Knowledge, attitudes, and practices about dengue fever among the population in Hodeidah, Yemen

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Cases have been recorded in almost all governorates in Yemen. In 2019, the Hodeidah governorate hadthe second highest death rate in the country. Good knowledge, attitudes, and practices (KAPs) among the public regarding dengue prevention are neededfor successful dengue prevention and control. Thisstudy aims to assess KAP about dengue fever among the population in Hodeidah, Yemen. Methods : A cross-sectional study was conducted (from June 1st to December 30th, 2019) among populations in six different geographical districts, urban (Al-Hali and Hawak) and rural (Bajil, Al-Zaydiyah, Al-Garrahi, and Al-Maraweah) in the Hodeidah governorate. A total of 422 household heads were chosen at random to complete questionnaires distributed in their neighborhoods. The data were entered and analyzed viathe Statistical Package for Social Sciences (SPSS) version 25. The chi-square test was used as a test of significance, where p < 0.05 wasthe cutoff for significance. Results The results revealed that 39% of the participants had good 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 were significantly associated(p<0.05) with attitudes. Additionally, residence, occupation, and gender were significantly associated (p<0.05) with practices. Conclusion : This study revealed that a relatively large proportion of the participants demonstrated a low level of knowledge, a positive attitude, and a level of practice toward dengue prevention.We recommend conducting health education on a regular basis and encouraging community participation in control activities against dengue. Health sciences/Diseases Health sciences/Health care Health sciences/Medical research Attitude Dengue Knowledge Practices Hodeidah Yemen Figures Figure 1 Figure 2 Background Dengue fever (DF) is a viral infection caused by one of four distinct serotypes of dengue virus, namely, DENV-1, DENV-2, DENV-3, and DENV-4, all of which belong to the Flavivirus genus within the Flaviviridae family ( 1 – 3 ). Transmission to humans predominantly occurs via the bite of infected Aedes aegypti, a highly anthropophilic mosquito that flourishes in densely populated ( 4 ). Although most dengue infections remain asymptomatic, they can cause a wide range of clinical manifestations, from a mild febrile illness to severe dengue hemorrhagic fever and shock syndrome ( 3 , 5 ). In recent decades, dengue fever has emerged as the most rapidly spread mosquito-borne viral disease ( 6 ). In 2019, the World Health Organization (WHO) classified dengue as one of the foremost global public health problems ( 7 ). Dengue fever is now endemic in more than 125 countries ( 8 , 9 ), placing approximately half of the global population at risk of this infection, mainly in tropical and subtropical areas ( 10 , 9 ). Globally, approximately 390 million dengue infections, of which 96 million progress to clinical cases, have been reported, establishing dengue as a significant vector-borne illness ( 9 ). Globally, the incidence of dengue continues to increase annually ( 6 , 11 ). The number of reported cases increased from 5.2 million in 2019 to 6.5 million in 2023 ( 12 ). In 2024, dengue reached an unprecedented peak, with approximately 14.6 million reported cases of dengue, including 7.5 million confirmed cases, over 52,000 severe cases, and approximately 12,000 deaths ( 8 ). This represents the highest number of global cases ever reported to the WHO. The rapid expansion of dengue transmission is driven by climate change, global warming, rapid urbanization, globalization, and enhanced vector habitat suitability ( 13 ). Dengue is still a major health problem worldwide; even though vaccines such as Dengvaxia and TAK-003 have been developed, their use is still limited, making prevention and mosquito control the primary strategies for reducing dengue disease transmission, especially in settings where insecticide resistance is widespread ( 14 ), ( 15 ). Effective dengue control depends mostly on reducing Aedes breeding sites and minimizing mosquito bites through environmental management and community participation ( 16 ),( 17 ).The success of these initiatives essentially depends upon the population's knowledge, attitudes, and practices (KAPs) related to disease transmission and preventative measures ( 18 , 19 ). As a result, successful control of dengue depends mostly on adequate knowledge and good practices of preventative (KAP) measures to educate the targeted population about the disease and measures to prevent it ( 20 ),( 21 ). Therefore, enhancing health education and improving community-level KAP toward dengue prevention are crucial for the success and sustainability of dengue control to lowering disease burden in endemic areas ( 22 ). Dengue is a major public health problem in Yemen, where it is endemic, and more than 60% of the population lives in risk areas ( 23 ) ( 24 ) .There were large increases in cases in 2019, 2020, 2021, 2022, and 2023. In 2020, the number of suspected dengue cases reported increased approximately seven times the number of cases reported in 2019 and six times the number of cases reported in 2018 ( 25 ). In 2024, there were 9,770 reported cases of dengue fever and 6 fatalities (CFR = 0.06%), with Hudaydah representing the highest incidence at 7,662 cases (78.4%) ( 26 ). The healthcare and surveillance systems in Yemen were affected by conflicts and war, which led to more outbreaks of dengue fever (DF) ( 25 ). The lack of knowledge regarding dengue infection and its preventive methods has been considered one of the main problems in dengue epidemiology ( 27 ). Moreover, studies have shown that better knowledge of dengue is a predictor of better practices in dengue prevention ( 19 , 20 , 28 , 29 ) .Moreover, Roslan et al. (2020) reported that people who have more knowledge about dengue are more likely to pursue more suitable dengue prevention measures than people with less knowledge ( 30 ) However, studies concerning DF among Yemeni people, including those in Hodeidah, are lacking. One study conducted by Saied et al. (2015) in rural areas of the Hodeidah governorate reported that the KAP regarding dengue fever was not sufficient ( 20 ). Dengue prevention and control are not possible without the effective participation of the local community to avoid vector breeding in and around residential areas. Thus, the evaluation of people’s KAP is highly important in the control of dengue fever ( 31 ). Despite the scale of disease in Hodeidah, no published study has documented for the KAP of the population. This study aims to assess KAP about dengue fever among communities in Hodeidah governorate, Yemen. This is the first study of KAP among the community in the Hodeidah Governorate, which may be useful for understanding the gap and improving the disease’s control and prevention. Methods Study design and setting A cross-sectional study was conducted (from June 1st to December 30th, 2019) among populations in six different geographical districts, urban (Al-Hali and Hawak) and rural (Bajil, Al-Zaydiyah, Al-Garrahi, and Al-Maraweah) in the Hodeidah governorate. The 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 bordering the Red Sea in the west, Saudi Arabia in the north, and the Gulf of Aden in the south. Geographically, 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. The climate is tropical, with high summer temperatures and mild winter temperatures, and rain is rare. Study population The 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. Sample size and technique The required sample size was calculated via the statistical formula (n = k2(pq)/d2) by considering the following assumptions: (n) the sample size, (p) the prevalence of knowledge about dengue fever prevention was 0.50 (as there were no previous data available in Hodeidah), (k2) the 95% confidence interval, and (d2) the acceptable maximum error (5%). The minimum sample size was 384 households. Thereafter, 10% ( 38 ) was added to account for nonresponse or incomplete data. Thus, the final sample size was 422 households (168 from urban areas and 254 from rural areas). A multistage random sampling method was used for this study. In the first stage, from a total of 26 districts, six (two urban: Al-Hali and Hawak; four rural districts: 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 subdistricts were randomly selected from the four districts, and then one village from each subdistrict was randomly selected according to the relative size of the population in the subdistrict, resulting in a total of eight villages. Additionally, in urban areas, 3 hara were randomly selected from each district. Thus, the total number of selected villages was 8, and the total number of 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 areas 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 providing informed consent and explaining the nature of the study. If the household head was not present, refused to participate, or did not meet the predetermined inclusion and exclusion selection criteria, the head of the next household was included until the sample size required was reached. Households were randomly selected, and household heads were invited to participate in the study after providing informed consent. If the household head was not present or refused to participate, the head of the next household was included until the sample size was reached. The individuals studied in the city were recruited via a simple random sampling method. Data collection Data were collected through face-to-face interviews via a structured questionnaire adapted from relevant literature from various studies ( 19 , 32 ), 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 sociodemographic 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, whereas the fourth part inquired about their regular practices (control and prevention) toward dengue. Scoring of Data A scoring system was developed. For knowledge, every question was rated on 3 answer options: "yes," "no," or "don’t know." All correct answers were scored as 1, whereas "Don’t know" and wrong answers were rated as 0, and the total results were divided into categories of good or poor knowledge based on a cutoff point of 50%. For attitudes, a 3-point Likert scale was used: 1 = disagree, 2 = not sure, and 3 = agree. Positive attitudes were considered if the score was greater than 50%, and positive attitudes were considered negative if the score was less than 50%. Likewise, for practice, the answers "Yes" and "No" were given scores of 1 and 0, respectively. Good practices were considered if the score was greater than 50%, and poor practices were considered if the score was less than 50%. Statistical analysis The data collected from the questionnaire were 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 associations between sociodemographic characteristics and KAP on DF, where a P value of 0.05 was the cutoff for statistical significance. The results are presented in tables and graphs. Results Sociodemographic characteristics of the study respondents Among the 422 study subjects, 254 (60.19%) lived in rural areas, whereas only 168 (39.81%) lived in urban areas. Among these, 53.6% were male, 122 (28.9%) were illiterate, and 35.5% were housewives (see Table 1 ). Table 1 Sociodemographic characteristics of the study participants, Hodeidah Governorate, 2019 socio demographic variables Frequency, %= n(%) Residence Rural 254(60.1) Urban 168(39.8) Sex Female 196(46.4) Male 226(53.6) Age < 20 17( 4 ) 20-<40 232(55) 40- 60 25(5.9) Marital status Married 367(87) Divorced 21( 5 ) Widowed 34(8.1) Educational Level Illiterate 122(28.9) Basic school 94(22.3) Secondary school 106(25.1) University 100(23.7) Occupational Level Unemployed 43(10.2) Govt. employed 63(14.9) Self-business 53(12.6) Housewife 150(35.5) Farmer 29(6.9) Fisher 8(1.9) Others 76( 18 ) Knowledge about dengue, DHF, its signs and symptoms, and transmission The majority of the respondents correctly reported that fever (81.0%), headache (67.5%), and joint pain (48.6%) were the main signs and symptoms of dengue fever. In addition, 79.9% of the respondents were unaware of DHF. The study also revealed that more than eighty percent of the respondents knew that dengue virus is transmitted by mosquito bites and that 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 the 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 presented in Supplementary Table 2. Attitudes of the respondent household heads toward dengue fever More than 90% of those polled agreed that DF is a serious disease. Additionally, 85.1% agreed that the disease was preventable. Only 67.8% agreed that they were at risk of contracting dengue fever. With respect to 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 (82.9%). Finally, 85.8% agreed that they play an important role in dengue prevention are presented in Supplementary Table 3. Practices of respondent household heads toward dengue fever More than eighty percent of the respondents reported covering water containers at home, and 87.4% said that they covered 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 sprays 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. A total of 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 the number of mosquitoes and prevent dengue are presented in Supplementary Table 4. Overall KAP scores Among the total participants, 39% had good knowledge, 63% had positive attitudes and 57% reported good practices regard dengue fever (Fig. 1). Figure 1: shows the overall KAP score of the participants. Figure (2): represents the main source of information of the respondents. These are: Health workers / hospitals (97.8%), TV / radio (61.6%), Family / friends (57.6%), Posters / billboards (32.0%), Internet (websites) (12.6%), and Brochures / pamphlets (9.0%). Associations between knowledge, attitudes, practices and socioeconomic factors Table 5 presents the associations 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 villages or rural areas had poorer knowledge than did those who lived in urban areas. Additionally, gender and occupation were significantly associated (p 0.05) with attitudes. In addition, 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 did. Residence, occupation, and gender all had significant (p 0.05) associations with practices. Good practices for preventing dengue were associated with living in urban areas (Chi2 = 8.883, p = 0.003), being female (Chi2 = 13.996, p = 0.000) and being housewives (Chi2 = 13.654, p = 0.034). Table 5 Association between socio-demographic characteristic and practice of respondents in Hodeidah Governorate, Yemen, 2019 Socio demographic variables Frequency, %= n (%) Knowledge Category n (%) \(\:{}^{2}\) \(\:\left(\varvec{P}\:\mathbf{v}\mathbf{a}\mathbf{l}\mathbf{u}\mathbf{e}\right)\:\) Attitude n (%) \(\:{}^{2}\:\) \(\:\left(\varvec{P}\:\mathbf{v}\mathbf{a}\mathbf{l}\mathbf{u}\mathbf{e}\right)\:\) Practice n (%) Good Poor Positive Negative Good Poor Residence Rural 254 (60.1) 84 (51.5%) 170 (65.6%) 8.304 (0.004*) 156 (61.4%) 98 (38.6%) 0.715 (0.398) 129 (50.8) 125 (49.2) 8.883 (0.003*) Urban 168 (39.8) 79 (48.5%) 89 (34.4%) 110 (65.5%) 58 (34.5%) 110 (56.4) 58 (43.6) Sex Female 196 (46.4) 75 (46.0%) 121 (46.7%) 0.020 (0. 887) 139 (70.9) 57 (29.1) 9.776 (0.002*) 130 (66.3 ) 66 (33.7) 13.996 (p < 0.001) Male 226 (53.6) 88 (54.0%) 138 (53.3%) 127 (56.2 ) 99 (43.8) 109 (48.2 ) 117 (51.8) Age < 20 17 ( 4 ) 7 (4.3%) 10 (3.9%) 0.286 (0.963) 10 (58.8) 7 (41.2) 3.528 (0.317) 13 (76.5) 4 (23.5) 4.140 (0.247) 20-<40 232 (55) 10 (6.1%) 15 (5.8%) 145 (62.5 ) 87(37.5) 125 (53.9 ) 107 (46.1 ) 40- 60 25 (5.9) 59 (36.2%) 89 (34.4%) 12 (48 ) 13 (52) 13 (52) 12 ( 48 ) Marital status Married 367 (87) 140 (85.9%) 227 (87.6%) 0.754 (0.668) 227 (61.8 ) 140(38.2) 2.090 (0.352) 207 (56.4 ) 160 (43.6) 0.077 (0.962) Divorced 21 ( 5 ) 10 (6.1%) 11 (4.2%) 16 (76.2) 5(23.8) 12 (57.1 ) 9 (42.9) Widowed 34 (8.1) 13 (8.0%) 21 (8.1%) 23 (67.6) 11 (32.4) 20 (58.8) 14 (41.2 ) Educational Level Illiterate 122 (28.9) 37 (22.7%) 85 (32.8%) 17.165 (0.001*) 68 (55.7 ) 54 (44.3) 3.920 (0.270) 72 (59 ) 50 ( 41 ) 1.346 (0.718) Basic school 94 (22.3) 27 (16.6%) 67 (25.9%) 62 (65.9) 32 (34.1) 56 (59.6) 38 (40.4) Secondary school 106 (25.1) 46 (28.2%) 60 (23.2%) 70 (66.1 ) 36 (33.9) 56 (52.8) 50 (47.2) University 100 (23.7) 53 (32.5%) 47 (18.1%) 66 (66) 34 ( 34 ) 55 (55) 45 (45 ) Occupational Level Unemployed 43 (10.2) 9 (5.5%) 34 (13.1%) 25.384 (p < 0.001) 24 (55.8) 19 (44.2) 18.308 (0.006*) 24 (55.8 ) 19 (44.2) 13.654 (0.034*) Govt. employed 63 (14.9) 36 (22.1%) 27 (10.4%) 39 (61.9 ) 24 (38.1) 37 (58.7 ) 26 (41.3) Self-business 53 (12.6) 26 (16.0%) 27 (10.4%) 31 (58.4) 22 (41.6) 28 (52.8 ) 25 (47.2 ) Housewife 150 (35.5) 46 (28.2%) 104 (40.2%) 110 (73.3) 40 (26.7) 97( 64.7) 53 (35.3) Farmer 29 (6.9) 8 (4.9%) 21 (8.1%) 16 (55.2) 13 (44.8) 10 (34.5) 19 (65.5 ) Fisher 8 (1.9) 5 (3.1%) 3 (1.2%) 1 (12.5) 7 (87.5) 2 (25 ) 6 (75) Others 76 ( 18 ) 33 (20.2%) 43 (16.6%) 156 (61.4) 98 (38.6) 41 (53.9 ) 35 (46.1 ) X 2− Chi-square , PV: p value , * Significant at P < 0.05. Discussion Today, dengue fever is the most common vector-borne viral infection in the world ( 33 ). Sociodemographic factors and KAPs play critical roles in both the incidence of dengue epidemics and the implementation of control measures ( 34 ). With an increasing 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. This study shows that only 39% of participant have a good level of knowledge about dengue fever, which is slightly lower than what was reported from pevious study in the Shabwah Governorate, Yemen in 2022 ( 20 ), Malaysia in 2020 ( 35 ) and Indonesia in 2015 ( 29 ),This finding is in line with a previous study conducted in Pakistan in 2023 ( 36 ). Our findings were higher compared to another study in Pakistan, 2010 ( 37 ). The present study revealed that fever, headache, and joint pain were the most common symptoms of DF. Fever was the most common symptom among the majority of the participants, which is similar to the findings of a previous study conducted in the Shabwah Governorate, Yemen, in 2022 ( 20 ); in Taiz (Yemen) ( 19 ); in rural areas of Yemen ( 32 ); and in Pakistan ( 38 ) and Cambodia ( 39 ), which show fever was reported as the primary symptom of DF. This could be explained by educational messages in the mass media citing fever as dengue’s primary symptom ( 40 ) or by the participants’ personal experience with the disease or witnessing a close friend or relative’s case. Thus, raising awareness of these signs and symptoms could aid in distinguishing DF from other febrile infectious diseases, particularly in developing nations where DF is endemic ( 20 ). Good knowledge of the signs and symptoms of DF is essential for identifying the disease and seeking early and appropriate health care to prevent complications ( 41 ). Unfortunately, the majority of participants (79.9%) did not identify the signs and symptoms of DHF, which is highly important in guiding households in seeking timely medical help and preventing morbidities and mortalities such as bleeding ( 42 ). Knowing that dengue virus is transmitted by mosquito bites was correctly answered by 81.5% of the participants. This finding is similar to that reported from rural communities in Hodeidah, Yemen (83.4%) ( 32 ), and lower than that reported in the Malaysian community (98.1%) ( 41 ) and from people visiting tertiary care hospitals in Pakistan (86.9%) ( 38 ), but higher than that reported in a study from Brazil (60.8%) ( 43 ). This difference may be because of differences in the study design. Although most of the participants said that mosquito bites are a transmission route of dengue fever, our results revealed that there was a gap in the knowledge concerning the mode of transmission, with 32.5%, 23.7%, and 21.1% of the household heads incorrectly identifying that dengue virus can also be transmitted by flies, direct contact with infected people, and eating food or drinking water, respectively. These findings were similar to those of a study among rural populations in Hodeidah governorate, Yemen, which revealed that approximately 52.2% of the participants believed that dengue can be transmitted through contact with infected people ( 32 ). In addition, a study among the urban population in Taize, Yemen, conducted by Alyousefi et al. ( 19 ), showed that approximately 20% of household heads have misconceptions about the modes of dengue fever transmission, including flies, contact with infected people, and drinking contaminated water. In addition, a previous study conducted in Hodeidah revealed that most participants believed that the disease could be transmitted from an infected person to a healthy person via direct contact. Bridging this gap in knowledge is important in planning and designing programs and activities to educate populations on preventive measures for 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 ( 44 ). 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 ( 45 ). The majority (91.5%) of participants in the current study 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) play a significant role in the transmission of DF by mosquitoes, respectively. Compared with studies in other parts of the world, this result matches a study in Nepal ( 45 ), in rural populations in Hodeidah governorate, Yemen ( 32 ), in the Shabwah Governorate, Yemen ( 20 ), and in Taiz, Yemen ( 19 ). This may be related to the increasing number of breeding sites, such as discarded tires, open water containers, and stagnant water, in regions where mosquitoes have long been a nuisance. the strengthening of mass mediamessages and educational programs in recent years may have helped to improved identification of risk factors ( 46 ) ( 20 ). Although most respondents were aware that mosquitoes are the disease vector, only a few correctly stated that mosquitoes bite primarily 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 ( 45 ). On the other hand, good knowledge of the biting time of dengue vectors was reported in a study conducted in rural areas of Hodeidah, Yemen (33.6%) ( 32 ). Moreover, approximately 71% of the participants were living in the urban areas of Taiz, Yemen ( 19 ). Our findings revealed that the majority of the participating students (63%) had a positive attitude toward dengue fever prevention, with a significant association with gender and occupation. this Similar to previous research conducted in Yemen’s Shabwah ( 20 ), Taiz ( 20 ),Taiz( 19 ) ,and Hodeidah ( 32 ) governorates, our study revealed a positive attitude regarding the severity and transmissibility. Despite the fact that most of the participants (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 ( 47 ) and Malaysia ( 48 ), as well as in Yemen's rural areas, where 57% of study participants believed that health authorities and the government were solely responsible ( 32 ). Surprisingly, in Malaysia, 95.3% of respondents believed that the public had a primary role in containing the dengue epidemic ( 49 ). Regarding preventive practices, more than half (57%) of participants had good practices against DF. This result was lower compared to a previous study conducted in Yemen’s Shabwah ( 20 ). In contrast, this finding is higher than studies conducted in Malaysia ( 35 ) and Indonesia ( 29 ). Also, residence, occupation, and sex had significant associations with practices. This is similar to a study conducted in Indonesia ( 29 ). The majority of the participants mentioned that they had 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 ditches around the house (81.8%) to minimize the risk of Aedes mosquito breeding. This finding is consistent with a study in Brazil, where the elimination of water containers was the most efficient means of controlling DF, accounting for 73% of the population ( 43 ). 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 ( 41 ). 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, which is the most popular method used to control the vector ( 50 ). In this study, health workers or hospitals were found to play a major role in disseminating information about dengue. This finding is similar to those of previous studies in Jamaica ( 44 ). Second, the respondents indicated that radio and television were the predominant sources of information regarding dengue. This finding is similar to that of the study performed in Jeddah ( 51 ). Therefore, mass media is a powerful tool for generating better awareness of dengue prevention and control ( 48 ). Limitations of the study Because the study is cross-sectional, it evaluates relationships at a single moment in time and does not account for the dynamics of the interactions between the variables examined. Furthermore, because the study was conducted using questionnaires administered by an interviewer, some participants may have provided socially desired responses to certain questions. Despite these limitations, the study's findings are expected to make a significant contribution to our understanding of the current issues of DF prevention in the study area. Conclusions This study revealed that a relatively large proportion of the participants demonstrated a low level of knowledge, a positive attitude, and a level of practice toward dengue prevention. Furthermore, this study revealed 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. Abbreviations DF Dengue fever DENV Dengue virus DENV-1 Dengue virus serotype 1 DENV-2 Dengue virus serotype 2 DENV-3 Dengue virus serotype 3 DENV-4 Dengue virus serotype 4 WHO World Health Organization KAP Knowledge, Attitudes, and Practices CFR Case Fatality Rate SPSS Statistical Package for Social Science X 2 Chi-square Declarations Ethics approval and consent to participate This study was approved by the Ethics Committee of the Department of Community Medicine at Hadhramout University, College of Medicine (HUCOM), Yemen with approval number [CM/REC 8/2018]. All study procedures were carried out in accordance with guidelines of the 1964 Declaration of Helsinki. All participants were informed about the purpose of the study, assured of confidentiality, and provided written consent prior to participation. Participation was voluntary, and respondents could withdraw at any time without consequence. Consent for publication Not Applicable Availability of data and materials The datasets generated and/or analyzed during the current study are not publicly available due to participant confidentiality but are available from the corresponding author on reasonable request. Competing interests No financial or commercial ties existed between the authors at the time of the research that might be considered a conflict of interest, as the authors affirm Funding The authors did not obtain any funding for this study. Authors' contributions M.H designed the study, developed the data collection tools, and supervised the fieldwork. M.H performed the data collection and contributed to data entry and validation. A.B supervised the fieldwork ,M.H and A.B conducted the statistical analysis and interpreted the results.M.H wrote the main manuscript draft, while A.B contributed to revising and refining the text. All authors reviewed and approved the final version of the manuscript. Acknowledgments The 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 Prof. Abdulla S. Bin Ghouth, head of the community medicine department, for their fruitful assistance. Authors' information Not applicable References Murugesan A, Manoharan M. Emerging and reemerging viral pathogens. Emerging and reemerging viral pathogens2020. p. 281-359. Kalimuddin S, Chia PY, Low JG, Ooi EE. Dengue and severe dengue. Clinical Microbiology Reviews. 2025:e00244-24. Ferreira-de-Lima VH, Lima-Camara TN. Natural vertical transmission of dengue virus in Aedes aegypti and Aedes albopictus: a systematic review. Parasites & vectors. 2018;11(1):77. Kweka EJ, Baraka V, Mathias L, Mwang’onde B, Baraka G, Lyaruu L, et al. Ecology of Aedes mosquitoes, the major vectors of arboviruses in human population. Dengue Fever-a Resilient Threat Face Innov. 2018;10. 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Yulfi H, Panggabean M, Darlan DM, Siregar IS, Rozi MF. Community-based intervention in mosquito control strategy: A systematic review. Narra J. 2025;5(1):e1015. Ghimire S, Pangeni S. A mixed method evaluation of knowledge, attitude and practice on dengue fever among Lalitpur Metropolitan City residents: a cross-sectional investigation. BMC Infectious Diseases. 2024;24(1):1124. Espinoza-Gómez F, Hernández-Suárez CM, Coll-Cárdenas R. Educational campaign versus malathion spraying for the control of Aedes aegypti in Colima, Mexico. Journal of Epidemiology & Community Health. 2002;56(2):148-52. Alyousefi TA, Abdul-Ghani R, Mahdy MA, Al-Eryani SM, Al-Mekhlafi AM, Raja YA, et al. A household-based survey of knowledge, attitudes and practices towards dengue fever among local urban communities in Taiz Governorate, Yemen. BMC infectious diseases. 2016;16(1):543. Saghir MA, Ahmed WA, Dhaiban MMA, Osman ME, Abduljabbar NI. Knowledge, attitude, and practices of the community toward dengue fever in Shabwah Governorate, Yemen: a descriptive study. Journal of the Egyptian Public Health Association. 2022;97(1):27. Rahman MS, Mehejabin F, Rashid R. A community based case-control study to determine the risk factors of dengue fever in Bangladesh. medRxiv. 2021:2021.08. 24.21262563. Shafie AA, Moreira Jr ED, Di Pasquale A, Demuth D, Yin JYS. Knowledge, attitudes and practices toward dengue fever, vector control, and vaccine acceptance among the general population in countries from Latin America and Asia Pacific: a cross-sectional study (GEMKAP). Vaccines. 2023;11(3):575. Organization WH. Report on the subregional meeting on dengue fever in the Red Sea rim, Cairo, Egypt, 20–22 July 2011. 2012. IOM. Malaria in Yemen: Needs assessment. 2017. World Health Organization. (2023). Dengue and severe dengue. https://www.who.int/news-room/fact-sheets/detail/dengue-and-severe-dengue (Accessed May 15, 2023) Electronic Integrated Disease Early Warning System & Response (eIDEWS) Yemen. (2024). Annual achievement report. Yemen. Wong LP, AbuBakar S, Chinna K. Community knowledge, health beliefs, practices and experiences related to dengue fever and its association with IgG seropositivity. PLoS neglected tropical diseases. 2014;8(5):e2789. Kamel M, Gnanakkan BD, Fauzi FZ, Hanafi MI, Selvarajah G, Jabar SA, et al. The KAP study on dengue among community in Taman Salak Baiduri, Sepang, Selangor. Age. 2017;18(2). Harapan H, Rajamoorthy Y, Anwar S, Bustamam A, Radiansyah A, Angraini P, et al. Knowledge, attitude, and practice regarding dengue virus infection among inhabitants of Aceh, Indonesia: a cross-sectional study. BMC infectious diseases. 2018;18(1):96. Roslan MA, Ngui R, Vythilingam I, Fatt CK, Soon OP, Keat LC, et al. Survey of dengue knowledge and prevention practices associated with sociodemographic status: a cross-sectional study among the community living in an urban area of Selangor, Malaysia. Journal of the American Mosquito Control Association. 2020;36(2):115-9. Hossain MI, Alam NE, Akter S, Suriea U, Aktar S, Shifat SK, et al. Knowledge, awareness and preventive practices of dengue outbreak in Bangladesh: A countrywide study. PloS one. 2021;16(6):e0252852. Saied KG, Al-Taiar A, Altaire A, Alqadsi A, Alariqi EF, Hassaan M. Knowledge, attitude and preventive practices regarding dengue fever in rural areas of Yemen. International health. 2015;7(6):420-5. Organization WH. Dengue and severe dengue. World Health Organization. Regional Office for the Eastern Mediterranean; 2014. Udayanga L, Gunathilaka N, Iqbal M, Pahalagedara K, Amarasinghe US, Abeyewickreme W. Socio-economic, Knowledge Attitude Practices (KAP), household related and demographic based appearance of non-dengue infected individuals in high dengue risk areas of Kandy District, Sri Lanka. BMC infectious diseases. 2018;18(1):88. Selvarajoo S, Liew JWK, Tan W, Lim XY, Refai WF, Zaki RA, et al. Knowledge, attitude and practice on dengue prevention and dengue seroprevalence in a dengue hotspot in Malaysia: A cross-sectional study. Scientific reports. 2020;10(1):9534. Jamal Mr, Suleman M, Umar M, Ahmad J, Shabir A, Khan S, Et Al. Knowledge, Attitudes and Practices Related to Dengue Fever In Peshawar, Khyber Pakhtunkhwa, Pakistan. Pakistan Medical Students Research Journal. 2023;1(1):19-22. Syed M, Saleem T, Syeda U-R, Habib M, Zahid R, Bashir A, et al. Knowledge, attitudes and practices regarding dengue fever among adults of high and low socioeconomic groups. Journal of the Pakistan Medical Association. 2010;60(3):243. Itrat A, Khan A, Javaid S, Kamal M, Khan H, Javed S, et al. Knowledge, awareness and practices regarding dengue fever among the adult population of dengue hit cosmopolitan. PloS one. 2008;3(7):e2620. Khun S, Manderson L. Community and school-based health education for dengue control in rural Cambodia: a process evaluation. PLoS neglected tropical diseases. 2007;1(3):e143. Elson WH, Ortega E, Kreutzberg-Martinez M, Jacquerioz F, Cabrera LN, Oberhelman RA, et al. Cross-sectional study of dengue-related knowledge, attitudes and practices in Villa El Salvador, Lima, Peru. BMJ open. 2020;10(10):e037408. Wong LP, Shakir SMM, Atefi N, AbuBakar S. Factors affecting dengue prevention practices: nationwide survey of the Malaysian public. PloS one. 2015;10(4):e0122890. Makornkan S, Saminpanya P, Toomsan A, Intachai P, Saengproa P, Marerngsit D. Knowledge, Attitude and Practice of Dengue Fever Prevention Among the Villagers of Moo 1 Baan Klongsai, Nhongyangsuea Subdistrict, Muaklek District, Saraburi Province, Thailand. catalyst journal of the institute for interdisciplinary studies. 2015;12(2):56. Degallier N, Vilarinhos P, de Carvalho ML, Knox MB, Caetano Jr J. People's knowledge and practice about dengue, its vectors, and control means in Brasilia (DF), Brazil: its relevance with entomological factors. Journal of the American Mosquito Control Association. 2000;16(2):114-23. Shuaib F, Todd D, Campbell-Stennett D, Ehiri J, Jolly PE. Knowledge, attitudes and practices regarding dengue infection in Westmoreland, Jamaica. The West Indian Medical Journal. 2010;59(2):139. Dhimal M, Aryal KK, Dhimal ML, Gautam I, Singh SP, Bhusal CL, 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):e102028. Stead M, Angus K, Langley T, Katikireddi SV, Hinds K, Hilton S, et al. Mass media to communicate public health messages in six health topic areas: a systematic review and other reviews of the evidence. Public Health Research. 2019;7(8). Phuanukoonnon S, Brough M, Bryan JH. Folk knowledge about dengue mosquitoes and contributions of health belief model in dengue control promotion in Northeast Thailand. Acta tropica. 2006;99(1):6-14. Hairi F, Ong C-H, Suhaimi A, Tsung T-W, bin Anis Ahmad MA, Sundaraj C, et al. A knowledge, attitude and practices (KAP) study on dengue among selected rural communities in the Kuala Kangsar district. Sage Publications Sage CA: Thousand Oaks, CA; 2003. p. 37-43. Al-Dubai S, Ganasegeran K, Mohanad Rahman A, Alshagga MA, Saif-Ali R. Factors affecting dengue fever knowledge, attitudes and practices among selected urban, semi-urban and rural communities in Malaysia. Southeast Asian J Trop Med Public Health. 2013;44(1):37-49. Flynn A. 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 medical journal. 2012;61(6). Ibrahim NKR, Al-Bar A, Kordey M, Al-Fakeeh A. Knowledge, attitudes, and practices relating to Dengue fever among females in Jeddah high schools. Journal of infection and public health. 2009;2(1):30-40. Additional Declarations No competing interests reported. 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1","display":"","copyAsset":false,"role":"figure","size":17486,"visible":true,"origin":"","legend":"\u003cp\u003eshows the overall KAP score of the participants.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8507909/v1/19514eec6811ff49730c12cc.png"},{"id":99858740,"identity":"b8b5708e-f610-4bcb-a1d6-585d6969fcf9","added_by":"auto","created_at":"2026-01-09 06:35:37","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":22310,"visible":true,"origin":"","legend":"\u003cp\u003eDistribution of participants according to their source of information regarding dengue fever (multiple responses allowed)\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8507909/v1/8ac906efa8b959e5e8795c82.png"},{"id":100376849,"identity":"c742d72f-48c4-4ea2-a6dd-544955de4d97","added_by":"auto","created_at":"2026-01-16 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caused by one of four distinct serotypes of dengue virus, namely, DENV-1, DENV-2, DENV-3, and DENV-4, all of which belong to the Flavivirus genus within the Flaviviridae family (\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Transmission to humans predominantly occurs via the bite of infected Aedes aegypti, a highly anthropophilic mosquito that flourishes in densely populated (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Although most dengue infections remain asymptomatic, they can cause a wide range of clinical manifestations, from a mild febrile illness to severe dengue hemorrhagic fever and shock syndrome (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn recent decades, dengue fever has emerged as the most rapidly spread mosquito-borne viral disease (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). In 2019, the World Health Organization (WHO) classified dengue as one of the foremost global public health problems (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Dengue fever is now endemic in more than 125 countries (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e), placing approximately half of the global population at risk of this infection, mainly in tropical and subtropical areas (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Globally, approximately 390\u0026nbsp;million dengue infections, of which 96\u0026nbsp;million progress to clinical cases, have been reported, establishing dengue as a significant vector-borne illness (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eGlobally, the incidence of dengue continues to increase annually (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). The number of reported cases increased from 5.2\u0026nbsp;million in 2019 to 6.5\u0026nbsp;million in 2023 (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). In 2024, dengue reached an unprecedented peak, with approximately 14.6\u0026nbsp;million reported cases of dengue, including 7.5\u0026nbsp;million confirmed cases, over 52,000 severe cases, and approximately 12,000 deaths (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). This represents the highest number of global cases ever reported to the WHO. The rapid expansion of dengue transmission is driven by climate change, global warming, rapid urbanization, globalization, and enhanced vector habitat suitability (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDengue is still a major health problem worldwide; even though vaccines such as Dengvaxia and TAK-003 have been developed, their use is still limited, making prevention and mosquito control the primary strategies for reducing dengue disease transmission, especially in settings where insecticide resistance is widespread (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e), (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Effective dengue control depends mostly on reducing Aedes breeding sites and minimizing mosquito bites through environmental management and community participation (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e),(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).The success of these initiatives essentially depends upon the population's knowledge, attitudes, and practices (KAPs) related to disease transmission and preventative measures (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). As a result, successful control of dengue depends mostly on adequate knowledge and good practices of preventative (KAP) measures to educate the targeted population about the disease and measures to prevent it (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e),(\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Therefore, enhancing health education and improving community-level KAP toward dengue prevention are crucial for the success and sustainability of dengue control to lowering disease burden in endemic areas (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDengue is a major public health problem in Yemen, where it is endemic, and more than 60% of the population lives in risk areas (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e) (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e) .There were large increases in cases in 2019, 2020, 2021, 2022, and 2023. In 2020, the number of suspected dengue cases reported increased approximately seven times the number of cases reported in 2019 and six times the number of cases reported in 2018 (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). In 2024, there were 9,770 reported cases of dengue fever and 6 fatalities (CFR\u0026thinsp;=\u0026thinsp;0.06%), with Hudaydah representing the highest incidence at 7,662 cases (78.4%) (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). The healthcare and surveillance systems in Yemen were affected by conflicts and war, which led to more outbreaks of dengue fever (DF) (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\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=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Moreover, studies have shown that better knowledge of dengue is a predictor of better practices in dengue prevention (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e) .Moreover, Roslan et al. (2020) reported that people who have more knowledge about dengue are more likely to pursue more suitable dengue prevention measures than people with less knowledge (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e) However, studies concerning DF among Yemeni people, including those in Hodeidah, are lacking. One study conducted by Saied et al. (2015) in rural areas of the Hodeidah governorate reported that the KAP regarding dengue fever was not sufficient (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDengue prevention and control are not possible without the effective participation of the local community to avoid vector breeding in and around residential areas. Thus, the evaluation of people\u0026rsquo;s KAP is highly important in the control of dengue fever (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). Despite the scale of disease in Hodeidah, no published study has documented for the KAP of the population. This study aims to assess KAP about dengue fever among communities in Hodeidah governorate, Yemen. This is the first study of KAP among the community in the Hodeidah Governorate, which may be useful for understanding the gap and improving the disease\u0026rsquo;s control and prevention.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and setting\u003c/h2\u003e \u003cp\u003eA cross-sectional study was conducted (from June 1st to December 30th, 2019) among populations in six different geographical districts, urban (Al-Hali and Hawak) and rural (Bajil, Al-Zaydiyah, Al-Garrahi, and Al-Maraweah) in the Hodeidah governorate. The Hodeidah governorate is the fourth largest governorate in the Republic of Yemen, covering a total area of 17,509 km\u0026sup2; with an estimated total population of 2,687,674. It is located in the west on a flat coastal plain bordering the Red Sea in the west, Saudi Arabia in the north, and the Gulf of Aden in the south. Geographically, 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. The climate is tropical, with high summer temperatures and mild winter temperatures, and rain is rare.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy population\u003c/h3\u003e\n\u003cp\u003e The 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\n\u003ch3\u003eSample size and technique\u003c/h3\u003e\n\u003cp\u003eThe required sample size was calculated via the statistical formula (n\u0026thinsp;=\u0026thinsp;k2(pq)/d2) by considering the following assumptions: (n) the sample size, (p) the prevalence of knowledge about dengue fever prevention was 0.50 (as there were no previous data available in Hodeidah), (k2) the 95% confidence interval, and (d2) the acceptable maximum error (5%). The minimum sample size was 384 households. Thereafter, 10% (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e) was added to account for nonresponse or incomplete data. Thus, the final sample size was 422 households (168 from urban areas and 254 from rural areas).\u003c/p\u003e \u003cp\u003eA multistage random sampling method was used for this study. In the first stage, from a total of 26 districts, six (two urban: Al-Hali and Hawak; four rural districts: 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 subdistricts were randomly selected from the four districts, and then one village from each subdistrict was randomly selected according to the relative size of the population in the subdistrict, resulting in a total of eight villages. Additionally, in urban areas, 3 hara were randomly selected from each district. Thus, the total number of selected villages was 8, and the total number of 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 areas 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 providing informed consent and explaining the nature of the study. If the household head was not present, refused to participate, or did not meet the predetermined inclusion and exclusion selection criteria, the head of the next household was included until the sample size required was reached.\u003c/p\u003e \u003cp\u003eHouseholds were randomly selected, and household heads were invited to participate in the study after providing informed consent. If the household head was not present or refused to participate, the head of the next household was included until the sample size was reached. The individuals studied in the city were recruited via a simple random sampling method.\u003c/p\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eData were collected through face-to-face interviews via a structured questionnaire adapted from relevant literature from various studies (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\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 sociodemographic 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, whereas the fourth part inquired about their regular practices (control and prevention) toward dengue.\u003c/p\u003e\n\u003ch3\u003eScoring of Data\u003c/h3\u003e\n\u003cp\u003eA scoring system was developed. For knowledge, every question was rated on 3 answer options: \"yes,\" \"no,\" or \"don\u0026rsquo;t know.\" All correct answers were scored as 1, whereas \"Don\u0026rsquo;t know\" and wrong answers were rated as 0, and the total results were divided into categories of good or poor knowledge based on a cutoff point of 50%. For attitudes, a 3-point Likert scale was used: 1\u0026thinsp;=\u0026thinsp;disagree, 2\u0026thinsp;=\u0026thinsp;not sure, and 3\u0026thinsp;=\u0026thinsp;agree. Positive attitudes were considered if the score was greater than 50%, and positive attitudes were considered negative if the score was less than 50%. Likewise, for practice, the answers \"Yes\" and \"No\" were given scores of 1 and 0, respectively. Good practices were considered if the score was greater than 50%, and poor practices were considered if the score was less than 50%.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eThe data collected from the questionnaire were 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 associations between sociodemographic characteristics and KAP on DF, where a P value of 0.05 was the cutoff for statistical significance. The results are presented in tables and graphs.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eSociodemographic characteristics of the study respondents\u003c/h2\u003e \u003cp\u003eAmong the 422 study subjects, 254 (60.19%) lived in rural areas, whereas only 168 (39.81%) lived in urban areas. Among these, 53.6% were male, 122 (28.9%) were illiterate, and 35.5% were housewives (see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSociodemographic characteristics of the study participants, Hodeidah Governorate, 2019\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003esocio demographic variables\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFrequency, %= n(%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eResidence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e254(60.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e168(39.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e196(46.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e226(53.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20-\u0026lt;40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e232(55)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40-\u0026lt;60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e148(35.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25(5.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eMarital status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e367(87)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDivorced\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWidowed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34(8.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eEducational\u003c/p\u003e \u003cp\u003eLevel\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIlliterate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e122(28.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBasic school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e94(22.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSecondary school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e106(25.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUniversity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100(23.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"6\" rowspan=\"7\"\u003e \u003cp\u003eOccupational\u003c/p\u003e \u003cp\u003eLevel\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnemployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43(10.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGovt. employed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e63(14.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSelf-business\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53(12.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHousewife\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e150(35.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFarmer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29(6.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFisher\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8(1.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e76(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eKnowledge about dengue, DHF, its signs and symptoms, and transmission\u003c/h2\u003e \u003cp\u003eThe majority of the respondents correctly reported that fever (81.0%), headache (67.5%), and joint pain (48.6%) were the main signs and symptoms of dengue fever. In addition, 79.9% of the respondents were unaware of DHF. The study also revealed that more than eighty percent of the respondents knew that dengue virus is transmitted by mosquito bites and that 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 the 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 presented in \u003cb\u003eSupplementary Table\u0026nbsp;2.\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eAttitudes of the respondent household heads toward dengue fever\u003c/h2\u003e \u003cp\u003eMore than 90% of those polled agreed that DF is a serious disease. Additionally, 85.1% agreed that the disease was preventable. Only 67.8% agreed that they were at risk of contracting dengue fever. With respect to 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 (82.9%). Finally, 85.8% agreed that they play an important role in dengue prevention are presented in \u003cb\u003eSupplementary Table\u0026nbsp;3.\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003ePractices of respondent household heads toward dengue fever\u003c/h2\u003e \u003cp\u003eMore than eighty percent of the respondents reported covering water containers at home, and 87.4% said that they covered 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 sprays 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. A total of 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 the number of mosquitoes and prevent dengue are presented in \u003cb\u003eSupplementary Table\u0026nbsp;4.\u003c/b\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cb\u003eOverall KAP scores\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eAmong the total participants, 39% had good knowledge, 63% had positive attitudes and 57% reported good practices regard dengue fever (Fig.\u0026nbsp;1).\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003eFigure 1: shows the overall KAP score of the participants.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eFigure (2): represents the main source of information of the respondents. These are: Health workers / hospitals (97.8%), TV / radio (61.6%), Family / friends (57.6%), Posters / billboards (32.0%), Internet (websites) (12.6%), and Brochures / pamphlets (9.0%).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eAssociations between knowledge, attitudes, practices and socioeconomic factors\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e5\u003c/span\u003e presents the associations 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 villages or rural areas had poorer knowledge than did those who lived in urban areas. Additionally, gender and occupation were significantly associated (p 0.05) with attitudes. In addition, females (Chi2\u0026thinsp;=\u0026thinsp;9.776, p\u0026thinsp;=\u0026thinsp;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 did. Residence, occupation, and gender all had significant (p 0.05) associations with practices. Good practices for preventing dengue were associated with living in urban areas (Chi2\u0026thinsp;=\u0026thinsp;8.883, p\u0026thinsp;=\u0026thinsp;0.003), being female (Chi2\u0026thinsp;=\u0026thinsp;13.996, p\u0026thinsp;=\u0026thinsp;0.000) and being housewives (Chi2\u0026thinsp;=\u0026thinsp;13.654, p\u0026thinsp;=\u0026thinsp;0.034).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAssociation between socio-demographic characteristic and practice of respondents in Hodeidah Governorate, Yemen, 2019\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"12\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e \u003cp\u003eSocio demographic variables\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eFrequency, %= n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eKnowledge Category n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:{}^{2}\\)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e \u003cp\u003e\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\left(\\varvec{P}\\:\\mathbf{v}\\mathbf{a}\\mathbf{l}\\mathbf{u}\\mathbf{e}\\right)\\:\\)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003eAttitude n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:{}^{2}\\:\\)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e \u003cp\u003e\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\left(\\varvec{P}\\:\\mathbf{v}\\mathbf{a}\\mathbf{l}\\mathbf{u}\\mathbf{e}\\right)\\:\\)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003ePractice n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePoor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePositive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNegative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003ePoor\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eResidence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e254 (60.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e84 (51.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e170 (65.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e8.304\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(0.004*)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e156 (61.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e98 (38.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e0.715\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(0.398)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e129 (50.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e125 (49.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e8.883\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(0.003*)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e168 (39.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e79 (48.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e89 (34.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e110 (65.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e58 (34.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e110 (56.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e58 (43.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e196 (46.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e75 (46.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e121 (46.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e0.020\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(0. 887)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e139 (70.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e57 (29.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e9.776\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(0.002*)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e130 (66.3 )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e66 (33.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e13.996\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(p\u0026thinsp;\u0026lt;\u0026thinsp;0.001)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e226 (53.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e88 (54.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e138 (53.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e127 (56.2 )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e99 (43.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e109 (48.2 )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e117 (51.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (4.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e10 (3.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003e0.286\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(0.963)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e10 (58.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e7 (41.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003e3.528\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(0.317)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e13 (76.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e4 (23.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003e4.140\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(0.247)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20-\u0026lt;40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e232 (55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 (6.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e15 (5.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e145 (62.5 )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e87(37.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e125 (53.9 )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e107 (46.1 )\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40-\u0026lt;60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e148 (35.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e87 (53.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e145 (56.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e99 (66.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e49 (33.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e88 (59.5 )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e60 (40.5 )\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (5.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e59 (36.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e89 (34.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e12 (48 )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e13 (52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e13 (52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e12 (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eMarital status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e367 (87)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e140 (85.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e227 (87.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003e0.754\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(0.668)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e227 (61.8 )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e140(38.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003e2.090\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(0.352)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e207 (56.4 )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e160 (43.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003e0.077\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(0.962)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDivorced\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21 (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 (6.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e11 (4.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e16 (76.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e5(23.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e12 (57.1 )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e9 (42.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWidowed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34 (8.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13 (8.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e21 (8.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e23 (67.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e11 (32.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e20 (58.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e14 (41.2 )\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eEducational\u003c/p\u003e \u003cp\u003eLevel\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIlliterate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e122 (28.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e37 (22.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e85 (32.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003e17.165 (0.001*)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e68 (55.7 )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e54 (44.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003e3.920\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(0.270)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e72 (59 )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e50 (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003e1.346\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(0.718)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBasic school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e94 (22.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27 (16.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e67 (25.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e62 (65.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e32 (34.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e56 (59.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e38 (40.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSecondary school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e106 (25.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e46 (28.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e60 (23.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e70 (66.1 )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e36 (33.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e56 (52.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e50 (47.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUniversity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100 (23.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e53 (32.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e47 (18.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e66 (66)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e34 (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e55 (55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e45 (45 )\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"6\" rowspan=\"7\"\u003e \u003cp\u003eOccupational\u003c/p\u003e \u003cp\u003eLevel\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnemployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43 (10.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9 (5.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e34 (13.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"6\" rowspan=\"7\"\u003e \u003cp\u003e\u003cb\u003e25.384\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(p\u0026thinsp;\u0026lt;\u0026thinsp;0.001)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e24 (55.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e19 (44.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\" morerows=\"6\" rowspan=\"7\"\u003e \u003cp\u003e\u003cb\u003e18.308\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(0.006*)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e24 (55.8 )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e19 (44.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\" morerows=\"6\" rowspan=\"7\"\u003e \u003cp\u003e\u003cb\u003e13.654\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(0.034*)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGovt. employed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e63 (14.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36 (22.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e27 (10.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e39 (61.9 )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e24 (38.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e37 (58.7 )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e26 (41.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSelf-business\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53 (12.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26 (16.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e27 (10.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e31 (58.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e22 (41.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e28 (52.8 )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e25 (47.2 )\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHousewife\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e150 (35.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e46 (28.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e104 (40.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e110 (73.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e40 (26.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e97( 64.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e53 (35.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFarmer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29 (6.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (4.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e21 (8.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e16 (55.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e13 (44.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e10 (34.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e19 (65.5 )\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFisher\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (1.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (3.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3 (1.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1 (12.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e7 (87.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e2 (25 )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e6 (75)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e76 (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e33 (20.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e43 (16.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e156 (61.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e98 (38.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e41 (53.9 )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e35 (46.1 )\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eX\u003csup\u003e2\u0026minus;\u003c/sup\u003e Chi-square\u003csup\u003e,\u003c/sup\u003e PV: p value\u003csup\u003e,\u003c/sup\u003e * Significant at P\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eToday, dengue fever is the most common vector-borne viral infection in the world (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). Sociodemographic factors and KAPs play critical roles in both the incidence of dengue epidemics and the implementation of control measures (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). With an increasing 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\u003eThis study shows that only 39% of participant have a good level of knowledge about dengue fever, which is slightly lower than what was reported from pevious study in the Shabwah Governorate, Yemen in 2022 (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e), Malaysia in 2020 (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e) and Indonesia in 2015 (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e),This finding is in line with a previous study conducted in Pakistan in 2023 (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). Our findings were higher compared to another study in Pakistan, 2010 (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe present study revealed that fever, headache, and joint pain were the most common symptoms of DF. Fever was the most common symptom among the majority of the participants, which is similar to the findings of a previous study conducted in the Shabwah Governorate, Yemen, in 2022 (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e); in Taiz (Yemen) (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e); in rural areas of Yemen (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e); and in Pakistan (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e) and Cambodia (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e), which show fever was reported as the primary symptom of DF. This could be explained by educational messages in the mass media citing fever as dengue\u0026rsquo;s primary symptom (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e) or by the participants\u0026rsquo; personal experience with the disease or witnessing a close friend or relative\u0026rsquo;s case. Thus, raising awareness of these signs and symptoms could aid in distinguishing DF from other febrile infectious diseases, particularly in developing nations where DF is endemic (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eGood knowledge of the signs and symptoms of DF is essential for identifying the disease and seeking early and appropriate health care to prevent complications (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). Unfortunately, the majority of participants (79.9%) did not identify the signs and symptoms of DHF, which is highly important in guiding households in seeking timely medical help and preventing morbidities and mortalities such as bleeding (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eKnowing that dengue virus is transmitted by mosquito bites was correctly answered by 81.5% of the participants. This finding is similar to that reported from rural communities in Hodeidah, Yemen (83.4%) (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e), and lower than that reported in the Malaysian community (98.1%) (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e) and from people visiting tertiary care hospitals in Pakistan (86.9%) (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e), but higher than that reported in a study from Brazil (60.8%) (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). This difference may be because of differences in the study design.\u003c/p\u003e \u003cp\u003eAlthough most of the participants said that mosquito bites are a transmission route of dengue fever, our results revealed that there was a gap in the knowledge concerning the mode of transmission, with 32.5%, 23.7%, and 21.1% of the household heads incorrectly identifying that dengue virus can also be transmitted by flies, direct contact with infected people, and eating food or drinking water, respectively. These findings were similar to those of a study among rural populations in Hodeidah governorate, Yemen, which revealed that approximately 52.2% of the participants believed that dengue can be transmitted through contact with infected people (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). In addition, a study among the urban population in Taize, Yemen, conducted by Alyousefi et al. (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e), showed that approximately 20% of household heads have misconceptions about the modes of dengue fever transmission, including flies, contact with infected people, and drinking contaminated water. In addition, a previous study conducted in Hodeidah revealed that most participants believed that the disease could be transmitted from an infected person to a healthy person via direct contact. Bridging this gap in knowledge is important in planning and designing programs and activities to educate populations on preventive measures for 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=\"CR44\" class=\"CitationRef\"\u003e44\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=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe majority (91.5%) of participants in the current study 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) play a significant role in the transmission of DF by mosquitoes, respectively. Compared with studies in other parts of the world, this result matches a study in Nepal (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e), in rural populations in Hodeidah governorate, Yemen (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e), in the Shabwah Governorate, Yemen (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e), and in Taiz, Yemen (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). This may be related to the increasing number of breeding sites, such as discarded tires, open water containers, and stagnant water, in regions where mosquitoes have long been a nuisance. the strengthening of mass mediamessages and educational programs in recent years may have helped to improved identification of risk factors (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e) (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAlthough most respondents were aware that mosquitoes are the disease vector, only a few correctly stated that mosquitoes bite primarily 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=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e). On the other hand, good knowledge of the biting time of dengue vectors was reported in a study conducted in rural areas of Hodeidah, Yemen (33.6%) (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). Moreover, approximately 71% of the participants were living in the urban areas of Taiz, Yemen (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOur findings revealed that the majority of the participating students (63%) had a positive attitude toward dengue fever prevention, with a significant association with gender and occupation. this Similar to previous research conducted in Yemen\u0026rsquo;s Shabwah (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e), Taiz (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e),Taiz(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) ,and Hodeidah (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e) governorates, our study revealed a positive attitude regarding the severity and transmissibility.\u003c/p\u003e \u003cp\u003eDespite the fact that most of the participants (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=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e) and Malaysia (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\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=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). Surprisingly, in Malaysia, 95.3% of respondents believed that the public had a primary role in containing the dengue epidemic (\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eRegarding preventive practices, more than half (57%) of participants had good practices against DF. This result was lower compared to a previous study conducted in Yemen\u0026rsquo;s Shabwah (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). In contrast, this finding is higher than studies conducted in Malaysia (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e) and Indonesia (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Also, residence, occupation, and sex had significant associations with practices. This is similar to a study conducted in Indonesia (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe majority of the participants mentioned that they had 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 ditches around the house (81.8%) to minimize the risk of Aedes mosquito breeding. This finding is consistent with a study in Brazil, where the elimination of water containers was the most efficient means of controlling DF, accounting for 73% of the population (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\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=\"CR41\" class=\"CitationRef\"\u003e41\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, which is the most popular method used to control the vector (\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn this study, health workers or hospitals were found to play a major role in disseminating information about dengue. This finding is similar to those of previous studies in Jamaica (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). Second, the respondents indicated that radio and television were the predominant sources of information regarding dengue. This finding is similar to that of the study performed in Jeddah (\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e). Therefore, mass media is a powerful tool for generating better awareness of dengue prevention and control (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eLimitations of the study\u003c/h2\u003e \u003cp\u003eBecause the study is cross-sectional, it evaluates relationships at a single moment in time and does not account for the dynamics of the interactions between the variables examined. Furthermore, because the study was conducted using questionnaires administered by an interviewer, some participants may have provided socially desired responses to certain questions. Despite these limitations, the study's findings are expected to make a significant contribution to our understanding of the current issues of DF prevention in the study area.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study revealed that a relatively large proportion of the participants demonstrated a low level of knowledge, a positive attitude, and a level of practice toward dengue prevention. Furthermore, this study revealed 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":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDF\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDengue fever\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDENV\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDengue virus\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDENV-1\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDengue virus serotype 1\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDENV-2\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDengue virus serotype 2\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDENV-3\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDengue virus serotype 3\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDENV-4\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDengue virus serotype 4\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWHO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWorld Health Organization\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eKAP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eKnowledge, Attitudes, and Practices\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCFR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCase Fatality Rate\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSPSS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eStatistical Package for Social Science\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eX\u003csup\u003e2\u003c/sup\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eChi-square\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Ethics Committee of the Department of Community Medicine at Hadhramout University, College of Medicine (HUCOM), Yemen with approval number [CM/REC 8/2018]. All study procedures were carried out in accordance with guidelines of the 1964 Declaration of Helsinki. All participants were informed about the purpose of the study, assured of confidentiality, and provided written consent prior to participation. Participation was voluntary, and respondents could withdraw at any time without consequence.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analyzed during the current study are not publicly available due to participant confidentiality but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eNo financial or commercial ties existed between the authors at the time of the research that might be considered a conflict of interest, as the authors affirm\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors did not obtain any funding for this study.\u003c/p\u003e\n\u003cp\u003eAuthors' contributions\u003c/p\u003e\n\u003cp\u003eM.H designed the study, developed the data collection tools, and supervised the fieldwork. M.H performed the data collection and contributed to data entry and validation. A.B \u0026nbsp; supervised the fieldwork ,M.H and A.B conducted the statistical analysis and interpreted the results.M.H wrote the main manuscript draft, while A.B contributed to revising and refining the text. All authors reviewed and approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003eAcknowledgments\u003c/p\u003e\n\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 Prof. Abdulla S. Bin Ghouth, head of the community medicine department, for their fruitful assistance.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' information\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMurugesan A, Manoharan M. 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Journal of infection and public health. 2009;2(1):30-40.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Attitude, Dengue, Knowledge, Practices, Hodeidah, Yemen","lastPublishedDoi":"10.21203/rs.3.rs-8507909/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8507909/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e In Yemen, dengue is one of the major public health concerns. Cases have been recorded in almost all governorates in Yemen. In 2019, the Hodeidah governorate hadthe second highest death rate in the country. Good knowledge, attitudes, and practices (KAPs) among the public regarding dengue prevention are neededfor successful dengue prevention and control. Thisstudy aims to assess KAP about dengue fever among the population in Hodeidah, Yemen.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: A cross-sectional study was conducted (from June 1st to December 30th, 2019) among populations in six different geographical districts, urban (Al-Hali and Hawak) and rural (Bajil, Al-Zaydiyah, Al-Garrahi, and Al-Maraweah) in the Hodeidah governorate. A total of 422 household heads were chosen at random to complete questionnaires distributed in their neighborhoods. The data were entered and analyzed viathe Statistical Package for Social Sciences (SPSS) version 25. The chi-square test was used as a test of significance, where p \u0026lt; 0.05 wasthe cutoff for significance.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e The results revealed that 39% of the participants had good 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 were significantly associated(p\u0026lt;0.05) with attitudes. Additionally, residence, occupation, and gender were significantly associated (p\u0026lt;0.05) with practices.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e: This study revealed that a relatively large proportion of the participants demonstrated a low level of knowledge, a positive attitude, and a level of practice toward 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, attitudes, and practices about dengue fever among the population in Hodeidah, Yemen","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-09 06:35:32","doi":"10.21203/rs.3.rs-8507909/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-07T11:44:41+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-30T03:53:22+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-20T11:14:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"214224351657479169309641936706654089328","date":"2026-02-27T01:43:12+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-25T03:30:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"188694346167629895662905694119487671154","date":"2026-02-24T16:24:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"222766163098646968708839169567069422844","date":"2026-02-24T16:03:10+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-24T15:46:42+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-23T13:14:18+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-05T03:16:19+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-05T03:14:20+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2026-01-03T15:29:26+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9e86ec8a-ed08-4a90-9a62-d280ff2d7e49","owner":[],"postedDate":"January 9th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":60666743,"name":"Health sciences/Diseases"},{"id":60666744,"name":"Health sciences/Health care"},{"id":60666745,"name":"Health sciences/Medical research"}],"tags":[],"updatedAt":"2026-05-14T04:54:01+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-09 06:35:32","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8507909","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8507909","identity":"rs-8507909","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}