Knowledge, perceptions and practices regarding Zika virus of university students in northern Colombia (Santa Marta, 2016)

Conocimientos, percepciones y prácticas sobre el virus del Zika en estudiantes universitarios del norte de Colombia (Santa Marta, 2016).

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Zika is a viral disease produced by an arbovirus of the flavivirus genus, transmitted by the mosquito Aedes aegypti¹. However, there might be other mosquitoes involved². This virus was reported for the first time in Uganda in 1947³. Then, reports arose on Yap Island in 2007, in French Polynesia in 2013 and on the Cook Islands and New Caledonia in 2014⁴. In February 2015, it was detected in South America on Easter Island (Chile), and in May 2015, two cases were detected in the State of Paraíba (Brazil)^5,6. Once it appeared in Brazil, it rapidly began to spread in several Latin American countries, including Colombia^7,8. The Zika virus has probably been in South America since 2013⁹. In October 2015, the first 9 cases of Zika were confirmed in Colombia in the department of Bolivar¹⁰, and then in other departments, like Atlántico¹¹, Sucre¹² and Magdalena¹³.

Zika quickly alerted different health organizations on the global scale, such as the World Health Organization (WHO), the Pan American Health Organization (PAHO), and governments from different countries like Colombia, due to neurological (microcephaly, meningoencephalitis, Guillain-Barré syndrome) and immunological (thrombopenic purpura, leukopenia) implications ^14-16; thus, Aedes aegypti vector prevention and control campaigns were implemented in some countries¹⁷.

Research done in Colombia and other parts of the world on the control of Aedes has reported that different factors, such as climate change, deficient socio-economic conditions, migratory patterns, inadequate public and health services^18-21, low level of knowledge^22,23, and inefficient control practices of Aedes, have allowed the vector and its diseases to proliferate. In a similar way, political and economic factors expressed in the healthcare system crises, the absence of public policies and permanent vector control programs have influenced the incidence and prevalence of vector-borne diseases (VBD), which is associated with low levels of appropriation of the strategies in order control them^24-27.

In addition to having suffered from Zika in 2015-2016, the population of Colombia, and, in particular, of the department of Magdalena and its capital Santa Marta, , has suffered from Dengue and Hemorrhagic dengue²⁸ since the 1980s, and most recently from Chikungunya. Before starting with this study, already 1,540 cases of Zika had been recorded in Santa Marta²⁹ during the sixth week of 2016 (week 17 of the Zika outbreak in Colombia). Considering this background, it was expected that the population’s level of knowledge, perception and practices in regards to Aedes control was high, and especially among the university-educated population, given that, as it is referred to in other research^30,31, at a greater education level, greater access to information and greater understanding of it.

On the basis that the Zika virus is new in Latin America and in other places in the world, and while this research was being developed, few publications were found^32-34 regarding the level of knowledge of this disease in Colombia. Thus, this study’s goal is to show evidence of the level of knowledge, perceptions and practices in regards to Zika among the population of university students in Santa Marta, Colombia.

Of the 171 surveyed students, 119 (59%) were women and 52 (30.4%) were men, between 18 and 44 years of age, and an average age of 21.6 years. In terms of public services, the 98.8% of students have access to electricity, 91.8% to water and 87.7% to sewage; 78.9% store water in tanks with a cover and 7.6% in tanks without a cover (Table 2).

Table 2
Sociodemographic and VBD information.

* Perception, not confirmed cases. Multiple answers were possible.

Of those surveyed, 15 (8.7%) stated that they have suffered from Dengue, three (1.7%) from Hemorrhagic dengue, 83 (48.5%) from Chikungunya, and 55 (32.1%) from Zika (Table 2). A total of 103 (60.2%) stated that they have heard of Zika. However, in analyzing the causative agent, only 50 (29.2%) know that it is a virus, 52 (30.4%) incorrectly said that it is caused by the Aedes mosquito, 33 (19,2%) did not know, and 13 (7.6%) answered “by any mosquito”. Regarding transmission, 78 (45.6%) considered the Aedes mosquito as responsible, 27 (15.7%) any mosquito, 24 (14%) that it is transmitted by other people and 34 (19.8%) do not know (Table 3).

Table 3
Knowledge of Zika virus and its Vector

* Multiple answers were possible.

In terms of the level of knowledge regarding the causative agent and the mode of transmission of Zika, in the High level (Level 2), there were 25 students (14.6%) who had knowledge about the causative agent and the mode of transmission. In the Medium level (Level 1), 79 (46.2%) students knew the causative agent or the mode of transmission. In the Low level (Level 0), 67 (39.2%) students did not answer to any of the questions (Table 3).

Regarding the symptoms, 133 (77.7%) students mentioned fever as the most frequent symptom, 118 (69%) headache, 110 (64.3%) skin rash, and 98 (57.3%) joint pains (Table 4). Of the 55 people who stated that they had suffered from Zika, once they felt the symptoms, they took the following actions: 26 (47.2%) self-medicated, 21 (38.1%) rested, 15 (27.2%) went to a healthcare center and 13 (23.6%) visited a doctor (Table 5).

Of those who attended a healthcare center or visited a doctor (28 students), their perception of the healthcare system and treatment was as follows: four (14.2%) suggested that medical attention and diagnosis was very good, five (17.8%) considered treatment very good and three (10.7%) claimed that the recommendations and control of the symptoms were very good. In general, they considered the medical attention to be between fair and good. Those, who did not attend a health center and who had suffered from Zika (27 people) offered various reasons for not going: 23 (85.1%) identified symptoms without needing to go to the doctor, 19 (70.3%) believe professionals at the healthcare center only prescribe acetaminophen and 17 (62.9%) think the quality of the health service is poor (Table 5).

Table 4
Knowledge and perception on Zika virus

Table 5
Perception on medical treatment.

In regards to the risks and consequences of Zika, 92 (53.8%) students considered the disease to be a very serious problem due to the implications it has on health (Table 4). One of those reasons is that pregnant women infected with Zika transmit the virus to her fetus, which can develop microcephaly and even die, “it is a very dangerous virus and affects pregnant women aggressively, deforming the fetus,” (Survey 23); it can also affect the nervous system, “cases of Zika present […] side effects such as Guillain-Barré syndrome” (Survey 57). It is a public health problem aggravated by the faults of the healthcare system, “it could cause a hospital crisis with the healthcare system in this country” (Survey 137). Some believe the disease has socioeconomic implications, claiming that “it affects a large part of the population and mostly people with few resources” (Survey 133), and it can “affect the communities in their economic development” (Survey 41). Finally, others share the perception that people have little knowledge on the topic, and are negligent when dealing with it, “because if they do not have the necessary knowledge, it could cause harm to society” (Survey 25) and “the negligence is greater, it predominates and is due to this that it is propagating more” (Survey 43).

In terms of how they learned of Zika, 144 (84.2%) students learned about it through TV, 118 (69%) through Internet, 85 (49.7%) through family and friends, 26 (15.2%) through home visits and 32 (18.7%) through campaigns in their place of study and/or work. In terms of who is responsible for eliminating or controling mosquito breeding sites, students provided various answers, such as: 108 (63.1%) it should be the community, 105 (61.4%) state-run institutions, 97 (56.1%) the family, and 96(56.1%) themselves (Table 4).

A large percentage of students know the most important strategies that must be implemented in order to control mosquito breeding sites: 138 (80.7%) mentioned eliminating standing water around the household, 134 (78.3%) mentioned fumigating inside the household, 137 (80%) mentioned controlling standing water, 130 (76%) fumigating around the household, 119 (69.5%) mentioned eliminating trash and weeds around the household, 120 (70.1%) mentioned collecting plastic containers and used tires, and 110 (64.3%) mentioned keeping the containers covered where water is stored. In terms of practices and strategies implemented to control the spread of Aedes, 58 (33.9%) students answered that they always cover containers where water is stored, 43 (25.1%) control standing water within the household, 35 (20.4%) avoid places infested with mosquitoes and standing water, and 33(19.2%) collect or perforate used tires or plastic containers. On the other hand, only eight (4.6%) use a mosquito net when they sleep and 12 (7%) use repellent (Table 6).

Table 6
Practices regarding Zika virus and its vector

Previous studies on VBD have shown that: a) having suffered from this type of disease and having been part of prevention campaigns increase the level of knowledge regarding how to control the transmission vector⁴⁴; and b) that a higher educational level reduces the risk of spreading the vector⁴⁵ and favors greater access to information and a greater understanding of the diseases^31,16. In the case of the population surveyed in Santa Marta, it was observed that these conditions coincide: they have recurrently suffered from VBD, they have been exposed to mass media campaigns and have a university-level education. Notwithstanding, in this study, it can be determined that 46.2% of students have a medium level of knowledge (Level 1). Even though more than half of students stated that they know what Zika is, only 29.2% know what the causative agent is and 45.6% what the mode of transmission is, and only one of every seven know the causative agent and the mode of transmission (Level 2). Apart from that, it was reported in several studies that at least a high percentage of those interviewed know that Zika is transmitted by mosquitoes (not specific for Aedes): a survey with students from a public university in the US (43% were health majors) found that 88% know how is transmitted⁴⁶; which is the same value found in a study in Lambayeque (Peru) regarding reproductive-age women²². In Villanueva (Colombia) 77% of the general population know what causes Zika and 74% know how it is transmitted^33, In Ecuador, 93% of the rural and urban population know how it is transmitted⁴⁷. in the U.S. 49% of pregnant women know what causes Zika, and 87% know how it is transmitted⁴⁸. A total of 90% of women of childbearing age in Kentucky (U.S.) know how it is transmitted¹⁶, which is very similar to the general population from suburban New York City (91% know how it is transmitted)⁴⁹.

One of every two surveyed students confused the causative agent of the disease with the mode of transmission, mentioning that it is caused by the Aedes mosquito. In terms of the mode of transmission, there is a lot of confusion and lack of knowledge, since almost half the students mentioned that it is transmitted through any mosquito, by air, by water, by

contaminated food⁵⁰, or that it can happen because of malnutrition. On the other hand, a few mentioned that it can be transmitted from person to person, in despite of at the moment of carrying out the survey, it had not yet been confirmed, nor had it been widely circulated information on sexual transmission⁵¹.

The low level of knowledge or confusion of the students regarding the causative agent and the mode of transmission of Zika, despite having some kind of university training, can be associated with the fact that this disease was new in Colombia, and the information campaigns that circulated through national and local media allowed the appropriation to be focused on information referring to the health risk, such as, the symptoms and collateral effects of diseases that can affect unborn children, instead of focusing on the ecology of the disease. The high level of knowledge of symptoms can be associated with the fact that one of every three students believes to have suffered from Zika at the time of the survey (not confirmed cases). These results contrast with those presented by in regards to Dengue³⁰, in which, unlike our study, the population had a low educational level but a high level of knowledge on the disease and the vector, as a result of educational and prevention campaigns offered by the national and regional authorities. This can be associated with the Dengue campaigns authorities have been developing and implementing for more than four decades, and the fact that the studies can coincide with recent campaigns that aim to control the vector.

Half of the students that suffered from this disease did not go to medical centers, since they thought they could identify the symptoms on their own. Others believed that the quality of the health service is poor, or that physicians only prescribe acetaminophen. Some students self-medicated and others used home remedies, such as medicinal plant infusions, like chamomile, cornstarch with camphor, and Caladryl®. Regarding those who went to a healthcare center, few people that considered medical attention to be useful. On one hand, the aforementioned shows the lack of credibility of the healthcare system; on the other hand, the sub-record presented in regards to this type of disease, due to great percentage of the people are not diagnosed or treated in the health centers, in this sense, a study in Aceh (Indonesia) shows a low level of knowledge in doctors (only 35.9% of the participants had good knowledge about Zika infection)⁵².

Despite the fact that one of every two students considers Zika to be very dangerous and more than half of them have a high level of knowledge about the most important strategies to control the vector, the prevention practices to counteract its spreading are deficient, as mentioned in the case of the people of Villanueva (Colombia)³³. This is because one of every five students states that they always cover water containers, one of four controls standing water inside the household, and one of every five collects and perforates used tires and plastic containers. Other important strategies, that are less implemented, are the use of a mosquito net to sleep (4.6%) and repellent (7%). The tendency to have a low level of knowledge regarding Zika and deficient vector control practices coincides with studies done on Dengue and Malaria. For example, research done two years later in a national plan to control Dengue and three years after the classic Dengue epidemic began allow this work⁴⁰, to explainsdue to the research done two that people possibly forgot what they learned during the campaigns. In other research⁴², the knowledge-practice gap resulted in a lack of time and interest among community organizations.

At the time this study was performed, the Zika epidemic was in full bloom, and the informational campaigns on this disease were circulating through different methods of communication. The reasons that can contribute to the understanding of the inconsistency between the level of knowledge and vector control practices are socio-cultural, environmental, economic and political.

From a cultural perspective, despite knowing the risks of Zika on health and its collateral effects, the population did not change its practices and habits to minimize the risk of contracting it, such as wearing long clothes, shoes and socks, using of a mosquito net on doors and windows, cleaning dark places, fumigating the inside of the household, collecting and perforating, and maintaining covered containers where water is stored. The aforementioned can be associated with the lack of knowledge of the disease's mode of transmission. From a social standpoint, no permanent collective practices that contribute to decreasing the risk of the vector spreading have been established. This is a evidence of the fact that, although half of those interviewed believe that both they and the community are responsible for controlling the spread of the vector, very few stated that they have participated in the neighborhood clean-up campaign. It is clear that the lack of interest and participation of the community to ensure the collective wellbeing can be associated with the fact that those interviewed are university students, mostly dependent on their parents. This students do not assume individual and collective responsibility, attributing the responsibility to others, similar to that established by⁵³.

At the environmental level, the city’s shortage of water requires the community to create transitory or permanent alternatives to store water, which does not go hand in hand with VBD vector control strategies, since their priority is water. In terms of economics, the city lacks rainwater collectors, and in some sectors sewage and trash collection, and the disorganized and unplanned growth of the city does not contribute to creating social and environmentally-friendly alternatives to control and decrease the vector’s longevity.

Finally, in political terms, the public health strategies implemented during the Zika epidemic seek to guarantee education, follow up, prevention and control of the VBD occurring only during crises and outbreaks. This is not only ineffective as a prevention strategy,; it contributes to the strengthening of the credibility of institutions in the eyes of citizens, and therefore to the transformation of socio-cultural practices of the population tthat can counteract the vector and the transmission of the VBD, as it has been seen by²⁵.

In conclusion, it is necessary to provide permanent VBD information, and implement control campaigns that do not only respond to crises, as it has been reported by other researchers, where the citizen participation and health education is only offered during epidemics or emergencies²⁷. This situation does not allow the communities to acquire a sufficient level of knowledge, which affects their active participation and the chance of controlling the vector permanently^54,55. While the health implications reported for Zika, such as microcephaly, are assumed to be worse than other VBD, they show it is important to develop short-term vaccines for this virus^48,56,57. Nevertheless, involving the communities is a priority, their worldviews and their narratives about the disease, as several authors have proposed^24-26,58,59. The way communities understand and face the disease and the vector will determine, on one hand, the communication strategies that should be implemented in order to learn the risks of acquiring VBD, its causes and consequences, and, on the other hand, the implementation of vector control strategies^25,60,61,62. In this way, interventions in prevention strategies must focus on the daily lives of the communities in relation to their sociocultural, economic and environmental particularities.