Community knowledge and attitude towards Japanese encephalitis in Darrang, India: a cross-sectional study

Abstract

Background: The prevalence of Japanese encephalitis (JE) in Assam was exceptional in a global context in the year 2014. Darrang district is amongst the most affected districts that is hit by deadly JE virus in Assam. Therefore, we conducted this study to evaluate the knowledge and attitudes of the residents regarding JE at Darrang. Methods: A descriptive, cross-sectional study was performed for the period of 3 months from November 2014 to January 2015 in Darrang. Multistage stage sampling was done to select participants from the district. A pretested interviewer-administered questionnaire was used to collect data from the participants. Descriptive analysis and logistic regression tests were used to analyze the data. Results: A total of 396 participants responded to the questionnaire, thus giving the response rate of 51.5%. One-fourth of the participants exhibited a good knowledge of JE (24.7%). The majority of the participants incorrectly answered the questions relating to management (83.3%) and prevention of JE (66.7%). Further, tertiary education and JE patient in family/relative were significantly associated with the knowledge of the participants (P < 0.001). A large proportion of the respondents exhibited positive attitudes towards JE (96.5%). Television was the major source of information of the participants regarding JE (29.2%). Conclusion: The findings of this study indicate a lack of knowledge regarding JE among the residents of Darrang. However, their attitudes towards JE were generally positive. Further studies on this topic need to be conducted throughout the state of Assam to identify and subsequently bridge the knowledge gaps among its residents.

Full Text

 Introduction

Japanese encephalitis (JE) is a vector-borne viral disease that afflicts swine, equids, and humans.[1],[2] It is caused by the Japanese encephalitis virus (JEV), of Flaviviridae family, and genus Flavivirus.[2] JE was first identified in Japan in 1871 and was called “summer encephalitis.”[3] In a later discovery in 1933, it was confirmed that Japanese Encephalitis B (JEB) virus was responsible for JE. The deadly JE virus can transmit through the bite of a mosquito, or can infect someone who is in direct contact with infected or contaminated mucous membranes, or can spread through an infected fluid in a laboratory, or during tissue samples collection.[2] Most of the people do not develop symptoms after getting infected with JE virus while others display mild to severe symptoms ranging from fever and headache to serious brain infections, such as encephalitis.[2] A patient suffering from JE may also develop body aches, neck stiffness, seizures, and coma. The morbidity and mortality rate of JE is very high; at least 10,000−15,000 children die from JE every year, and 50% of the infected children who survive the illness are left with physical, cognitive, or psychiatric disabilities.[4],[5]

Japanese encephalitis is endemic to large parts of Asia and the Pacific. Hills and Phillips[6],[7] reported that around 3 billion people around the globe are at risk of JE. The epidemic of JE was considered a major public health problem since many cases were reported in different parts of India, especially in the pediatric population.[8] JE was first identified in 1955 in Tamil Nadu, a southern state in India,[9] where 65 cases were reported from 1955 to 1966.[10] In 1973, a major outbreak in West Bengal was reported with a fatality rate of 42.6%. Since then, JE has penetrated in different states of India and several outbreaks have been reported throughout the country.[6] The epidemic of 2005 surpassed all the previous outbreaks in India. Northern India, mainly Uttar Pradesh, was majorly affected by JE in that particular year, resulting in 6061 cases and 1500 deaths.[8] In recent years, a sharp surge has been observed in the number of cases of JE in Assam, a north-eastern state of India. Phukan et al[11] reported a five-fold increase in the number of cases in 2014 compared with 2010 in Assam. The major reported reasons for such an increase were the recent climatic changes, and changes in agricultural practices, and socio-cultural behavior, an abundance of potential mosquito vectors, and amplifying hosts in Assam state. As per the statistics , Assam is positioned as a vulnerable state for JE. Sharma et al,[12] showed that more than 50% of the total cases of JE in India were reported from Assam in 2014. Darrang district of Assam is amongst the most affected districts hit by the deadly JE virus. The prevalence of human, animal, and bird vectors are greater in this district compared with others.[13] Moreover, it is thought that flooding of paddy fields is one of the important reason which increases the mosquito population and so makes this district vulnerable for JE.[14] Therefore, it is essential to assess the knowledge and attitudes of the people of Darrang regarding JE.

 Materials and Methods

A descriptive cross-sectional study was conducted for the period of 3 months from November 2014 to January 2015 in Darrang district located in the state of Assam, India. Darrang is divided into four tehsils (sub-district), which are further sub-divided into towns.[15] The study was conducted in the Darrang district because of the reports suggesting an increase in the number of cases.[16] Sampling was carried out in 3 stages. Firstly, 2 tehsils (Mangaldai and Dalgaon) were randomly selected out of the 4 tehsils of Darrang. Secondly, 3 towns (out of 6) from Mangaldai and 2 towns (out of 4)from Dalgaon were randomly selected.[17] Thirdly, the residents of each selected town were randomly approached at common public places (shopping malls, restaurants, grocery stores, banks, hospitals) and were invited to participate in the study. These locations were selected for data collection because of the availability of the socio-economically diverse population. The data collectors spent an average of 5 hours in each location at randomly chosen time of the day to recruit participants for the survey. Those participants were excluded that were not willing to participate in this study or if they were not the residents of the respective locality. Data were collected on pre-designed and pre-tested forms by the team of authors responsible for data collection. All the eligible participants were briefed regarding the objectives and the outcomes of the research before data collection.

A sample of 384 participants was required for this study. However, by assuming a response rate of 80%, a total of 460 participants were approached. This sample size was calculated using the Raosoft software in which the population size was entered as 928,500, power as 80%, response distribution as 50%, confidence interval as 95%, and margin of error as 5%, respectively.[18] An interviewer-administered questionnaire was designed and used to collect the data from the subjects. The questionnaire was first designed after a thorough literature review of the related publishedstudies.[1],[2],[5],[8],[9],[10],[12],[13],[19],[20],[21] After that, the initial version of the questionnaire was sent to three expert academicians for content validity. The suggested revisions were made to the questionnaire before sending them to a small sample of 15 participants for face validity. The corrections suggested by the survey participants were then made in view of similar published work.[1],[2],[5],[8],[9],[10],[12],[13],[19],[20],[21] SPSS 20 for Windows (IBM Corporation, Armonk, New York). was used in computing the reliability coefficient of the questionnaire. The Cronbach’s alpha value of 0.77 and 0.71 was computed for knowledge and attitude sections, respectively. The responses of the pilot study were not included in the final analysis.

The questionnaire consisted of 24 items that are divided into four sections. The first section refers to the demographic information and comprises of five questions regarding gender, age, occupation, education of the participants, and a known JE patient in a family or among relatives. The second section involves 11 questions that assess the knowledge of participants regarding JE. Questions on knowledge were used to assess general knowledge of the participants regarding JE and its components. Knowledge regarding JE was assessed by asking questions regarding its causative agent, signs and symptoms, incubation period, diagnosis, vaccine, and treatment. The third section examines the attitudes of the participants regarding JE. This section includes seven statements. Questions on attitudes were used to assess the feelings and beliefs towards JE. The last part explores the source of information of participants regarding JE.

The collected data were then subjected to statistical analysis. Descriptive analysis was used to express the results as frequency and percentages. Knowledge was assessed by giving a score of 1 to the correct answer and 0 to the wrong answer. The scaled measurement of knowledge ranged from a maximum score of 11 to a minimum score of 0. The definition of “good” knowledge was based on participants’ mean knowledge score. A score of <7 was considered poor knowledge while a score of ≥7 was considered good knowledge. Similarly, attitudes of the participants were scored 1 for strongly disagree, 2 for disagree, 3 for agree, and 4 for strongly agree. The scaled measurement of attitude ranged from a maximum score of 28 to a minimum score of 7. A score of <18 (median attitude score) was considered negative attitude, and a score of ≥18 was considered positive attitude. Logistic regression analysis was used to assess the association between independent variables (demographic characteristics) and dependent variables (knowledge and attitudes). A P value of less than 0.05 was reported as statistically significant.

The ethical committee of Joint Health Services, Darrang district, Assam, approved the study. Participation of respondents was voluntary and their responses were dealt with the high level of confidentiality and anonymity. Participants were briefed regarding the objectives of the study, and written information was provided to them about the survey before data collection. Written consent was taken from the participants, however, verbal informed consent was obtained from the participants where literacy (inability to read and write) was an issue. The oral informed consent process was approved by the health services department and the ethics committee.

 Results

A total of 396 participants responded to the questionnaire, giving a response rate of 86.1%. The majority of the participants were male (n = 246, 62.1%), in paid employment (n = 132, 33.3%), and aged between 31 and 50 years. The highest qualification of more than half the participants was higher secondary school certificate (n = 202, 51%) while only a few respondents had JE patients in either their family or as relatives (n = 16, 4%). The demographic information of the participants is summarized in [Table 1].{Table 1}

Overall, 24.7% participants had good knowledge of JE. The majority of the participants were aware of JE (86.9%), its symptoms (79.3%), and transmission (76.3%), however, their knowledge in areas relating to the management and prevention strategies of JE were only 16.7% and 33.3%, respectively. The results showed that 38.6% and 22.7% respondents correctly answered questions about the availability of vaccines worldwide, and in India, respectively [Table 2]. It was observed that participants with a tertiary level of education were more knowledgeable about JE (OR = 7.74, P < 0.001). Similarly, it is found that respondents who had any JE patient in their family or a relative infected with JE had good knowledge about it (OR = 13.2, P < 0.001). Association of the demographic variables with the knowledge of participants towards JE is presented in [Table 3].{Table 2}{Table 3}

[Table 4] describes the attitudes of participants towards JE. A large proportion of the respondents exhibited positive attitudes towards JE (96.5%). All the participants (100%) agreed or strongly agreed that JE was a serious illness. Similarly, 98.5% respondents agreed or strongly agreed that residents of Assam should be vaccinated against the JE virus. However, 26.7% participants did not consider stagnant water and poor sanitization as important causes of JE in Assam. Further, Logistic regression analysis did not reveal any significant association between demographic variables and attitudes of the participants [Table 5]. Television was the major source of information regarding JE for the participants as depicted in [Figure 1] (29.2%).{Table 4}{Table 5}{Figure 1}

 Discussion

The survey findings show poor knowledge of people of Darrang about JE, although 86.9% participants were aware of this disease. These results are relatively better than previously conducted studies.[22] The likelihood of this variation might be the increased awareness about JE because of a sharp rise in the number of cases of JE in Darrang, leading to a debate among the people, various influential groups, and social activists. In contrast, the knowledge of participants regarding the key issues of vaccination, preventive measures, and management were considerably poor. Local government in Assam has introduced special campaigns to immunize the residents against JE. However, WHO report suggests that lack of proper knowledge is one of the reasons for the failure of vaccine acceptance.[23] We urge the involved stakeholders to educate the people about JE and its vaccination as well as its regular immunization schedule. Organized mass media campaigns and employing healthcare workers for an educational purpose can help in addressing this problem. Culex Vishnui group of mosquitoes are primarily responsible for transmission of JE in Assam. They usually breed in water and irrigational fields during the monsoon period. All these characteristics features position the people of Darrang at a risk of contracting JE as it is the most flood affected region of the state.[13] The lack of knowledge of the participants about the preventive measures against JE is alarming because of the high risk that it poses. We think that there is an urgent need to incorporate the component of preventive measures against the spread of JE in all the campaigns initiated by the government and other non-governmental organizations. Another key issue that needs to be highlighted is the lack of knowledge of the participants about the availability of vaccines. These findings raise concerns about the vaccination availability in the Darrang district. We assume that the failure to curb JE infection in Darrang could be because of a decreased access to vaccination. This assumption is also supported by research that indicates a high prevalence of JE following vaccination campaign. High availability of vaccines can be one of the most effective ways to control the spread of JE.[24] Vaccination of entire population of Darrang is vital to eradicate JE from this part of the country.

The results suggest that education was the major factor associated with the knowledge of participants towards JE. The results are in accordance with a previously published study in which participants with no formal education had significantly less knowledge about mosquito-borne diseases.[25] These findings emphasize the need to customize interventions to provide much-needed knowledge to uneducated people of Assam district. The study showed that participants who had any JE patient in their family or a relative with JE were more knowledgeable about it. These findings were supported by another research where participants with a family history of a mosquito-borne disease had a higher knowledge of the disease.[26] However, to aid the campaign against JE, it is essential to educate the public in general about JE.

A large proportion of the participants exhibited positive attitudes towards JE and agreed that JE is a serious illness. Our findings are more encouraging than other published studies about attitudes towards mosquito-borne disease.[27],[28] A majority of the respondents reported that residents of Assam should be vaccinated against JE. Reports suggest that children are most commonly affected by JE in the Southeast Asian region.[29] However, the virus is no longer confined to children and has affected adults in different districts of Assam.[30] Our findings show that the respondents favor immunization for all the residents of Assam because of the risk posed by JE. In February 2014, a mass vaccination campaign was organized to vaccinate adults (15–70 years) against JE in seven districts of Assam.[31] To effectively control the incidence of JE in Assam, it is essential to launch a statewide immunization program, covering all the districts of Assam. Stagnant water, poor sanitation, large number of migratory water birds and piggeries create an infectious environment in the rainy season that led to massive JE epidemic in Assam.[32] However, one-quarter of the patients did not agree with the statement that stagnant water and poor sanitation were the important causes for the spread of JE in Assam. Strong efforts should be made by the government to enhance vector control, sanitation, and surveillance through environmental educational program throughout the state of Assam. Assessment of association of a demographic variable with the attitudes of participants towards JE did not reveal significant differences. The most likely reason could be that the majority of the participants (96.5%) showed a positive attitude towards controlling JE.

Television was a major source of information about JE for the public. In contrast, another study reported that majority of the people were informed about JE by healthcare workers.[32] This difference could be possible because the referenced study was conducted in Haryana, a northern state in India. Mass media campaigns regarding awareness of the disease or vaccine are widely accepted by communities in Haryana because of their faith in government services.[32] Shortage of healthcare workers in the state of Assam could also be an influencing factor.[33] In view of the lack of evidence, it is difficult to say about the faith of the Darrang community on the health services provided by the local government. Healthcare workers are important members of mass media campaigns and their social and professional attitudes are important for the success of any awareness campaign.[33] We urge the researchers to investigate the perception of the Darrang community about the role of healthcare workers in the society.

Strength and limitations:

One of the major strengths of our study is that it has explored an area where the availability of literature is limited. In addition, the inclusion of participants from areas highly affected by JE was another key feature of this study. Furthermore, this study also highlighted some of the important knowledge gaps among participants that were essential to address in order to effectively eradicate this disease from the community. Our findings can assist policymakers to design and implement customized interventions in order to address the threatening complications of JE. However, this study also has some limitations. Cautions should be taken while interpreting these results as we only recruited participants from Darrang district in this study.

The findings may not be generalizable to the broader Assam population. Since the participation in this study was voluntary, we cannot ignore the potential for self-selection bias by community members who were more concerned about JE. This was a study based on a convenience sample, therefore, the study may not account for the differences within the population. Moreover, we were not able to gather the information of non-respondents. Hence, it is difficult to say whether any specific subgroup systematically failed to respond; although it does not reflect the internal validity of the findings, it may decrease the overall generalizability of the findings. As a general limitation to knowledge and attitude research, we cannot ignore the tendency of participants to provide more socially desirable responses. Despite these limitations, we think that our findings could play a vital role in addressing the issue of JE in Darrang.

 Conclusions

The study concludes that knowledge of the participants towards JE was poor, despite their positive attitudes. Tertiary education and the presence of JE patient in family/relatives were significant predictors of good knowledge of the participants. There is a need to establish educational campaigns to increase the knowledge of the people of Darrang about JE. Further studies can investigate the faith of the Darrang community in their healthcare workers with regards to the education provided about JE. Such studies should be replicated in other districts of Assam to improve the validity of our findings.

Acknowledgement

Nil

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors

Competing interest

The authors declare that they have no competing interests

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Authors’ Contribution

AA and MUK contributed to concept development, questionnaire design, data analysis and interpretation, manuscript preparation and finalization. LJG, APS, and MK contributed to concept development and data collection. ASB contributed to manuscript preparation and manuscript finalization. All authors approved the final submitted version of the article.

References