Study to assess the knowledge and practice of accredited social health activist workers regarding dengue in Bengaluru urban district Karnataka India.
Dengue viruses are arboviruses capable of infecting humans by the bites of virus-infected Aedes aegypti and albopictus mosquito causing disease. The World Health Organization estimates that presently about two-fifths of the world population is at risk for this viral infection.  Symptomatic dengue virus infections can present with a wide range of clinical manifestations, from mild febrile illness dengue fever (DF) to a life-threatening hemorrhagic shock syndrome or organ dysfunction.  DF is characterized by fever, headache, muscle and joint pains, rash, nausea, and vomiting. Some infection results in dengue hemorrhagic fever (DHF)--a syndrome that in its severe form can threaten the patient's life primarily through increased vascular permeability and shock. DF and DHF are caused by the four dengue viruses DEN 1, 2, 3, and 4, which are closely related antigenically. There is no vaccine or specific treatment for dengue/severe dengue, but early detection and access to proper medical care lowers fatality rates below 1%. Vector control is one of the most important preventive measures in combating dengue.  India is one of the seven identified countries in the South East Asia region regularly reporting incidence of DF/DHF outbreaks and may soon transform into a major niche for dengue infection in the near future. Both viral and host factors are thought to contribute to the manifestations of disease in each infected individual.  The upsurge in the incidence of dengue cases shows that there is still need to increase the level of awareness in the public about vector-borne diseases especially the DF. National Health Mission envisioned universal access to health, with a strong focus on community involvement. This was to enhance the people's participation in health and enable action on its various social determinants. Accredited Social Health Activist (ASHA) workers are one among the key instruments for achieving this goal. There are defined job responsibilities and guidelines for reporting of an outbreak of dengue.  At the village level, ASHA, and AWW, and other members of village health and hygiene committee should be sensitized by the area health worker (ANM/MPW) on prevention and control of dengue. In general, in an outbreak situation, there is clustering of fever cases of similar nature in the affected areas. An outbreak of fever would be considered if the number of fever cases of similar nature reported by the health workers/ASHA/other health volunteers is five or more in a village during a period of 7 days. ASHA/Aanganwadi workers or any voluntary organization would report occurrence of fever outbreak to the ANM/health workers as well as to the medical officer, sector primary health centers. Recognition and reporting of such outbreak of suspected DF cases by ASHA and other health volunteers would trigger the health system for prompt remedial measure and containment of the disease.  Various knowledge, attitude, and practice (KAP) studies have been conducted on ASHA workers in the field of child health, maternal and child health, nutrition, general awareness, malaria, etc. There are many KAP studies available on the community, but there are very few specific studies with regard to the dengue KAP among the ASHA workers. Hence, this study was undertaken in Bengaluru urban district with the following objectives:
1. To assess the knowledge and practices of ASHA workers regarding dengue control.
2. To associate their knowledge and practice with education and total duration of service.
MATERIALS AND METHODS
A cross-sectional study conducted in Bengaluru urban district which comprises four talukas and has 571 ASHA workers. Study carried out during the month of July-August 2017 when there was sudden increase (epidemic) in the dengue cases. As there were no specific documented data available with regard to dengue KAP among the ASHA workers. We conducted a pilot study in 5% of total ASHA workers and then computed an estimated for the value for 'P' which then was applied to calculate sample size. The value of P used in this study is 72% for KAP which was obtained after pilot study. Using the formula: N = 4pq/[d.sup.2] calculated at 5% significance level with 10% allowable error a sample size of 155 was obtained and for the study 155 + 10 extra for loss to follow-up, a total of 166 ASHA's were considered. By population probability sampling method from all the four talukas of Bengaluru urban district by simple random method, 166 ASHA workers who were working in their respective places for minimum of 3 months were included for the study. In the majority of the places recruitment of ASHA workers were based guidelines and in few places when no suitable person with desired qualification was available in those places educational qualification was relaxed as per the norms. 
Those who could not be contacted at least twice during the visit were excluded. After taking an informed verbal consent, data were collected using a pre-tested semi-structured questionnaire regarding sociodemographic profile, their knowledge regarding dengue and the preventive measures practiced by the ASHA workers in their field practice area by their records, based on the guidelines provided on Job responsibilities of ASHA workers in control of dengue and operational definition of complete implementation of preventive services in their field practice area by ministry of health and family welfare services. 
The data were entered in Microsoft Excel. SPSS version 16 was used for analysis. Data were analyzed using descriptive statistics such as frequencies, mean, and standard deviation were used, Chi-square test analysis was applied to know the association between the various variables. P [less than or equal to] 0.05 was considered statistically significant.
Mean age of the ASHA workers was found to be 33.4 [+ or -] 6.63 years with average educational level of 8.93 [+ or -] 2.06 standards. About 32 (19.3%) of ASHA workers were educated up to 7th standard, 125 (75.3%) had completed their education until 10th standard, 9 (5.4%) were educated until PUC. Average work duration was 4.92 [+ or -] 2.24 h and 30 [+ or -] 5.55 numbers of houses were visited per day. All the ASHA workers were trained in dengue prevention 166 (100%) which was conducted once in that year, and the average number of Information Education and Communication activities conducted were 2 per month to the community [Table 1]. Majority of the ASHA workers were aware of the characteristics symptoms of the DF 160 (96.4%), their role when suspected DF case was 161 (97.0%), complete preventive measures to practice 157 (94.5%), mode of transmission 152 (91.6%), breeding sites of mosquitoes 146 (88.0%), and man-made disease 147 (88.6%), whereas only 51(30.7%) were known of the danger signs of DF [Table 2]. About 101 (60.8%) of ASHA workers were not aware of self-protective measures, 140 (84.3%) were aware of partial control measures, only 3 (1.8%) were aware of complete control measures, and 23 (13.9%) were not aware of the control measure at all. Of the study participants, 147 (88.6%) knew that dengue is a man-made disease. ASHA workers who had work experience of more than 2 years had higher knowledge and practice about the dengue. Knowledge about danger signs and control measures were significantly higher among the ASHA workers with more than 2 years of experience [Table 3]. Awareness of control measures and knowledge about danger signs were less in both the groups. Although the knowledge and practice measures of dengue were better understood by ASHA workers with higher education, it was not statistically significant [Table 4]. About 68.7% of ASHA workers received the good response by the community with regard to the discussion on dengue, whereas 24.1% and 43.4% of ASHA workers were encountered the problems of lack of community participation and rejection for the preventive measure like emptying the open vessels [Figure 1].
A total of the 166 ASHA workers who were trained in dengue prevention, were residing and working in their respective places, covering a population of 800-1000 as per NRHM guidelines. Mean age of the ASHA workers was 33.4 [+ or -] 6.63 years with average educational level of 9th standards. Majority of the ASHA workers was aware of the characteristics symptoms of the DF such as their role when suspected DF, complete preventive measures, mode of transmission, and breeding sites of mosquitoes; whereas only 51(30.7%) were known of the danger signs of DF. Awareness of self-protective measures and control measures was poor. ASHA workers who had work experience of more than 2 years had higher knowledge and practice about the dengue, including the knowledge about danger signs and control. Majority of ASHA workers was encountered the problems of lack of community participation and rejection for the preventive measure like emptying the open vessels.
As per the NRHM guidelines all the ASHA workers resided and were working in their respective villages covering a population of 800-1000. All 166 workers were trained and it is been known that ASHA training is a continuous process which helps in improving her knowledge and skills for better implementation of the program.  Mean age of ASHA workers was 33 [+ or -] 6.63 years which are similar to many other studies. [9-12] Thus, majority of the ASHAs was young and this may be strength for program as they are enthusiastic and may deliver better service with proper motivation and capacity building.  Mean education of ASHA workers found in this study 8.93 [+ or -] 2 was similar to Mahyavanshi et al. study  which is sufficient enough for their proper learning and performance. Majority of ASHA's had knowledge about symptoms of DF, mode of transmission, breeding sites of mosquitoes, etc., similar results to the other studies whereas only 30.72% knew the danger signs of dengue which is very essential for early referral to hospital to prevent complications and deaths due to dengue, this aspect has been enhanced and given importance in guidelines for reporting of an outbreak of dengue [6,14] and these results indicate that this aspects needs to be stressed in their training program. [15,11] Although the study showed 143 (86.1%) practiced complete preventive measures, nearly 15% of the ASHA workers were lacking in that, hence there is need for reinforcement in the training sessions. [15,14]
One of the important factor influenced was about one-fourth of the workers complained that there was lack of community participation in implementation of control measures. Similar observation was noticed Malhotra and Kaur study,  Kohli et al. study in Delhi,  and Sreedevi et al. study in Karnool.  A study by Arpit et al. among the link workers of public health centers where the overall knowledge was increased from 15.7% to 25.6% after intervention (P < 0.0001).  Current study showed better knowledge and practice in ASHs with more years of experience than compared to the higher level education similar observations noted by Mahyavanshi et al. study in Surendranagar district wherein the duration of total services increased, knowledge, and practices also improved.  It is recommended that an assessment of the information that ASHAs have retained from theoretical and practical training must be conducted before ASHAs are able to work in the field, so that valuable information is not provided in error or omitted when they are counseling.
Strength and Limitations of this Study
Major strength of the study is selection of the study participants by randomization techniques as it represents the all ASHA workers in Bengaluru urban district, chances of bias are less. There are very few specific studies with regard to the dengue KAP among the ASHA workers. Hence, this study will add on to the knowledge in understanding the gaps knowledge and practices of ASHA workers regarding dengue control. Limitations of this study are that as it is self-administered questionnaire by ASHA workers, on-field practical assessment is not done by investigator hence detailed attitude component could not be carried out.
Present study showed that ASHAs knowledge is good but their practices are poor due to number of problems faced by them like lack of community participation which need to be addressed through skill-based training in terms of good communication and problem solving. Monitoring should be made an integral part of ASHA working in the field to ensure that knowledge is converted into practices as well. There are still lacunae left among some percentage of ASHA workers in their knowledge and practices about the dengue control. Training is the backbone of capacity building and functioning of ASHAs. Hence, it must be done timely, properly, and effectively. It has to be ensured during training that all ASHAs (100%) are well aware about their job responsibilities and are capable to fulfill their work. Hence, frequency and quality of training for ASHA workers needs to be strengthened by hands-on training sessions.
The authors would like to thank the Health and Family Welfare Department, Karnataka, India, and also the Department of Community Medicine, BGS Global Institute of Medical Sciences, Bengaluru, Karnataka.
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Source of Support: Nil, Conflict of Interest: None declared.
Poornima Chandrashekar (1), Savita S Patil (2), Bhanu Murthy Ramkrishnappa (3)
(1) Department of Health and Family Welfare Services, Regional Health and Family Welfare Training Centre, Bengaluru, Karnataka, India,
(2) Department of Community Medicine, BGS Global Institute of Medical Sciences, Bengaluru, Karnataka, India, department of Health and Family Welfare Services, K.C. General Hospital, Directorate of Health and Family Welfare Services, Bengaluru, Karnataka, India
Correspondence to: Savita S Patil, E-mail: email@example.com
Received: December 22, 2017; Accepted: January 11, 2018
Table 1: Basic profile of the ASHA workers Variables Values Mean age of the ASHA workers 33.4 [+ or -] 6.63 Mean education (standards) 8.93 [+ or -] 2.06 Mean Work duration in hours per day 4.92 [+ or -] 2.24 Number of houses visited per day 30 [+ or -] 5.55 Trained in dengue prevention (%) 166 (100) Training with regard to dengue attended in a year One Number of IEC activities conducted 2/month ASHA: Accredited Social Health Activist, IEC: Information Education and Communication Table 2: Details regarding knowledge about dengue characteristics (n=166) Characteristics Frequency n (%) Symptoms about dengue fever 160 (96.4) Danger signs of dengue fever 51 (30.7) Mode of transmission 152 (91.6) Breeding sites of mosquitoes 146 (88.0) Biting time 143 (86.1) Their role when suspected dengue fever case 161 (97.0) Man-made disease 147 (88.6) Complete preventive measures to practice 157 (94.5) Table 3: Knowledge and practice based on work experience Variables Responses Working experience (in years) n (%) [less than or equal to] 2 years (n=14) Knowledge about Not aware (%) 13 (92.8) danger signs Aware (%) 1 (7.2) Practice of Not aware (%) 2 (14.3) preventive measures Aware (%) 12 (85.7) Man-made disease Not aware (%) 1 (7.1) Aware (%) 13 (92.9) Control measures Aware of complete control measures 1 (7.1) Aware of partial control measures 9 (64.3) Not aware control measure at all 4 (28.6) Self-protection Not aware of self-protective 8 (57.1) measures measures Aware and following 5 (35.7) Aware not following 1 (7.1) Variables Working Total (%) n=166 experience (in years) n (%) >2 years (n=152) Knowledge about 102 (67.1) 115 (69.2) * danger signs 50 (32.9) 51 (30.8) Practice of 7 (4.6) 9 (5.4) preventive measures 145 (95.4) 157 (94.6) Man-made disease 18 (11.8) 19 (11.4) 134 (88.2) 147 (88.6) Control measures 2 (1.3) 3 (1.8) 131 (86.2) 140 (84.3) * 19 (12.5) 23 (13.9) Self-protection 93 (61.2) 101 (60.8) measures 50 (32.9) 55 (33.1) 9 (5.9) 10 (6) P<0.05 statistical significant Table 4: Knowledge and practice based on education Variables Responses Education Up to 7th (n=32) Knowledge about danger Not aware (%) 24 (75.0) signs Aware (%) 8 (25.0) Practice of preventive Not aware (%) 2 (6.2) measures Aware (%) 30 (93.8) Man-made disease Not aware (%) 2 (6.2) Aware (%) 30 (93.8) Control measures Aware of control measures 27 (84.4) Not aware control measure at all 5 (15.6) Self-protection Not aware of self-protective 24 (75.0) measures measures Aware and following 6 (18.8) Aware not following 2 (6.2) Variables Responses Education 8th standard and above (n=134) Knowledge about danger Not aware (%) 91 (67.9) signs Aware (%) 43 (32.1) Practice of preventive Not aware (%) 7 (5.2) measures Aware (%) 127 (94.8) Man-made disease Not aware (%) 17 (12.7) Aware (%) 117 (87.3) Control measures Aware of control measures 116 (92.8) Not aware control measure at all 13 (13.4) Self-protection Not aware of self-protective measures measures 77 (57.5) Aware and following 49 (36.6) Aware not following 8 (6.0) Variables Responses Total (%) n=166 Knowledge about danger Not aware (%) 115 (69.3) signs Aware (%) 51 (30.7) Practice of preventive Not aware (%) 9 (5.4) measures Aware (%) 157 (94.6) Man-made disease Not aware (%) 19 (11.4) Aware (%) 147 (88.6) Control measures Aware of control measures 143 (86.1) Not aware control measure at all 23 (13.9) Self-protection Not aware of self-protective measures measures 101 (60.8) Aware and following 55 (33.1) Aware not following 10 (6) Figure 1: Response by the community during the activity response by the community 68.7% lack of comminty participation 24.1% didn't allow preventive measures 43.4% others 7.2% Note: Table made from bar graph.
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|Title Annotation:||Research Article|
|Author:||Chandrashekar, Poornima; Patil, Savita S.; Ramkrishnappa, Bhanu Murthy|
|Publication:||International Journal of Medical Science and Public Health|
|Date:||Mar 1, 2018|
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