Zika Virus: Knowledge Assessment of Residents and Health-Care Providers in Roatán, Honduras, following an Outbreak

INTRODUCTION

Zika virus (ZIKV) is a mosquito-borne flavivirus that gained global attention for its rapid epidemic spread through the Americas in 2015–2016 and severe teratogenic effects, including microcephaly and fetal loss, when contracted during pregnancy.¹ To date, more than 80 countries or territories have reported cases of ZIKV infection.² Although mosquito-borne transmission is overwhelmingly predominant, sexual transmission (male to female, female to male, and male to male) is well described.^3–7 At the time of writing, 13 countries have reported sexual transmission of ZIKV; 49 cases of sexually transmitted ZIKV have been reported in the United States.^8,9 Zika virus is capable of persisting in the genital tract even after the virus has been cleared from blood and urine.¹⁰ Consequently, Centers for Disease and Control and Prevention recommends either sexual abstinence or barrier contraceptive methods (e.g., condom use) for extended periods of time following potential exposure to ZIKV to prevent sexually transmitted infection.¹¹

Despite public health educational campaigns that were launched following the emergence of ZIKV,¹² few studies have evaluated the outcomes with respect to knowledge of ZIKV and concomitant practices to prevent ZIKV.^13–15 In October 2016, the local health authorities in Roatán, Honduras, initiated a public health educational campaign, following the local emergence of ZIKV¹⁶; ZIKV informational posters were positioned at local airports and hospitals. The educational campaign coincided with an increase in mosquito control efforts. In 2017, approximately 6 months following initiation of the public health campaign, we sought to assess the knowledge of ZIKV and associated preventive practices among the residents and their health-care providers (HCPs) in Roatán. In addition to general knowledge of ZIKV, the survey sought to evaluate awareness of ZIKV’s risk to pregnancy and sexual health specifically. Insight into educational outcomes can be used to aid local governments to develop or refine policies and interventions.¹⁷ In this case, interventions relate to achievement of ZIKV control.

THE STUDY

A paper-based survey was administered to residents (N = 348) and HCPs (N = 44) at the Roatán Public Hospital and four clinics (public and private) in Roatán (March–May 2017). Roatán is the largest of the Bay Islands. Roatán Public Hospital is the only public hospital in Roatán, thus offering broad representation by geography and demographic on the island. The survey was adapted from the “Knowledge, Attitudes and Practice surveys: Zika virus disease and potential complications Resource Pack” that was developed by the World Health Organization (WHO) to evaluate local prevention and control measures related to ZIKV mitigation.¹⁸ The WHO survey was modified with minor amendments to the wording and length of the original questionnaire. The survey was piloted with 16 residents and four HCPs, representing each of the study sites. The survey was conducted in the participant’s preferred language—either English or Spanish–using both open- and closed-ended questioning. Trained Honduran and United States medical students administered the survey. The survey included 37 questions pertaining to 1) demographic characteristics; 2) knowledge of ZIKV clinical presentation, modes of transmission, and related preventive measures; 3) attitudes of participants to ZIKV risk, contraception use, and abortion (including perception of stigma); and 4) practices to prevent mosquito-borne and sexual transmission of ZIKV. The complete list of questions is available in the Supplemental Material.

On conclusion of the study enrollment, participants’ addresses were mapped using a hand-held eTrex 20 (Garmin, Lenexa, KS); the latter generated global positioning system coordinates for the participants’ homes. The survey, laboratory test data, and global positioning system coordinates were uploaded into ArcGIS version 10.3.1 software (Esri, Inc., Redlands, CA). The participants’ knowledge scores were mapped using the corresponding study participants’ home locations. The survey data were tabulated for all questions and summarized using counts and percentages. The total score, representing ZIKV knowledge, was calculated by adding one point for each correct response to Questions 5–12 and Questions 16–18 (Supplemental Material). For the bivariate analyses, the χ² test was used to compare categorical variables; analysis of variance was used to compare scores over groups within covariates. All statistical analyses were conducted using Stata 15.0 (StataCorp, College Station, TX).

A total of 375 residents and 50 HCPs were approached, of whom 92.8% (N = 348) of residents and 88.0% (N = 44) of HCPs were enrolled successfully (Table 1). The median age of participants was 31 (range 18–31) years, 75.8% (N = 297) were female, 39.3% (N = 154) had less than a high school education, 41.3% (N = 162) were high school graduates, and 19.4% (N = 76) were college graduates.

There was a statistically significant difference in the total knowledge score between HCPs and residents (mean 17 versus 11, respectively; P < 0.001, standard deviation: 5.1). The majority of residents (86.3%, N = 300) and HCPs (79.5%, N = 35) knew that ZIKV was transmitted via mosquitos (Table 2); 60.6% (N = 211) of residents and 77.3% (N = 34) of HCPs stated that ZIKV transmission was occurring in Roatán. Just over half (54.5%, N = 24) of HCPs reported that ZIKV posed a serious health concern to the community versus 68.4% (N = 238) of residents. Less than half of residents (43.1%, N = 150) reported being informed by their HCPs regarding individual actions that could be taken to prevent ZIKV infection. When asked, “What actions have you taken to protect yourself from getting infected with ZIKV?” the most frequently reported actions among participants included elimination of standing water (34.4%, N = 11 residents versus 68.2%, N = 30 HCPs), wearing protective clothing (25%, N = 8 residents versus 39.8%, N = 76 HCPs), and the use of a mosquito net (12%, N = 23 residents and 40.6%, N = 13 HCPs).

Only 6% (N = 19) of residents and 14% (N = 6) of HCPs knew that ZIKV could be transmitted sexually. Few participants abstained from sex to prevent ZIKV infection (2.6%, N = 5 residents and 9.4%, N = 3 HCPs). Furthermore, although condoms were reportedly available, their use to prevent ZIKV infection was low (1.6%, N = 3 residents and 12.5%, N = 4 HCPs). Despite that the vast majority of participants (91.1%, N = 317 and 86.4%, N = 38 of residents and HCPs, respectively) reported that they trusted HCPs to provide the most accurate information regarding ZIKV, only 4% (N = 7) of respondents reported that their HCP had discussed sexual abstinence and 7.9% (N = 14) had discussed condom use as a way to prevent ZIKV infection with them.

Only 56.9% (N = 198) of residents and 75.0% (N = 33) of HCPs reported that women should avoid becoming pregnant if at risk of ZIKV exposure; at the time of the survey, 15.6% (N = 61) of all subjects were pregnant or reported having had a partner who was pregnant in the past year. Among residents who were either pregnant or had a partner who was pregnant within the last year, 57.6% (N = 34) reported concern about becoming infected with ZIKV. Residents and HCPs were asked whether they would support abortion in reference to ZIKV-associated fetal abnormalities. In this setting, the majority (65.2%, N = 278 residents and 76.5%, N = 36 HCPs) disapproved of abortion. Mapping of the total Zika knowledge scores suggested that knowledge was spatially heterogeneous on the island (Figure 1). The total knowledge scores among the respondents varied by location, from a low of 6.75 in Crawfish Rock to a high of 14.29 in West End. There were statistically significant differences in the knowledge scores among respondents between the locations with the lowest total scores (i.e., Crawfish Rock, Flowers Bay, and Punta Gorda) and those with the highest scores (i.e., Los Fuertes, Oak Ridge, and West End) after adjusting for multiple comparisons (P < 0.06; Supplemental Table 1). Census data are needed to improve the correlation of knowledge scores with income or level of education.¹⁹

Spatial distribution of Zika Knowledge Scores among residents and health-care providers in Roatán, Honduras, March 2017–May 2017. The regions displayed in the insets are those for which we obtained the most samples. Island-wide Zika knowledge score appears to be normally distributed with the sample mean (11.78), median (12), and standard deviation (5.11). This figure appears in color at www.ajtmh.org.

Citation: The American Journal of Tropical Medicine and Hygiene 99, 1; 10.4269/ajtmh.18-0014

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Spatial distribution of Zika Knowledge Scores among residents and health-care providers in Roatán, Honduras, March 2017–May 2017. The regions displayed in the insets are those for which we obtained the most samples. Island-wide Zika knowledge score appears to be normally distributed with the sample mean (11.78), median (12), and standard deviation (5.11). This figure appears in color at www.ajtmh.org.

Citation: The American Journal of Tropical Medicine and Hygiene 99, 1; 10.4269/ajtmh.18-0014

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• Download figure as PowerPoint slide

Spatial distribution of Zika Knowledge Scores among residents and health-care providers in Roatán, Honduras, March 2017–May 2017. The regions displayed in the insets are those for which we obtained the most samples. Island-wide Zika knowledge score appears to be normally distributed with the sample mean (11.78), median (12), and standard deviation (5.11). This figure appears in color at www.ajtmh.org.

Citation: The American Journal of Tropical Medicine and Hygiene 99, 1; 10.4269/ajtmh.18-0014

• Download Figure
• Download figure as PowerPoint slide

The study has limitations. First, a convenience sample of survey venues was used. Second, the research personnel administered the surveys (rather than have the participants complete on their own); therefore, the responses were subject to social desirability bias. Furthermore, despite the high rates of participation, one is unable to assess ZIKV knowledge in nonresponders, that is, selection bias needs to be acknowledged. Nonetheless, the study provides insight into the awareness, beliefs, and actions of Roatán residents and HCPs, which could enable public health officials to improve messaging and bolster the ZIKV response effort.

CONCLUSION

Despite a public health education campaign in Roatán, the limited knowledge of ZIKV sexual transmission may impede local eradication efforts that are focused, primarily, on mosquito control. Since 2015, the WHO has issued recommendations aimed to decrease ZIKV infection.²⁰ The WHO states that the guidance is “intended to inform the general public and to be used by health-care workers and policy makers.” Our study suggests that both residents and HCPs in ZIKV-endemic regions, such as Roatán, may not be adequately informed of their risks of exposure and the available resources to prevent ZIKV infection and its associated complications. Similarly, studies conducted in the continental United States (United States and United States Virgin Islands) indicated the need to improve messaging in regard to modes of transmission, whereby most of the participants did not know that ZIKV could be spread through sex.^14,15 Refinement and possible expansion of educational initiatives are needed to control ongoing ZIKV transmission and/or improve preparedness during future outbreaks.

Supplementary Material