p u b l i c h e a l t h x x x ( 2 0 1 5 ) 1 e7

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Public Health

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Original Research

Community knowledge, awareness and preventive

practices regarding dengue fever in Puducherry e
South India

S. Jeelani*, S. Sabesan, S. Subramanian

Vector Control Research Centre, Indian Council of Medical Research (ICMR), Indira Nagar, Gorimedu, Puducherry
605006, India

article info abstract

Article history: Objectives: To ascertain the knowledge, attitudes and practices of adult population in
Received 24 June 2014 Puducherry, India, regarding Dengue Fever (DF).
Received in revised form Study design: A cross-sectional survey was carried out to assess the Knowledge, Awareness
26 December 2014 and Preventive practices (KAP) among a selected community in Puducherry on DF,
Accepted 22 February 2015 following a major dengue outbreak in 2012.
Available online xxx Methods: Between October 2012 & February 2013, an epidemiological survey was conducted
among 400 households (HHs) from the most affected areas during dengue outbreak, which
Keywords: came under eight health delivery jurisdictions i.e. Primary Health Centres (PHCs) in
Community knowledge Puducherry. Knowledge of dengue and the use of preventive measures were assessed by
Dengue fever means of a pre-tested structured questionnaire. Logistic regression analysis was done to
Puducherry examine the association between different levels of education and income status with the
knowledge of DF. The DF knowledge map was created based on the results achieved
through the questionnaire using Arc GIS 10.2 software.
Results: Although about 86% of the participants had heard of dengue, although there was no
adequate knowledge on dengue vector breeding habitat as 68% of the respondents thought
drains & garbage as breeding places of dengue vectors. Only 25% of participants were aware
of clean water as a breeding habitat. Insufficient knowledge of disease symptoms was
found, with fever (59%) being the most common symptom.
Conclusions: There is a lack of in-depth knowledge on dengue epidemiology in the Pudu-
cherry community and observation revealed that more needs to be done by the Govern-
ment as well as community members to prevent vector mosquito breeding.
© 2015 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.

* Corresponding author. Division of Vector Ecology and Surveillance, Vector Control Research Centre (ICMR), Indira nagar, Gorimedu,
Puducherry 605006, India. Tel.: þ91 7358807101; fax: þ91 4132272041.
E-mail address: suhailjeelani@gmail.com (S. Jeelani).
http://dx.doi.org/10.1016/j.puhe.2015.02.026
0033-3506/© 2015 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Jeelani S, et al., Community knowledge, awareness and preventive practices regarding dengue
fever in Puducherry e South India, Public Health (2015), http://dx.doi.org/10.1016/j.puhe.2015.02.026
2 p u b l i c h e a l t h x x x ( 2 0 1 5 ) 1 e7
Introduction
Dengue is one of the most dreadful arboviral diseases of
humans with over half of the world's population living in
areas of risk. An estimated 3.5 billion people, or half the
world's population, are at risk for dengue virus (DENV)
infection in tropical and subtropical countries.1 Sporadic
outbreaks of Dengue fever (DF) have been reported in India
for over two centuries2,3 but the earliest virologically
confirmed outbreak occurred in 1956 in Vellore, Tamil Nadu.4
The first major outbreak of dengue began in 1963 in Calcutta,
West Bengal, from where it spread to other states, eventually
affecting most parts of the country.5 The frequency, magni-
tude and geographical distribution of epidemic dengue and
potential occurrence of life-threatening dengue hemorrhagic
fever (DHF) have increased dramatically in the past 40 years
as the viruses and the mosquito vectors have both expanded
geographically in the tropical regions of the world.6 The fac-
tors responsible for this increase and expansion are societal
changes such as population growth, urbanization, changing
habitats and behaviour, and lack of effective vector con-
trol.7e9 High human population density and inadequate water
supply (water storage practice) are regarded as major con-
tributors to dengue epidemics.10,11
The vector mosquitoes transmitting the DENV are Aedes
species mainly Aedes aegypti & Ae. albopictus. The infection,
earlier restricted to urban/semi-urban areas, can now be seen
in rural areas as well.12 Over the last decade, the geographical
distribution of DF has included new countries and more rural
areas, making it the most rapidly expanding arboviral disease
in the world.13 Despite mass communication and educational
approaches, community participation is far below expecta-
tion. Community participation in turn depends on peoples'
awareness, knowledge and attitude towards the disease.14
Several socio-economic studies in different countries indi-
cate variations in knowledge and practice-related to
mosquito-borne diseases.15,16 Puducherry experienced its
first major outbreak in 2003 with 60 confirmed cases of
infection from the district in 10 urban and 9 rural Primary
Health Centres (PHCs).17 A four-fold increase of dengue cases
had been observed in 2011 (n ¼ 230 cases). For the year 2012, a
six-fold increase had been recorded with a total of 1391
dengue cases. The increasing incidence of DF and the lack of
relevant studies on the knowledge, awareness and practice
(KAP) of the Puducherry community regarding DF trans-
mission and prevention prompted us to conduct the present
study.
Methods
Study area
The study was conducted in Union territory of Puducherry,
geographically located at 162 km south of Chennai, sur-
rounded by the Bay of Bengal on the east, and on the other
sides by the Cuddalore and Villipuram districts of Tamil Nadu
(Fig. 1). Puducherry experiences hot and humid climate with
temperature normally varying between 26 and 38  C.
Please cite this article in press as: Jeelani S, et al., Community knowledge, awareness and preventive practices regarding dengue
fever in Puducherry e South India, Public Health (2015), http://dx.doi.org/10.1016/j.puhe.2015.02.026
Sampling design
Areas from where the maximum number of dengue cases
have been reported (under 8 PHCs) in the previous year were
selected for the study. Knowledge of dengue fever was
assessed using questions aimed at ascertaining the com-
munity's understanding of the disease epidemiology (symp-
toms, transmission, etiology and vector) and standard
preventive strategies (mosquito nets, mats, water storage). In
a population of 165,252, assuming 50% prevalence of good
knowledge, with an error margin of 5% at a 95% level of con-
fidence, the minimum number of respondents required to
fulfil the objectives of this study was 383. The samples were
distributed in proportion to the population in the dengue
affected villages.
Field based data collection
A household survey was carried out between October 2012 and
February 2013 using a structured questionnaire, translated
into local language i.e. Tamil. Head of the family or any adult
family member above 18 years of age available at home during
the survey was interviewed following informed consent. The
questionnaire was divided into three sections. The first sec-
tion covered the sociodemographic information about the
respondents. The second section was about knowledge
regarding the symptoms, spread of dengue and preventive
practices in use against mosquitoes. The section third con-
sisted of checklists that indicate data on water storage and
waste disposal practices within the household, including
vector indices.
Ethical clearance
The protocol of this study was approved by the Institutional
Human Ethics Committee (IHEC) of Vector Control Research
Centre (VCRC) on 14th February, 2012. The objectives of the
study were explained to the local community including com-
munity leaders and health professionals. Sufficient time was
given to ask questions and it was emphasized that participa-
tion in the survey was voluntary and they could quit any time
during the interview. Those who wished to participate were
required to sign a consent form prepared in accordance with
the guidelines of IHEC prior to the use of questionnaires.
Data analysis
The data collected from the survey were accessed into an
Excel database and later analysed using IBM SPSS version 20.
Logistic regression analysis was done to examine the associ-
ation between different levels of education, and income status
with the knowledge of DF. Microsoft Excel version 2013 was
used to draw graphs and charts wherever appropriate.
Additionally, each question was assigned with a score
(ranging from 0 to 4) depending upon the type of question, and
the score achieved by a respondent was described as knowl-
edge score of that particular respondent. The total knowledge
score was determined by taking the average of score achieved
by all the respondents in a particular area. Location of the
areas surveyed was recorded using hand-held global
 p u b l i c h e a l t h x x x ( 2 0 1 5 ) 1 e7 3

Fig. 1 e Map showing the study sites.

positioning system (GPS) and a map was generated based on female (67.3%), house makers (53.7%) and had education up to
the knowledge score achieved by each area, using the GIS high school (59.3%).
mapping software developed by Esri, Arc GIS 10.2 software
(Fig. 2). Dengue related knowledge

The outcome of the survey pertaining to awareness on dengue

Results transmission, its symptoms and treatment are shown in

The socio-economic details of the study population are given

in Table 1. A total of 400 respondents were interviewed and Table 1 e Sociodemographic characteristics of the study
the data so obtained was used for primary analysis. 40.5% of population.
the people were from higher socio-economic group and 59.5% Distribution of respondents No. of respondents %
from lower socio-economic group. A majority of them was Gender distribution
Male 129 32.3
Female 271 67.7
Age distribution
18e30 118 29.5
30e45 142 35.5
45e60 87 21.7
>60 53 13.3
Educational status
Illiterate 64 16.0
Primary 55 13.8
High school 139 34.7
Intermediate 70 17.5
Diploma 17 4.3
Graduation or above 55 13.8
Occupation
Labour 45 11.3
Agriculture 8 2.0
House wife 215 53.7
Student 24 6.0
Employed 65 16.3
Business 43 13.7
Fig. 2 e Map showing the distribution of dengue Income
knowledge in the study area. Dengue knowledge map was Low 238 59.5
created based on the overall area-wise knowledge using Medium 104 26.0
licenced GIS software, Arc GIS 10.2 (Esri). High 58 14.5

Please cite this article in press as: Jeelani S, et al., Community knowledge, awareness and preventive practices regarding dengue
fever in Puducherry e South India, Public Health (2015), http://dx.doi.org/10.1016/j.puhe.2015.02.026
4 p u b l i c h e a l t h x x x ( 2 0 1 5 ) 1 e7

Table 2 e Knowledge on dengue spread, symptom and Table 4 e Knowledge of vector breeding, biting time and
treatment. preventive practices.
Variable n % Variable n %
a a
Awareness of dengue Common breeding sites
Yes 342 85.5 Stagnant water 146 42.5
No 58 14.5 Septic tank 33 9.6
Mode of spreadb Drains & garbage 232 67.8
Mosquito bite 283 82.7 Clean water holding containers 86 25.1
Contaminated food/water 28 8.2 Don't know 16 4.7
Don't know 44 12.9 Most frequent mosquito biting timea
Human to human spread Morning 152 44.4
Yes 91 26.6 Noon 37 10.8
No 215 62.9 Evening 201 58.8
Don't know 36 12 Night 77 22.5
Common symptomsb Preventive practicesa
Fever 203 59.4 Liquid vaporizer 251 62.7
Body pain 80 23.4 Coil 97 24.3
Headache 72 21.1 Electric bat 27 6.8
Skin rashes 58 15.5 Mosquito net 26 6.5
Vomiting 49 14.3 Nothing 51 12.8
Don't know 139 40.6 a
Multiple response options.
Medicines against dengue
Yes 33 10.2
No 93 27.2
Don't know 214 62.6 dengue mosquito breeds in clean water-holding containers.
a Most of the people knew that mosquito usually bites either at
Rest of the knowledge related questions were asked only to those
respondents who replied ‘Yes’ to this question. evening (58.8%) or at morning time (44.4%). Preventive prac-
b
Multiple response options. tices regarding dengue were consistent with the knowledge
about these practices, with majority of the people relying on
liquid vaporizers (62.7%) and/or mosquito mats (24.3%).
Table 2. Among the total respondents, 85.5% have heard of
dengue fever and most of them (82.7%) were aware that it is
Source of information on dengue fever
transmitted through mosquito bites. A few of them (8.2%)
opined that this disease is transmitted through contaminated
Television (55%) was identified as the main source of public
water & food. When asked about the common symptoms,
information followed by Newspaper (38%) and Radio (31%).
fever was the most consistent response (59%) followed by
29% of the respondents have heard about dengue through
body pain (23%) and headache (21%). No significant associa-
Govt. awareness campaigns and only 6.8% heard it in school
tion was found between DF knowledge and respondent's area
(Table 5).
of residence (refer: Table 3).
The extent of knowledge regarding vector breeding sites,
biting behaviour and preventive practices were summarized in Water supply and storage practices
Table 4. When respondents were asked about the breeding
habitat of the vector mosquitoes, 67.8% of them answered Most of the households were found to store water in different
drains and garbage, and only 42.5% of them were aware that types of containers in all the study sites. Nearly 42% of HHs
they breed in stagnant water and 4.7% were ignorant about the used small containers (plastic/metal vessel) for storing water,
breeding habitat of mosquitoes. Only 25.1% were aware that while as 31% of HHs used plastic fibre (‘Sintex’) tanks and only
12.5% used cemented tanks/cisterns for water storage. 19% of
the HHs stated that they did not require water to be stored
Table 3 e Association between dengue fever knowledge (Fig. 3).
and area of residence.
Variable Rural (n) Urban (n) Chi-square (c2) P-value
Awareness of dengue Table 5 e Source of information about the dengue
Yes 167 175 c2 ¼ 1.29 received by the respondent in the survey (n ¼ 342).
No 33 25 P ¼ 0.26
Variable Frequency (n) Percentage (%)
Transmission of dengue
Yes 135 148 c2 ¼ 0.84 Where participants have heard about denguea:
No 32 27 P ¼ 0.30 Television 188 55.0
Symptoms of dengue News paper 132 38.0
Yes 92 111 c2 ¼ 2.46 Radio 123 31.0
No 75 64 P ¼ 0.12 Awareness campaign 117 29.3
School 27 6.8
No significant difference in dengue knowledge was found between
a
rural and urban areas. Multiple response options.

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fever in Puducherry e South India, Public Health (2015), http://dx.doi.org/10.1016/j.puhe.2015.02.026
 p u b l i c h e a l t h x x x ( 2 0 1 5 ) 1 e7 5

Table 7 e Dengue fever knowledge among respondents of

different educational status.
Level of No. of persons Persons with OR (95% CI)
education interviewed dengue
knowledge (%)
Illiterate 64 70.3 1.0
Up to High 194 59.3 1.6 (0.9e3.0)a
school
Intermediate 87 51.7 2.2 (1.1e4.4)b
Graduation 55 49.1 2.5 (1.2e5.2)b
& above
a
Respondents with qualification up to high school were 1.6 times
more knowledgeable than illiterates, but there was no statistical
significance.
b
Participants with a qualification of intermediate or above were
more than two times more knowledgeable as compared to illiterate.

Fig. 3 e Water storage practices reported by participants

during the survey (n ¼ 400). *Multiple responses. Nearly
42% of HHs used small containers (plastic/metal vessel) for
storing water, while as 31% of HHs used plastic fibre
(‘Sintex’) tanks.
high-income group, and it was still poor with the lower-
income group. Logistic regression analysis revealed that
knowledge of dengue was independent of socio-economic
group (c2 ¼ 1.54; P ¼ 0.46). There was no much difference in
knowledge among the middle and high income groups (Fig. 4).

Waste disposal practices

Data regarding the waste disposal practices employed by
study population is presented in Table 6. In only 48% of HHs,
waste generated is collected by Municipality squad on daily or
alternate day basis, while as 38% of the HHs were dumping it
in vacant sites and 11% throwing indiscriminately outside
their house. Out of the 400 HHs in study population, only 44%
were found to have dustbins in their house.
Respondents were also divided into different educational
groups and their knowledge regarding dengue fever was
assessed. A significant association was found between degree
of knowledge and level of education among respondents.
Participants with a qualification of intermediate (OR ¼ 2.2, 95%
CI 1.1e4.4) or above (OR ¼ 2.5, 95% CI 1.2e5.2) were more than
two times more knowledgeable as compared to illiterate.
However, persons with qualifications up to high school were
1.6 times more knowledgeable than illiterates, but there was
no statistical significance (Table 7).
The respondents were also classified into different income
groups using updated version of Kuppuswamy's Socio-
economic Scale18 to assess their knowledge related to DF.
There was no adequate DF knowledge among the middle- and
Discussion
Although most of the people (>50%) in this study have
considerable knowledge about the DF, they did not fully
recognize breeding sites of the dengue vector. People associ-
ated ‘dirty’ sites such as sewage drains & garbage, where they
found larvae of other mosquito species, with dengue. There is a
marked hierarchy of people's perceptions of breeding sites.
Three manifestations of dengue are currently known; DF, DHF
and dengue shock syndrome. However, fever is the most
common presenting symptom in all of them.15 The level of
knowledge on DF reported in this study is comparable to that
found in similar KAP studies conducted in India,19,20
Pakistan,21 Thailand22 and Jamaica.15 Most respondents were
not able to correctly identify typical symptoms of DF apart
from a few who identified fever as an obvious symptom. Fever
was also the most frequently stated symptoms in similar
studies conducted in India,19,20 Thailand,22 Laos,23 Nepal,24,25

Table 6 e Waste disposal practices reported by

respondents during the survey (n ¼ 400).
Waste disposal practices n %
Collected by municipality 191 47.7
Dumping in vacant sites 151 37.7
Throwing indiscriminately 43 10.8
Set on fire 8 2.0
Dumping in drainage 7 1.8
Have dustbin in house Fig. 4 e Dengue fever knowledge among different income
Yes 176 44 groups. No significant association was found between
No 224 56 income and dengue knowledge (c2 ¼ 1.54; P-value ¼ 0.46).

Please cite this article in press as: Jeelani S, et al., Community knowledge, awareness and preventive practices regarding dengue
fever in Puducherry e South India, Public Health (2015), http://dx.doi.org/10.1016/j.puhe.2015.02.026
6 p u b l i c h e a l t h x x x ( 2 0 1 5 ) 1 e7

the Philippines26 and Jamaica.15 Presumably the participants There is an urgent need for the Public Health authorities to
in this study could not state typical symptoms of DF because organize health education programmes on dengue disease to
they had not personally experienced the disease nor witnessed increase community knowledge and also to sensitize the
a case from a close relative or member of the community. The community to participate in integrated vector control pro-
poor knowledge of symptoms associated with DF among the gramme to resolve dengue problem.
study population means that this disease may easily be
confused with other common causes of fever such as influ-
enza, typhoid, etc. Though there was a difference in knowledge
Author statements
among rural and urban areas, it was not statistically signifi-
cant. Knowledge about vector breeding and biting behaviour
Acknowledgements
was inadequate. Most of the respondents reported that
mosquitoes transmitting DF breed in drains and garbage (67%)
The authors are grateful to the Director, Vector Control
while less than half of them reported stagnant water as
Research Centre (VCRC) for providing the required facilities to
breeding source. More than half of the respondents reported
carry out the present study. The help & support of Mr. KHK
that mosquitoes bite during morning (58%) and evening time
Raju, Technical assistant, VCRC for mapping and
(44%). This finding was consistent with some previous studies
Mr. P. Kumaran, Technician C, VCRC in translating the ques-
which indicated the majority of respondents knew that dengue
tionnaire in English to local language, Tamil are greatly
vectors might bite at sunrise or sunset.21,27 In this study, tele-
acknowledged. The Community Respondents are greatly
vision was reported as the most common source of informa-
acknowledged for their whole hearted participation in the
tion. This is similar to previous studies whereby mass media
survey.
was cited to have a major role in disseminating information
about dengue.28,20,29 However a study in Laos PDR friends and
Ethical approval
relatives were the major source of information regarding
dengue fever.30 Another study in Thailand found that health
The study was approved by the Institutional Human Ethics
personnel were the main source of dengue fever information.31
Committee (IHEC) with reference no. IHEC-1207, Dated: 14/02/
Generally, in all houses, people used to store water for
2012.
bathing/drinking purposes in large containers viz., metal/
plastic drums, cemented tanks/cisterns etc. A large number of
Funding
small containers viz., metal/plastic pots were also used to
fetch water and for storage when the water supply was
The author Mr. Suhail Jeelani Shah received financial support
inadequate. These water-storing containers became ideal
from University Grants Commission (UGC), New Delhi, India
breeding grounds for Aedes mosquitoes, whenever it was
under Moulana Azad National Fellowship for Minority Stu-
stored for longer duration without a proper lid to cover the
dents (No. F.1e17.1/2011MANF-MUS-JAM-5414).
containers. In this study, the majority (81%) of HHs practice
water storing in the containers and more than 40% of them
Competing interests
store water in small plastic/steel containers. It was observed
that in most of the areas, waste generated is collected by None declared.
Municipality squad on daily or alternate day basis, but still
people are throwing the waste indiscriminately outside their
houses. This shows the non-seriousness and irresponsible
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