A cross-sectional study: Knowledge, attitude and practice (KAP) and risk factors on dengue fever among children in Eastern India

Study Design

This analysis is grounded in the cross-sectional data obtained during the baseline data collected in West Bengal, India, with the primary objective of evaluating the effectiveness of a community mobilization intervention for dengue control. Originally designed to collect data from 68 clusters and recruit 5,848 children aged 2 to 12 years, the study encountered challenges related to the pandemic and regional instability. Consequently, the baseline data collection had to conclude prematurely, resulting in complete data being gathered from four clusters and partial data from seven clusters. This data collection occurred between November 2022 and October 2023.Participation eligibility in selected clusters hinged on the presence of children aged 2 to 12 years within households, provided that both the parent or legal guardian and the child consented to the data collection.

Exclusions from this analysis comprised households and children with tainted blood samples and/or indeterminate serology results.¹³ Trained interviewers conducted household surveys in Portuguese during door-to-door visits, targeting the principal adult respondent in each household. The surveys covered a spectrum of topics, including living conditions, socioeconomic status, social capital, and the basic health history of the involved children. Additionally, respondents were queried on aspects of dengue knowledge, attitudes, and practices (KAP).¹⁴

The Knowledge, Attitudes, and Practices (KAP) module comprised a combination of partially categorized questions, multiple-choice queries, dichotomous inquiries, and Likert scale responses. In the knowledge domain, five questions were designed to assess awareness of dengue symptoms, modes of transmission, and strategies for dengue prevention. The attitude domain, consisting of five questions, aimed to evaluate perceptions about dengue and the acceptability of dengue prevention practices. The practice domain encompassed six items pertaining to the adoption of preventive practices and behaviors related to seeking dengue treatment.¹⁶ To create a comprehensive KAP index, a scoring system was implemented, assigning maximum scores of 10, 8, and 10.5 points for knowledge, attitude, and practice, respectively. The total KAP score for households, reaching a maximum of 28.5 points, was then categorized into groups: low (<15 points or <50% of maximum points), moderate (>15 or <22 points or between 50% to 75% of the maximum score), or high (>22 points or >75% of the maximum score).¹⁵

Statistical Analysis

Statistical analyses were performed to examine the primary outcome of dengue seropositivity (negative or positive) in this study. Seroprevalence, along with 95% confidence intervals, was estimated using a one-proportion z-test. Chi-squared tests were employed to investigate the relationship between each domain of Knowledge, Attitudes, and Practices (KAP) (categorized as low, moderate, or high) and dengue seropositivity. Kendall rank correlation tests were utilized to assess associations between pairs of KAP domains (i.e., Knowledge and Attitudes, Knowledge and Practices, and Attitudes and Practices). Univariate regression analyses were conducted to explore associations between sociodemographic covariates and seropositivity.¹⁷

Subsequently, a multivariable regression model was constructed to evaluate associations between the risk of seropositivity and potential predictors, including KAP, age, race, average monthly household income, household water storage method, recent dengue episode, dengue death history within the household, and education level and occupation status of the household's principal adult respondent. The selection of variables was informed by hypothesized causal associations and confounders identified through a comprehensive literature review and direct acyclic graphs.

For both univariate analyses and multivariable regression models, relative risks (RR) and 95% confidence intervals were estimated using Zou's modified Poisson regression approach—a method that offers estimates of relative risk, as opposed to odds ratios, particularly when the outcome is common.

Children's ages were categorized into two groups: 2-5 years old and 6 to 12 years old. Race was classified into five categories based on the Instituto Brasileiro de Geografia e Estatística's classification used for the Indian census. Distinctions were made between households with no potable water storage or sealed individual water tanks and those with open water storage methods (e.g., buckets, pots). Households were considered to have a dengue history if they reported a recent dengue episode or the death of a family member due to dengue. The household education level of the adult respondent was categorized based on the completion of elementary school, considering its importance for literacy. Occupation status was divided into respondents with paid employment at the time of the questionnaire versus those who were unemployed, retired, or in other categories. Monthly household incomes were categorized as low (<500 Indian real), moderate (>500 or <2500 Indian real), or high (>2500 Indian real), considering Fortaleza's cost of living and the average household income of the resident population in the Ceara state.¹⁸ All statistical analyses were conducted using R version 4.2.0.

Characteristics of Participating Households and Children

There were 392 households and 483 children who provided a blood sample of sufficient quality for this analysis. The mean age of participating children was 6.5 years with an almost equal proportion of boys and girls participating in the study (Table 1). The mean age (SD) of household principal adult respondents was 29 years with the majority being female (n=345, 88%). Children were most often reported as being multiracial (n=285, 73%). Parental respondents had a high completion rate of elementary school (n=276, 70%) and most households had a moderate household income (n=354, 65%).

Only five percent (n=20) of households achieved over 75% for overall KAP, while most households achieved scores between 50% and 75% (n=271, 69%), and 101 households scored lower than 50% of the total score (26%). The results of the Kendall rank correlation tests and Chi-squared tests demonstrate that the three domains have a statistically significant positive association with each other. However, in univariate tests there was no evidence of an associationbetween children’s seropositivity and the household’s level of each individual domain (knowledge, practice, or attitude) or with the overall KAP measure.

Demographic and Socioeconomic Determinants of DengueSeropositivity in Children In the multivariable regression model, the parental education level, households’ KAP level, age of the child, and household water storage method were shown to be significantly associated withthe risk of dengue seropositivity in children (Table 3).

Among all included predictors, children’s age was most strongly associated with the risk of dengue seropositivity, which was significantly higher among children aged 6-12 years compared to children aged 2-5 years old (RR: 6.2, 95% CI: 3.4-10.7, p<0.001). Children of parents with higher education levels, who at least completed elementary school, were less likely to be seropositive (RR: 0.7, 95% CI: 0.5-0.9, p=0.004). There were no statistically significant associations detected between dengue seropositivity and monthly household income, principal adult’s occupation, children’s race, or household’s dengue history. Children living in households without potable water storage or using sealed water tanks were found to be significantly associated with a lower risk of dengue seropositivity (RR: 0.7, 95% CI: 0.6-1.0, p=0.041).

Notably, our result showed that higher values of KAP were associated with an increased risk of dengue seropositivity (RR: 2.1, 95% CI: 1.1-4.0, p=0.027).

AUTHORS CONTRIBUTION

All author have contributed equally.