Original Research

Health Workers’ Perceived Challenges for Dengue Prevention and Control in the

Bienvenido A. Veras-Estévez MD MPH and Helena J. Chapman MD MPH PhD

ABSTRACT educators, clinicians and an administrator. Question topics included INTRODUCTION Mosquito-transmitted dengue remains an endemic occupational experiences in dengue prevention and control; views threat to population health in various tropical and subtropical regions. on vector control in communities; perceived challenges for citizens’ adherence to recommended practices; and suggested measures for Recommended dengue prevention practices focus on vector control strengthening adherence to vector control at local and national levels. and reducing human–mosquito interactions, by practices such as Thematic analysis was used to identify salient themes. removing standing water, wearing protective clothing and using repellent, as well as seeking medical care when symptomatic. Health RESULTS Health workers described the following perceived workers in the community educate and empower citizens about challenges: 1) limited individual economic resources; 2) individual recommended prevention practices, and thus are indispensable in lack of awareness, education or action; 3) limited cohesion among implementing national dengue initiatives at the local level. However, community members; and 4) limitations in sustainability of government their health messages may not resonate with all community members, interventions. They made 14 recommendations related to the 4 resulting in low adherence to recommended prevention practices. perceived challenges. Understanding the factors associated with low adherence to dengue prevention and control measures is essential for strengthening CONCLUSIONS These fi ndings evince the complex interplay of national dengue initiatives. economic, environmental, health, political and social factors that can directly or indirectly infl uence individual and community adherence OBJECTIVE Identify health workers’ perceived challenges for dengue to recommended dengue prevention measures. By understanding prevention and control strategies and describe their recommendations how these intrinsic and extrinsic factors hinder adherence, health for strengthening dengue control in the Dominican Republic. authorities can adapt national policies to strengthen community participatory action in vector control, empower leadership potential by METHODS From January through March 2005, a qualitative study health workers and community members, and provide an appropriate was conducted in fi ve provinces of the Dominican Republic. Based systemic approach to preventing disease transmission. on literature review and consultations with clinical specialists, a semistructured interview guide of nine questions was designed. KEYWORDS: Dengue, dengue virus, arbovirus, community health, A purposive sample of 19 health workers (10 men, 9 women) was prevention, control, communicable disease control, qualitative interviewed, including public health practitioners, entomologists, research, Dominican Republic

INTRODUCTION Traditional vertical or “top-down” vector control strategies, Dengue is the most important mosquito-borne viral infection including government-run pesticide spraying, initially showed across the globe, with approximately 50−100 million cases promising results in global mosquito control, but lacked annually.[1] Novel modeling and mapping frameworks have placed sustainable funding over time.[10] These were followed by a estimated dengue burden at 390 million infections and 96 million transition to horizontal or “bottom-up” approaches that took into clinical cases annually, with almost 4 billion people at risk in 128 account multiple factors associated with DENV transmission and countries in tropical and subtropical geographic regions.[2,3] Four employed integrated, community-based strategies for health serotypes of dengue virus (DENV 1−4) may be transmitted by the education and promotion, based on community empowerment primary vector, the female Aedes aegypti mosquito. Infection with and collaboration among stakeholders directly and indirectly one DENV strain confers permanent immunity to that strain, but involved in vector control.[11] Health education campaigns that provides limited protection against subsequent infection by other have emphasized recommended vector control practices and strains.[4] active participation by community members in reducing Aedes populations in and around their homes have been shown to Following World War II, in the 1950s and 1960s, A. aegypti increase knowledge and awareness of dengue, but knowledge eradication programs in the Americas Region were effective in does not necessarily equal action.[12] Innovative approaches can controlling the spread of yellow fever and dengue.[5] However, integrate dengue prevention and control strategies—sustaining after vector control programs were discontinued in the late political support, forming community-based partnerships, 1960s, A. aegypti reemerged in the Region and expanded its strengthening active epidemiological surveillance programs, and distribution.[6] International population movement and trade building empowered communities—to promote long-term vector facilitated air and sea transport of people and animals as well as control and community behavioral changes. As observed in Cuba, A. aegypti vectors.[7,8] Also, increased human population density intersectoral collaboration and community participation, coupled and expanded urbanization to “megacities,” along with limited with political will, are bulwarks of dengue prevention and control vector surveillance programs, created an ideal environment strategies.[13] for continued arbovirus transmission.[9] Geographic spread and reinfestation of Aedes vectors in the Americas and lack of In 2012, WHO developed an operational framework for integrated sustainable vector control programs have continued into the 21st vector management strategies incorporating fi ve elements: century. 1) advocacy, social mobilization and legislation (e.g., policy

26 Peer Reviewed MEDICC Review, October 2017, Vol 19, No. 4 Original Research development, community empowerment); 2) collaboration symptoms). Evidence of cohesive community action has been within the health sector and with other sectors (e.g., enhanced observed in two Latin American countries. Cuba’s health communication among stakeholders); 3) an integrated approach system emphasizes national promotion of healthy behaviors, (e.g., use of resources for multiple diseases or methods); 4) such as vector control and immunization practices, through evidence-based decision-making (e.g., application of scientifi c active leadership by families and communities.[21] Argenti- fi ndings to practice); and 5) capacity-building (e.g., provision na’s health system has highlighted the need for cohesion and of resources to manage strategies).[14] Health workers (HWs) progress to reach specific health goals, empowering commu- play an indispensable role in implementing national initiatives at nity members to be active and responsible stakeholders in the local level.[15] In integrated dengue prevention and control decision-making about vector control.[22] strategies, HWs serve in various capacities to educate community members about the threat of DENV infection and actions to There are high hopes for the fi rst licensed dengue vaccine and improve compliance with vector control recommendations in and other vaccine candidates,[23] but it is still critically important to around their homes. better understand behavioral, environmental and socioeconomic factors that may increase the number of mosquito breeding sites The Dominican Republic (DR) is an upper–middle-income in and around homes, and thus risk of DENV infection. With the country with rapid population growth and increasing poverty complex dynamics of dengue prevention and control strategies rates. The population of 8.6 million habitants in 2000, with 32% in the DR, HWs can encounter challenges in adherence to of DR citizens living at or below the poverty threshold, increased recommended vector control measures among community to 9.9 million habitants in 2010, with 41.6% living at or below members. the poverty threshold.[16] Although approximately 98% of the population has access to electricity,[16] households typically do This study’s objective was to identify HWs’ perceived challenges not have consistent 24-hour service, and thus must store water for dengue prevention and control strategies, using a qualitative for family use in large tanks inside or outside the home.[17] approach, and describe their recommendations for strengthening future actions for dengue control in DR communities. To address this challenge, PAHO and the DR Ministry of Health and Welfare (MISPAS) developed the National Strategy for METHODS Integrated Dengue Prevention and Control, which proposed fi ve Study type, setting and sample From January through March specifi c actions for entomology: 1) conduct operational research; 2005, a qualitative study using an ethnographic approach[24] 2) incorporate areas for applying innovative techniques by was conducted in of fi ve DR provinces: personnel trained in vector control; 3) promote collaborative in ; Baní in Peravia Province; San Felipe in training for all vector control personnel; 4) strengthen the ; Navarrete, Sabana Iglesias, Tamboril, overall structure of the vector control program and affi liated Villa González and Santiago de los Caballeros, in Santiago de laboratories; and 5) implement timely biological, chemical and los Caballeros Province; and Santo Domingo, in the National physical vector control strategies in prioritized areas.[18] One District of the same name. These municipalities were selected example of a physical or environmental vector control strategy because epidemiologic surveillance found laboratory-confi rmed in the DR was the traditional national campaign, Cloro Untado, cases of dengue there. Table 1 presents the demographic and Tanque Tapado (chlorine applied, tanks covered), which epidemiologic characteristics of study sites. focused on HW-led community participatory action in vector control, and was widely disseminated by radio and television Inclusion criteria Individuals included were HWs who had announcements. This campaign aimed to teach community specifi c responsibilities or leadership roles in implementing members and school children the importance of using chlorine- dengue prevention and control during endemic or epidemic soaked cloths to coat the inside surfaces of water storage tanks, periods, had clinical or other expertise in dengue prevention and most importantly, covering all water storage containers, to and control, and recognized dengue burden in their local reduce potential mosquito breeding sites.[19] community or the DR.

To improve early dengue case Table 1: Demographic and epidemiologic characteristics of study sites by identification and reporting, a Population Dengue MIS-PAS established a passive Province Municipality cases, 2004b dengue surveillance system, Total Male Female located in the departments of La Vega Jarabacoa 56,931 29,075 27,856 43 epidemiology in designated Peravia Baní 107,926 52,897 55,029 105 health centers.[20] However, it Puerto Plata San Felipe 146,882 72,295 74,587 123 is not known how much reported Sabana Iglesias 12,232 6,289 5,943 12 surveillance data help promote Villa González 29,126 14,761 14,365 17 community leadership (e.g., Santiago Navarrete 42,210 21,204 21,006 16 juntas de vecinos— neighbor- Tamboril 49,810 24,863 24,947 14 hood councils—and nongov- Santiago de los Caballeros 622,101 302,619 319,482 319 ernmental organizations) or stimulate development of health National District Santo Domingo 913,540 430,698 482,842 273 interventions to disseminate Sources: aDominican Republic National Statistics Offi ce. VIII National Census of Population and Housing, 2002. Santo health information (e.g., reduce Domingo; Dominican Republic National Offi ce of Statistics; 2002. Available from: https://www.one.gob.do/Estadisticas/263/ poblacion-y-vivienda. bDominican Republic Ministry of Health Department of Epidemiology, Summary of Dengue Cases by standing water, identify disease Municipality and Province, 2004 (Unpublished).

MEDICC Review, October 2017, Vol 19, No 4 Peer Reviewed 27 Original Research

Exclusion criteria HWs were ex- Table 2: Participant characteristics cluded who showed no interest in No. Sex Profession Job title* Job category* Municipality Province dengue burden in their local com- Primary school 1 Female Educator Education Villa González Santiago munity or nation or did not want to teacher participate in this study. 2 Female Nurse Health promoter Public health Villa González Santiago 3 Female Nurse Health promoter Public health Villa González Santiago Researchers recruited a purpo- 4 Male Health inspector Entomology technician Entomology Navarrete Santiago sive sample of 19 HWs (10 men, 5 Male Nurse Epidemiology coordinator Public health Sabana Iglesias Santiago 9 women), up to 5 individuals in 6 Male Health inspector Epidemiology coordinator Public health Tamboril Santiago each province, based on refer- 7 Male Health inspector Entomology technician Entomology Santiago Santiago rals from administrative or clinical Entomology 8 Male Bioanalyst Laboratory technician Santiago Santiago experts at provincial or regional laboratory health centers. The sample in- Infectious disease Santo 9 Male Physician Clinical Santo Domingo cluded public health practitioners, specialist Domingo entomologists, educators, clini- 10 Male Physician Primary care physician Clinical Baní Peravia cians and an administrator. Table 11 Female Physician Health promoter Public health San Felipe Puerto Plata 2 displays study participants’ de- Santo 12 Female Physician Hospital assistant director Administration Santo Domingo mographic characteristics. Domingo Entomology service Santo 13 Male Entomologist Entomology Santo Domingo Data collection Using a socioeco- director Domingo logical framework to guide study Supervisor, Dengue Santo design, methods and analysis,[25] 14 Female Physician Prevention and Control Public health Santo Domingo Domingo we developed a semistructured Program interview guide of nine ques- 15 Female Health promoter Educator Public health Jarabacoa La Vega tions to facilitate discussion with High Biology and chemistry 16 Male Education Jarabacoa La Vega participants. Interview questions school teacher teacher were prepared in English, trans- 17 Female Nurse Health promoter Public health Jarabacoa La Vega lated into Spanish, and verifi ed by 18 Female Health promoter Educator Public health Jarabacoa La Vega a bilingual Dominican physician. Director, neighborhood 19 Male Health promoter Public health Jarabacoa La Vega Stem interview questions are dis- council played in Appendix 1. We defi ned *assigned based on researchers’ consensus perceived challenges according to the health belief model, a health behavior model that aims to Prior to beginning data collection, we used scientifi c literature explain health behavior based on individuals’ attitudes and be- and previous experiences in community health campaigns to liefs about factors that enable or hinder them from completing develop preliminary categories. After in-depth coding of interview specifi c actions.[26] Based on literature review and consultations transcripts by each researcher, we conferred to discuss coded with clinical specialists, question topics included 1) occupational nodes. Discrepancies in coding procedures were discussed in experiences in dengue prevention and control, 2) views on vector order to improve interobserver reliability. Using thematic analysis, control in communities, 3) perceived challenges for community we reviewed the fi nal coded nodes and reached conclusions members’ compliance with recommended practices, and 4) rec- on major emerging themes.[29,30] Card sorting (using cards ommendations to strengthen adherence to vector control strate- to organize topics into general categories) and peer debriefi ng gies at local and national levels. (seeking feedback or critique from colleagues not involved in the study and therefore unlikely to be biased) techniques were used Interviews were conducted in two steps. First, participants to enhance validity and reliability.[29,31] were asked to describe their educational and professional responsibilities in their community. Second, participants were Ethics The study was approved by the institutional review boards asked to respond to nine questions about their experiences and of the University of Florida (Gainesville, USA) and the Hospital perceptions of dengue prevention and control (Appendix 1). Regional Universitario José María Cabral y Báez (HRUJMCB) Interviews used probing techniques to encourage participants to (Santiago de los Caballeros, DR). Participation was voluntary and elaborate.[27] Interviews were conducted in Spanish in a quiet required written informed consent. area in the community or a closed offi ce in the local health clinic. The length of each interview depended on how extensively RESULTS participants elaborated on responses. Interviews were digitally Semistructured interviews lasted between 5 and 18 minutes. recorded, and after each, researchers prepared fi eld notes by Perceived challenges included 1) limited individual economic hand, including participant observations, informal dialogue with resources, 2) lack of individual awareness, education or action, participants, and a daily log of time schedules.[27] Data c ollection 3) limited cohesion among community members, and 4) limited was concluded when data saturation was reached, i.e., no new sustainability of government interventions. Figure 1 displays a themes emerged.[28] conceptual model based on salient themes.

Analysis Interview data and fi eld notes were transcribed and Limited individual economic resources Most participants deidentifi ed by the second author and verifi ed by the fi rst author. expressed that community members’ limited economic resources

28 Peer Reviewed MEDICC Review, October 2017, Vol 19, No. 4 Original Research

Figure 1: Conceptual model of health workers’ perceived challenges In addition to geographic distance from health institutions, to community members’ adherence to dengue prevention and participants described the social context and poor plumbing control measures infrastructure, where community members must constantly store water for household use. One male participant mentioned: • Limited cohesion among community members There are communities that do not have indoor plumbing and they must store water, or if they have household plumbing, then • Limited sustainability of water may not arrive for several days. . . . It is also a social government interventions problem, not having household plumbing, having to store water, Extrinsic and storing water without proper protection. (Participant 9, in- fectious disease specialist)

Adherence Lack of awareness, education or action by individuals Most Community to dengue Challenges participants reported that MISPAS representatives have conducted Member prevention and health seminars about dengue in local communities, recognizing control measures that community members should be aware of recommended strategies to prevent and control mosquitoes in and around their Intrinsic households. One female participant lauded these educational campaigns: • Limited individual economic We are more aware and these health seminars have provided resources knowledge for us to better protect ourselves from other diseas- • Individual lack of awareness, es. (Participant 18, educator) education or action In contrast, one participant stated that some community members who participated in these health seminars still believe that can directly infl uence adherence to recommended strategies mosquito-transmitted DENV infection is a myth, stating: for dengue prevention and control. One participant shared the There are people who ignore mosquito bites. They think that belief that community members may become disheartened when people are not infected [with dengue] by mosquitoes . . . [but] families must prioritize how their monthly income is used: the concept of mosquitoes [as vectors] has been proven. (Par- They [people] want to protect themselves, but they cannot be- ticipant 7, entomology technician) cause they are poor, . . . have three children, . . . husband works only a little. . . . [and] the small amount that he earns goes to Another participant went on to relate that community members supporting his family. There are not enough funds to spend on really do understand dengue as a health threat, but are apathetic. mosquito nets or other methods to protect themselves from He stated: mosquitoes. (Participant 5, epidemiology coordinator) Many people do not use prevention measures, . . . not because of ignorance, but rather laziness. We have all heard or seen Some participants described challenges community members news about dengue on TV, at church, at neighborhood councils with limited economic resources have in setting priorities among and during home visits. (Participant 5, epidemiology coordina- daily activities and expenses. One participant stated: tor) People have many other worries and often forget about local measures they should use for dengue [prevention and control]. Another participant described adherence to recommended . . . They have many other problems to resolve, and this is just measures immediately after a dengue case appears, but then one more. (Participant 9, infectious disease specialist) declining over time and eventually disappearing: People only become scared when they see a close [dengue] Another participant commented that his daily wages are case or someone dies, but after that, unfortunately, it [the health approximately RD$150–$200, equivalent to US$4–$5, which he message] goes in one ear and out the other. (Participant 9, in- needs to spend on food for his family. Thus, purchasing insect fectious disease specialist) repellent represents a substantial proportion of his household income (a situation that could be shared by many community Limited cohesion among community members Many members): participants said that the ideal situation is when community Repellent can now cost you . . . the equivalent of RD$100, members join forces to combat a disease threat. For example, which is almost half someone’s daily income. (Participant 16, one participant mentioned: biology and chemistry teacher) When a [dengue] case happens, we join as a community, as friends and neighbors, as the neighborhood council. We always Participants also shared that, although community members live in communities here, we meet, and so we are always to- are informed about dengue, geographic distance from health gether with one another and resolve any issues. (Participant 19, institutions can be an obstacle to health care service access. One director, neighborhood council) participant stated that delay in seeking health care services can infl uence poor health outcomes: However, one participant clearly stated that there are limitations in Sometimes, it is diffi cult for people who live in the communities such ideal cohesive action: to seek medical care. They leave everything for the last mo- This small town is also waiting for the state to resolve this [den- ment, and when they get to the hospital, they have advanced gue] problem for them. (Participant 9, infectious disease spe- disease. (Participant 7, entomology technician) cialist).

MEDICC Review, October 2017, Vol 19, No 4 Peer Reviewed 29 Original Research

Some participants mentioned that national dengue initiatives need Another male participant mentioned that a main limitation of the to come down to the community level, to enhance community dengue surveillance system is lack of clinical preparedness for preparedness. One participant emphasized the key element of differential diagnosis between dengue and dengue-like clinical collaborative action: presentations: This is not only a problem of the state. The community must [It’s not clear] whether [registered] dengue cases actually refl ect become [actively] involved. If the community does not become true dengue cases, since we receive reports of dengue that are [actively] involved, become aware and take collective mea- not true dengue cases, . . . so we have to be careful. We should sures, we will not accomplish anything. (Participant 9, infectious urge the Ministry of Health to recognize that the registry is not disease specialist) adequate. (Participant 9, infectious disease specialist)

Another participant stated that educating community members Recommendations Table 3 displays HWs’ identifi ed challenges has resulted in a shared sense of responsibility: and related recommendations for improving community members’ We try to advise people, to inform them and educate them that adherence to dengue prevention and control measures. this is not only a problem for the community [as a whole] but rather for everyone [as individuals]. (Participant 7, entomology DISCUSSION technician) This is the fi rst known study to describe how HWs perceive community members’ adherence to recommended local dengue Participants stated that mosquitoes can fl y from house to house, prevention and control measures in the DR. Although several which makes vector control a challenge. One participant said one years have passed since data collection, we decided to publish person’s adherence to recommended measures might be offset this article because the study objective remains relevant and by neighbor’s lack of adherence, using her own experience as an timely in light of emerging epidemics of four arboviral infections example: in Latin America and the Caribbean (DENV, chikungunya, Zika When I leave my house and I cover and place chlorine in the and Mayaro).[32–35] HWs carry out multiple responsibilities water tanks, yet perhaps sometimes my neighbors do not [use in vector control in their respective municipalities in the fi ve prevention measures]. In my house, there are no mosquitoes, provinces, and their voices are essential to inform stakeholders but beside my house, there are mosquitoes. It [dengue] can- about observed gaps in delivery of health education programs not be controlled because the mosquito fl ies from one house to and health care services in their communities. Given current and another. (Participant 18, educator) future threats of arboviral disease transmission in Latin America and the Caribbean, we believe that these study fi ndings can be Another participant echoed this challenge: instrumental in better understanding challenges to strengthened You do not accomplish anything by individually using prevention community participatory action in vector control in the DR. measures if the entire community does not perform these tasks. (Participant 9, infectious disease physician) Dengue became a mandatory reportable disease in the DR in 1995, and MISPAS’s surveillance system was reestablished in Limited sustainability of government interventions Many 1997, enforcing active case fi nding, and revised in 2000, facilitating participants reported that MISPAS does not provide a suffi cient community-based participation for dengue control, such as the workforce to educate and empower community members about Cloro Untado, Tanque Tapado initiative.[35] PAHO leadership adherence to recommended dengue prevention measures or adopted Resolution CD43.R4 in 2001, emphasizing dengue’s economic support to obtain the necessary resources for local increasing burden and health threat in the Americas Region. distribution. One male participant stated: [18] Over time, DR national priorities for dengue prevention and Right now, I would like to work [as a health inspector], but I do control have evolved, including a proposal for additional training of not have transportation . . . [so] sometimes I have to walk from HWs at municipal and provincial levels.[18] The leadership role of home. (Participant 6, epidemiology coordinator) HWs in local communities, however, has been undervalued as an essential component for community education and empowerment Another participant mentioned that federal support has transi- for adherence to recommended dengue preventive measures, tioned in priority from active surveillance to health promotion, both in the DR and globally.[36,37] stating: Unfortunately, there is no one in this community who worries In this study, participants described intrinsic challenges they about resource allocation for active [dengue] surveillance. In considered obstacles to community members’ adherence to the past, they conducted surveillance in the communities. Now, recommended measures. They mentioned that community they visit each house but their messages focus on community members appeared to prioritize other work or domestic prevention. (Participant 5, epidemiology coordinator) responsibilities over vector control. Since many preventive measures are cost-free, such as removing standing water in This description of lack of sustainable dengue programs at the and around the household, two factors will continue to challenge community level comes from anotherparticipant: how HWs educate and empower community members in I worry a lot, since local levels, provinces and local community understanding dengue’s severity. First, daily life in the DR involves health clinics have still not developed or implemented a local high temperatures and humidity, inconsistent electricity services, plan for dengue prevention and control. They are not energized and need for water storage in large plastic or metal tanks.[17] to act. . . To avoid [future] cases, we need to create a permanent Thus, living daily with mosquitoes becomes the norm and can mechanism for [dengue] prevention and control. (Participant 13, create a false sense of invincibility to dengue or other mosquito- entomology service director) transmitted diseases.[38] Second, how community members

30 Peer Reviewed MEDICC Review, October 2017, Vol 19, No. 4 Original Research

Table 3: Health workers’ recommendations for improving community adherence to dengue prevention and control measures Perceived challenge Recommendation Illustrative quote

“It is not only about publishing news or distributing pamphlets to Increase access to (and number of) educational people. You have to make sure that people learn. You should be programs for community members, adapting a there, sit next to them, explain, and show them cases.” (Partici- “train the trainer” approach pant 10, primary care physician)

“If it is a poor neighborhood with unsanitary conditions . . . we Implement sustainable educational programs for can say that the people live in extreme poverty and cannot take community members that emphasize key health care of themselves well . . . they leave everything for the last facts and motivate their adherence to prevention moment . . . sometimes there is nothing . . . and many times Limited individual measures when there is no solution, it is too late to take care of the patient.” economic resources (Participant 7, entomology technician) “If people have [knowledge about dengue], but do not have the Facilitate widespread distribution of chlorine for economic resources, they will not be able to obtain the means prevention measures, as a local impact strategy [for prevention measures] to protect themselves.” (Participant 5, epidemiology coordinator)

Offer community members other prevention “For example, sleeping covered up with clothing [and sheets], not means at little or no cost letting mosquitoes bite you.” (Participant 8, laboratory technician)

“I think that community health educators are the most important sources of information, constant information. Sometimes, be- cause they work right in the community, they can bring the health Emphasize HWs’ essential roles in community message directly. They do not just preach what to do, but they education and follow-up for dengue prevention serve as an example. This is not the same as a health worker and control or educator who works in a community or neighborhood and presents a health seminar about a prevention measure but does nothing.” (Participant 9, infectious disease specialist) Lack of individual aware- Highlight use of innovative health promotion “It is a [TV or radio] commercial that is directed to the entire ness, education or action strategies to disseminate health messages via population, where everyone can understand the message and TV, radio and social media can help to prevent dengue.” (Participant 11, health promoter) “Home measures. . . if we complete all the domestic tasks [recommended for dengue prevention] and each person is Promote individuals’ moral responsibility as com- responsible for his or her own house, then I believe that [through] munity members to educate by example all these things that we are talking about, from the collective point of view, we can eliminate mosquitoes and dengue.” (Participant 9, infectious disease specialist) “We shouldn’t wait for someone to become sick before we teach people about dengue. We have to take the initiative and Empower community members to understand teach our community how to prevent it. We should all take into their infl uence through sustainable collective account the fundamental importance of public health education. action . . ., Dominican physicians should take leadership on this issue because it affects the whole society.” (Participant 10, primary Limited cohesion among care physician) community members “Perhaps to involve the churches because people hear so much and the voice of the churches is followed. . . if preaching the [gospel] word also incorporates some [dengue] prevention Actively seek and incorporate other community measures, I think that would help people in the congregation . . organizations (e.g., schools, churches) to widely . that at least one or two family members will attend the church disseminate health messages service and hear the [health] message, and perhaps can promote this health information and collectively impact the community.” (Participant 9, infectious disease specialist)

(Continued overleaf)

MEDICC Review, October 2017, Vol 19, No 4 Peer Reviewed 31 Original Research

“These people [health promoters] dedicate their time to meet with youth groups, organizations for mothers, other associations. . . . Expand coverage of dengue prevention They dedicate time to health education and promotion of preven- programs (e.g., youth groups, organizations for tion strategies, teaching about dengue, distributing brochures, mothers, other associations) and sharing videos and movies. We have observed that this initiative has provided positive results.” (Participant 14, supervi- sor, Dengue Prevention and Control Program) “I believe that there’s probably a divide among primary care, noti- Identify limitations in local and national surveil- fi cation and surveillance that has to be overcome for the program lance and diagnostic systems to serve as a to proceed adequately with trustworthy statistics.” (Participant 9, framework for future action Limited sustainability of infectious disease specialist) government interventions “This is a very poor province. We do not have suffi cient health personnel for patient followup, so we try to organize things and Strengthen local level support by increasing the prevent [dengue transmission] because we face a big challenge number of health workers in clinical care.” (Participant 14, supervisor, Dengue Prevention and Control Program) “Sometimes I have to use my personal funds to pay for transpor- Provide incentives to health workers through tation by motorcycle because I believe in public health and try economic resources and continuing education to help. We need to have more support so that we can work [as opportunities health promoters] in these communities.” (Participant 6, epidemi- ology coordinator) perceive disease risk is intimately linked with the perceived benefi ts expand health education and strengthen dengue surveillance of investing energy and time in consistent use of recommended programs. vector control practices at home.[39] Since the clinical spectrum of dengue infection runs from nonsevere (e.g., asymptomatic, As in other Latin American and Caribbean nations, the DR’s cold-like symptoms) to severe (e.g., hemorrhage),[40] people’s national health system has undergone reforms aimed at understanding of the disease can infl uence health-seeking strengthening health care service delivery to all DR citizens; the behaviors.[38,39] Moreover, without a solid and comprehensive process was initiated in 2002.[43] In this transition, they have faced understanding of dengue severity and other disease threats at the limitations in economic and health sectors, including 1) fl uctuating community level, erroneous risk awareness and poor preventive economic situations amidst a national economic crisis in 2003 practices will prevail, impeding advances in national priorities for and an international economic crisis in 2008; 2) epidemiologic dengue prevention and control. transition with emergence of noncommunicable diseases as a major population health problem; and 3) continued failure to meet Participants also mentioned extrinsic challenges that directly targets for basic health indicators (e.g., life expectancy and infant infl uence the strength and impact of local leadership in the mortality) and health equity.[43] In national and regional dialogue DR’s most vulnerable communities. Despite the existence to strengthen dengue control strategies, health authorities have of nongovernmental organizations with social missions, dual proposed steps to enhance capacity building and quality control in challenges exist in dengue prevention and control. First, MISPAS six components: clinical diagnosis and management, entomology, has allocated economic resources for the integrated rollout of environmental health, epidemiology, health promotion and health interventions during dengue epidemics, at the expense of laboratory evaluation.[18] Activities proposed by PAHO related local and national infrastructure for public health preparedness. A to health promotion include building intersectoral collaborations prompt public health response to epidemics, without appropriate among agencies or organizations, increasing capacity building for preparedness, can imperil the ability to withstand future emerging health care workers, and establishing research capacity through disease epidemics.[41] Second, with limited followup, training monitoring and evaluation processes; but strategies to enhance opportunities, and professional incentives in local leadership, incentives, expertise and leadership development among HWs HWs may be apathetic and perceive their stakeholder role in have tended to be overlooked.[18] decision-making as unimportant.[42] In turn, this low morale may lead HWs to pursue employment outside of the local community, Dengue epidemics have occurred every three to fi ve years in in national or international agencies that can provide fi nancial many Latin American and Caribbean nations,[44] and public stability and career advancement. health preparedness for dengue prevention and control strategies remains key for reduced disease transmission (and consequently Participants described a panorama of inadequate sustainable morbidity and mortality rates). With increased attention to community participation in dengue control action, driven by four health inequities related to social determinants of health across primary intrinsic and extrinsic factors. At the time of this study, the Americas Region,[45] national dengue initiatives should there were no regulations in place to empower communities to highlight the One Health approach, where transdisciplinary develop the necessary leadership to conduct health initiatives. collaborations can focus on interactions between human, animal An understanding of the infl uence of these intrinsic and extrinsic and environmental health.[46] factors can inform DR health authorities’ discussions of steps to increase community participation in regular and sustainable For this study, semistructured interviews were ideal for eliciting dengue initiatives, including increased political commitment to HWs perceived challenges for adherence to dengue prevention

32 Peer Reviewed MEDICC Review, October 2017, Vol 19, No. 4 Original Research and control measures in diverse rural and urban DR communities. health collaborations for vector control and prevention will be As future steps, however, focus group discussions may provide essential to develop sustainable dengue prevention and control further insight into the complex and interconnected factors that initiatives in low-resource settings such as the DR. infl uence adherence to recommended vector control practices. In turn, these insights may lead to new local and national policies ACKNOWLEDGMENTS in vector control practices that integrate, encourage and build on The authors thank study participants for sharing their experiences enhanced moral responsibility and solidarity among community and views of dengue prevention and control in the DR. We also members. acknowledge peer debriefi ng provided by academic professors and clinicians at the Universidad Católica Tecnológica del This study has some limitations. First, participants were selected Cibao School of Medicine and the HRUJMCB Department of from municipalities in fi ve DR provinces located in the north- Epidemiology during data analysis. and south-central geographic regions and thus fi ndings might not be generalizable across the DR. However, since dengue is endemic throughout the DR, variation within or between sites, and APPENDIX 1: INTERVIEW QUESTIONS differences from the eastern and western provinces not included, may not be meaningful. Second, data collection was completed I. Occupational experiences in dengue prevention and control one year after a major dengue outbreak, suggesting increased 1. How would you describe your daily work routine regarding awareness and community mobilization at the time, due to a dengue prevention and control in the community? national call to action. However, since HWs are familiar with their II. Views on dengue prevention and control in communities daily practice in dengue prevention and control, recall bias may 2. How would you describe the general level of concern in the have been minimized. Third, only two researchers participated in community about dengue as a health problem? data collection and analysis, so we understand that other data 3. How do citizens use protection methods against mosquitoes in interpretations are possible.[47] However, peer debriefi ng with the community? a panel of experts provided indispensable feedback on the four 4. Describe an example of when and why citizens used protection emerging themes for this study. The addition of a rank order of methods against mosquitoes in the community. these four themes, based on perceived individual contribution to dengue prevention and control, might strengthen future dengue III. Perceived challenges related to reduced citizens’ adherence to recommended prevention measures action at the community and national levels. 5. Describe an example of when and why citizens did not use protection methods against mosquitoes in the community. CONCLUSIONS 6. Why do you think that some people protect themselves against HWs perceived challenges for dengue prevention and control in mosquitoes while others do not? the DR refl ect the complex interplay of economic, environmental, 7. Do you think that someone who has had dengue is more likely health, political and social factors that can directly or indirectly to use protection against mosquitoes than someone who has not? infl uence individual and community adherence to recommended Why? 8. Do you think that someone who knows more people who have prevention measures. By better understanding how these intrinsic had dengue is more likely to use protection against mosquitoes and extrinsic factors hinder adherence, health system authorities than someone who knows fewer or no people who have had can revise national policies to strengthen community participatory dengue? Why? action in vector control, empower leadership potential among HWs 9. What do you believe can be done to improve adherence to vec- and community members, and provide an appropriate systemic tor control practices in your community and in the DR? approach to prevention of disease transmission. Transdisciplinary

REFERENCES 1. World Health Organization. Global strategy for 8. Lounibos LP. Invasions by insect vec- neva: World Health Organization; 2007 Jan. dengue prevention and control, 2012−2020. Ge- tors of human disease. Annu Rev Entomol. 34 p. n eva: World Health Organization; 2012 Aug. 43 p. 2002;47:233−66. 16. The World Bank [Internet]. Washington, D.C.: 2. Bhatt S, Gething PW, Brady OJ, Messina JP, 9. Gubler DJ. Dengue, urbanization and globaliza- The World Bank; c2017. Dominican Republic; Farlow AW, Moyes CL, et al. The global dis- tion: the unholy trinity of the 21st century. Trop 2016 [cited 2017 Mar 5]. Available from: http:// tribution and burden of dengue. Nature. 2013 Med Health. 2011 Dec;39(4 Suppl):3−11. data.worldbank.org/country/dominican-republic Apr;496(7446):504−7. 10. Kyle JL, Harris E. Global spread and persistence 17. Whiteford LM. The ethnoecology of dengue fe- 3. Brady OJ, Gething PW, Bhatt S, Messina JP, of dengue. Annu Rev Microbiol. 2008 Oct ver. Med Anthropol Q. 1997 Jun;11(2):202−23. Brownstein JS, Hoen AG, et al. Refi ning the 13;62:71−92. 18. Pan American Health Organization; Ministry of global spatial limits of dengue virus transmission 11. Spiegel J, Bennett S, Hattersley L, Hayden Public Health (DO). Informe fi nal: estrategia na- by evidence-based consensus. PLoS Negl Trop MH, Kittayapong P, Nalim S, et al. Barriers and cional de gestión integrada de prevención y con- Dis. 2012 Aug 7;6(8):e1760. bridges to prevention and control of dengue: trol del dengue, República Dominicana [Internet]. 4. Diamond MS, Harris E, Ennis FA. Defeating den- the need for a social-ecological approach. Eco Santo Domingo (DO): Ministry of Public Health gue: a challenge for a vaccine. Nat Med. 2012 Health. 2005 Dec;2(4):273−90. (DO); 2004 Nov [cited 2017 Apr 1]. Available from: Nov;18(11):1622−3. 12. Parks W, Lloyd L. Planning social mobilization http://www.paho.org/dor/index.php?option=com 5. Morrison AC, Zielinski-Gutierrez E, Scott TW, and communication for dengue fever prevention _docman&view=download&category_slug= Rosenberg R. Defi ning challenges and proposing and control: a step-by-step guide. Geneva: World prevencion-y-control-de-enfermedades-1&alias solutions for control of the virus vector Aedes ae- Health Organization; 2004. 138 p. =46-estrategia-nacional-de-gestion-integrada gypti. PLoS Med. 2008 Mar;5(3):e68. 13. Guzmán MG. Thirty years after the Cuban den- -de-prevencion-y-control-del-dengue-2004&Item 6. Tapia-Conyer R, Betancourt-Cravioto M, Mé- gue hemorrhagic epidemic of 1981. MEDICC id=273. Spanish. ndez-Galván J. Dengue: an escalating public Rev. 2012 Apr;14(2):46−51. 19. Ministry of Public Health (DO). Dirección Gen- health problem in Latin America. Paediatr Int 14. Drexler A, editor. Handbook for integrated vector eral de Epidemiología. Alerta epidemiológica Child Health. 2012 May;32 Suppl 1:14−7. management. Geneva: World Health Organiza- No. 2 [Internet]. Santo Domingo (DO): Ministry 7. Gratz NG, Steffen R, Cocksedge W. Why tion; 2012 Jun. 67 p. of Public Health (DO); 2013 [cited 2017 Mar 5]. aircraft disinsection? Bull World Health Org. 15. Lehmann U, Sanders D. Community health Available from: http://digepisalud.gob.do/docs/ 2000;78(8):995−1004. workers: what do we know about them? Ge- Vigilancia%20Epidemiologica/Alertas%20epi

MEDICC Review, October 2017, Vol 19, No 4 Peer Reviewed 33 Original Research

demiologica/Dengue/Nacional/Alerta%20Den aprendidas en los primeros seis meses. Rev 2010 [cited 2017 Jan 21]. 19 p. Available from: gue%20agosto%202013.pdf. Spanish. Panam Salud Pública. 2014 Nov;36(5):336–41. http://www.who.int/healthsystems/topics/finan 20. Ministry of Public Health (DO). Normas naciona- Spanish. cing/healthreport/DRNo10FINALV2.pdf les para la vigilancia epidemiológica de enfer- 33. Fauci AS, Morens DM. Zika virus in the Ameri- 44. Gómez-Dantés H, Willoquet JR. Dengue in the medades transmisibles y otros eventos. Serie cas – yet another arbovirus threat. N Engl J Med. Americas: challenges for prevention and control. de Normas Nacionales No. 11. Santo Domingo 2016 Feb 18;374(7):601–4. Cad Saúde Pública. 2009;25 Suppl 1:S19–31. (DO): Ministry of Public Health (DO); 1998. 460 34. Muñoz M, Navarro JC. Virus mayaro: un arbovi- 45. Pan American He alth Organization; World Health p. Spanish. rus reemergente en Venezuela y Latinoamérica. Organization. Últimos adelantos técnicos en la 21. Chapman HJ. Holistic approach in preventing Biomédica. 2012;32(2):286–302. Spanish. prevención y control del dengue en la Región de spread of infectious diseases: a Cuban example. 35. Ministry of Public Health (DO). Informe de situ- las Américas, 2014 [Internet]. Washington, D.C.: Perspect Public Health. 2016 Jul 1;136(4):189. ación de salud de la República Dominicana, World Health Organization; 2014 [cited 2017 22. Ministry of Health Buenos Aires; United Na- 2003 [Internet]. Santo Domingo (DO): Ministry Apr 9]. Available from: http://www2.paho.org/hq/ tions Children’s Fund. Participación social en of Public Health (DO); 2006 [cited 2017 Apr 1]. index.php?option=com_docman&task=doc_view la prevención, del dengue, zika y chikungunya: Available from: http://digepisalud.gob.do/docs/ &Itemid=270&gid=27234&lang=es. Spanish. adaptación de la guía para el promotor. 3rd ed Analisis%20de%20Situacion/Informe%20de%20 46. World Health Organization. One Health [Internet]. [Internet]. New York: United Nations Children’s Situacion%20de%20Salud/Informe%20de%20 Geneva: World Health Organization; 2017 Sept Fund; 2016 [cited 2017 Mar 25]. Available from: Salud%202003.pdf. Spanish. [cited 2017 Oct 5]. Available from: http://www.who https://www.unicef.org/argentina/spanish/salud 36. Georges AS, Mehra V, Scott K, Sriram V. Com- .int/features/qa/one-health/en/ _MANUAL_DENGUE_A5-Version2016_web munity participation in health systems research: 47. Miles MB, Huberman AM, Saldaña J. Qualitative .pdf. Spanish. a systematic review assessing the state of re- data analysis: a methods sourcebook. 3rd ed. 23. Wichmann O, Vannice K, Asturias EJ, de Al- search, the nature of interventions involved and Thousand Oaks (US): Sage Publications, Inc.; buquerque Luna EJ, Longini I, López AL, et al. the features of engagement with communities. 2013 Apr 18. 408 p. Live-attenuated tetravalent dengue vaccines: the PLoS One. 2015 Oct 23;10(10):e0141091. needs and challenges of post-licensure evalua- 37. Atkinson JA, Vallely A, Fitzgerald L, Whittaker tion of vaccine safety and effectiveness. Vaccine. M, Tanner M. The architecture and effect of par- THE AUTHORS 2017 Oct 9;35(42):5535–42. ticipation: a systematic review of community par- Bienvenido A. Veras-Estévez, physician spe- 24. Creswell JW, Poth CN. Qualitative inquiry and re- ticipation for communicable disease control and cializing in epidemiology, with a master’s degree search design: choosing among fi ve approaches. elimination. Implications for malaria elimination. in public health. Team leader, Department of 4th ed. Thousand Oaks (US): Sage Publications, Malar J. 2011 Aug 4;10:225. Research, Universidad Católica Tecnológica del Inc.; 2017 Jan 25. 488 p. 38. Wong LP, AbuBakar S. Health beliefs and practic- Cibao Faculty of Health Sciences, La Vega, Do- 25. McLeroy KR, Bibeau D, Steckler A, Glanz K. es related to dengue fever: a focus group study. minican Republic. Research manager, Depart- An ecological perspective on health promo- PLoS Negl Trop Dis. 2013 Jul 11;7(7):e2310. tion programs. Health Educ Q. 1988 Win- 39. Suárez R, González C, Carrasquilla G, Quintero ment of Epidemiology and Statistics, Hospital ter;15(4):351–77. J. An ecosystem perspective in the socio-cultural Regional Universitario José María Cabral y Báez, 26. Skinner CS, Tiro J, Champion VL. The health evaluation of dengue in two Colombian towns. Santiago de los Caballeros, Dominican Republic. belief model. In: Glanz K, Rimer BK, Viswanath Cad Saúde Pública. 2009;25 Suppl 1:S104–14. K, editors. Health behavior: theory, research, and 40. World Health Organization. Dengue: guidelines Helena J. Chapman (Corresponding author: practice. 5th ed. San Francisco (US): Jossey- for diagnosis, treatment, prevention and control: hchapman@ufl .edu), physician specializing in Bass; 2015. p. 75–94. new edition. Geneva: World Health Organization; public health, with a master’s degree in public 27. Bernard HR. Research methods in anthropology: 2009. 147 p. qualitative and quantitative approaches. 5th ed. 41. Institute of Medicine, Board on Global Health, health (epidemiology) and doctorate in public Lanham (US): AltaMira Press; 2011 May 16. 680 p. Committee on Emerging Microbial Threats to health (One Health). Department of Environ- 28. Charmaz K. Constructing grounded theory. 2nd Health in the 21st Century. Microbial threats to mental and Global Health, University of Florida ed. Los Angeles: Sage Publications Inc.; 2014 health: emergence, detection, and response. 1st College of Public Health and Health Professions Apr 9. 416 p. ed. Smolinski MS, Hamburg MA, Lederberg J, (UF PHHP), Gainesville, Florida, USA. This re- 29. Ryan GW, Bernard HR. Techniques to identify editors. Washington, D.C.: National Academies search was conducted while the author was a themes. Field Methods. 2003 Feb 1;15(1):85–109. Press; 2003 Aug 25. 398 p. graduate student in the Department of Epidemi- 30. Sandelowski M, Barroso J. Classifying the 42. Willis-Shattuck M, Bidwell P, Thomas S, Wyness fi ndings in qualitative studies. Qual Health Res. L, Blaauw D, Ditlopo P. Motivation and retention ology at the UF PHHP. 2003 Sep;13(7):905–23. of health workers in developing countries: a sys- 31. Lincoln YS, Guba EG. Naturalistic inquiry. 1st tematic review. BMC Health Serv Res. 2008 Dec ed. Newbury Park (US): Sage Publications; 1985 4;8:247. Submitted: April 21, 2017 Apr. 416 p. 43. Rathe M. Dominican Republic: Can universal Approved for publication: September 23, 2017 32. Pimentel R, Skewes-Ramm R, Moya J. Chikun- coverage be achieved? Background Paper, 10 Disclosures: None gunya en la República Dominicana: lecciones [Internet]. Geneva: World Health Organization;

34 Peer Reviewed MEDICC Review, October 2017, Vol 19, No. 4