue fever prevention answered correctly by the respondents (n = 374). Items Number Percentage
1. Covering water jars after using immediately. 7. Examining discarded item that can hold water koaround the house. 8. If yes, do you ever put them in the garbage or nndispose them. 9. Using mosquito net/mosquito coils in your house. 10. Participation when the community has been nnasprayed fog. 11. Participation in any campaigns of dengue aaaainfection in your community. 12. Examining the mosquito larvae in water containers in the toilet. 13. Checking and cleaning roof gutters in the rainy aaaaseason.
368 284 211 271 45 59 293 244
98.4 75.9 56.4 72.5 12.0 15.8 78.3 65.2
Table 11 shows a summarized response for the practice part of the questionnaire. Ninety eight percent of the respondents cover the water jars after using it immediately which is a very good practice. The questions with the least number of correctly answered were 12% and 16%, for the question regarding community participation in dengue fever prevention (Item 10 and 11).
45
30%
28% None Night 41% Daytime Always
1%
Figure 6: shows the time the respondents use mosquito coils or electric mosquito hihihihihihi controllers to prevent from mosquito bites (n = 374).
Majority of the respondents (41%) use during night time only and 28% of the respondents do not use. Thirty percent use day and night time and only one percent use during day time. Twenty eight percent who did not use anything to prevent from mosquito bites might find mosquito bites as of not a nuisance to them. People who were using mosquito coils or mats at night meant that they were not aware of dengue transmitting mosquito as a day biting mosquito.
4.6 Observation Results Twenty five percent of the households had water collection on the plates supporting flower pots at home and only 5% of the household had stored water containers in the toilet. None of the houses had dirty water in indoor plants. Of the interviewed households, 59% had dirty housing environment. Most of the houses doors and windows remain closed all the daytime and inside was relatively
46 dark. This can be a preferable resting place for Adult Aedes mosquitoes. Forty seven percent of the households had empty cans, discarded bottles or anything that can hold water around the house. And 54% of the households had not covered the stored water containers/tanks.
4.7 Comparison of Practice score between the grouping variables To compare the practice scores between the different groups (age groups, gender, education, occupation, etc), chi-square test was used. No statistically significant difference was found between any of the groups except for the gender and knowledge. Also correlation coefficient test was used between knowledge and attitude with the practice scores treating the variables as continuous variables. The following tables (Table 11 to 21) provide the details of these tests. Table 12: Association between gender and practices on dengue prevention (n = 374) Gender Level Poor Practice Fair Practice High Practice Total Male No. (%) 73(49.0) 69(46.3) 7(4.7) 149(100) Female No. (%) 87(38.7) 110(48.9) 28(12.4) 225(100) Total No. (%) 160(42.8) 179(47.9) 35(9.4) 374(100) 8.11 0.01 ChiSquare P value
Gender had association with level of practice behaviors among the respondents in this study (p = 0.01), as shown in Table 12. Females had higher practice behavior than males in prevention of dengue fever.
47 Table 13: Association between age and level of practice behaviors against dengue fever prevention (n = 374). Age Level 20 - 30 No. (%) 56 (44.8) 61 (48.8) 8 (6.4) 125 (100) 31- 40 No. (%) 68 (46.3) 66 (44.9) 13 (8.8) 147 (100) df = 6 41 - 50 No. (%) 27 (35.5) 39 (51.3) 10 (13.2) 76 (100) Above 51 Total No. (%) No. (%) 9 (34.6) 13 (50.0) 4 (15.4) 26 (100) p = 0.45 160 (42.8) 179 (47.9) 35 (9.4) 374(100)
Poor Practice Fair Practice Good Practice Total 2 = 5.77
As shown in Table 13 there is no association between age and level of practice.
Table 14: Association between marital status and level of practice behaviors against dengue fever prevention (n = 374). Marital Status Level Single No. (%) Poor Practice Fair Practice Good Practice Total 2 = 6.47 9 (60.0) 5 (33.3) 1 (6.7) 15 (100.0) Married No. (%) 133 (41.1) 162 (50.2) 28 (8.7) 323 (100.0) df = 6 Divorced/ Widowed No. (%) 18 (50.0) 12 (33.3) 6 (16.7) 36 (100.0) p = 0.37 160 (42.8) 179 (47.9) 35 (9.4) 374 (100.0) Total No (%)
There was no clear association of marital status with practice level (p = 0.37).
48 Table 15: Association between level of education and level of practice behaviors against dengue fever prevention (n = 374). Education Level Primary Secondary No. (%) No. (%) Graduat Total e/ No (%) Post graduate No. (%) 160 (42.8) Poor Practice Fair Practice Good Practice Total 67 (40.9) 82 (50.0) 15 (9.1) 164 (100.0) 70 (42.7) 76 (46.3) 18 (11.0) 164 (100.0) 23 (50.0) 21 (45.7) 2 (4.3) 46 (100.0) 179 (47.9) 35 (9.4) 374 (100.0)
2 = 2.67
df = 4
p = 0.61
Moreover education was not associated with level of practices behavior of dengue fever prevention.
49 Table 16: Association between employment status and level of practice behaviors kdlkasdkfagainst dengue fever prevention (n = 374). Employment Status Level Employed No. (%) Unemployed Economically Total Active No. (%) No (%) No. (%)
110 (45.1) 113 (46.3) 21 (8.6) 244(100.0) df = 4
38 (38.0) 54 (54.0) 8 (8.0) 100 (100.0)
12(40.0) 12 (40.0) 6 (20.0) 30 (100.0) p = 0.18
160 (42.8) 179 (47.9) 35 (9.4) 374 (100.0)
As shown in Table 16, there was no clear association of employment status with preventive behaviors against dengue fever.
50 Table 17: Association between number of members in the family and practices of dengue preventive behavior. No. of family members Level 01 - 10 No. (%) 11 - 20 No. (%) 21 - 40 No. (%) Total No (%)
134 (44.5) 139 (46.2) 28 (9.3) 301 (100.0) df = 4
21 (36.8) 31 (54.4) 5 (8.8) 57 (100.0)
5 (31.3) 9 (56.3) 2 (12.5) 16 (100.0) p = 0.68
160 (42.8) 179 (47.9) 35 (9.4) 374 (100.0)
As well as number of family members had not association with level of practice behaviors regarding dengue fever prevention.
51 Table 18: Association between history of dengue in the family members in the last 2yrs and level of practice against dengue fever prevention (n = 374).
Dengue History Level No. Yes % No. No % No.
Total
Poor Practice Fair Practice High Practice
27 41 5
37.0 56.2 6.8
133 138 30
44.2 45.8 10.0
160 179 35
42.8 47.9 9.4
Total
73
100.0
301
100.0
374
100.0
X2 = 2.63
df = 2
p = 0.27
From the results of association between dengue history among the family members and level of practice behaviors among the respondents found out that there was no significant in association (p = 0.27), as shown in Table 18.
52 Table 19: Association between received information regarding dengue fever and level of practice behaviors against dengue fever prevention (n = 374).
Received dengue information Level No. Yes % No. No % No. Total %
Poor Practice Fair Practice High Practice Total
139 166 30 335 X2 = 3.72
41.5 49.6 9.0 100.0
21 13 5 39 df = 2
53.8 33.3 12.8 100.0
160 179 35 374 p = 0.15
42.8 47.9 9.4 100.0
There was no significant association between the respondents who received information regarding dengue fever and with the level of practice behaviors about dengue fever among the respondents in this study (p = 0.15)
53 Table 20: Association between knowledge and level of practice behaviors against dengue fever prevention (n = 374). Knowledge Low No. (%) Moderate No. (%) High No. (%) Total No (%)
Level
85 (49.4) 72 (42.9) 15 (8.7) 172 (100.0) df = 4
64 (41.3) 83 (53.5) 8 (5.2) 172 (100.0)
11 (23.4) 24 (51.10) 12 (25.5) 47 (100.0) p = 0.00
160 (42.8) 179 (47.9) 35 (9.4) 374 (100.0)
Knowledge had highly statistically significant association with level of practice behaviors regarding dengue prevention among the respondents (p = 0.00).
54 Table 21: Association between attitude and level of practice behaviors against dengue fever prevention (n = 374). Attitude Negative No. (%) Neutral No. (%) Positive No. (%) Total No (%)
Level
27 (47.4) 21 (36.8) 9 (15.8) 57 (100.0) df = 4
63 (40.0) 83 (52.5) 12 (7.5) 158 (100.0)
70 (44.0) 75 (47.2) 14 (8.8) 159 (100.0) p = 0.17
160 (42.8) 179 (47.9) 35 (9.4) 374 (100.0)
Attitude had no association between the levels of practice behaviors against dengue fever prevention among the respondents (Table 21).
Knowledge, Attitude and Practice regarding dengue fever were also treated as continuous variables, and correlation coefficients were computed. Knowledge about dengue fever had significant positive correlation with practices of dengue preventive behavior (p = 0.000), meaning people who have high knowledge on dengue fever will have good practices against dengue fever prevention. In comparison, attitude showed no correlation with level of practices against dengue fever prevention (p = 0.69), as shown in Table 23. Hence, there was uniformity between chi-square testing and correlation analysis concerning the associations of knowledge and attitude with
55 practice. This implied that there was no major bias due to the preference of cut off points for classifying the knowledge and attitude.
Table 22: Correlations of total score of practices of dengue preventive behavior with total knowledge score among the participants. Practice against dengue Variables r p
Knowledge
0.183
0.000
Correlation was significant at the 0.01 level.
Table 23: Correlations of total score of practices of dengue preventive behavior with total attitude score among the participants. Practice against dengue Variables r p
Attitude
0.033
0.69
56 4.8 Summary This chapter has provided a detailed description of the study findings. The findings from the survey questionnaire and the observations are discussed according to individual items and over all scores obtained from all the items. The overall scores were then tested for any statistically significant relationship between the major demographics of the study participants. The next chapter will discuss the significance of the study findings, implications for practice as well as research. It will also analyze the study findings with respect to its limitations.
57
CHAPTER DISCUSSION, CONCLUSION AND RECOMMENDATION
In this chapter, a brief description of the major findings and their significance to practice will be discussed with its limitations. It will conclude with recommendations for further research.
5.1 Socio demographic characteristics of respondents The results of this study showed that the demographic data were not correlated with level of practice scores except for gender. Therefore, the demographic characteristics investigated in this study were not significantly associated with level of practice excluding the variable of gender. This study only found that gender had significant association with level of practice behaviors of dengue fever prevention among the respondents. Females had good practice than males in practice of dengue fever prevention. This might be because it is believed in the population that females should take care of the households while the kids and male have other responsibilities. This study was not consistent with the study of Teetipsatit (2005) that male and female of household leader had no relationship with preventive behavior on dengue hemorrhagic fever. Level of education status had no association with the practice of dengue prevention. This does not mean that education was not an important factor but there might be other factors which fall short to apply education into practice. One reason might be educated people will have more of other responsibilities and have less time
58 to practice prevention of dengue fever. People are acquainted with the correct way to do things but they are careless to put them into practice. There was no significant association between dengue history among the family members and level of practice behaviors among the respondents (p = 0.27), as shown in Table 18. This indicated that dengue history was not an important confounder in this analysis.
5.2 Knowledge about dengue fever The mean survey score was found to be 8.60 from a possible 14 points with a standard deviation of 2.45. Clearly the respondents who participated in this study had a low level of knowledge (46%) in spite of the fact that 90% of the respondents had received information regarding dengue fever. This might be because people do not absorb all the information they get and tend to forget most of the information. It is also a matter of motivation and perceived benefits. If people do not see the benefit of a given behavior they do not practice it, regardless of understanding. It might be that the educational information is insufficient to address people's understandings of disease transmission and/or the education methods used are flawed. Forty one percent of the respondents had moderate level of knowledge and it could be that the respondents who filled questionnaires had previous history of dengue fever themselves or either a member of their family. 5.2.1 Areas of high level of knowledge The highest average percentage scored by the respondents was the question on whether empty stagnant water from old tires, trash cans, and flower pots can be a breeding place for mosquitoes. The responses indicated that 91% were aware
59 that empty stagnant water from old tires, trash cans, and flower pots can be mosquito breeding places. The respondents of this study had a good knowledge regarding that stored water containers or tanks for drinking water without being covered should be cleaned every 7 days. A high percentage (87%) of the participants responses to this question was correct. (Refer to Table 5). Another area in which the respondents scored well is the question about dengue fever being a severe, flu-like illness that affects infants, young children and adults. An average of 86% respondents who participated in the survey got the answers correct to this question. (Refer to Table 5). 5.2.2 Areas of knowledge deficit Majority of the respondents (70%) incorrectly, answered the question on abate sand being beneficial in killing the mosquito larvae. Referring to Table 5 only 30% could identify that abate sand as a beneficial in killing the mosquito larvae. As well as for question 12, 68% of the respondents had no knowledge about abate sand, if put in the standing water, can help to prevent the mosquito breeding for 3 months. This shows that the community is unaware of the importance of abate sand. Another very important area that the respondents lacked knowledge was that dengue transmitting mosquito bites during day time. Refer to Table 5; only 40% of the respondents answered it correctly which means the rest 60% of the respondents had no idea regarding it. This is an important area which needs to be emphasized more during the prevention programs.
60 Sixty percent of the respondents felt that dengue fever can be transmitted from one person to another. This is another important issue which needs to be emphasized on. Nearly half (54%) of the respondents were unaware that dengue can occur in all seasons. Lack of knowledge regarding dengue fever that can occur throughout the year would make people lack of awareness on preventive behavior of dengue fever. Among the people in this community, knowledge had significant positive association with practice of dengue prevention. This result was consistent with the study of Koenraadt et al. (2006) who found out in the study that there is a direct link between knowledge on dengue prevention and container protection practices, whereas measures against adult mosquitoes are used only when people experience a mosquito nuisance problem. It was consistent with another study which was done by Van Benthem et al. (2002), who found out that people with knowledge of dengue reported a significantly higher use of prevention measures than people without knowledge of dengue Future health education programs should put emphasis on those areas where they have a knowledge deficit about dengue fever as knowledge is positively associated with practice. Therefore, if they had better knowledge about dengue fever then they would also be likely to have a better practice regarding dengue prevention.
5.3 Attitude towards dengue fever The mean survey score for attitude about dengue fever prevention was found to be 45.63 from a possible 60 points with a standard deviation of 5.66. Evidently, the
61 respondents who participated in this study had positive attitude. In spite of that they might not be concerned about practicing the preventive behaviors. The possible reason might be that most of the respondents are employed (65%) and therefore they dont find time to do activities related to practicing dengue fever prevention. There might be so many other factors hindering as behavior does not depend only on attitude and knowledge. Such as motivation, perceived benefits, social factors, taboos, etc are some of the factors that can hinder practice. This study had no significant association with attitude and practice of dengue fever prevention. This approved with the study of Hairi et al. (2003) where they had conducted a study on Knowledge, Attitude and Practices (KAP) on dengue among selected rural communities in the Kuala Kangsar district and found out that there was no significant association seen between attitude and preventive practice on dengue. It is also consistent with the study done by Limros (2006) who conducted a study on Preventive Behaviors against Dengue Infection among Family Health Leaders in Kongkrailat District, Sukhothai Province found out that attitude showed no correlation with breeding place prevention. This study revealed out few incorrect attitudes towards dengue prevention among the respondents. Thirty seven percent of the respondents felt that dengue control should be the responsibility of the government. Maybe these people believe and might not appreciate the importance of their role in disease prevention. The participation of the community during campaigns of dengue fever was 16% and 12% participated when the community had been sprayed. The Ministry of Health, by itself, is in no position to meet the challenge of increased disease transmission in the island.
62 There is a need for a determined effort of collaboration with various public and private organizations. Majority of the respondents (41%) used mosquito coils or mosquito mats during night time only and 28% of the respondents did not use anything. Thirty percent used during day and night time and only one percent used during day time. This showed that almost half of them did not know the biting time of dengue mosquitoes. It is quite important to know the biting time of dengue mosquitoes because most people tend to protect from mosquito bites only at night and fall short to protect themselves during the day, which raises the risk of dengue infection. Future health education efforts should emphasize on this point as well.
5.5 Observation Some of the good findings found out after observation was that only few households (25%) had water collection on the plates supporting flower pots at home. One reason might be because most of the households dont use plates to support flower
pots. 5% of the household had stored water containers in the toilet. None of the houses had dirty water in the flower vases or indoor plants. This might be because most of them kept indoor plants inside their rooms and some kept flower vases outside the room
in the balcony while, due to privacy concern, the observation was carried out mainly in the living area and the surroundings of the house, not the rooms. So the real picture might not have been revealed. Observation results showed that 59% had dirty housing environment. Doors and windows in most of the houses remain closed all daytime and the inside was relatively dark. This can be a preferable resting place for Adult Aedes mosquitoes.
63 Therefore people living in these houses might be at risk of getting dengue fever. Seventy six percent of the respondents reported that they examined and checked around their house for any discarded item which can hold water (Table 11). But when observed 47% of the households had empty cans and discarded bottles that can hold water around the house. This might be because when people were asked they might have reported disposing discarded containers even though they are not practicing it. Discarded containers are potential mosquito breeding sites. A previous study reported that discarded containers contained plenty of organic matter and subsequently tended to produce large number of adult Aedes mosquitoes which had faster development and better survival (Tun-Lin W, et. al). Fifty four percent of the households had not covered the stored water containers/tanks and this creates a good environment for mosquito breeding places.
5.5 CONCLUSIONS The results of this study showed that the demographic data were not correlated with practice scores except for gender. Females had higher practice behavior than males in prevention of dengue fever. Knowledge was significantly associated with practice. Hence people who have high knowledge regarding dengue fever will have a good practice in prevention of dengue fever. Measures against mosquitoes are probably only used when people experience a mosquito nuisance. Most of the people did not see dengue as a threat to their community; therefore proper prevention programs need to be developed to make the community more aware which then will motivate people to modify their behavior. Consequently this increased awareness will in turn might bring further benefits to the community and this highly beneficial
64 process will continue over time. Closing the gap between knowledge and practice will continue to be a vital challenge for dengue control, as well as targets for reduction of mosquitoes.
5.6 RECOMMENDATIONS On the basis of the findings in this study, the following issues should be considered for improving preventive behavior against dengue fever among the people. 1. Public education is necessary to address the knowledge gap revealed in the study. Therefore educational programs should be organized for improving knowledge about dengue fever and it should focus mainly on increasing the awareness of the people regarding the importance of abate sand (temephos sand), that dengue fever can occur in all the season and dengue transmitting mosquito is a day biting mosquito. The office in every district should carry out these educational campaigns with the help of Ministry of Health or Vector Borne Disease Control Unit throughout the year and not only during the rainy season. 2. A management plan for dengue prevention and control should be developed by the Ministry of Health and which clearly delegates lines of authority for policy decisions and for communication and coordination. 3. Further research related to disease, vector management, factors hindering practices and behavioral changes is needed in order to develop and implement effective and reliable dengue prevention and control programs.
65
5.6.1 Future research suggestion
Due to time and resource limitation, the study has been conducted only in Male, the capital of Maldives and hence it might not be a representation of the country as a whole. In future, more studies should be conducted in other Atolls as well to find out the pattern of Knowledge, Attitude and Practice of dengue fever in these populations. In the measurement tool of the practice part few questions are of doublebarrelled questions and the main problem with this type of question is that one does not know which particular question a respondent has answered. In future studies, these types of questions should be avoided, especially if it is a self-administered questionnaire. Future studies should actively look for factors hindering preventive practice of dengue fever as behavior depends on many other factors beside knowledge. Such as motivation, perceived benefits, etc.
66
REFERENCE
Bloom, B.S. (1956). Taxonomy of Educational Objectives. New York: David McKay. Center for Disease Control [CDC] Health Center. (2007). Center for Disease Control Dengue Fever. Retrieved December 25, 2007, from
http://www.svinfectologia.org/Dengue CDC 2007[1].doc Chusongsang, P. (2005). Factors affecting Dengue Hemorrhagic Fever prevention and control behaviors of household leaders and primary school teachers in Khuan Khanun District, Phatthalung Province. Masters thesis, Faculty of Graduate Studies, Chulalongkorn University. Clark, D.V., Mammen, M.P., Jr., Nisalak, A., Puthimethee, V., & Endy, T.P. (2005). Economic Impact of Dengue Fever/Dengue Hemorrhagic Fever in Thailand at the Family and Population Levels. American Journal of Tropical Medicine Hygiene. 72(6), 786-791. Claro, L.B., Tomassini, H.C., & Rosa, M.L. (2004). Dengue prevention and control: a review of studies on knowledge, beliefs, and practices. Cad. Sade Pblica 20 (6), 1447-1457 Male, Maldives. Interviewed, February 14, 2008. Gubler, D.J. (1998). Dengue and dengue hemorrhagic fever. Clinical Microbiology Rev. 11(3), 480 - 96. Gupta, P., Kumar, P., Aggarwal, O.P. (1998). Knowledge, attitude and practices related to dengue in rural and slum areas of Delhi after the dengue epidemic of 1996. Journal of Communicable Diseases. 30(2), 107-112.
67 Hairi, F., Ong, C.H., Suhaimi, A., Tsung, T.W., Bin Anis Ahmad, M.A., Sundaraj, C., et al. (2003). Knowledge, attitude and practices (KAP) study on dengue among selected rural communities in the Kuala Kangsar district. Asia Pacific Journal of Public Health. 15(1), 37- 43 Harving, M.L., & Ronsholt, F. F. (2007). The economic impact of dengue Medical
haemorrhagic fever on family level in Southern Vietnam. Danish Bulletin. 54(2), 170 - 172. International Center for Eye Health. 20(61), 17.
(2007). Journal of Community Eye Health.
Koenraadt, C.J., Tuiten, W., Sithiprasasna R., Kijchalao, U., Jones, J.W., Scott, T.W. (2006). Dengue knowledge and practices and their impact on Aedes aegypti populations in Kamphaeng Phet, Thailand. American Journal of Tropical Medicine Hygiene. 74(4), 692-700. Kumar, K.R. & Gururaj, G. (2005). Community Perception Regarding Mosquito in Karnataka State, India. Dengue Bulletin. 29, 157 -164. Limros, T. (2006). Preventive Behaviors against Dengue Infection among Family Health Leaders in Kongkrailat District, Sukhothai Province. Masters thesis, College of Public Health, Chulalongkorn University. Matta, S., Bhalla, S., Singh, D., Rasania, S.K., Singh, S. (2006). Knowledge, Attitude & Practice (KAP) on Dengue fever: A Hospital Based Study. Indian Journal of Community Medicine. 31(3), 185-186. Ministry of Planning and National Development, Republic of Maldives. (2008). Quick Facts. Retrieved December 25, 2007, from http://www.planning.gov.mv.
68 New Horizons for Learning. (2007). Assessment Terminology: A Glossary of Useful Terms. Retrieved February 28, 2008, from
http://www.k12.hi.us/~atr/evaluation/glossary.htm Polit, D.F. & Beck, C.T. (2004). Nursing Research: Principles and Methods. (7th edition). Philadelphia: Lippincott Williams & Wilkins. Roberts, K. & Taylor, B. (1998). Nursing research process: an Australian perspective. Melbourne: Nelson ITP. Shepard, D.S., Suaya, J.A., Halstead, S.B., Nathan, M.B., Gubler, D.J., Mahoney, R.T., et al. (2004). Cost-effectiveness of a pediatric dengue vaccine. Vaccine. 22 (9-10), 1275-1280. Swaddiwudhipong, W. (1992). A survey of knowledge, attitude and practice of the prevention of dengue hemorrhagic fever in an urban community of Thailand. Southeast Asian Journal of Tropical Medicine of Public Health. 23(2), 207211. Teetipasatit, S. (2005). Factors associated to preventive behavior on Dengue
Haemorrhagic Fever among family leaders in Ban Chang-lo, Bangkok-Noi, Bangkok. Masters thesis, Faculty of Graduate Studies, Mahidol University. Tun-Lin W., Burkot, T.R., & Kay, B.H. (2004). Effects of temperature and larval diet on development rates and survival of the dengue vector Aedes aegypti in north Queensland, Australia. Med Vet Entomol. 14(1), 31-37. Van Benthem B.H., Khantikul, N., Panart, K., Kessels, P.J., Somboon. P., & Oskam, L. (2002). Knowledge and use of prevention measures related to dengue in north Thailand. Tropical Medicine of Int. Health . 7(11), 993-1000.
69 Wesson, D.W. (2006). Biostatistics: A Foundation for Analysis in the Health Sciences. (8th edition). USA: John Wiley & Sons Inc. World Health Organization [WHO] Regional Office for South- East Asia. (2007). Situation of Dengue/Dengue Hemorrhagic Fever in South East-Asia Region. Retrieved December 25, 2007, from
http://www.searo.who.int/EN/Section10/Section332_1098.htm World Health Organization [WHO]. (1997). Dengue Haemorrhagic Fever: Diagnosis, Treatment, Prevention and Control. (2nd edition). Geneva: WHO.
70
APPENDICES
71 APPENDIX A Questionnair e Part I: Socio-demographic characteristics Serial No: .. 01. Age . 02. Gender 03. Marital Status ( ( ( 04. Education Level ( ( 05. Employment Status ( ( 06. Income ( ( ) Male ) Married ) Single ) Primary ) Graduate ) Employed ( ( ( ( ( ( ) Female ) Divorced ) Widow ) Secondary ) Postgraduate ) Unemployed
) Economically Active ) None ) 1500-300 ( ( ) 900-1500 ) Above 3001
07. How many members in your house .. 08. How many children younger than 15yrs of age 09. Have you had dengue fever in the last 2yrs 10. Any member in your family had dengue fever ( ( ) Yes ) Yes ( ( ) No ) No
Source of information about Dengue Fever 11. Have you ever received any information about dengue Select the sources from which you got the information ( ) T.V ( ) Leaflets ( ) Radio ( ) Friends ( ) Newspaper ( ) Family ( ) Magazines ( ) others ( ) Yes ( ) No
72 Part I: Knowledge about dengue infection
Yes 01. The principal mosquito vector for dengue fever is Aedes aegypti. 02. Dengue fever is a severe, flu-like illness that affects infants, young children and adults. 03. Dengue patients have chills, headache, pain upon moving the eyes, and low backache. 04. Rainy season is the only epidemic season for dengue infection. 05. Mosquitoes transmitting dengue infection bites only during day time. 06. The mosquito that transmits dengue infection lays its egss in dirty sewage water. 07. Empty stagnant water from old tires, trash cans, and flower pots can be breeding places for mosquitoes. 08. Dengue viruses are transmitted to humans through bites of infective female Aedes mosquitoes 09. Only method of controlling dengue infection is to combat the vector mosquitoes. 10. There is no specific treatment for dengue infection and the drug of choice is paracetamol. 11. Abate sand can be beneficial in killing the mosquito larvae. 12. Abate sand, if put in the standing water, can help to prevent the mosquito breeding for 3 months. 13. Stored water containers/tanks for drinking water without being covered should be cleaned every 7days. 14. I am afraid of getting it dengue fever If one of my family members has DF.
No
73
Part III: Attitude towards dengue fever

Strongly Agree Neither agree nor Disagree disagree Strongly Disagree
Agree
01. DF is a disease that cannot be prevented. * 02. Eliminating the breeding places is the responsibility of the public health staff and health volunteer. * 03. Only method of controlling or preventing dengue and DHF is to combat the vector mosquitoes. 04. Only smogging is enough to prevent mosquito and no need for other ways. * 05. Everybody has a chance to be infected with dengue virus. 06. Person who once got dengue infection cannot get dengue infection again. * 07. It is possible to recover completely from dengue infection. 08. Elimination of larval breeding sources is a waste of time and very complicated. * 09. Restricting and checking the availability of potential breeding habits should be conducted every 1-2 times/year. 10. Strong and healthy person will not get dengue infection. * 11. Sleeping in mosquito net can prevent dengue infection. 12. You are one of the important people in preventing dengue fever.
74
Part III: Practice regarding dengue infection Dont Have
Yes 01. Do you cover water jars after using immediately. 02. Do you have a cover in your water tanks. 03. If there is a mosquito larvae in your water tank, do you ever do anything to get rid of it. Which method? 04. Do you ever examine the mosquito larvae in the flowers pots. How often? 05. Do you change the water of the indoor plants every week. 06. Do you ever drain off the water in the plates of the flower pot. How often? 07. Do you examine any discarded thing that can hold water around your house. 08. If yes, do you ever put them in the garbage or dipose them. 09. Do you use mosquito net/mosquito coils in your house. When? 10. Do you participate when your community has been sprayed fog. 11. Do you participate in any campaigns of dengue infection in your community. 12. Do you ever examine the mosquito larvae in water containers in the toilet. 13. Do you check and clean your roof gutters in the rainy season. 3. 6. 4. 9.
No
75 Part V: Observation Check list
Yes
No
larvae present
01. The housing environment is kept neat and tidy.
02. Dirty water in the flower vases or indoor plants. 03. Water collection on the plates supporting flower pots at home.
04. Any kind of stored water containers inside the toilet. 05. There are coconut shells, discarded bottle, cans or anything that can hold water around the house.
06. Dirty water in the containers for pet. 07. Stored water containers/tanks and all the water jars are covered.
76 APPENDIX B Reliability Test for Questionnaire
RELIABILITY ANALYSIS - SCALE (ALPHA) 1. Knowledge Item Total Statistics Scale Cronbach's Scale Mean Variance if Corrected Alpha if if Item Item Item-Total Item Deleted Deleted Correlation Deleted 7.87 7.292 .276 .721 7.97 6.792 .416 .706 8.17 5.730 .781 .650 8.20 5.821 .726 .658 8.10 5.955 .707 .663 7.97 6.861 .382 .709 8.13 6.464 .456 .699 8.27 6.547 .397 .707 8.53 6.740 .410 .706 8.03 7.964 -.129 .767 7.90 7.266 .244 .724 8.07 6.340 .547 .687 8.00 9.034 -.533 .804
k2 k3 k4 k5 k6 k7 k8 k9 k10 k11 k12 k13 k14
Reliability Coefficients No. of Cases = 30 Alpha = 0.73 No. of Items = 14
77 2. Attitude Item Total Statistics Scale Cronbach's Scale Mean Variance if Corrected Alpha if if Item Item Item-Total Item Deleted Deleted Correlation Deleted 38.43 38.737 .415 .684 40.03 31.482 .576 .650 38.03 47.689 -.362 .744 39.23 39.013 .268 .706 38.10 43.610 .212 .709 39.33 37.471 .423 .682 38.13 42.947 .186 .711 39.40 36.869 .429 .680 39.47 37.223 .438 .679 40.20 30.028 .714 .619 41.20 38.097 .493 .675 38.13 45.085 -.046 .732
a1 a2 a3 a4 a5 a6 a7 a8 a9 a10 a11 a12
78 3. Practice Item Total Statistics Scale Cronbach's Scale Mean Variance if Corrected Alpha if if Item Item Item-Total Item Deleted Deleted Correlation Deleted 6.07 9.857 .006 .815 6.50 7.845 .642 .771 6.40 8.041 .581 .777 6.53 7.706 .699 .765 6.67 8.023 .618 .774 6.53 7.706 .699 .765 6.27 8.892 .312 .802 6.20 9.614 .060 .819 6.17 9.661 .054 .818 6.87 8.533 .633 .779 6.83 8.213 .725 .770 6.33 9.126 .198 .812 6.63 8.585 .385 .796
p1 p2 p3 p4 p5 p6 p7 p8 p9 p10 p11 p12 p13
79
CURRICULUM VITAE
Name: Date of Birth: Place of Birth:
Ms. Nahida Ahmed 25th April 1976 S. Hithadhoo/Maldives
PROFESSIONAL QUALIFICATION: September 2000 - September 2002 Post RN, Bsc Nursing Degree Baqai College of Nursing Baqai Medical University Karachi WORKING EXPERIENCE: February 2007 - April 2008 Senior Staff Nurse Indira Gandhi Memorial Hospital Male Rep. of Maldives October 2002 - February 2007 Staff Nurse Grade II Indira Gandhi Memorial Hospital Male Rep. of Maldives 1994 - 1996 Medical Records Officer Trainee Indira Gandhi Memorial Hospital Male Rep. of Maldives

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TABLE OF CONTENTS

CDC CFR DALYs DF DHF DSS KAP RNA SPSS TV WHO

countries reported increase in dengue cases

(Bangladesh, Bhutan, Indonesia,

CHAPTER II LITERATURE REVIEW

17 2.6 Manifestations of Dengue Virus infection

Dengue shock syndrome

With unusual haemorrhage

Figure 2: Manifestation of dengue virus

CHAPTER III RESEARCH METHODOLOGY

3.13 Data Analysis and Statistic Application

History of dengue in the last 2yrs Yes No 73 301 19.5 80.5

4.3 Knowledge on Dengue Fever

Number None Weekly Alternate days Daily Total 236 86 9 43 374

Percentages 63.1 23.0 2.4 11.5 100

The remaining 8 analyzable items were all assessed as zero-one indicator

368 284 211 271 45 59 293 244

98.4 75.9 56.4 72.5 12.0 15.8 78.3 65.2

28% None Night 41% Daytime Always

Poor Practice Fair Practice Good Practice Total 2 = 5.77

As shown in Table 13 there is no association between age and level of practice.

Poor Practice Fair Practice Good Practice Total 2 = 6.16

110 (45.1) 113 (46.3) 21 (8.6) 244(100.0) df = 4

38 (38.0) 54 (54.0) 8 (8.0) 100 (100.0)

12(40.0) 12 (40.0) 6 (20.0) 30 (100.0) p = 0.18

160 (42.8) 179 (47.9) 35 (9.4) 374 (100.0)

Poor Practice Fair Practice Good Practice Total 2 = 2.29

134 (44.5) 139 (46.2) 28 (9.3) 301 (100.0) df = 4

21 (36.8) 31 (54.4) 5 (8.8) 57 (100.0)

5 (31.3) 9 (56.3) 2 (12.5) 16 (100.0) p = 0.68

160 (42.8) 179 (47.9) 35 (9.4) 374 (100.0)

Dengue History Level No. Yes % No. No % No.

Poor Practice Fair Practice High Practice

37.0 56.2 6.8

44.2 45.8 10.0

42.8 47.9 9.4

Received dengue information Level No. Yes % No. No % No. Total %

Poor Practice Fair Practice High Practice Total

139 166 30 335 X2 = 3.72

41.5 49.6 9.0 100.0

53.8 33.3 12.8 100.0

160 179 35 374 p = 0.15

42.8 47.9 9.4 100.0

Poor Practice Fair Practice Good Practice Total 2 = 24.55

85 (49.4) 72 (42.9) 15 (8.7) 172 (100.0) df = 4

64 (41.3) 83 (53.5) 8 (5.2) 172 (100.0)

11 (23.4) 24 (51.10) 12 (25.5) 47 (100.0) p = 0.00

160 (42.8) 179 (47.9) 35 (9.4) 374 (100.0)

Poor Practice Fair Practice Good Practice Total 2 = 6.46

27 (47.4) 21 (36.8) 9 (15.8) 57 (100.0) df = 4

63 (40.0) 83 (52.5) 12 (7.5) 158 (100.0)

70 (44.0) 75 (47.2) 14 (8.8) 159 (100.0) p = 0.17

160 (42.8) 179 (47.9) 35 (9.4) 374 (100.0)

Correlation was significant at the 0.01 level.

CHAPTER DISCUSSION, CONCLUSION AND RECOMMENDATION

(2007). Journal of Community Eye Health.

) Economically Active ) None ) 1500-300 ( ( ) 900-1500 ) Above 3001

72 Part I: Knowledge about dengue infection

Part III: Attitude towards dengue fever

Part III: Practice regarding dengue infection Dont Have

75 Part V: Observation Check list

01. The housing environment is kept neat and tidy.

76 APPENDIX B Reliability Test for Questionnaire