Use of the Health Belief Model for the Assessment of Public Knowledge and Household Preventive Practices in Dhaka, Bangladesh, a Dengue-Endemic City

Journal of Xi'an University of Architecture & Technology ISSN No : 1006-7930

USE OF THE HEALTH BELIEF MODEL FOR THE ASSESSMENT OF PUBLIC KNOWLEDGE AND HOUSEHOLD PREVENTIVE PRACTICES IN DHAKA, BANGLADESH, A DENGUE-ENDEMIC CITY

Tanvir Abir, PhD (1) Associate Professor, College of Business Administration, International University of Business Agriculture and Technology, Dhaka -1230, Bangladesh.

Professor Nazmul Ahsan Kalimullah, PhD (2) Vice-Chancellor, Begum Rokeya University, Rangpur. Rangpur- 5404, Bangladesh.

Taha Husain (3) Lecturer, Department of Gender and Development Studies, Begum Rokeya University, Rangpur. Rangpur- 5404, Bangladesh.

Dewan Muhammad Nur -A Yazdani (4) (* Corresponding Author) Assistant Professor, College of Business Administration - CBA International University of Business Agriculture and Technology—IUBAT University, Dhaka -1230, Bangladesh.

Abu Taher Md Sanaullah Nury (5) Deputy Director (MIS-Dev), Management Information System Unit, Directorate General of Family Planning, Ministry of Health and Family Welfare, Bangladesh.

Kazi Fayzus Salahin (6) Senior Executive, Research, SRGB Research & Consulting Limited.

Kingsley Agho, PhD (7) Senior Lecturer, School of Science and Health, Western Sydney University, Australia.

Abstract

Prevention is the most efficient way to get rid of any pandemic; it is no exception to Dengue Fever (DF). Assessment of public knowledge and health credentials is critical for designing strategies for any disease prevention. This study aims to explore awareness, health perceptions and preventative measures of Dengue Fever (DF) in various social and economic segments in Dhaka, Bangladesh. A cross-sectional questionnaire survey of 242 respondents attending the dengue awareness events was conducted. The information on socio- demographic characteristics of the participants and their knowledge, attitude and practice on dengue fever was collected. The findings of this study revealed that there is no doubt among the 76.4% (n=185) participants that Ades Mosquito is mainly responsible for Dengue. The majority 97.5% (n=236) of the respondent believe that dengue is becoming a serious health

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problem in this region. The causes of dengue in this region are water mismanagement (39.7%), water clogged (33.9%), poor drainage system (18.2 %). This study found different responses associated with the characteristic of insect and 99.2% of the respondents have not enough knowledge about dengue and Aedes mosquito. Also, the respondents have not shown enough attitude and awareness (96.3%) to dengue, and most of the respondents have moderate level (72.3%) prevention practices on dengue fever (DF). Finally, this study concluded that the Health Belief Model does not work in Bangladesh.

Keywords: Dengue, Public Knowledge, Preventive Practice, Bangladesh, Hemargic Fever, Public Awareness Introduction Dengue is a mosquito-borne1 disease which is caused by Aedes aegypti's2 bite (Kumar and R. Kumar, 2013). While dengue is an ancient disease, Chinese medical records incorporated the first indication of the disease. Accordingly, the disease was first identified in 992 AD in China. However, some researchers claim the illness mentioned in China's Xin monarchy documents (265-420 BC) was described as a poisonous water disease' caused by flying insects (Bostan et al., 2016). Among the places where dengue mosquitoes and viruses are found in South Asia, the Caribbean, the Indian subcontinent, South and Central America, Africa, the Pacific Islands and Australia. In the Philippines and Thailand, around 1950s dengue was first diagnosed as an outbreak. The outbreak of Dengue Fever (DF) had only been seen in nine countries before 1970. But now, in more than 100 countries3, dengue fever (DF) is being seen. The disease has widespread in the last 25 years of the 20th century (Prasittisuk et al., 1998; Kuno, 2009). In South America and Asia Dengue is more prevalent than anywhere else in the world. In 2019 alone, 1.6 million people were infected with the mosquito-transmitted disease in South America. The prevalence of dengue is extreme in most countries in Southeast Asia, countries such as the Philippines, Sri Lanka, Malaysia, Cambodia, Laos, Vietnam and Thailand are work victim of dengue epidemic. As the amount of Aedes mosquito permeates, the number of patients suffering from dengue is growing. Nearly 40% of the world's total population is at risk for dengue (Villar et al., 2015). The disease has grown as much as 30 times in the last 50 years. As a result of this rapid expansion, this disease affects about 100 million people in the world's tropical areas. Because of this disease, 20000 people die in a year alone and about 25 people per minute (WHO, 2012a). Other than those urbanizations and polluted climates, the climate change such as temperature rise, constant rainfall and travel from one continent to another continent is increasing the prevalence of dengue fever (DF) (Karim, Munshi, Anwar, and Alam, 2012). Rachel Lowe, an assistant professor at the London School of Medicine and Hygiene, says the warmer climate has created a favorable environment for dengue outbreaks through virus reproduction and mosquito breeding (Prothom-Alo, August 9, 2019). Thus, the dengue fever (DF) and dengue mosquito have taken a dire shape for everyone. About six billion people will be at risk of getting dengue fever (DF) by 2080 (Messina et al., 2019).

1 An Arboviral infection 2 A type of vector mosquito or insect 3 Every year, 1 million dengue cases are diagnosed in 125 countries, and about 10000 deaths are reported (Messina et al., 2019).

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Bangladesh as a subtropical country has nearly all the specific weather conditions that enable the Aedes aegypti and Aedes albopictus to thrive. Dengue is affecting more and more people in the country because of this urbanization, climate change and demographic factors (Chowdhury, 2019; Lam, 1993). This epidemic of the disease has been in the country for the last two decades (IEDCR, 2019). In previous years, Dengue area included only several of the country's divisional cities but recently patients with dengue were found in remote areas of the country4 as well. The number of people affected doubled in 2019 relative to the statistic from 2018 and in the same year 107 deaths attributed to dengue (The Daily Star, 2019; IEDCR, 2019). The prevalence of dengue fever (DF) in Bangladesh is generally high due to the monsoon season from July through October (WHO, 2019). During this time the drain, floral tub, barrel and plastic containers filled with stagnant water, which is conducive for mosquitoes to lay the eggs on it. The Disease Control Division of the Department of Health, the Ministry of Local Government, the City Corporation and the Pesticides Department of the Municipality of Bangladesh work in mosquito control during this time (Islam, 2019). Yet failure to kill mosquitoes and lack of effective anti-mosquito medicines in cities shows that Bangladesh is far behind in dengue disease control (Morol, 2019). In such a situation this study aims to examine the triggers and solutions of Bangladesh's dengue epidemic. Literature review The studies that have been done on Dengue have highlighted the causes of Dengue prevalence, the effects of Dengue and the ways to prevent dengue. In Australia's case, Russell et al., (2009) studied the possible impact of climate change on dengue spread in Australia. According to them, dengue outbreaks are currently limited to Queensland, Australia, but with rising temperatures, Aedes mosquitoes are likely to rise significantly in some Australian regions. Important factors for the future spread of dengue and vectors are increased reproduction of dengue mosquitoes in Asian and Pacific countries, and transmission of viruses from Asian and Pacific countries. In his study, Gubler (2011) contended that half of the world's population lives in areas at risk of dengue. During the past 40 years, the dengue epidemic has increased dramatically. Several factors are responsible for this increased outbreak but the significant ones are urbanization, globalization and lack of mosquito control. The cities have modern airports through which millions of travellers fly each year, but the mosquito control system is not successful. As a result, the virus spreads from one area to another and the dengue takes on the appearance of an epidemic. Wu et al., (2009) explain dengue incidence in Taiwan as a result of high temperatures and urbanization. Their work investigates how dengue mosquitoes can be affected by temperature and other environmental factors. They presented dengue mosquito spatial patterns in 356 cities using the Geographic Information System (GIS) and found that the dengue risk increases when urbanization is high and the average monthly temperature is greater than 18

4 According to data from DGHS (2019), 87,953 people were infected with Dengue in the country from 1 January to 30 September 2019, of whom 57,166 were in the Dhaka Division, 6740 in the Chittagong Division, 9009 in the Khulna Division, 5704 in the Barisal Division, 4724 in the Rajshahi Division, 953 in the Sylhet Division and 2143 in the Mymensingh Division.

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degrees Celsius. The monthly average 1-degree Celsius rise in temperature increases the risk of dengue infection by 1.95 times. Harving and Rönsholt (2007) reflect on the family-level economic impact of dengue hemorrhagic fever. For their study, they included 155 children aged 0-15 in South Vietnam. Parents or guardians of children who were hospitalized for 10 weeks were interviewed to determine the cost of care for their child. The study found that the average (direct and indirect) family expenditure on treating a child in South Vietnam is around $61. Hospitalization costs are reduced parental income which creates an economic burden on a family. Clark, Mammen, Nisalak, Puthimethee, and Endy (2005) emphasized the economic impact of dengue hemorrhagic fever on Thailand's family level. This study shows that the direct hospitalization expense per hospitalized patient unit, the indirect cost due to productivity loss, is about $61, which is higher than the average monthly income in Thailand. All studies show the economic effect of dengue hemorrhagic fever on the family level. These two studies only discussed the economic impact of dengue, but there is a lack of discussion on the social impact that dengue has. Recent reports from Ooi, Goh, and Gubler, (2006) indicate that dengue infections in Singapore have risen over the last decade. The explanation for such an epidemic is the lack of safe and effective dengue virus tetravalent vaccine and the lack of sustainable prevention. Researchers stressed the need to increase the cost of successful vector control programs, reduce Aedes aegypti species and restrict the importation of dengue virus into Singapore to avoid dengue. Researchers even said, in Singapore, prevention of dengue infection is not feasible without eliminating dengue in neighboring countries. Therefore, regional efforts to control dengue need to be made. Banu et al., (2012) shows the impact of climate change in Bangladesh with the prevalence of dengue epidemic. The changing climate such as temperature and humidity affects vectors and viruses which result in vector-borne diseases becoming severe and spreading. Authors predicted that the temperature would rise to 3.3 degrees Celsius by the end of this century and thousands of dengue cases would increase due to no adaptation of the socio-economic conditions. Raheel et al., (2010) researched dengue in the Indian subcontinent. Their research aims at examining the reported cases of dengue hemorrhagic fever and defining the triggers for the dengue fever (DF) outbreak. Their study results show that climate change, rainfall, temperature and humidity are contributing to outbreaks of dengue. Mosquito-borne diseases like dengue have been growing in the Indian subcontinent for the last few years. Salje et al., (2019) conducted the study on dengue in Bangladesh, which has been transformed into a common disease and burden. They selected 5866 individuals who had been tested for IgG serum and in terms of collecting data. They found that 40% of the people are infected nationally and 2.4 million people are infected annually. As a result of their research, dengue can be prevented in Bangladesh by increasing vector surveillance and understanding how dengue is spreading. It is evident from the literature review above that researchers have researched the causes of dengue, the consequences of dengue and ways of avoiding dengue. But there is no research work conducted in Bangladesh portraying the field causes and remedies of dengue fever (DF) in Bangladesh. Thus, there remains a research lacuna in this particular field of study. This study aims to meet that research lacuna.

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Methodology Study duration and location A cross-sectional study survey was conducted in June 2019 at Dhaka city (DNCC5 and DSCC6), Bangladesh. The facilities between these two locations are similar to one another with a community formation and residential buildings. Sampling procedure and survey A purposive sampling method was used to select a sample of participants to represent the general community of DNCC and DSCC. By using a sample size calculator (G power calculator), it was estimated that a minimum of 242 households should be sampled to gain a 90% confidence level, with a maximum allowable difference of 0.05 in detecting the KAP proportions in the population. A dengue awareness event was held at both localities separately and the survey was done reporting a total number of 242. A structured questionnaire on knowledge, attitude and practice of dengue control was prepared. It was printed in local language and the questionnaire was divided into three sections; the first section covered the knowledge on Aedes and dengue consist of 16 questions, the second part concerned with attitude and consists of 08 questions which were based on Health Belief Model (HBM) and covered concepts known as severity, susceptibility, perceived barrier and perceived benefit. For scoring, a Likert scale 1 to 5 was given to each perception varying from strongly agree, agree, neutral, disagree, strongly disagree. The last part was related to practices with 19 questions in total. The overall reliability of the questionnaire was acceptable with Cronbach-alpha value of 0.763 (Cronbach, 1951).

Data analysis The data collected from the questionnaire were entered and analyzed using the Statistical Package for Social Sciences (SPSS) version 23.0. All of the questions were analyzed and assessed individually using a scoring system. Each of the appropriate answers was given a point and was totaled for each section. Respondents were considered to have sufficient knowledge (16 questions), satisfactory attitude (08 questions) and have good preventive practices (19 questions) if they correctly answered 75% in each of the section of the questions. Result and Discussion Prevailing Knowledge on Aedes and dengue Table 1:Knowledge on Aedes and dengue

Variables Frequency Percentage Dengue is becoming a health problem in the area Yes 236 97.5 No 6 2.5 Causes of dengue in the area Unmanaged waste 96 39.7

5 Dhaka North City Corporation 6 Dhaka South City Corporation

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Water clogged 82 33.9 Bushes around the residential area 10 4.1 A drainage system does not work 44 18.2 Don’t know 10 4.1 Who can be infected by dengue? Children only 5 2.1 Adults only 9 3.7 Anyone 224 92.6 Don’t know 4 1.7 Is dengue dangerous? Yes 232 95.9 No 4 1.7 Don’t know 6 2.5 Why dengue is dangerous? Can be caused to death 215 88.8 No cure 8 3.3 Don't know 19 7.9 Sign and Symptoms Continuous fever 187 77.3 Skin rash 129 53.3 Muscle pain 182 75.2 Nausea/vomiting 105 43.4 Headache 144 59.5 Small bleeding at gum and nose 54 22.3 Diarrhoea 25 10.3 Don't know 2 .8 Treatment of dengue Immediately see a doctor 207 85.5 Drink plain water 13 5.4 Drink papaya leaf juice 13 5.4 Drink coconut water 2 .8 Drink liquid more 2 .8 Drink 100 plus (isotonic drinks) 1 .4 Don't know 4 1.6 Causes of dengue Any mosquito 10 4.1 Aedes mosquito 185 76.4 Dengue virus 35 14.5 Contaminated water 9 3.7 Don't know 3 1.2 Carrier of dengue Any mosquito 34 14.0 Aedes mosquito 178 73.6 Dengue virus 20 8.3 Contaminated water 3 1.2 Don't know 7 2.9 Characteristics of the insect Brown and hairy 8 3.3 Black and white stripes on the head 58 24.0

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Shelled body with stripes on the wings 17 7.0 Black and white stripes on the body and legs 106 43.8 Don't know 53 21.9 Timing of the insect's biting habits Dawn and early morning 74 30.6 Late evening and dusk 40 16.5 At night only 6 2.5 Early morning and late evening 108 44.6 Don't know 14 5.8 The life cycle of the insects from egg to adult Days 7 91 37.6 Days 14 31 12.8 Days 21 23 9.5 Don't know 97 40.1 What are the insects breeding spots? Clearwater 121 50.0 Murky water 79 32.6 Don't know 42 17.3 Where are the potential breeding spots inside the house Pot liner 126 52.1 Kitchen cutlery tray 91 37.6 Toilet flush/tank 130 53.7 Cistern 29 12.0 Refrigerator tray 134 55.4 Don't know 1 .4 Where are the potential breeding spots outside the house Clogged gutter/drain 148 62.2 Water storage container, jar 150 63.0 Unclosed cans and bottles 123 51.7 Solid waste that can store water 99 41.6 Old tires that can store water 141 59.2 Don't know 8 3.4 How to prevent breeding spot Allow fogging inside the house 39 16.3 Managed waste and recyclables properly 157 65.4 Used mosquito aerosol spray 134 55.8 Install mosquito nets at house windows 127 52.9 Prevent stagnant water 63 26.3 Clear the clogged water every 3 days 155 64.6 Always closed containers that can store water 113 47.1 Eliminate mosquito breeding spots weekly 97 40.4 Install mosquito nets at house windows 80 33.3 Use mosquito nets at the time (day time of sleeping 106 44.2 Don't know 13 5.4

Knowledge on Dengue There is no doubt among the 76.4% (n=185) respondents, that Ades Mosquito is mainly responsible for Dengue. The majority 97.5% (n=236) of the respondent believe that dengue is

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becoming a serious health problem in this region. Among the total number of the participant 95.9% (n= 232) knows that dengue is dangerous diseases and 88.8% (n=215) believe that dengue can cause death. When they asked about the cause of dengue in this region or area 39.7% (n=96) said about unmanaged water, 33.9% (n=82) said about water clogged, 18.2 %( n=14) said about drainage system is not work and similarly, 4.1 %( n=4) given opinion that they don’t know about that. Anyone can be infected by the dengue said by majority respondent and their percentage is 92.6% (n=224). Dengue is an upcoming disaster and serious issue that’s why having sufficient knowledge about sign and symptoms of dengue infection is very important. To know about the depth of knowledge about sign and symptoms of dengue among the respondents, we set multiple response questions to understand the knowledge of the symptomatology of dengue, and the result is that 8% (n=2) said that they don’t know about the sign and symptoms of dengue, in contrast, majority of the respondent's response associated with dengue are-continuous fever 77.3% (n=187), headache 59.5% (n=144), skin rash 53.3% (n=129), muscle pain 75.2% (n=182), small bleeding at gun and nose 22.3% (n=54), diarrheoa 10.3% (n=25), nausea/ vomiting 43.4%(n=105). When they were asked about what they would do immediately after infected by dengue, majority of the respondent said that they would immediately seek for treatment and their percentage is 85.5% (n=207), in contrast equally 5.4 % (n=13) said that they would drink papaya leaf juice and drink plain water.

Knowledge on Ades Mosquito There is no doubt among the 73.6% (n= 178) respondent that Ades mosquito is the carrier of the dengue disease. This study found different or multiple responses to the characteristics of the insect. Common response associate with the characteristic of insect is- brown and hairy 3.3% (n=8), black and white stripes on the head 24% (n= 58), shelled body with stripes on the wings 7% (n=17), black and white stripes on the body and legs 44.6% (n=106). In contrast, 21.9% (n=53) respondent said that they don’t know about the characteristics of the insect. On the timing of the mosquito biting habits, 30.6% (n=74) of the respondent said ‘dawn and early morning’ while 44.6% (n=108) respondent said ‘early morning and late evening’ and dusk 16.5% (n=40), and 5.8% (n=14) respondent don’t know about the timing of the mosquito biting habits. Majority of the respondent 40.1% (n=97) don’t know about the duration of Ades Mosquito life cycle from egg to adult. Most of the respondent is informed about the potential breeding spots inside the house. They mentioned several spots and these are-pot liner 52% (n=126), toilet flush/tank 53.7% (n=130), refrigerator tray 55.4% (n=134). Respondent also mentioned several techniques to prevent breeding spots. Majority of the respondent 65. 4% (n=157) said that they should manage waste and recyclables properly, 64.6% (n=155) said that they should clean the clogged water every 3 days, 44.2% (n=106) said that they should use mosquito nets at the time of sleeping. Table 02: Attitude scoring of the respondents based on the health belief model

Statements Strongly Agree (%) Neutral Disagree Strongly Agree (%) (%) Disagree (%) (%) Dengue fever (DF) is very dangerous 62.8 26.9 5.4 3.3 1.7 Dengue fever (DF) can cause death 19.8 33.9 9.5 24.8 12

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Dengue fever (DF) can occur without 15.7 59.9 14.9 7 2.5 presences of skin rashes Continuous fever worries you 31 56.6 8.7 1.7 21 Despite having medical facilities still 31.8 41.3 17.4 7.4 2.1 afraid of dengue fever (DF) Very worried when get bitten by a 28.5 37.6 20.2 9.9 3.7 mosquito Not worried on water logged 11.2 35.1 8.7 34.3 10.7 You can be infected with dengue fever 23.6 52.5 17.8 2.5 3.7 (DF) If you are healthy, you will not be 8.7 19.8 12 40.1 19.4 infected with dengue fever (DF) You ware often bitten by mosquitoes 12.4 22.7 19.8 33.1 11.9 but never fall sick Do you believe that dengue fever (DF) 19.4 58.7 11.6 5 5.4 could be prevented and controlled? Do you think that eliminating the Ades 8.3 51.7 21.5 12.8 5.8 mosquito is complicated and time- consuming? Do you think that you have an important 20.2 44.2 26.4 4.1 4.9 role in dengue fever (DF) prevention? Do you think that dengue is a major 27.3 48.8 11.6 8.7 3.7 problem for the people of Bangladesh? Do you think that dengue is difficult to 12.8 21.5 20.7 41.7 3.3 detect? Do you think that the environment is 14 50 26 6.6 3.3 conducive to disease transmission? Do you think that dengue has high 22.7 39.3 26 7 5 morbidity? Do you think dengue epidemic is an 22.7 55 11.2 7.9 3.3 alarming diagnosis? Do you think that dengue decreases 16.9 40.5 19 17.4 6.2 economic productivity?

Attitude towards Dengue Using Health Believed Model (HBM) we developed some questions to understand the attitude of the respondent regarding dengue and Ades mosquito prevention (Table 2). Respondents are confident enough that dengue is a dangerous and serious illness. Majority of the respondent 62.8% strongly agree that dengue fever (DF) is very dangerous. In contrast, interesting findings is that similarly 1.7% of the respondent strongly disagree with this statement. Among the participant of this study 19.8% strongly agree with this statement that dengue fever (DF) can occur death and 33.9% of the participant simply agree with this statement. In contrast, 12% of the whole respondent strongly disagree with this statement that dengue can occur death. 31.8% of the respondent still strongly agrees that they are afraid of dengue fever (DF) despite having medical facilities and 41.3% respondent are simply agree with this statement. Most of the people of this region are very worried when they get bitten by a mosquito. 28.5% of the respondent strongly agree with this statement that they are worried when they get bitten by a mosquito and 37.6% of the respondent simply agree with this statement. In opposite 9.9% strongly disagree with this statement. 23.6% of the

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respondent strongly believes that anyone can be infected by the dengue fever (DF) and 52.5% simply agree with this statement. In contrast, 2.5% strongly disagree with this statement. Continuous fever is a sign of dengue fever (DF) and it is an issue of worry. 31% respondent strongly agree with this opinion and 56.6% simply agree with this opinion. Dangerous dengue fever (DF) can be controlled and prevent through raising awareness among the people. Here 19.4% respondent is strongly and 58.7% of the respondent simply agree with this statement. And here interesting findings is that still, 5.4% disagree with this statement. Each person has an important role in preventing dengue fever (DF). Here our study finds out that 22.2% of the research sample strongly agree with this statement and 44.2% simply agree with this statement. In contrast, 4.9% of the research sample strongly disagree with this statement. Dengue is an upcoming threat to the overpopulated area. And dengue is a threat to the health wellbeing of this country. Here 27.3% of the respondents strongly agree that it is a major problem of this country and 46.8% simply agree with them. In opposite, 3.7% of people still here they do not agree with them. Environment plays an important role in the transmission of dengue diseases among people. This study finds out that majority of the respondent simply agree with this statement and their number is 50% and 14% strongly agree with them. Sometimes dengue causes a death that means dengue has high morbidity. Here this study finds out that 22.7% strongly agree with this statement with additional 39.3% of the respondent. Impact of dengue can decrease the economic productivity. 16.9% of the respondent strongly agrees with this statement and 40.5% respondents are simply agreed with them.

The practice of dengue control Table 03: Prevention practices of the respondents Variables Frequency Percentage Do you throw waste in tied plastic trash and tightly closed the trash bin? Yes 186 76.9 No 56 23.1 Do you Ensure water containers were tightly closed each time after used? Yes 182 75.2 No 60 24.8 Do you destroy damaged equipment that can store water? Yes 159 65.7 No 83 34.3 Do you clean water inside the container once a week? Yes 172 71.1 No 70 28.9 Do you check for mosquito breeding spot outside the house? Yes 123 50.8 No 119 49.2 Do you check for mosquito breeding spot inside the house? Yes 185 76.4 No 57 23.6

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Do you use mosquito aerosol/spray every day? Yes 113 46.7 No 129 53.3 Do you use mosquito net during day time sleeping? Yes 115 47.5 No 127 52.5

Several positive practices mentioned by the respondent when collecting data on dengue control issue. Preventive practice can control dengue fever (DF) and can reduce the vulnerability of the dengue situation. Majority of the respondent 76.9% (n=180) throw waste in tied plastic trash and tightly closed the trash. In opposite, 23.1% (n=56) don’t have good practice. The number of respondent 75.2% (n=182) ensure their water containers is tightly closed each time after use. In contrast, 24.8% (n=60) don’t do that. Majority of the respondent 71.1% (n=172) clean their water inside the container once a weak and 28.9% (n=70) of the respondent doesn’t do that. 65.7% (n=159) respondent destroy damaged equipment that can store water. Regularly 50.8% (n=123) respondent check for mosquito breeding spot outside the house and 76.4% (n=185) inside the house. In contrast, 49.2% (n=119) do not check the mosquito breeding spot outside the house and 23.6% (n=57) inside the house. One of the interesting findings of this study is that majority of the respondent 52.5% (n=127) do not use mosquito net during the time of sleeping and only 47.5% (n=115) respondent use a mosquito net. Majority of the participant 53.3% (n=129) do not use mosquito aerosol/spray every day in contrast, 46.7% (n= 113) respondent use it in regular basis.

Knowledge, Attitude and Practice Score As depicted in the below table (Table 4) 99.2% of the respondents have not enough knowledge about dengue and Aedes mosquito. Also, they have not shown enough attitude (96.3%) in dengue. However, most of the respondents have moderate level (72.3%) prevention practices on dengue. Table 4: Knowledge, Attitude and Practice Score

Particular Frequency Per centage Knowledge Score Poor Knowledge 240 99.2 Moderate Knowledge 2 .8 Attitude Score Unfavorable Attitude 233 96.3 Neutral Attitude 4 1.7 Favorable Attitude 5 2.1 Practice Score Low level 54 22.3 Moderate level 175 72.3 High level 13 5.4

Correlation Testing Table 5: Correlation between knowledge, attitude and practices of dengue prevention

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Variable r-Value p-Value interpretation

Knowledge vs -0.017 0.792 Small negative Attitude correlation Attitude vs Practice +0.064 0.325 Small positive correlation Knowledge vs +0.031 0.631 Small positive Practice correlation

The above table (Table 5) shows that there is a positive significant correlation between knowledge and practices of dengue; also, there is a positive correlation between attitude and practice; but there is a negative relationship between knowledge and attitude, i.e. there is no relationship on knowledge and attitude.

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Table 6: Bivariate and multinomial logistic regression model

Gender Parameter Estimates B Std. Wal df Sig. Error d Knowledge Male Moderate Intercept -4.256 .712 35.71 1 .000 Knowledge 4 Gender 0 . . 0 .

Attitude Male Favorable Intercept -3.843 .584 43.37 1 .000 Attitude 7 Gender 0 . . 0 . Female Favorable Intercept -3.839 .715 28.86 1 .000 Attitude 2 Gender 0 . . 0 . Neutral Intercept -3.146 .511 37.96 1 .000 Attitude 4 Gender 0 . . 0 .

Practice Male Moderate level Intercept 1.138 .200 32.37 1 .000 9 Gender 0 . . 0 . High level Intercept -1.551 .416 13.88 1 .000 5 Gender 0 . . 0 . Female Moderate level Intercept 1.232 .248 24.68 1 .000 3 Gender 0 . . 0 . High level Intercept -1.253 .463 7.324 1 .007 Gender 0 . . 0 .

The model in the table (Table 6) depicts that there is a negative relationship with the gender- based knowledge, attitude and practices. So, there is evidence that the Health Belief Model does not work in Bangladesh. The respondents do not have much knowledge of dengue and Aedes mosquitos, also they do not have a favorable attitude and practice to prevent the diseases and to reduce the breading place of Aedes mosquitos.

Conclusion It can be claimed that the adult population of Dhaka city, Bangladesh do not have adequate knowledge related to dengue. Yet, the overall prevalence of sufficient knowledge based on these criteria is moderate. This interpreted into poor attitude yet perplexed as the respondents have good preventive practices against the disease. Possibly, the critical dengue situation in their areas compelled them to conduct preventive practices. Among citizens in Dhaka, public awareness regarding dengue is limited. Awareness, understanding of the hazard and self- efficacy are significant predictors of effective prevention strategies for dengue. Prevention and control approaches should be concentrated on increasing consciousness of the hazard through television. The health campaigns will indeed be constructed to increasing the soul- efficacy of individual people.

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Analysis regarding public knowledge and health attitudes on hemorrhagic fever holds the most significant part in the implementation of outbreak prevention measures. The findings of this research illustrate the extent of general knowledge, health commitments and current prevention measures toward dengue fever (DF). We analyzed awareness of dengue and prevention measures related to demographic characteristics and public health values. The findings of the study are taken into consideration to help design health campaigns addressing the reduction and management of dengue fever (DF). This study also reveals that public awareness has a significant effect on the implementation of prevention measures on dengue. Knowledge regarding dengue could be propagated throughout the community to maximize the knowledge and awareness of the vulnerability to this outbreak. This will also be essential that health campaigns provide details that can improve patient trust and may also help alleviate this outbreak in the community by adopting appropriate measures to prevent.

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