Strengthening the perception-assessment tools for dengue prevention: a cross-sectional survey in a temperate region (Madeira, Portugal)

Background Community participation is mandatory in the prevention of Dengue outbreaks. Taking public views into account is crucial to guide more effective planning and quicker community participation in preventing campaigns. This study aims to assess community perceptions of Madeira population in order to explore their involvement in the A. aegypti’s control and reinforce health-educational planning. Due to the lack of accurate methodologies for measuring perception, a new tool to assess the community’s perceptions was built. Methods A cross-sectional survey was performed in the Island’s aegypti-infested area, exploring residents’ perceptions regarding most critical community behaviour: aegypti-source reduction and their domestic aegypti-breeding sites. A novel tool defining five essential topics which underlie the source reduction’s awareness and accession was built, herein called Essential-Perception (EP) analysis. Results Of 1276 individuals, 1182 completed the questionnaire (92 · 6%). EP-Score analysis revealed that community’s perceptions were scarce, inconsistent and possibly incorrect. Most of the population (99 · 6%) did not completely understood the five essential topics explored. An average of 54 · 2% of residents only partially understood each essential topic, revealing inconsistencies in their understanding. Each resident apparently believed in an average of four false assumptions/myths. Significant association (p<0.001) was found between both the EP-Score level and the domestic presence of breeding sites, supporting the validity of this EP-analysis. Aedes aegypti’s breeding sites, consisting of décor/leisure containers, presented an atypical pattern of infestation comparing with dengue prone regions. Conclusions The studied population was not prepared for being fully engaged in dengue prevention. Evidences suggest that EP-methodology was efficient and accurate in assessing the community perception and its compliance to practices. Moreover, it suggested a list of myths that could persist in the community. This is the first study reporting an aegypti-entomological pattern and community’s perception in a developed dengue-prone region. Tailored messages considering findings of this study are recommended to be used in future campaigns in order to more effectively impact the community perception and behaviour.

Residents seemed to understand the local risk they are submitted and, thus the urgency of being involved in the aegypti-control.
Residents recognized the presence of mosquitoes that transmit diseases in their residential area; however they believed that a dengue outbreak will not emerge in the island. Alledgedly some made this confusion because they did not recognize dengue as a mosquitoborne disease (20·3%). Eventually some residents could think that Madeira is "protected" since those kind of severe epidemic diseases historically never occured in temperate countries.
These residents were not aware of the the urgency of being involved in the aegypti-control. Alledged myths 3 and 4: (i) -"Dengue is not a mosquito-borne disease"; (ii) -"Dengue only occur in tropical/non-develloped countries".
Residents did not recognize the presence of mosquitoes, in their residential area, that can transmit diseases; but admitted that a dengue outbreak can emerge in the island. These residents did not have a correct notion of the aegypti's distribution area. Since 22·2% out of these group referred not be 'biten by mosquitoes', they could believe that they are at lower risk of being infected in an eventual outbreak.
Residents did not understand the risk they are subjected to and neither the urgency of being involved in the aegypti-control. Alledged myths 5 and 6: (i) -"Mosquitoes are allocated in a specific area and are not able to spread through the island"; (ii) -"Since I do not feel the byte, I am not a risk of being biten/infected".
Residents did not recognize mosquitoes that transmit diseases in their residential area neither the possibility of a dengue outbreak in the island.
Residents did not understand the risk they are subjected to neither the urgency of being involved in the aegypti-control. Alleged Myth 7 : "Madeira's residents are not at risk"

Concept 5
Concept 6 % Domestic Attribute Residents know that mosquitoes can breed inside houses and recognized that domestic aegypti-control do have impact in the reduction of aegypti-population.
Residents seemed to understand the domestic attribute of the aegypti-control and, thus why community is the key intervenient in the aegypticontrol.
Residents know that mosquitoes can breed inside houses but they did not believe that the domestic aegypti-control have impact in the reduction of the aegypti's population. They probably believed that other intervenients have much more impact in the reduction of the aegypti's population.
Residents did not understand the domestic attribute of the aegypti-control, neither why community is the key intervenient in the aegypti-control. Alledged Myth 8: "Local health authorities are the key intervenient in the control of mosquitoes ".
Mosquitoes cannot breed inside houses but domestic aegypti-control do have impact in the reduction of aegypti-population in the neighborhood. Those respondents believed in their role in domestic aegypticontrol but did not understood why that control has an impact.
Residents did not understand the the domestic attribute of the aegypti-control, neither why community is the key intervenient in the aegypticontrol. Alledged Myth 9: "Other protective measures can control mosquitoes". X X 27·7% (327 ind.) Residents do not know that mosquitoes transmit disease, neither that their involvement have an impact in the control of mosquitoes.
Residents did not understand the domestic attribute of the aegypti-control, neither why community is the key intervenient in the aegypti-control. Alleged Myth 10: " I am (Community is) not an intervenient in the aegypti-control".

Concept 7
Concept 8 % Mosquito Breeding Residents only identifyied water-containers (and not other false issues) as mosquitoes' breeding contributors.
Residents seemed to understand where do mosquito breed and, thus the need of the aegypti-control activities.
These residents did not comprehend what lead to the breeding of new mosquitoes and, thus did not understand the proposed measures to control them.
Residents seemed to not understand where mosquitoes breed and neither the need of the aegypti-control activities. Alledged Myths 11 and 12: "Clean houses or houses without pets/animals do not have mosquitoes" or "Clean people did not need to be involved in mosquito control".
Residents did not identify water-containers neither other false issues (food debris and pets) as mosquitoes' breeding contributors.
These residents did not know where do mosquitoes breed.
Residents seemed to not understand where mosquitoes breed and neither the need of the aegypti-control activities.
Residents did not identify water-containers but did identify other false issues (food debris and pets) as mosquitoes' breeding contributors Residents are completely mistaken regarding mosquitoes breeding and, thus did not uderstand the need of the aegypti-control activities. Alledged Myths 11 and 12: "Clean houses or houses without pets/animals do not have mosquitoes" or "Clean people did not need to be involved in mosquito control".

Concept 9
Concept 10 % Control Measures Residents only recognized water-containers removal (and not other false measures) as "effective to control mosquitoes" Residents seemed to recognize effective control measures and, thus understand how the domestic aegypti-control should be done.
Residents recognized water-containers removal and also other false measures (such as insecticide indoor application and flyswatter use) as "effective to control mosquitoes" Residents seemed to not be focused on effective control measures and, thus did not understand how the domestic aegypti-control should be done. Alledged Myth 13: "Using insecticides or the flyswatter, I am already contributing to control the aegypti-mosquito" Residents did not recognize water-containers removal neither other false measures (such as insecticide indoor application and flyswatter use) as "effective to control mosquitoes". These residents did not know how to control mosquitoes.
Residents not recognized effective control measures and, did not understand how domestic aegypti-control should be done. X X 15·6 (184 ind.) Residents recognized water-containers removal and also other false measures (such as insecticide indoor application and flyswatter use) as "effective to control mosquitoes" Residents seemed to not be focused on effective control measures and thus did not understand how the domestic aegypti-control should be done. Alleged Myth 13: "By using protective meausres (such as insecticides or the flyswatter), I am already contributing to control the aegypti-mosquito" n TOTAL (Scored Population) = 1182 individuals