Knowledge, Attitude and Practices about Dengue fever among population in Hodeidah, Yemen

Knowledge, Attitude and Practices about Dengue fever among population in Hodeidah, Yemen | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Knowledge, Attitude and Practices about Dengue fever among population in Hodeidah, Yemen Mohammed Ahamed Mohammed Hajjam This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8149458/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract In Yemen, dengue is one of the major public health concerns. Cases have been recorded in almost all governorates in Yemen. In 2019, Hodeidah governorate has the second highest death rate in the country. Good knowledge, attitudes, and practices (KAP) among the public regarding dengue prevention are required for the success of dengue prevention and control. The study aims to assess KAP about dengue fever among the population in Hodeidah, Yemen. Methodology : A cross-sectional study was conducted (from June 1st to December 30th, 2019) among the populations in six different geographical districts, urban (Al-Hali and Hawak) and rural (Bajil, Al-Zaydiyah, Al-Garrahi, and Al-Maraweah) in Hodeidah governorate. A total of 422 household heads were chosen at random to complete questionnaires distributed in their neighborhoods. The data was entered and analyzed using the Statistical Package for Social Sciences (SPSS) version 25. The Chi-square test was used as a test of significance, where p < 0.05 is the cutoff for significance. Results : The results showed that nearly half (49%) of the participants demonstrated a moderate level of knowledge, 63% had a positive attitude, and 57% had good practices for dengue prevention. The level of education, residence, and occupation were significantly associated (p<0.05) with the knowledge level. Occupation and gender showed significant associations (p<0.05) with attitudes. Also, residence, occupation, and gender showed significant associations (p<0.05) with practices. Conclusion and Recommendations : This study concluded that the larger proportion of the participants demonstrated a moderate level of knowledge, a positive attitude, and a low level of practice towards dengue prevention. We recommend conducting health education on a regular basis and encouraging community participation in control activities against dengue. Epidemiology Attitude Dengue Knowledge Practices Hodeidah Yemen 1. INTRODUCTION Dengue fever is a mosquito-borne viral disease caused by one of four unique serotypes of dengue virus (DENV1-4), which are members of the Flavivirus genus [ 1 , 2 ]. It is primarily spread by Aedes aegypti [ 1 , 2 ]. Although most dengue infections remain asymptomatic, they can cause a wide range of clinical manifestations, from a mild non-specific febrile illness to severe symptoms such as plasma leakage [ 3 ]. DF has emerged as a major public health concern with a large worldwide impact in recent years [ 2 ]. More importantly, it has been categorized as one of the top ten global health hazards for 2019, according to the World Health Organization (WHO). With an estimated four billion people at risk in more than 141 countries in the world [ 4 ]. Annually, approximately 400 million dengue cases and 22 000 deaths occur worldwide [ 2 ]. Notably,the number of cases has significantly increased has increased recently from 3.34 million cases in 2016 to 4.2 million cases in 2019 [ 1 ]. To conclude, the myriad of dengue cases has brought concern to all countries, including Yemen. In Yemen, dengue is endemic, with 60% of Yemen’s population live in risk areas [ 5 , 6 ]. In 2019, the incidence of dengue fever rose sharply and continued to increase. The sporadic cases and outbreak turned into a catastrophic situation where cases have been recorded in almost all governorates in Yemen. Hodeidah governorate has the second highest death rate in the country. In 2020, the number of suspected dengue cases reported was an increase of about seven times the number of cases in 2019, and six times the number of cases reported in 2018 [ 7 ]. In the absence of a vaccine or specialized therapy for dengue, the only possible mode of prevention is vector control, and preventing mosquito bites through community empowerment and engagement is an effective strategy for prevention [ 8 ]. As a result, the effectiveness control of dengue is highly dependent on the adequate knowledge and good practices of preventive (KAP) measures of the targeted population about the disease and its preventive measures [ 9 ]. The lack of knowledge regarding dengue infection and its preventive methods has been considered one of the main problems in dengue epidemiology [ 10 ]. Moreover, Studies show that people with better knowledge of dengue are one of the predictors of better practices in dengue prevention [ 9 , 11 , 12 ]. Meanwhile, Roslan et al. (2020) claimed that people who have more knowledge about dengue are more likely to pursue more suitable dengue prevention measures compared to people with less knowledge [ 13 ]. However, a lack of studies regarding DF among Yemeni people was found, including Hodeidah. One study was conducted by Saied et al. (2015) in rural areas of the Hodeidah governorate found that KAP) regarding dengue fever were not sufficiently [ 14 ]. Dengue prevention and control is not possible without the effectual participation of the local community to avoid vector breeding in and around residential areas. Thus, evaluation of people’s (KAP) is of great importance in the control measure of dengue fever [ 15 ]. Despite the scale of disease in Hodeidah, no documented evidence exists for the KAP of the population. This study aims to assess KAP about dengue fever among communities in Hodeidah governorate, Yemen. 2. MATERIALS AND METHODS 2.1. Study area Hodeidah governorate is the fourth largest governorate in the Republic of Yemen, covering a total area of 17,509 km2 with an estimated total population of 2,687,674. It is located in the west on a flat coastal plain, bordered by the Red Sea in the west, Saudi Arabia in the north, and the Gulf of Aden in the south. Administratively, the governorate is subdivided into 26 districts, three of which are urban (AL-Hawa, AL Hali, and AL Mina). The remaining districts are in rural areas. 2.2. Study design and population A cross-sectional study was conducted (from June 1st to December 30th, 2019) among the populations in six different geographical districts, urban (Al-Hali and Hawak) and rural (Bajil, Al-Zaydiyah, Al-Garrahi, and Al-Maraweah) in Hodeidah governorate, Yemen. Participants were all household heads (either male or female) who had lived in at least six districts for at least one year and agreed to participate; those who were unwilling to participate, those unable to communicate because of mental illness or severe hearing defects, and those who had migrated from other districts were excluded. 2.3. Sample Size and technique The required sample size was calculated by using the statistical formula: (n = k2(pq)/d2) by considering the following assumptions: (n) is the sample size, (p) the prevalence of knowledge about dengue fever prevention was taken as 0.50 (as there was no previous data available in Hodeidah), (k2) the 95% level of confidence, and (d2) the acceptable maximum error (5%). The minimum sample size was 384 households. Thereafter, 10% (38) was added to account for non-response or incomplete data. Thus, the final sample size was 422 households (168 from urban and 254 from rural areas). A multi-stage random sampling method was used for this study. In the first stage, from a total of 26 districts, six (2 urabn: Al-Hali and Hawak, and four rural: Bajil, Al-Zaydiyah, Al-Garrahi, and Al-Maraweah) districts were randomly selected by proportional allocation. In the second stage, for each selected rural district, two sub-districts were randomly selected from the four districts, and then one village from each sub-district was randomly selected according to the relative size of the population in the sub-district, making a total of eight villages. Also, in urban areas, 3 hara were randomly selected from each district. Thus, the total number of selected villages was 8, and the hara was 6. In the third stage, in each hara (village) that was randomly selected, the head of household (either male or female) was selected by simple random sampling to represent each district, amounting to 168 from urban and 254 from rural areas. Finally, at each household, the head of household (either male or female) was interviewed, whosoever was available at the time of data collection and was willing to participate in this study after obtaining their informed consent and explaining the nature of the study. If the household head was not present, refused to participate, or did not meet the pre-determined inclusion and exclusion selection criteria, the head of the next household was included until the sample size required was reached. 2.4. Data Collection Data was collected through face-to-face interviews using a structured questionnaire adapted from relevant literature from various studies [ 9 , 14 ], along with a few modifications based on local practices. Initially, it was designed in the English language and later translated into the Arabic language (the mother tongue of Yemen). The questionnaire was reviewed by experts in this field of study. Each interview lasted between 15 and 20 minutes. The questionnaire included four parts. The first part consisted of questions on the socio-demographic details of the participants. The second part included questions on knowledge about dengue (disease signs and symptoms, complications, vectors and breeding sites). The third part included questions on attitudes, while the fourth part inquired about their regular practices (control and prevention) towards dengue. 4.1 Scoring of Data: A scoring system was developed. For knowledge, every question was rated on 3 answer choices: "yes," "no," or "don’t know." All correct answers were scored 1, while "Don’t Know" and wrong answers were rated as 0 and the total results were divided into three categories: low knowledge (< 50%), moderate knowledge (≥ 50 - < 75%), and high knowledge (≥ 75%). For attitudes, using a 3-point Likert scale, 1 = disagree; 2 = not sure; and 3 = agree. Positive attitudes were considered if the score was more than the median value of the total score, and it was considered negative if they scored less than the median value. Likewise, for practice, the answers "Yes" and "No" were given scores of 1 and 0, respectively. Good practices were considered if the score was more than the median value of the total score, and it was considered poor practices if they scored less than the median value. 2.7. Statistical Analysis The collected data from the questionnaire was reviewed, coded, and entered into a computerized database before being analyzed with IBM SPSS Statistics, version 25. Frequencies and percentages (descriptive statistics) were calculated for categorical variables. A Chi-square test was used to determine the significance of the association between socio-demographic characteristics and KAP on DF, where P value 0.05 is the cut-off for statistical significance. The results were presented in tables and graphs. 2.3. Ethical issue This study was approved by the Institutional Research and Ethics Committee of the Department of Community Medicine at Hadhramout University, College of Medicine (HUCOM), Yemen. CM/REC 8/2018 (reference number). Participation was on a voluntary basis, and informed consent was obtained from participants after an explanation of the study objectives. Their confidentiality and privacy were assured throughout the interview. 3. RESULTS 3.1. Socio-demographic characteristics of the study respondents From a total of 422 study subjects, 254(60.19%) lived in rural areas , while only 168(39.81 %) were from urban areas; Among these, (53.6%) were male, 122 (28.9%) were Illiterate and (35.5%) were housewives, see table (1) . 3.2. Knowledge about dengue,DHF, its signs and symptoms, transmission Out of total participation, 49% had a low knowledge level, 41% had a moderate knowledge level, and only 10% had a high knowledge level towards DF. The majority of the respondents could correctly tell that fever (81.0%), headache (67.5%), and joint pain (48.6%) are the main signs and symptoms of dengue fever. In addition, 79.9% of respondents were unaware of DHF. The study also found that more than eighty percent of respondents knew that dengue virus is transmitted by mosquito bites, and 58.3% said that dengue mosquito bites at night. Flying, direct contact with infected people, and eating food or drinking water as another mode of transmission of dengue fever were recognized by 32.5%, 23.7%, and 21.1% of respondents, respectively. More than one third of the participants knew that clean, stagnant water is the breeding place for the mosquito. In addition, covering water containers and insecticide spray are preventive measures that could contribute to reducing the spread of vector mosquitoes and were recognized by 92.9% and 90.8% of respondents, respectively. Details on the correct responses of the participants are provided in table (2). 3.3. Attitude of respondent household heads towards dengue fever The distribution of attitudes towards DF indicated that 63% of the participants had positive attitudes while 37% had negative attitudes. More than 90% of those polled agreed that DF is a serious disease.Also, 85.1% agreed that the disease is preventable. Only 67.8% agreed that they were at risk of contracting dengue fever. Regarding the responsibility of dengue control, more than sixty percent agreed that the elimination of breeding sites should be the responsibility of public health staff only. Surprisingly, the majority (73.7%) agreed that it is not necessary to seek immediate treatment for dengue fever as there is no cure for it. Sleeping under a bed net can help prevent dengue infection, was agreed upon (82.9%). Finally, (85.8%) agreed that they have an important role in dengue prevention, see table (3). 3.4. practices of respondent household heads towards dengue fever In this study, 57% of the participants had good practices and 43% had poor practices towards dengue. More than eighty percent of respondents reported covering water containers at home, and 87.4% said that they cover water tanks immediately after use. Only a minority reported using preventive measures against mosquitoes, such as sleeping under mosquito nets (41.5%), window screens (46.2%), door screens (22.8%) and covering their bodies with clothes (45%). More than one-third said that they use insecticide spray and creams to repel mosquitoes to prevent mosquito bites. As a practice, 34.7% said that they would check for Aedes larvae in the water in cans and bottles around their homes. Among them, 25.8% would participate in community cleaning campaigns. 84.5 percent said that they visited a health center or facility when they felt sick. More than half of the study population (66.1%) felt that they should eliminate stagnant water around their houses to reduce mosquitoes and prevent dengue. see table (4). 3.5. Association between knowledge, attitude, practice and socioeconomic factors Table 5 presents the association between KAP and socioeconomic factors that may affect them in the study population. The level of education, residence, and occupation were significantly associated (p 0.05) with the knowledge level. The respondents who lived in the villages or rural areas had poorer knowledge than those who lived in urban areas. Also, it shows that gender and occupation had significant associations (p 0.05) with attitudes. In addition to that, females (Chi2 = 9.776, p = 0.002) were reported to have a more positive attitude than males. Among the different occupations, housewives (73.3%) and government employees (61.9%) possessed comparatively more positive attitudes than others. Residence, occupation, and gender all had significant (p 0.05) associations with practices.Having good prevention practices towards dengue was associated with people who lived in urban areas (Chi2 = 8.883, p = 0.003), females (Chi2 = 13.996, p = 0.000) and housewives (Chi2 = 13.654, p = 0.034). 4. DISCUSSION Today, dengue fever is the most common vector-borne viral infection in the world [ 1 ]. Socio-demographic factors and KAPs among the population play a critical role in both the incidence of dengue epidemics and the implementation of control measures [ 2 ]. With an upward trend in the incidence of dengue outbreaks in Yemen (mainly in Hoddidah), this study was conducted to assess KAP about dengue fever among communities in Hodeidah governorate, Yemen. Our study revealed that 94.3%) of household respondents had heard about dengue fever, which is more than a study in India, where only 60% of the respondents had previously heard about dengue fever. This may be due to the fact that the target population in the study in India was only rural people [ 16 ]. In another study done in urban settlement areas of South Delhi, the result is nearly consistent with the finding of our study. In the Delhi study, 90% reported being aware of dengue [ 17 ] and 78% in a study done in Brazil [ 18 ]. Similarly, focus group discussions undertaken in 2014 in Dhaka, Bangladesh, determined that the majority (91.3%) of the community members had heard about DF [ 19 ]. These findings are in line with those from a study conducted in Vietnam, which found that 97% of the participants had heard of DF [ 20 ]. Whereas in Yemen, (72.2%) of the febrile patients seeking healthcare in Taiz hospitals and healthcare centers have heard about DF [ 21 ]. In this study, health workers or hospitals were cited to have a major role in disseminating information about dengue. This is similar to previous studies in Thailand [ 22 ] and in Jamaica [ 23 ], where only about half of the participants obtained information about dengue disease from health workers. Thus, information, education, and communication (IEC) intervention programs may need to be reviewed so that health workers can maximize the opportunity of clinic visits and communicate in effective ways to prevent dengue disease. Secondly, respondents indicated that radio and television were the predominant sources of information regarding dengue. This is similar to the study done in Jeddah [ 24 ]. Therefore, the mass media is a powerful tool in generating better awareness about dengue prevention and control [ 25 , 22 ]. The present study illustrates that (81%), (67%), and 48.6%) of households mention that fever, headache, and joint pain are the most quoted symptoms subsequently. This agrees with other studies conducted in rural areas of Hodeidah, which revealed that the majority (93.7%) of the participants were aware of DF symptoms, which included fever, headache, pain behind the eyes, joint pain, muscle pain, and skin rash [ 14 ]. These findings were quite similar to those reported in Malaysia, where 95 percent of participants stated that the main symptoms of DF are chills and high fever, intense headaches, muscle and joint pains [ 26 ]. Of course, fever was the most common cited symptom among the majority of the participants, and this is similar to a previous study conducted in Pakistan [ 27 ]. Cambodia [ 28 ]. Delhi [ 17 ] Yemen [ 9 , 14 ]. On the other hand, some studies showed a lower percentage of knowledge of fever as the symptom, such as in Thailand (59%) [ 22 ], as well as Jamaica (49.5%) [ 23 ]. The poor knowledge of the spectrum of symptoms associated with dengue means that it may be confused with most other causes of fever such as the flu. The implication of this is that presentation to the clinic may be delayed until complications arise. Good knowledge of signs and symptoms of DF is essential to identify the disease and to seek early and appropriate health care to prevent complications[ 29 ]. Unfortunately, the majority of participants (79.9%) did not identify the signs and symptoms of DHF which is of great importance in guiding households in seeking timely medical help and prevent morbidities and mortalities as bleeding[ 30 ]. Knowing that dengue virus is transmitted by mosquito bites was correctly answer by 81.5% of the participations. This finding is similar to that reported from rural communities of Hodeidah, Yemen (83.4%) [ 14 ] and lower than Malaysian community (98.1%) [ 29 ], from people visiting tertiary care hospitals in Pakistan (86.9%) [ 27 ], but higher than a study from Brazil (60.8%) [ 18 ]. This difference may be because of the differenced in the study design. Despite that most of participation said that mosquito bite is transmission route of dengue fever, our results showed that there was a gap in the knowledge about the mode of transmission with 32.5%, 23.7%, and 21.1% of the household head wrongly identifying that dengue virus can also have transmitted by flies, direct contact with infected people and eating food or drinking water, respectively. These findings were quite similar to a study among rural populations in Hodeidah governorate, Yemen, which revealed that about 52.2% of the participant believed that dengue can be transmitted through contact with infected people [ 14 ]. In addition,a study among urban population in Taize, Yemen conducted by Alyousefi et al [ 9 ]. showed that about 20% of household heads have misconceptions about the modes of dengue fever transmission, including flies, contact with infected people and drinking contaminated water. Bridging this gap in knowledge is important in planning and designing programs and activities to educate populations on preventive measures towards dengue. Our above result was similar to other results that have misconceptions about the transmission mode of dengue fever from Jamaica, where 33.5% and 28.2% believed that dengue fever can be transmitted by flies and ticks, respectively [ 23 ]. Another similar result was from Nepal, which revealed that dengue fever can be transmitted by flies, by ticks, through food and water or by direct contact, and was recorded by 32.0, 42.0, 51.0, and 56.0%, respectively [ 31 ]. The majority (91.5%) of our respondents correctly answered that stagnant water is the breeding site for Aedes mosquitoes, as 88.9%, 87%, and 56% of the participants knew that water storage containers without cover, stagnant water in old tyres and trash cans, and stagnant water in air conditioners could be breeding places for the mosquito (A.aegypti), respectively. Compared with studies in other parts of the world, this result matches a study in Nepal, where more than 90.0% of lowland and highland populations identified stagnant water collections around houses as the breeding sites of mosquitoes [ 31 ].This might be due to the fact that many breeding places, such as discarded tyres, open water containers, and stagnant water, are common in the area of residence where mosquitoes have been a nuisance for ages. A study conducted in Yemen by Alyousefi et al. showed that the majority of the respondents (> 90.0%) recognized stagnant water and keeping water in uncovered water containers as a factor contributing to the spread of mosquitoes [ 9 ]. According to the study conducted by Saied et al., the majority of the respondents (86.1%) correctly answered that stagnant water in old tyres and trash cans can be breeding places for mosquitoes [ 14 ]. Higher proportions of correct awareness of the breeding sites of Aedes aegypti were also reported from other countries, such as Malaysia [ 26 ]. Though most respondents were aware that mosquitoes are the disease's vector, only a few correctly stated that mosquitoes primarily bite during the day. The percentage reflects poor knowledge about the activity of mosquitoes, leading to poorer protective practices against them to avoid being bitten. This finding is comparable with other studies carried out in Nepal, where only 8% of the lowland and 5% of the highland participants knew that Aedes albopictus and Aedes aegypti mosquitoes bite during the daytime [ 31 ]. Aside from these, our findings in this regard are better than those of a study conducted in Jamaica that reported only 5% of the participants who knew the biting time of the DF mosquito [ 23 ]. On the other hand, good knowledge of the biting time of dengue vectors was reported from a study conducted in the rural areas of Hodeidah, Yemen (33.6%) [ 14 ]. Meanwhile, about 71% of the participants in the urban areas of Taiz, Yemen [ 9 ]. According to the findings, more than sixty percent of the respondents (63%) showed a positive attitude towards dengue fever prevention and control. This indicated that more than half of the people were aware of the risk of dengue, DHF, and were supportive of dengue control. Health beliefs were found to influence dengue preventive practices [ 32 ]. Based on the Health Belief Model (HBM) [ 33 – 34 ], people’s health beliefs depend upon their perception of susceptibility to disease and their exposure to related campaigns. Therefore, although our respondents have a lower percentage of knowledge, more than half of them have a positive attitude towards dengue prevention. In our current study, 93.1% of respondents thought dengue was a serious but preventable disease (85.1%). This correct attitude is important to cultivate among the community so that they become aware of the prevention method. This is also elicited by a previous study in Indonesia [ 12 ]. Another study from Yemen's rural areas found that 65.7% of those polled agreed that DF is serious [ 14 ]. Also, a study conducted in Vietnam showed that a high proportion (96%) of the participants recognized that DF is a severe yet preventable disease [ 20 ]. As was reported in Malaysia [ 35 ], the majority of the respondents (92.9%) would seek immediate medical attention in case any of their family members had dengue fever. Despite the fact that most of the subjects (89.3%) had positive attitudes regarding the importance of community participation in controlling DF, some (64.2%) of the participants assumed that the elimination of breeding sites was solely the responsibility of the public health staff. This reflected the reason why the majority (74.2%) of our respondents did not participate in community cleanliness activities or campaigns to help prevent dengue fever in the community. Personal responsibility was found to be a problem in dengue control in many countries, including Thailand [ 36 ], Malaysia [ 25 ], and Puerto Rico [ 36 ], as well as in Yemen's rural areas, where 57% of study participants believed that health authorities and the government were solely responsible [ 14 ]. Surprisingly, in Malaysia, a study found that 95.3% of respondents believed that the public had a primary role in containing the dengue epidemic [ 26 ]. Regarding preventive practice, the majority of the participants mentioned that they have taken measures against dengue by covering water tanks immediately after use (87.4%), covering their water containers (84.1%) and frequently cleaning water-filled containers and diches around the house (81.8%) in order to minimize the risk of Aedes mosquito breeding. This finding is in coherence with a study in Brazil, where the elimination of water containers was the most efficient means of control of DF, according to 73% of the people [ 18 ]. A survey of KAP on the prevention of DHF in an urban community reported that covering water containers was the most common practice to prevent mosquito breeding in drinking-water containers [ 22 ]. In addition, a study in Malaysia reported that 98.5% of the respondents knew that the proper disposal of items that retain water is a correct preventive measure for dengue [ 29 ]. Furthermore, the results from a study conducted in the West Indies showed that all of the participants did something to control the DF vector at home and to ensure that no stagnant water was present in containers in the yard as the most popular method used to control the vector [ 38 ]. 5. Conclusions and Recommendations This study concluded that the larger proportion of the participants demonstrated a moderate level of knowledge, a positive attitude, and a low level of practice towards dengue prevention. Furthermore, this study found a significant relationship between KAP and sociodemographic factors such as level of education, gender, residence, and occupation. We recommend conducting health education on a regular basis and encouraging community participation in control activities against dengue. Declarations Acknowledgements The authors are grateful to all the study respondents who participated in this research wholeheartedly. 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Wong, L.P., Shakir, S.M.M., Atefi, N., AbuBakar, S., Factors affecting dengue prevention practices: nationwide survey of the Malaysian public. PloS One. 2015; 10,e0122890 Makornkan S, et al. Knowledge, Attitude and Practice of Dengue Fever Prevention Among the Villagers of Moo 1 Baan Klongsai, Nhongyangsuea Subdistrict, Muaklek District, Saraburi Province, Thailand. Catalyst. 2015; 12(2): 56-62. Dhimal M, et al. Knowledge, attitude and practice regarding dengue fever among the healthy population of highland and lowland communities in central Nepal. PLoS One. 2014;9(7):1-15 Lennon J., The use of health belief model in dengue health education. Dengue Bull, 2005. 29: p. 217–219. Rosenstock, I.M. Historical origins of the health belief model. Health Education Monographs. 1974; 2:328–335. Christina L, et al. The Health Belief Model as an Explanatory Framework in Communication Research: Exploring Parallel, Serial, and Moderated Mediation. Health Commun.2015; 30(6): 566–576 Wong, L.P., Abu Bakar, S. Health beliefs and practices related to dengue fever: a focus group study. PLoSNegl Trop Dis. 2013;11;7(7). Phuanukoonnon, S., Brough, M. & Bryan, J. H. Folk knowledge about dengue mosquitoes and contributions of health belief model in dengue control promotion in Northeast Thailand. Acta Tropica. 2006; 99: 6-14. Pérez-Guerra CL, Zielinski-Gutierrez E, Vargas-Torres D, Clark GG: Community beliefs and practices about dengue in Puerto Rico. Rev Panam Salud Publica 2009, 25:218–226. Flynn A. A study exploring the knowledge, attitudes and practices A Study Exploring the Knowledge, Attitudes and Practices of Young People Regarding Dengue Fever and the Extent of Community Involvement in Vector Control of the Disease in Trinidad and Tobago. West Indian Med J. 2012; 61 (6): 616 Tables Tables 1 to 5 are available in the Supplementary Files section Additional Declarations The authors declare no competing interests. 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Hajjam","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+klEQVRIiWNgGAWjYFACHgYGCSDmZ2Zs//EByGdjJ1aLZHtzg+QMkBZmYrSAgMGZ4w3SYDYhLboNvAc/WMjYRTPcSGwwtvm1TZ6PmYHxw8cc3FrMDvAlS0jwJOc2zkhsSM7tu23YxszALDlzGz4tPAZALcy5zRKJDYdze24zArWwMfPi12L8Q4KnPrdNIrGx2bLntj0xWsyAtgDN5znYzMzw43YiYS2HecwsJHiO585gb2xj7G24ndzGzNiM3y/He4xvS/ZU5+4/zP6M4cef27bz25sPfviIRwsoFpgle6AcxjYw2YBHPVThhx8w5h+CikfBKBgFo2AEAgB7qE5wiGpIGgAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0009-0008-5846-6387","institution":"Rapid Response Team, Epidemiological Surveillance and Diseases Control, Office of Public Health and Population, Hodeida , Yemen","correspondingAuthor":true,"prefix":"","firstName":"Mohammed","middleName":"Ahamed Mohammed","lastName":"Hajjam","suffix":""}],"badges":[],"createdAt":"2025-11-19 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10:00:12","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":604335,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8149458/v1/d29dce86-a05d-4eb7-8997-ecc6f70c49e2.pdf"},{"id":96381511,"identity":"4772fc17-f745-4484-942f-e72dcb771bd4","added_by":"auto","created_at":"2025-11-20 12:19:11","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":52709,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-8149458/v1/63daacc1c13ca8b0d6d53f5a.docx"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eKnowledge, Attitude and Practices about Dengue fever among population in Hodeidah, Yemen\u003c/p\u003e","fulltext":[{"header":"1. INTRODUCTION","content":"\u003cp\u003eDengue fever is a mosquito-borne viral disease caused by one of four unique serotypes of dengue virus (DENV1-4), which are members of the Flavivirus genus [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. It is primarily spread by Aedes aegypti [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Although most dengue infections remain asymptomatic, they can cause a wide range of clinical manifestations, from a mild non-specific febrile illness to severe symptoms such as plasma leakage [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eDF has emerged as a major public health concern with a large worldwide impact in recent years [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. More importantly, it has been categorized as one of the top ten global health hazards for 2019, according to the World Health Organization (WHO). With an estimated four billion people at risk in more than 141 countries in the world [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Annually, approximately 400\u0026nbsp;million dengue cases and 22 000 deaths occur worldwide [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Notably,the number of cases has significantly increased has increased recently from 3.34\u0026nbsp;million cases in 2016 to 4.2\u0026nbsp;million cases in 2019 [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. To conclude, the myriad of dengue cases has brought concern to all countries, including Yemen.\u003c/p\u003e\u003cp\u003eIn Yemen, dengue is endemic, with 60% of Yemen\u0026rsquo;s population live in risk areas [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In 2019, the incidence of dengue fever rose sharply and continued to increase. The sporadic cases and outbreak turned into a catastrophic situation where cases have been recorded in almost all governorates in Yemen. Hodeidah governorate has the second highest death rate in the country. In 2020, the number of suspected dengue cases reported was an increase of about seven times the number of cases in 2019, and six times the number of cases reported in 2018 [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn the absence of a vaccine or specialized therapy for dengue, the only possible mode of prevention is vector control, and preventing mosquito bites through community empowerment and engagement is an effective strategy for prevention [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. As a result, the effectiveness control of dengue is highly dependent on the adequate knowledge and good practices of preventive (KAP) measures of the targeted population about the disease and its preventive measures [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe lack of knowledge regarding dengue infection and its preventive methods has been considered one of the main problems in dengue epidemiology [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Moreover, Studies show that people with better knowledge of dengue are one of the predictors of better practices in dengue prevention [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Meanwhile, Roslan et al. (2020) claimed that people who have more knowledge about dengue are more likely to pursue more suitable dengue prevention measures compared to people with less knowledge [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. However, a lack of studies regarding DF among Yemeni people was found, including Hodeidah. One study was conducted by Saied et al. (2015) in rural areas of the Hodeidah governorate found that KAP) regarding dengue fever were not sufficiently [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eDengue prevention and control is not possible without the effectual participation of the local community to avoid vector breeding in and around residential areas. Thus, evaluation of people\u0026rsquo;s (KAP) is of great importance in the control measure of dengue fever [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Despite the scale of disease in Hodeidah, no documented evidence exists for the KAP of the population. This study aims to assess KAP about dengue fever among communities in Hodeidah governorate, Yemen.\u003c/p\u003e"},{"header":"2. MATERIALS AND METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e2.1. Study area\u003c/h2\u003e\u003cp\u003eHodeidah governorate is the fourth largest governorate in the Republic of Yemen, covering a total area of 17,509 km2 with an estimated total population of 2,687,674. It is located in the west on a flat coastal plain, bordered by the Red Sea in the west, Saudi Arabia in the north, and the Gulf of Aden in the south. Administratively, the governorate is subdivided into 26 districts, three of which are urban (AL-Hawa, AL Hali, and AL Mina). The remaining districts are in rural areas.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e2.2. Study design and population\u003c/h2\u003e\u003cp\u003eA cross-sectional study was conducted (from June 1st to December 30th, 2019) among the populations in six different geographical districts, urban (Al-Hali and Hawak) and rural (Bajil, Al-Zaydiyah, Al-Garrahi, and Al-Maraweah) in Hodeidah governorate, Yemen. Participants were all household heads (either male or female) who had lived in at least six districts for at least one year and agreed to participate; those who were unwilling to participate, those unable to communicate because of mental illness or severe hearing defects, and those who had migrated from other districts were excluded.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e2.3. Sample Size and technique\u003c/h2\u003e\u003cp\u003eThe required sample size was calculated by using the statistical formula: \u003cb\u003e(n\u0026thinsp;=\u0026thinsp;k2(pq)/d2)\u003c/b\u003e by considering the following assumptions: \u003cb\u003e(n)\u003c/b\u003e is the sample size, \u003cb\u003e(p)\u003c/b\u003e the prevalence of knowledge about dengue fever prevention was taken as 0.50 (as there was no previous data available in Hodeidah), \u003cb\u003e(k2)\u003c/b\u003e the 95% level of confidence, and \u003cb\u003e(d2)\u003c/b\u003e the acceptable maximum error (5%). The minimum sample size was 384 households. Thereafter, 10% (38) was added to account for non-response or incomplete data. Thus, the final sample size was 422 households (168 from urban and 254 from rural areas). A multi-stage random sampling method was used for this study. In the first stage, from a total of 26 districts, six (2 urabn: Al-Hali and Hawak, and four rural: Bajil, Al-Zaydiyah, Al-Garrahi, and Al-Maraweah) districts were randomly selected by proportional allocation. In the second stage, for each selected rural district, two sub-districts were randomly selected from the four districts, and then one village from each sub-district was randomly selected according to the relative size of the population in the sub-district, making a total of eight villages. Also, in urban areas, 3 hara were randomly selected from each district. Thus, the total number of selected villages was 8, and the hara was 6. In the third stage, in each hara (village) that was randomly selected, the head of household (either male or female) was selected by simple random sampling to represent each district, amounting to 168 from urban and 254 from rural areas.\u003c/p\u003e\u003cp\u003eFinally, at each household, the head of household (either male or female) was interviewed, whosoever was available at the time of data collection and was willing to participate in this study after obtaining their informed consent and explaining the nature of the study. If the household head was not present, refused to participate, or did not meet the pre-determined inclusion and exclusion selection criteria, the head of the next household was included until the sample size required was reached.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003e2.4. Data Collection\u003c/h2\u003e\u003cp\u003eData was collected through face-to-face interviews using a structured questionnaire adapted from relevant literature from various studies [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], along with a few modifications based on local practices. Initially, it was designed in the English language and later translated into the Arabic language (the mother tongue of Yemen). The questionnaire was reviewed by experts in this field of study. Each interview lasted between 15 and 20 minutes. The questionnaire included four parts. The first part consisted of questions on the socio-demographic details of the participants. The second part included questions on knowledge about dengue (disease signs and symptoms, complications, vectors and breeding sites). The third part included questions on attitudes, while the fourth part inquired about their regular practices (control and prevention) towards dengue.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003e4.1 Scoring of Data:\u003c/h2\u003e\u003cp\u003eA scoring system was developed. For knowledge, every question was rated on 3 answer choices: \"yes,\" \"no,\" or \"don\u0026rsquo;t know.\" All correct answers were scored 1, while \"Don\u0026rsquo;t Know\" and wrong answers were rated as 0 and the total results were divided into three categories: low knowledge (\u0026lt;\u0026thinsp;50%), moderate knowledge (\u0026ge;\u0026thinsp;50 - \u0026lt; 75%), and high knowledge (\u0026ge;\u0026thinsp;75%). For attitudes, using a 3-point Likert scale, 1\u0026thinsp;=\u0026thinsp;disagree; 2\u0026thinsp;=\u0026thinsp;not sure; and 3\u0026thinsp;=\u0026thinsp;agree. Positive attitudes were considered if the score was more than the median value of the total score, and it was considered negative if they scored less than the median value. Likewise, for practice, the answers \"Yes\" and \"No\" were given scores of 1 and 0, respectively. Good practices were considered if the score was more than the median value of the total score, and it was considered poor practices if they scored less than the median value.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003e2.7. Statistical Analysis\u003c/h2\u003e\u003cp\u003eThe collected data from the questionnaire was reviewed, coded, and entered into a computerized database before being analyzed with IBM SPSS Statistics, version 25. Frequencies and percentages (descriptive statistics) were calculated for categorical variables. A Chi-square test was used to determine the significance of the association between socio-demographic characteristics and KAP on DF, where P value 0.05 is the cut-off for statistical significance. The results were presented in tables and graphs.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003e2.3. Ethical issue\u003c/h2\u003e\u003cp\u003e This study was approved by the Institutional Research and Ethics Committee of the Department of Community Medicine at Hadhramout University, College of Medicine (HUCOM), Yemen. CM/REC 8/2018 (reference number). Participation was on a voluntary basis, and informed consent was obtained from participants after an explanation of the study objectives. Their confidentiality and privacy were assured throughout the interview.\u003c/p\u003e\u003c/div\u003e"},{"header":"3. RESULTS","content":"\u003cp\u003e\u003cstrong\u003e3.1.\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;Socio-demographic characteristics of the study respondents\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFrom a total of 422 study subjects, 254(60.19%) lived in rural areas , while only 168(39.81 %) were from urban areas; Among these, (53.6%) were male, 122 (28.9%) were Illiterate and (35.5%) \u0026nbsp;were housewives, see table \u003cstrong\u003e\u003csup\u003e(1)\u003c/sup\u003e\u003c/strong\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.2. Knowledge about dengue,DHF, its signs and symptoms, transmission\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOut of total participation, 49% had a low knowledge level, 41% had a moderate knowledge level, and only 10% had a high knowledge level towards DF. The majority of the respondents could correctly tell that fever (81.0%), headache (67.5%), and joint pain (48.6%) are the main signs and symptoms of dengue fever. In addition, 79.9% of respondents were unaware of DHF. The study also found that more than eighty percent of respondents knew that dengue virus is transmitted by mosquito bites, and 58.3% said that dengue mosquito bites at night. Flying, direct contact with infected people, and eating food or drinking water as another mode of transmission of dengue fever were recognized by 32.5%, 23.7%, and 21.1% of respondents, respectively. More than one third of the participants knew that clean, stagnant water is the breeding place for the mosquito. In addition, covering water containers and insecticide spray are preventive measures that could contribute to reducing the spread of vector mosquitoes and were recognized by 92.9% and 90.8% of respondents, respectively. Details on the correct responses of the participants are provided in table (2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.3.\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;Attitude\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eof respondent household heads towards dengue fever\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe distribution of attitudes towards DF indicated that 63% of the participants had positive attitudes while 37% had negative attitudes. More than 90% of those polled agreed that DF is a serious disease.Also, 85.1% agreed that the disease is preventable. Only 67.8% agreed that they were at risk of contracting dengue fever. Regarding the responsibility of dengue control, more than sixty percent agreed that the elimination of breeding sites should be the responsibility of public health staff only. Surprisingly, the majority (73.7%) agreed that it is not necessary to seek immediate treatment for dengue fever as there is no cure for it. Sleeping under a bed net can help prevent dengue infection, was agreed upon (82.9%). Finally, (85.8%) agreed that they have an important role in dengue prevention, see table (3).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.4.\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;practices of respondent household heads towards dengue fever\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn this study, 57% of the participants had good practices and 43% had poor practices towards dengue. More than eighty percent of respondents reported covering water containers at home, and 87.4% said that they cover water tanks immediately after use. Only a minority reported using preventive measures against mosquitoes, such as sleeping under mosquito nets (41.5%), window screens (46.2%), door screens (22.8%) and covering their bodies with clothes (45%). More than one-third said that they use insecticide spray and creams to repel mosquitoes to prevent mosquito bites. As a practice, 34.7% said that they would check for Aedes larvae in the water in cans and bottles around their homes. Among them, 25.8% would participate in community cleaning campaigns. 84.5 percent said that they visited a health center or facility when they felt sick. More than half of the study population (66.1%) felt that they should eliminate stagnant water around their houses to reduce mosquitoes and prevent dengue. see table (4).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.5.\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;Association between knowledge, attitude, practice and socioeconomic factors\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 5 presents the association between KAP and socioeconomic factors that may affect them in the study population. The level of education, residence, and occupation were significantly associated (p 0.05) with the knowledge level. The respondents who lived in the villages or rural areas had poorer knowledge than those who lived in urban areas. Also, it shows that gender and occupation had significant associations (p 0.05) with attitudes. In addition to that, females (Chi2 = 9.776, p = 0.002) were reported to have a more positive attitude than males. Among the different occupations, housewives (73.3%) and government employees (61.9%) possessed comparatively more positive attitudes than others. Residence, occupation, and gender all had significant (p 0.05) associations with practices.Having good prevention practices towards dengue was associated with people who lived in urban areas (Chi2 = 8.883, p = 0.003), females (Chi2 = 13.996, p = 0.000) and housewives (Chi2 = 13.654, p = 0.034).\u003c/p\u003e"},{"header":"4. DISCUSSION","content":"\u003cp\u003eToday, dengue fever is the most common vector-borne viral infection in the world [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Socio-demographic factors and KAPs among the population play a critical role in both the incidence of dengue epidemics and the implementation of control measures [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. With an upward trend in the incidence of dengue outbreaks in Yemen (mainly in Hoddidah), this study was conducted to assess KAP about dengue fever among communities in Hodeidah governorate, Yemen.\u003c/p\u003e\u003cp\u003eOur study revealed that 94.3%) of household respondents had heard about dengue fever, which is more than a study in India, where only 60% of the respondents had previously heard about dengue fever. This may be due to the fact that the target population in the study in India was only rural people [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. In another study done in urban settlement areas of South Delhi, the result is nearly consistent with the finding of our study. In the Delhi study, 90% reported being aware of dengue [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] and 78% in a study done in Brazil [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Similarly, focus group discussions undertaken in 2014 in Dhaka, Bangladesh, determined that the majority (91.3%) of the community members had heard about DF [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. These findings are in line with those from a study conducted in Vietnam, which found that 97% of the participants had heard of DF [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Whereas in Yemen, (72.2%) of the febrile patients seeking healthcare in Taiz hospitals and healthcare centers have heard about DF [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn this study, health workers or hospitals were cited to have a major role in disseminating information about dengue. This is similar to previous studies in Thailand [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] and in Jamaica [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], where only about half of the participants obtained information about dengue disease from health workers. Thus, information, education, and communication (IEC) intervention programs may need to be reviewed so that health workers can maximize the opportunity of clinic visits and communicate in effective ways to prevent dengue disease. Secondly, respondents indicated that radio and television were the predominant sources of information regarding dengue. This is similar to the study done in Jeddah [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Therefore, the mass media is a powerful tool in generating better awareness about dengue prevention and control [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe present study illustrates that (81%), (67%), and 48.6%) of households mention that fever, headache, and joint pain are the most quoted symptoms subsequently. This agrees with other studies conducted in rural areas of Hodeidah, which revealed that the majority (93.7%) of the participants were aware of DF symptoms, which included fever, headache, pain behind the eyes, joint pain, muscle pain, and skin rash [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. These findings were quite similar to those reported in Malaysia, where 95 percent of participants stated that the main symptoms of DF are chills and high fever, intense headaches, muscle and joint pains [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Of course, fever was the most common cited symptom among the majority of the participants, and this is similar to a previous study conducted in Pakistan [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Cambodia [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Delhi [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] Yemen [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. On the other hand, some studies showed a lower percentage of knowledge of fever as the symptom, such as in Thailand (59%) [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], as well as Jamaica (49.5%) [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe poor knowledge of the spectrum of symptoms associated with dengue means that it may be confused with most other causes of fever such as the flu. The implication of this is that presentation to the clinic may be delayed until complications arise. Good knowledge of signs and symptoms of DF is essential to identify the disease and to seek early and appropriate health care to prevent complications[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Unfortunately, the majority of participants (79.9%) did not identify the signs and symptoms of DHF which is of great importance in guiding households in seeking timely medical help and prevent morbidities and mortalities as bleeding[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eKnowing that dengue virus is transmitted by mosquito bites was correctly answer by 81.5% of the participations. This finding is similar to that reported from rural communities of Hodeidah, Yemen (83.4%) [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] and lower than Malaysian community (98.1%) [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e], from people visiting tertiary care hospitals in Pakistan (86.9%) [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], but higher than a study from Brazil (60.8%) [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. This difference may be because of the differenced in the study design.\u003c/p\u003e\u003cp\u003eDespite that most of participation said that mosquito bite is transmission route of dengue fever, our results showed that there was a gap in the knowledge about the mode of transmission with 32.5%, 23.7%, and 21.1% of the household head wrongly identifying that dengue virus can also have transmitted by flies, direct contact with infected people and eating food or drinking water, respectively. These findings were quite similar to a study among rural populations in Hodeidah governorate, Yemen, which revealed that about 52.2% of the participant believed that dengue can be transmitted through contact with infected people [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. In addition,a study among urban population in Taize, Yemen conducted by Alyousefi et al [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. showed that about 20% of household heads have misconceptions about the modes of dengue fever transmission, including flies, contact with infected people and drinking contaminated water. Bridging this gap in knowledge is important in planning and designing programs and activities to educate populations on preventive measures towards dengue.\u003c/p\u003e\u003cp\u003eOur above result was similar to other results that have misconceptions about the transmission mode of dengue fever from Jamaica, where 33.5% and 28.2% believed that dengue fever can be transmitted by flies and ticks, respectively [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Another similar result was from Nepal, which revealed that dengue fever can be transmitted by flies, by ticks, through food and water or by direct contact, and was recorded by 32.0, 42.0, 51.0, and 56.0%, respectively [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe majority (91.5%) of our respondents correctly answered that stagnant water is the breeding site for Aedes mosquitoes, as 88.9%, 87%, and 56% of the participants knew that water storage containers without cover, stagnant water in old tyres and trash cans, and stagnant water in air conditioners could be breeding places for the mosquito (A.aegypti), respectively. Compared with studies in other parts of the world, this result matches a study in Nepal, where more than 90.0% of lowland and highland populations identified stagnant water collections around houses as the breeding sites of mosquitoes [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].This might be due to the fact that many breeding places, such as discarded tyres, open water containers, and stagnant water, are common in the area of residence where mosquitoes have been a nuisance for ages.\u003c/p\u003e\u003cp\u003eA study conducted in Yemen by Alyousefi et al. showed that the majority of the respondents (\u0026gt;\u0026thinsp;90.0%) recognized stagnant water and keeping water in uncovered water containers as a factor contributing to the spread of mosquitoes [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. According to the study conducted by Saied et al., the majority of the respondents (86.1%) correctly answered that stagnant water in old tyres and trash cans can be breeding places for mosquitoes [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Higher proportions of correct awareness of the breeding sites of Aedes aegypti were also reported from other countries, such as Malaysia [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThough most respondents were aware that mosquitoes are the disease's vector, only a few correctly stated that mosquitoes primarily bite during the day. The percentage reflects poor knowledge about the activity of mosquitoes, leading to poorer protective practices against them to avoid being bitten. This finding is comparable with other studies carried out in Nepal, where only 8% of the lowland and 5% of the highland participants knew that Aedes albopictus and Aedes aegypti mosquitoes bite during the daytime [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Aside from these, our findings in this regard are better than those of a study conducted in Jamaica that reported only 5% of the participants who knew the biting time of the DF mosquito [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. On the other hand, good knowledge of the biting time of dengue vectors was reported from a study conducted in the rural areas of Hodeidah, Yemen (33.6%) [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Meanwhile, about 71% of the participants in the urban areas of Taiz, Yemen [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAccording to the findings, more than sixty percent of the respondents (63%) showed a positive attitude towards dengue fever prevention and control. This indicated that more than half of the people were aware of the risk of dengue, DHF, and were supportive of dengue control. Health beliefs were found to influence dengue preventive practices [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Based on the Health Belief Model (HBM) [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e], people\u0026rsquo;s health beliefs depend upon their perception of susceptibility to disease and their exposure to related campaigns. Therefore, although our respondents have a lower percentage of knowledge, more than half of them have a positive attitude towards dengue prevention.\u003c/p\u003e\u003cp\u003eIn our current study, 93.1% of respondents thought dengue was a serious but preventable disease (85.1%). This correct attitude is important to cultivate among the community so that they become aware of the prevention method. This is also elicited by a previous study in Indonesia [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Another study from Yemen's rural areas found that 65.7% of those polled agreed that DF is serious [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Also, a study conducted in Vietnam showed that a high proportion (96%) of the participants recognized that DF is a severe yet preventable disease [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. As was reported in Malaysia [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e], the majority of the respondents (92.9%) would seek immediate medical attention in case any of their family members had dengue fever.\u003c/p\u003e\u003cp\u003eDespite the fact that most of the subjects (89.3%) had positive attitudes regarding the importance of community participation in controlling DF, some (64.2%) of the participants assumed that the elimination of breeding sites was solely the responsibility of the public health staff. This reflected the reason why the majority (74.2%) of our respondents did not participate in community cleanliness activities or campaigns to help prevent dengue fever in the community. Personal responsibility was found to be a problem in dengue control in many countries, including Thailand [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e], Malaysia [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], and Puerto Rico [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e], as well as in Yemen's rural areas, where 57% of study participants believed that health authorities and the government were solely responsible [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Surprisingly, in Malaysia, a study found that 95.3% of respondents believed that the public had a primary role in containing the dengue epidemic [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Regarding preventive practice, the majority of the participants mentioned that they have taken measures against dengue by covering water tanks immediately after use (87.4%), covering their water containers (84.1%) and frequently cleaning water-filled containers and diches around the house (81.8%) in order to minimize the risk of Aedes mosquito breeding. This finding is in coherence with a study in Brazil, where the elimination of water containers was the most efficient means of control of DF, according to 73% of the people [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eA survey of KAP on the prevention of DHF in an urban community reported that covering water containers was the most common practice to prevent mosquito breeding in drinking-water containers [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. In addition, a study in Malaysia reported that 98.5% of the respondents knew that the proper disposal of items that retain water is a correct preventive measure for dengue [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Furthermore, the results from a study conducted in the West Indies showed that all of the participants did something to control the DF vector at home and to ensure that no stagnant water was present in containers in the yard as the most popular method used to control the vector [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e"},{"header":"5. Conclusions and Recommendations","content":"\u003cp\u003eThis study concluded that the larger proportion of the participants demonstrated a moderate level of knowledge, a positive attitude, and a low level of practice towards dengue prevention. Furthermore, this study found a significant relationship between KAP and sociodemographic factors such as level of education, gender, residence, and occupation. We recommend conducting health education on a regular basis and encouraging community participation in control activities against dengue.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAcknowledgements\u003c/h2\u003e\u003cp\u003eThe authors are grateful to all the study respondents who participated in this research wholeheartedly. Special thanks to Prof. Ali Mohammad Batarfi, dean of the Faculty of Medicine, HUCOM, and to my supervisor, Prof. Ahlam S. Bin Briek, professor of community medicine in the community medicine department, and to Prof. Abdulla S. Bin Ghouth, head of the community medicine department, for their fruitful assistance.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWorld Health Organization. Dengue and Severe Dengue. 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Health Education Monographs. 1974; 2:328\u0026ndash;335. \u003c/li\u003e\n\u003cli\u003eChristina L, et al. The Health Belief Model as an Explanatory Framework in Communication Research: Exploring Parallel, Serial, and Moderated Mediation. Health Commun.2015; 30(6): 566\u0026ndash;576\u003c/li\u003e\n\u003cli\u003eWong, L.P., Abu Bakar, S. Health beliefs and practices related to dengue fever: a focus group study. PLoSNegl Trop Dis. 2013;11;7(7). \u003c/li\u003e\n\u003cli\u003ePhuanukoonnon, S., Brough, M. \u0026amp; Bryan, J. H. Folk knowledge about dengue mosquitoes and contributions of health belief model in dengue control promotion in Northeast Thailand. Acta Tropica. 2006; 99: 6-14.\u003c/li\u003e\n\u003cli\u003eP\u0026eacute;rez-Guerra CL, Zielinski-Gutierrez E, Vargas-Torres D, Clark GG: Community beliefs and practices about dengue in Puerto Rico. Rev Panam Salud Publica 2009, 25:218\u0026ndash;226.\u003c/li\u003e\n\u003cli\u003eFlynn A. A study exploring the knowledge, attitudes and practices A Study Exploring the Knowledge, Attitudes and Practices of Young People Regarding Dengue Fever and the Extent of Community Involvement in Vector Control of the Disease in Trinidad and Tobago. West Indian Med J. 2012; 61 (6): 616\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 5 are available in the Supplementary Files section\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Hadramout University ","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Attitude, Dengue, Knowledge, Practices, Hodeidah, Yemen","lastPublishedDoi":"10.21203/rs.3.rs-8149458/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8149458/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eIn Yemen, dengue is one of the major public health concerns. Cases have been recorded in almost all governorates in Yemen. In 2019, Hodeidah governorate has the second highest death rate in the country. Good knowledge, attitudes, and practices (KAP) among the public regarding dengue prevention are required for the success of dengue prevention and control. The study aims to assess KAP about dengue fever among the population in Hodeidah, Yemen.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethodology\u003c/strong\u003e: \u0026nbsp;A cross-sectional study was conducted (from June 1st to December 30th, 2019) among the populations in six different geographical districts, urban (Al-Hali and Hawak) and rural (Bajil, Al-Zaydiyah, Al-Garrahi, and Al-Maraweah) in Hodeidah governorate. A total of 422 household heads were chosen at random to complete questionnaires distributed in their neighborhoods. The data was entered and analyzed using the Statistical Package for Social Sciences (SPSS) version 25. The Chi-square test was used as a test of significance, where p \u0026lt; 0.05 is the cutoff for significance.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: The results showed that nearly half (49%) of the participants demonstrated a moderate level of knowledge, 63% had a positive attitude, and 57% had good practices for dengue prevention. The level of education, residence, and occupation were significantly associated (p\u0026lt;0.05) with the knowledge level. Occupation and gender showed significant associations (p\u0026lt;0.05) with attitudes. Also, residence, occupation, and gender showed significant associations (p\u0026lt;0.05) with practices.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion and Recommendations\u003c/strong\u003e: This study concluded that the larger proportion of the participants demonstrated a moderate level of knowledge, a positive attitude, and a low level of practice towards dengue prevention. We recommend conducting health education on a regular basis and encouraging community participation in control activities against dengue.\u003c/p\u003e","manuscriptTitle":"Knowledge, Attitude and Practices about Dengue fever among population in Hodeidah, Yemen","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-20 12:19:06","doi":"10.21203/rs.3.rs-8149458/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9e86ec8a-ed08-4a90-9a62-d280ff2d7e49","owner":[],"postedDate":"November 20th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":58214734,"name":"Epidemiology"}],"tags":[],"updatedAt":"2025-11-20T12:19:06+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-20 12:19:06","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8149458","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8149458","identity":"rs-8149458","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}