Socioeconomic and demographic predictors of resident knowledge, attitude, and practice regarding arthropod-borne viruses in Panama

Arthropod-borne viruses (e.g., Arboviruses) are responsible for over 1 million deaths a year globally, in addition to causing hundreds of billions of dollars in societal costs [1]. Dengue virus (DENV), Chikungunya virus (CHIKV), and Zika virus (ZIKV) are three particularly significant arbovirus threats. They are primarily transmitted to humans, the principal host, by Aedes aegypti and Aedes albopictus mosquitoes, whose ranges and capacity to spread disease have greatly expanded in recent decades as a result of globalization [2], urbanization [3], and climate change [4]. The risk of disease outbreak due to these arboviruses is not only reliant on the presence of infected mosquitoes, but also requires a susceptible host population to sustain transmission. For comprehensive risk assessments of DENV, CHIKV and ZIKV, Aedes vector surveillance can be supplemented with information on socioeconomic and demographic characteristics of human communities, as these are likely key predictors of viral transmission dynamics [5, 6]. Observing the distribution of medical knowledge, fear of transmission, and disease prevention practices across communities of varying socioeconomic and demographic characteristics can inform management procedures to areas where public education and outreach may be more effective means of disease prevention than vector control.

Knowledge, Attitude, and Practice (KAP) surveys have been used for decades to gauge community risk for numerous medical issues ranging from HIV/AIDS [7] to tobacco use [8]. For arbovirus transmission risk assessments, KAP surveys can be used to estimate knowledge of vector behavior and disease characteristics, attitudes or fears towards the vectors and viruses, and applications of any methods they use to prevent themselves from encountering mosquito vectors. Survey responses can be linked with data on the respondent’s personal attributes (e.g. age, sex, education level, financial situation, medical history) to identify common trends or differences among groups in an attempt to define risk predictors [9]. KAP surveys have been commonly applied in malaria zones in Asia and Sub-Saharan Africa, identifying education and income as a direct socioeconomic predictors of knowledge of malaria transmission as well as quantifying the relationships between past exposure to the disease and future preparedness [10–13]. Demographic characteristics such as age have also been found to be linked with KAP, specifically revealing that knowledge is lowest among older respondents [14]. KAP studies in endemic Dengue Fever regions have shown that a community can be knowledgeable of risk, yet not take any precautions to avoid Dengue transmission [15, 16]. Further studies have found the reverse, where communities can have very little knowledge of Dengue transmission, yet employ high levels of preventatives measures [17]. This seeming contradiction indicates the importance of conducting assessments of community KAP at each individual region of interest, rather than extrapolating results from other studies. One key gap in the literature is the understanding of variations in resident KAP as it pertains to multiple spatially coexisting diseases. As both vectors and pathogens continue to arise in novel locations, it is important to understand how residents view emerging diseases compared to endemic ones. To date, yet few KAP studies on the emergent threats of ZIKV and CHIKV have taken place in the Americas, where dengue is considered endemic [18, 19].

In this study, we attempt to estimate how resident knowledge, attitudes, and practices concerning three arboviruses vary between socioeconomically differing communities. Understanding a community’s capacity to withstand disease in the context of socioeconomics is an important aspect of social determinants of health [20]. Economic stability [21, 22], education [23], social context [24], and the built environment [25] all contribute to the relative health risk of an individual. They impact one’s access to healthcare [26], social support [27], public safety [28], and even exposure to pathogens [29, 30]. Therefore, examining the increasing risk of arbovirus transmission under the lens of social determinants of health can provide meaningful feedback for public health authorities in regions where residents may be at a greater risk due to specific socioeconomic conditions. Here we address this subject in Panama City, Panama, a region where both arbovirus transmission and socioeconomic polarization are particularly high.

While DENV has been endemic in Panama since 1970, CHIKV was first reported in 2014, followed by ZIKV in 2015. All three arboviruses are now present in Panama City, the largest city in Central America and a hub of international trade and tourism, with 2.5 million people arriving to the city from abroad in 2017. Additionally, Latin America has the highest income inequality of any region on Earth [31, 32], with Panama having the second most unequally distributed wealth in the region, with a Gini coefficient of 0.50. Panama City specifically has a considerable division between high and low income communities, ranking in the top 20 of cities on Earth with the most unequally distributed wealth. About 48% of the country lives below the poverty line while the wealthiest 20% own 50% of the nation’s overall wealth [32, 33]. This has led to vastly different neighborhood environments and community demographics, including highly wealthy and educated high-rise communities situated in close proximity to communities of extreme poverty. With a constant influx of potential hosts, stark socioeconomic contrasts, a climate supporting year-round mosquito development, and risk of three separate arboviruses, Panama City represents an ideal location to apply KAP surveys as a mean of assessing outbreak preparedness in the region. We frame our study within the context of social determinants of arbovirus transmission risk by administering KAP surveys to contrasting neighborhoods within the same urban region. Based on the results of previous investigations, we expect lower relative knowledge and fewer practices related to the prevention of DENV, CHIKV, and ZIKV among residents of communities of lower SES. We also expect relative knowledge about emergent CHIKV and ZIKV to be lower than that of endemic DENV.

Our results reveal several key insights regarding the knowledge, attitudes, and practices of residents of four focal neighborhoods of Panama City and the socioeconomic and demographic groups that they belong to. Since knowledge scores were normally distributed and the mean was approximately halfway between selecting none of the correct answers and all of the correct answers, we identify a considerable lack of accurate knowledge regarding the causes, symptoms, and prevention of DENV, CHIKV, and ZIKV. First, over half of the respondents believed that vaccines exist for each disease. While there is a theoretical risk that respondents believed the DENV vaccine available in Brazil at the time was also available in Panama, we find this unlikely given the high percentages of respondents who also thought a CHIKV and ZIKV vaccine existed. Overall, this presents a dichotomy, as this is either an admission that they have not had the supposed vaccine even if though they believe it exists or they are confusing it with other vaccines they may have had. Regardless, this is a considerable piece of misinformation that is pervasive among our sample pool and not restricted to any particular SES or demographic group. This is also an inverse of the more common problem, where the public is unaware of a vaccine that indeed does exist for a particular disease [53–55]. Further qualitative studies with this specific sample are needed to explore beliefs about nonexistent vaccines. Overall, we suggest that future studies carefully word their questions regarding this particular topic so as to avoid confusion on behalf of the respondent and reduce issues in interpretation.

Similarly, at least two-thirds of respondents misleadingly believe that the three diseases are curable, though it is highly possible that respondents confused the idea of “cured” with “treated.” The proportions of respondents who were familiar with each disease, combined with those who correctly identified the lack of vaccine and cure, follows the chronological pattern of the diseases arrive in Panama. DENV, which is endemic [56], commanded the highest awareness and lowest rates of incorrect answers. This was followed by CHIKV [57], which arrived in 2014, and ZIKV which arrived in 2015 [58]. It is expected that respondents would be more knowledgeable about threats that had existed locally for the longest time, though our results indicate that education efforts should not ignore such longstanding threats even amongst the rise of more novel ones. It also raises the key question of when, if ever, does resident KAP regarding a novel threat reach the levels of an endemic threat. Additionally, in light of our results, public education campaigns may be most needed in communities with higher relative proportions of residents over 70 years of age, residents who in free unions, as well as residents whose family earns less than $2500 a month. It is unclear why these specific residents had lower relative knowledge scores, yet both age and income can be key aspects of social determinants of health within a community [59]. Thus, further investigations into these potentially at-risk groups may be warranted.

Our attitude results indicate high levels of concern across our entire sample pool, regardless of specific disease. Respondents were also highly likely to seek out medical attention if they believed they had contracted the disease. Interestingly, the majority of respondents reported being bitten by a mosquito zero times per day on average. While this question is entirely based on the respondent’s perception and is not verified, it does provide an insight into the experience of local residents regarding biting mosquitoes as an aspect of their environment as have other studies on perceptions of vectors and vector-borne disease [60–62]. It is certainly possible that some residents have learned to ignore frequent biting that has simply become a normal component of their lives or that others may be overestimating based on differences in their personal feelings towards biting as a nuisance [63]. Since the response was directly related to neighborhood SES, with residents in the lower SES neighborhoods reporting significantly higher amounts of biting than those in high SES neighborhoods, follow-up studies may seek to investigate this division in perception and whether it is related to actual biting rates. Further, with higher attitude scores related to both high SES neighborhoods and high monthly family income, we illustrate a key difference in the degree of concern between differing groups, as reported biting is higher in low SES neighborhoods but concern is higher in high SES neighborhoods. Addressing heightened concern in high SES neighborhoods should be a focus of local outreach efforts, in addition to education campaigns in low SES neighborhoods that ensure public concern is appropriate.

Practices involving the reduction of standing water were widely reported by all respondents. The elimination of breeding habitat is a key method of reducing local vector abundance [64], and so the high rates of reported utilization of these practices is certainly a positive result for Panama City. However, the relatively low rate of respondents who regularly keep their doors and windows closed is potentially concerning, as mosquitoes often take refuge indoors to escape the heat of the mid-day [65–67]. Follow-up studies would be required to determine whether air conditioning is equally or unequally available across socioeconomic and demographic groups, and if limited access to air-conditioning prompts residents to maintain open doors and windows. An important potential complication to these results could be the type of structure that the respondent resides in. Responsibilities for vector control in some housing structures or communities may fall on building management rather than residents. This is more likely to be the case in the high SES neighborhoods where high rises and gated communities may manage on-site vector control for residents.

With the largest proportion of residents receiving their information from television rather than through other sources, we suggest that outreach and educational messages utilize available broadcast networks in the region. This is in line with other studies, which have also found television to be a key source of information on vector control practice [43, 68, 69]. Since the number of practices taken to avoid contracting the three diseases varied significantly by neighborhood SES, we suggest that greater steps be taken to inform residents in low SES communities of the effectiveness of vector control measures. It is not immediately clear why, when controlling for other factors, individuals with bachelor’s degrees or higher engaged in fewer practices, as other studies have generally found that education is directly related to the participation in such practices [70, 71]. The inverse relationship between respondent’s knowledge score and the number of sources of information indicates that there may be increased risk of misinformation when one diversifies their sources of knowledge on mosquitoes and the viruses they transmit.

While SES is indeed a cursory label of a community, both attitude and practice scores were predictable at the SES level, while knowledge was only predictable at the individual level.

Our study indicates that low-SES communities with high proportions of low income residents, low education, and elderly residents should be the target of arbovirus prevention programs. In general, these results support our initial hypotheses that lower relative knowledge and fewer practices related to the prevention of DENV, CHIKV, and ZIKV would be found in communities of lower socioeconomic status (SES). We also expected and found relative knowledge about emergent CHIKV and ZIKV to be lower than that of endemic DENV. However, we did not foresee concern to be higher in areas where biting was reported less often, as was found in the high SES neighborhoods. This highlights variation in the experiences of residents in socioeconomically contrasting neighborhoods, and such information must be taken into account when education campaigns are designed. Each community may require programs specifically tailored to meet their needs, based on the particular socioeconomic and demographic proportions of the residents. While the objective of the study was to observe SES-scale or neighborhood-scale effects, we found that there was enough individual-scale diversity across all four neighborhoods for more specific socioeconomic and demographic attributes to be used as determinants of knowledge, attitude, and practice. Thus, we caution future studies seeking to identify generalizations across entire neighborhoods to be cognizant of the level of variation among residents even in seemingly homogenous communities. Overall, with knowledge of CHIKV and ZIKV lower than that of DENV across all of our respondents, we suggest increasing messaging regarding the two more novel threats. Despite CHIKV and ZIKV being present in Panama City for four and 3 years respectively, resident knowledge is still not at the level of DENV. Such information can be helpful in both designing KAP studies as well as educational interventions across Latin America, where CHIKV and ZIKV are emerging threats and differences between socioeconomic groups can be particularly stark. Beneficial follow-up studies and qualitative research would examine a greater variety of neighborhoods, such as some in a more intermediate SES range, as well as investigations into the efficacy of educational campaigns.