Original article

Knowledge, attitudes, practices and perceptions about Zika in women of childbearing age in Amazonas, Peru

Susan Y. Mateo ^1,2, Licensed nurse, specialist in field epidemiology, Master of Science in epidemiological research
Jessica C. Guzmán-Cuzcano ³, Physician, Master in Public Health with mention in Epidemiology, Master in Public Health with mention in Epidemiology
E. Ricardo Peña-Sánchez ⁴, Physician, Master in research sciences
Carmen Yon ¹, Biologist
Betsabet Valderrama ^1,2, Licensed nurse, specialist in field epidemiology, Master of Science in epidemiological research
Julia Carrasco ¹, Sociologist, Doctor of Public Health
Lenin La Torre ^2,5, Licensed nurse, specialist in field epidemiology, Master of Science in epidemiological research
Fernando Chapilliquen ¹, Biologist, Master of Public Health
Marlith Aguilar ⁵, Licensed nurse, Master of Public Health
Eduardo Quezada ⁶, Physician, specialist in field epidemiology
Tomas Pershing Bustamante ⁵, Licensed nurse, Doctor of Education Management

¹ Centro Nacional de Epidemiología, Prevención y Control de Enfermedades, Lima, Perú.
² Programa de Especialización en Epidemiología de Campo, Universidad Nacional Mayor de San Marcos, Lima, Perú.
³ Dirección Ejecutiva de Prevención y Control de Daños no Trasmisibles, Enfermedades Raras y Huérfanas, Ministerio de Salud, Lima, Perú.
⁴ Facultad de Medicina Humana, Universidad de San Martín de Porres. Chiclayo, Perú.
⁵ Red de salud Bagua, Amazonas, Perú.
⁶ Dirección Regional de Salud Amazonas, Amazonas, Perú.

This study is part of the activities of the technical unit of epidemiological surveillance of Metaxenic and other vector-borne diseases of the National Center for Epidemiology, Prevention and Disease Control of the Ministry of Health, Peru. Descriptive study with a mixed quantitative-quantitative approach on knowledge, attitudes, practices and perception about Zika in women of childbearing age, department of Amazonas - Peru.

ABSTRACT

Objective. To describe the knowledge, attitudes, practices, and perceptions about Zika in women of childbearing age (WCA) in the department of Amazonas in Peru, following a Zika outbreak.

Materials and methods. Descriptive study with a mixed quantitative-qualitative approach. We carried out stratified sampling, by applying a survey to a sample of 723 WCA aged 15 to 49 years in the district of Bagua, department of Amazonas, then we carried out four focus groups with 35 WCA in each group. Frequencies and the grounded theory were used for quantitative and qualitative analysis respectively. Interpretation of both methods was integrated using a narrative approach.

Results. We found that 86.3% of WCA knew that it is possible to get sick with Zika, 10.1% knew that it is transmitted through sexual intercourse, 2.2% knew that it can be transmitted during pregnancy and 68.5% consider that the information is insufficient. In practice, 60% (n=434) used mosquito nets, 53.4% (n=386) covered water containers and 7.3% (n=4) perceived local government involvement. Qualitative data showed distrust of vector control and expressed the need for psychological support for pregnant women and their families.

Conclusions. There are gaps in the knowledge and practices of WCA regarding the prevention of sexual and vertical transmission of Zika; WCA distrust vector control, do not perceive local government involvement, suggest psychological support should be provided to pregnant women with Zika, as well as to mothers with disabled children, and wish to access more information about Zika.

Keywords: Knowledge; Attitudes; Practices; Prevention; Zika; Women of reproductive age (Source: MeSH NLM).

INTRODUCTION

Zika is an arbovirus associated with severe sequelae such as congenital brain anomalies ⁽¹⁾ or Guillain-Barré syndrome ⁽²⁾. It is considered that the cost of the Zika epidemic in Latin America, in three years, was 7 to 18 billion dollars and that the long-term costs will be associated with the sequelae ⁽³⁾. Furthermore, since its arrival into the continent, there has been an ongoing debate on reproductive rights versus the option of abortion, due to the potential sequelae in newborns ⁽⁴⁾.

The first native cases of Zika in Peru were documented in 2016. Sustained transmission has been observed in the department of Amazonas since the report of the first outbreak between 2017 and 2018 with cases in pregnant women and women of childbearing age (WCA) ^(5,6). The main response interventions focused on intensifying actions against the Aedes aegypti vector ⁽⁷⁾ and recommended condom use and delaying pregnancy ⁽⁸⁾. Given this type of measures, it is essential to know the perception, knowledge, attitudes and practices (KAP) of the community, especially of WCA, in order to identify whether the recommendations were understood, accepted and practiced in this population and to allow rethinking strategies with scientific evidence.

Some studies describe the lack of knowledge regarding sexual transmission ^(9,10), age and schooling ⁽¹¹⁾ as factors that could represent barriers to the prevention of Zika. Although low risk perception among pregnant women has been reported ⁽¹²⁾, there is limited information on the perceptions of WCA about the risk of disease and their attitudes regarding prevention measures implemented by the health sector and local governments. Therefore, our study aimed to determine the knowledge, attitudes, practices and perceptions of WCA about the disease, complications, interventions and recommendations implemented after a Zika outbreak in the department of Amazonas.

MATERIALS AND METHODS

Study design and population

Descriptive study, with a mixed quantitative-qualitative approach. It was conducted between November and December 2018 on WCA aged 15 to 49 years, residents of the district of Bagua, department of Amazonas. The district of Bagua is located in the northern jungle of Peru, at an altitude of 420 meters and has environmental characteristics that favor the presence of the Aedes aegypti vector ⁽¹³⁾.

For the quantitative approach, we developed a questionnaire based on the KAP survey on Zika and its complications for community settings by a multidisciplinary team of the World Health Organization (WHO) ⁽¹⁴⁾, which was made available for use in member countries. Since it is an instrument that has not been tested in the field, the WHO recommends the application of a pilot test. For our study, questions were selected according to the research objectives. The instrument was validated by four experts with experience in field epidemiology, epidemiological surveillance of congenital diseases and research. The review process included the evaluation of the questionnaire by using a rating card with six categories: sufficiency, congruence, wording, clarity-precision, relevance and pertinence of the items. A pilot test was also conducted in the city of Bagua Grande in the province of Utcubamba-Amazonas, with a non-probabilistic sample of 5% of the study sample (36 WCA), to adapt it to the context, improve the structure of the questions and determine the time required to fill out the instrument. At the beginning of the study, 40 questions were selected from the WHO survey that addressed the research objective. After review by the experts, five questions were ordered and reformulated. As a result of the implementation of the pilot test, three questions were removed, one question was added and the structure of question 19 was modified for better understanding. The final survey consisted of 38 questions, divided into four sections: sociodemographic data, knowledge, attitudes and practices; the average time to complete the survey was 15 to 30 minutes.

Subsequently, four focus groups were formed, using a semi-structured guide with 17 open-ended questions on perceptions of Zika. The average duration of each focus group was 60 to 120 min and was moderated by a professional with experience in qualitative research. The instrument was validated by expert judgment.

Sample and sampling

For the quantitative phase, we considered the estimated population of women aged 15-49 years in 2018 (6,862 WCA), published in the National Institute of Statistics and Informatics. An expected proportion of 50% (proportion of correct answers of knowledge and practices) was considered to obtain the maximum sample size, reliability level of 95%, margin of error of 5%, rejection rate of 0.1 and design effect of 1.8. The resulting sample of 721 women was calculated using Epidat 4.1 software (Xunta de Galicia- OPS).

The sampling was stratified by two-stage clusters, so a sample of subjects was selected for each sector of the district of Bagua (19 sectors). The first level unit was a random selection of blocks in each sector using the 2018 cadastral sketch of the District Municipality, proportional to the size of each cluster. The second level unit was the dwellings within each block and we randomly selected four dwellings per block. In each dwelling we sought for a WCA aged 15 to 49, if the subject was not found in the selected address, the next dwelling to the right was chosen.

For the qualitative approach, a non-probabilistic purposive sample of WCA who voluntarily agreed to participate in the focus groups was selected and the invitation was extended to all WCA during the application of the survey. The focus groups were formed according to their arrival; four groups were formed with a minimum of eight and a maximum of eleven WCA.

Data collection

The questionnaires were applied from November 26 to December 31, 2018. Previously, enumerators and supervisors were trained, in order to ensure the correct application of the instrument. There were twenty enumerators, distributed in each sector, and three supervisors who monitored six to seven enumerators in order to ensure the quality of the information collected. The survey was administered to WCA who were at home and who wished to participate in the study.

During the application of the survey each enumerator in charge of a sector made the invitation for the focus groups, seeking to include the entire rural and urban socioeconomic spectrum. From the 4th to the 7th of December 2018, four focus groups were carried out, each group had a moderator who used the semi-structured guide and led the focus groups. Likewise, there were two observers who recorded the field notes and the participants’ responses through a voice recorder.

Study variables

The quantitative survey included, in addition to the sociodemographic variables, 16 questions on knowledge, 9 questions on attitudes and 15 on practices. For the collection of qualitative data, stimulation questions were used for five topics: dissemination of information about Zika, knowledge about the disease, prevention of the disease, consequences for the pregnant woman and complications of the disease.

Analysis plan

For the descriptive quantitative analysis, we used absolute and relative frequencies and measures of central tendency and dispersion (mean and standard deviation) for the categorical and numerical variables, respectively. The statistical software Stata version 12 (Stata Corp LLC, USA) was used.

The qualitative analysis included the extraction of key quotes that were coded and grouped into five sections: Dissemination of information, knowledge about the disease, prevention of the disease, consequences in pregnant women and complications due to Zika. For the analysis, we used the grounded theory methodology, based on the analysis of the content of the responses, seeking to elaborate an integrating theory to explain the perception of each topic.

The quantitative-qualitative integration was carried out in the data interpretation phase, by using narrative integration with a constructive approach (weaving approach) ⁽¹⁵⁾. The integration followed the interpretation of the five sections, allowing to broaden, deepen and contextualize the study findings.

Ethical aspects

The study was approved by the Ethics Committee of the Hospital Nacional Dos de Mayo- Lima (evaluation 093-2018-CEIB- HNDM). All participants signed an informed consent form before the application of the survey and the focus group, after being informed of the purpose, risks and benefits of the research. Likewise, an informed consent form was used for underage participants. The data recorded in the instruments were anonymous in order to protect the participant’s identity and privacy.

RESULTS

A total of 723 WCA were surveyed, the mean age was 31.8 years with a standard deviation (SD) of 8.9 years; 75.8% (n=548) were housewives, 45.8% (n=331) completed at least secondary school, 53.9% (n=389) were cohabitants, 62.5% (n=449) were Catholic and 87.4% (n=632) were from urban areas. From the total WCA surveyed, 4.4% (n=32) were pregnant women and the average monthly income was 781 soles (Table 1). The four focus groups included 35 WCA between 17 and 49 years of age (three groups of eight and one group of eleven) from the district of Bagua, none of whom reported being pregnant.

Table 1. Sociodemographic characteristics of women of childbearing age, Bagua district, Amazonas department. 

* Mean ± SD. ^a cost in soles. ^b time in minutes. SIS (Integral Health Insurance). HCC. (Healthcare center).

Knowledge about the disease

Regarding knowledge, 86.3% (n=624) considered that it is possible to become ill with Zika; 35.6% (n=257) believed that it can cause a rash; 10.1% (n=73) that it can be transmitted through sexual intercourse and 2.2% (n=16) that it can be transmitted during pregnancy. A total of 97.1% (n=702) of the WCA would advise a patient with Zika to go to a health facility. Regarding practices, 94.2% (n=681) reported that if they had a rash, they would go to the health facility (Table 2).

Table 2. Knowledge, attitudes and practices on general aspects of Zika disease in women of childbearing age, Bagua district, Amazonas department, Peru. 

HCC. (Healthcare center), * multiple choice question, total does not add up to 100%.

In the focus groups, we found that Zika is perceived as "similar" to dengue and they consider that it "affects pregnant women". Most of them relate transmission to the bite of the "mosquito". However, some recognize transmission during pregnancy (Annex 1).

Dissemination of information about Zika

Regarding information on Zika, 85.8% (n=620) of the WCA received information more than a year ago; 41.1% (n=297) heard it on the radio; 34.3% (n=248) through talks by health personnel and 23.7% (n=171) on television. Of the total of participants, 68.5% (n=495) considered that the information received is still insufficient and would like to obtain more information on prevention 48% (n=347) and treatment 41.1% (n=297) Table 3. In the focus groups, participants indicated that information on Zika was broadcasted "fast" on radio and television. On the other hand, they indicate that other dissemination strategies should be considered (Annex 1).

Table 3. Knowledge, attitudes and practices on Zika dissemination among women of childbearing age, Bagua district, Amazonas department, Peru. 

HCC: Healthcare center. * multiple choice question total does not add up to 100%.

Disease prevention

WCA believe that Zika can be prevented by using mosquito nets 60% (n=434) and covering water containers 53.4% (n=386); 3.6% (n=26) believe it can be prevented by avoiding sexual intercourse and 1.9% (n=14) by using a condom. Of the participants, 36.1% (n=261) considered that families are responsible for preventing Zika, 27.3% (n=197) that the health sector is responsible, 16.5% (n=119) that local governments and 27% (n=195) believe that everyone is responsible. Regarding practices, 74.4% (n=538) of WCA reported having taken some measure to protect themselves and 81.8% (n=591) to protect their family. Fourteen percent (n=101) reported that they kept the sachet of larvicide in the container and 7.9% (n=57) allowed the health brigades to enter their home. On the other hand, only 4.4% (n=32) used condoms, 1% (n=7) avoided sexual intercourse and 0.6%(n=4) received education within their families; 84.2% (n=609) considered that the health sector had taken preventive measures, 67.6% (n=489) through focal (larval) control. Of the WCA, 7.6% (n=55) consider that the local government has carried out activities, of which 7.3% (n=4) have coordinated with the local healthcare center (Table 4). In the focus groups, they considered that the health sector continues to do the "same thing", they are suspicious of the impact of the new larvicide for focal control, they believe that spraying does not control the vector and "contaminates". They perceive that the population is not "aware" of Zika prevention and give importance to education within the family and educational centers (Annex 1).

Table 4. Knowledge, attitudes and practices on Zika disease prevention among women of childbearing age, Bagua district, Amazonas department, Peru. 

* multiple choice question total does not add up to 100%.

Consequences of Zika in pregnant women

Of the participants, 60.2% (n=435) believe that Zika causes risk of miscarriage, 30.2% (n=218) that it increases the risk of malformation in the newborn, and 19.2% (n=139) believe that they should not get pregnant in order to prevent Zika. Regarding practices, 31.7% (n=229) would choose to use condoms to prevent pregnancy, 62.8% (n=454) of WCA would go to prenatal controls if they were pregnant and with Zika and 98.3% (n=711) believe that they should be tested for Zika during prenatal controls (Table 5). In the focus groups, WCA believe that abortion would not be a choice. WCA perceive the concern and distress that a pregnant woman with Zika could suffer and the importance of psychological care (Annex 1).

Table 5. Knowledge, attitudes and practices on the consequences of Zika in pregnant women, Bagua district, Amazonas department. 

* multiple choice question total does not add up to 100%.

Complications of Zika

Regarding complications, 38.7% (n=280) of WCA have heard of microcephaly, of which 87.1% (n=244) related it to zika; 82.1% (n=230) considered when the baby is born with a small head to be a complication of Zika. On the other hand, 5.5% (n=44) had heard about Guillain Barré, of which 52.5% (n=21) related it to Zika and 42.5% (n=17) considered that it causes difficulty in moving. Of the WCA, 34.7% (n=251) were concerned that Zika could cause disability to their babies; 75.1% (n=543) believed that the mother of a baby with a disability could suffer discrimination. Regarding practices, 58.7% (n=424) would use contraceptive methods to prevent complications; 2.6% (n=19) would take a child with a disability to a specialist or rehabilitation 1.9% (n=14) (Table 6). In the focus groups, WCA perceived that children with Zika are not necessarily born with malformations (Annex 1).

Table 6. Knowledge, attitudes and practices on complications of Zika in women of childbearing age, Bagua district, Amazonas department, Peru. 

* multiple choice question, total does not add up to 100%; ^a Total number is the number of WCA who answered yes to the question: Have you heard of microcephaly before,? ^b Total number are the WCA who answered yes to the question: Have you heard of Guillan Barré syndrome before?

DISCUSSION

The participants did not identify sexual and vertical transmission of Zika as forms of transmission, a situation similar to the study by Nelson E. et al, in which only 2% of women identified sexual intercourse as a route of transmission ⁽¹⁶⁾. On the other hand, exanthema was one of the clinical manifestations least recognized as characteristic of the disease; similar findings were also described in the dengue and Zika endemic areas of the Dominican Republic, where only 8% of the population recognized this manifestation as the main sign of Zika ⁽¹⁶⁾, despite being a frequent characteristic of the disease ⁽¹⁷⁾.

In addition, the most frequently recognized symptoms of Zika were fever, headache, and malaise, characteristic manifestations of dengue, which would reflect not only lack of knowledge, but also confusion between the two arboviruses. These findings have also been described in Iquitos ⁽¹⁸⁾ and could be related to the greater public health impact (fatal cases) and greater media coverage given to dengue. The influence of media coverage, in addition to risk communication by official media, on the knowledge, practices and familiarity of the population with the disease has been described ⁽¹⁹⁾, which is key to improving adherence to preventive measures.

Radio, talks by health personnel, and television were the mostly reported sources of information about the disease, reflecting mass dissemination efforts during the Zika outbreak in Bagua ⁽²⁰⁾. However, in the focus groups, the perception was that information via radio and television is brief and they suggest that health personnel should conduct more educational talks. Delet J. et al., in a study conducted in Martinique, reported that 64.3% of pregnant women suggested dissemination strategies other than radio and television ⁽²¹⁾. In addition, the focus groups participants considered it necessary to have access to more information on prevention, treatment and less repetitive messages; therefore, not only the media should consider the interests of the population ⁽²²⁾, but also the quantity and quality of the information.

The low percentage of condom use or sexual abstinence to prevent Zika is compatible with similar findings in other countries in the region. D’Angelo DV. et al. found, in Puerto Rico, that these preventive measures were not common practice among pregnant women ⁽²³⁾. Although no details of perceptions of these preventive measures were collected in the focus groups, the study by Weldon C. describes cultural barriers ⁽¹⁸⁾ and may be related to reluctance by the partner or low frequency of use in the context of a conjugal relationship.

Similar results have been described in other regions of Peru; for example, Palma H. et al. found, in Piura, that the population justified their reluctance to vector control because they did not perceive the desired effect ⁽²⁴⁾. Although the focus group participants recognized the work of the health sector, they reported that the lack of coordination between the local government and the health sector is an important limitation. The study by Weldon C., et al. suggested complementing vector control with short informative talks on prevention ⁽¹⁸⁾, which, together with the participation of community agents and local government, could represent an alternative to optimize interventions. Pérez-Guerra C. et al. found that the population considers that local governments should participate actively and sustainably ⁽²⁵⁾.

Regarding education within the family, educational centers were also considered important spaces for the transmission of preventive messages. Guber DJ. et al. considered that health behavior modifications in the community can take years, so it is important to initiate programs based on the family and community ⁽²⁶⁾. Previous evidence reports that the insertion of health programs in schools significantly increases the knowledge of students ⁽²⁷⁾, who, in turn, deliver information to their homes ⁽²⁵⁾.

The majority of the WCA considered that Zika can cause miscarriage, a finding similar to that reported by Burgos S., et al. in Lambayeque-Peru, where 50% of participants recognized the risk of miscarriage during pregnancy ⁽²⁸⁾; they also considered that pregnant women at risk should attend scheduled prenatal controls, as well as being tested for Zika. Pooransingh S. et al. in Trinidad and Tobago found that 88% of pregnant women considered that they should be tested for Zika and 76.9% considered that pregnant women with Zika should see a doctor ⁽²⁹⁾.

Qualitative results suggest that participants do not consider abortion as a preventive measure. Pooransingh S. et al. reported that 62% of pregnant women did not agree that women with Zika should have abortions ⁽²⁹⁾. However, they perceived that the distress suffered by pregnant women with Zika, or by mothers of children with sequelae, requires psychological care. The WHO mentions that pregnant women with Zika are highly likely to develop symptoms of distress ⁽³⁰⁾; therefore, it is important to guarantee their specialized care.

The proportion of WCA who have heard about microcephaly, Guillain-Barré syndrome and its relationship to Zika is low. Similar findings were observed in the study by Pooransingh S. et al. who found that 37.4% of pregnant women considered that there was a link between Zika and Guillain Barré syndrome ⁽²⁹⁾; Nelson E. et al. found that 10.4% of the population of women considered microcephaly as a risk for their babies ⁽¹⁶⁾.

Our study had limitations that may affect the conclusions, the first being that the answers may have been affected by recall bias and social desirability bias. However, the integration of quantitative and qualitative findings allowed us to go deeper into some aspects that would not have been possible to clarify with either of the two individual approaches. In addition, the study used the WHO survey as a basis and was validated by expert judgment and pilot testing in a similar jurisdiction, which improved the understanding of the questions in the questionnaire. On the other hand, the focus groups did not include pregnant women; the participants were the WCA who had the time and perhaps greater concern about the subject. Likewise, the study was conducted in urban and peri-urban areas of the city of Bagua, so WCA from native communities were not included. However, the invitation was extended to all sectors and those responsible for the fieldwork sought to include participants from most sectors.

In conclusion, the results show gaps in knowledge and prevention practices for sexually transmitted Zika. There are important perception barriers about vector control activities, lack of coordination between local government and health services, and there is a need for more and better information about Zika. The role of the family and educational centers is considered very important and underutilized, as well as the need to optimize prenatal control, screening and psychological support for pregnant women with Zika and mothers of children with sequelae. It is recommended that authorities responsible for prevention and control interventions, at all levels of government, should contextualize intervention strategies according to local conditions. This type of research is very useful to support the evaluation of interventions before, during and after an outbreak.

Acknowledgments: Yliana Margot Rojas Medina, psychologist at the National Center for Epidemiology, Disease Prevention and Control, for her support at the beginning of the study.

Authorship contributions: Conceptualization of the project: SML, JGC, EPS. Study design: EPS, JCR, SML. Data analysis and interpretation: SML, JCR. Article writing: SML, EPS. Observation review: SML. All authors participated in the literature search, collection of results, critical revision and approval of the final version.

Conflicts of interest: The authors declare that they have no conflicts of interest.

Funding:This article was carried out as part of the activities of the technical unit for epidemiological surveillance of Metaxenic and other vector-borne diseases of the National Center for Epidemiology, Prevention and Disease Control of the Ministry of Health, Lima, Peru.

Disclaimer: The views expressed in this publication do not necessarily reflect the views of the Centro Nacional de Epidemiología, Prevención y Control de Enfermedades.

Supplementary material: Available in the electronic version of the RPMESP.

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Correspondence: Susan Yanett Mateo Lizarbe; suyanett@gmail.com

Cite as: Mateo SY, Guzmán-Cuzcano J, Peña-Sánchez ER, Yon C, Valderrama B, Carrasco J, et al. Knowledge, attitudes, practices and perceptions about zika in women of childbearing age in Amazonas, Peru. Rev Peru Med Exp Salud Publica. 2021;38(4):551-61. doi: https://doi.org/10.17843/rpmesp.2021.384.8558.

Received: 14/06/2021
Approved: 01/12/2021
Online: 22/12/2021