Transcript The Important Role of Social Sciences in the Prevention of

The Important Role of Social Sciences
in the Prevention of Dengue:
Controlling Mosquitoes Produced
in Containers
Gary G. Clark, Ph.D.
Mosquito and Fly Research Unit
CMAVE, ARS, USDA
Gainesville, Florida
* June 19, 2014
Presentation topics
 CDC’s Dengue Branch and dengue
 Aedes aegypti (Aa) and containers in
the Florida Keys
 The “community” and Aa control
 Role of social sciences
 Behavior change and dengue control
 Social sciences and dengue prevention
 Skills, barriers, motivation, cues, and
personal protection (and challenges)
Dengue Branch
Centers for Disease Control and Prevention
San Juan, Puerto Rico
Mission
 Develop national and international
surveillance programs for dengue/DHF
 Provide laboratory reference and
diagnostic services
• Provide training in clinical and laboratory
diagnosis of dengue
• Provide epidemic aid and investigate
epidemics
Dengue Branch
Mission (cont.)
• Conduct field and laboratory research
on biology and control of Aedes aegypti
• Develop, implement and evaluate new
community-based prevention strategies
• Conduct research and provide
consultation on improved surveillance,
prevention and control programs
• Serve as a World Health Organization
Collaborating Center
Dengue Branch
Focus
Domestic program- Puerto Rico and the
US Virgin Islands; state health departments
in the US
International program- Interactions with
countries with dengue problems, primarily
in the Americas
Recent emphasis on vaccine development
Dengue Branch
Program Philosophy
Research, development and public service
in Puerto Rico as a prelude to extending
experiences and lessons learned here to
other countries that are concerned about
the worsening problem of dengue/DHF.
Aedes aegypti
Aedes aegypti
• Lives around human habitations in urban
areas
• Lays eggs and produces larvae
preferentially in artificial containers
• Strong preference for human blood;
primarily a daytime feeder; often found
indoors
• Most important vector of dengue viruses in
the world
Containers with Aedes aegypti found
by the Keys MAD at the house where
the first 2009 dengue case resided
• On-site
• Metal container
• Pond with fish (no larvae)
• Neighboring residences
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Plant trivets
Bromeliads
Plastic containers
Abandoned swimming pool
And what they found near the
residence of the second case
Sweep of area yielded larvae•
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On the rooftop next door
Fountain
Bird bath
Light fixture
Bromeliads
These “containers” then became the
focus of what the Keys MAD
wanted community residents to
eliminate or control
They were hoping to see “community
participation” and find evidence of
(human) behavior change that yielded a
reduction in production sites for female
Aedes aegypti.
The traditional focus of dengue vector
control programs (especially in dengue
endemic areas) has been on:
• Widespread reliance on and use of
insecticides
• Reliance on government agencies for
control actions
• Vertically-structured programs
• “Community participation” = Government
directed programs
Why promote community participation
for dengue prevention and control?
• Aedes aegypti is often produced in close
proximity to households
• Human behaviors create larval mosquito
habitats
• Governments often lack sufficient funds
and personnel for control programs
• Permanent solution requires mutual
understanding and teamwork
Why does the community
not “participate”
in current dengue control programs?
• Minimal consideration of community’s
problems (e.g., crime, unemployment) and its
priorities
• Reduction of government services leads to
pressure on the community to take action
• Program failures often blamed on the
community
• Limited or no funding is provided to support
community actions
Social sciences relevant to modern
dengue prevention programs
• Anthropology- describes local culture
• Sociology- identifies and proposes
solutions to societal problems
• Social work- identifies and resolves
problems at the individual, family or
community level
• Psychology- understands individual human
behavior
• Health promotion- modifies human
behavior and the environment
Roles of social sciences in modern
dengue prevention programs (I)
• Provide a better understanding of
individual and community behavior
• Identify reasons for existing behaviors
which contribute to mosquito production
• Identify factors which will change these
behaviors
Roles of social sciences in modern
dengue prevention programs (II)
• Develop community-relevant
interventions and communicate their
benefits to the community
• Interact with vector control and
communications specialists to develop
action plans
• Develop tools to evaluate and monitor
behavior change
Current approach to behavior change
often assumes that:
• People do not know or recognize
what will be beneficial to them
• The community is an “empty
receptacle”
• Everyone needs the same information
for behavioral change to occur
• “Proper knowledge” leads to “correct”
behavior change
• The government knows best
Theories of behavior change
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Social learning theory
Theory of reasoned action
Health belief model
Stages of change theory
Elder, Geller, Hovell and Mayer 1994
Why use these behavioral theories?
They help us:
• Identify factors (i.e., knowledge, peers,
environment) which influence our behavior
• Increase understanding of these factors and
why people do or do not respond to proposed
interventions
• Define factors which motivate and/or enhance
desired behaviors
• Modify current approach which often focuses
on health education (not behavior change)
Knowledge-based approach versus
behavior-based approach
Focus on knowledge
Focus on behavior change
People lack knowledge
People seek benefits and
evaluate the pros and
cons of their decisions
Everyone needs the same
information
Audience is segmented
based on its needs and
special characteristics
Technical information
> non-participatory format
Messages are simple
easy to understand;
provide skills; and
persuade/motivate
Prochaska’s Stages of Change Model*
1. Precontemplation- Have not yet decided to
change
2. Contemplation- Seriously considering
change but not yet ready to start
3. Preparation- Made a commitment and
planning to take action soon (within a month)
4. Action- Now is the time “to do it”
5. Maintenance- Have taken action (6 months)
and realized that you can do it
6. Termination- Health habits are now
practiced
* Prochaska and DiClemente (1985) Cognit. Ther. Res.
How can we use social sciences
to develop a community-based
intervention program?
Using social sciences in dengue
prevention
1. Conduct formative research with residents
to determine the role and function of the
most productive Aedes aegypti habitats in
the domestic environment.
Why do residents have tires, flower vases,
cans, buckets, 55-gallon metal drums, clay
water jars, or pilas in or on their premises?
Or in Key West– Why are “metal containers,
plant trivets, plastic containers, fountains,
bird baths and light fixtures” present with
larvae in their yards?
Social sciences in dengue prevention
2. Conduct formative research to define
factors (e.g., irregular water supply,
excessive rainfall, or inadequate solid
waste disposal) which contribute to the
production of Aedes aegypti
mosquitoes.
Why do residents not participate in
programs?
Social sciences in dengue prevention
3. Analyze information obtained from the
formative research and begin to
develop possible solutions to the
problems that have been identified.
Explore possible interventions with
“key informants” (i.e., the person in the
family responsible for targeted
containers).
Social sciences in dengue prevention
4. In collaboration with community
members, conduct pilot tests of
proposed solutions to determine their
efficacy.
Which interventions will prevent larval
development and/or adult emergence
of Ae. aegypti?
Social sciences in dengue prevention
5. In collaboration with community
members, determine which
interventions are feasible, economical
and acceptable to community
members.
Any “solution” that is not accepted by
the community will not be adopted.
Social sciences in dengue prevention
6. Develop and pre-test messages that
promote specific interventions for
target audiences.
Messages should be:
- evaluated before being released;
- container-specific; and
- tailored to the person whose
behavior we want to change.
Social sciences in dengue prevention
7. Identify communication channels that
are appropriate for the message and
the target audience.
Messages may require multiple (e.g.,
mass media and interpersonal)
channels and should be disseminated
via the target audience’s “preferred”
source of information.
Social sciences in dengue prevention
8. Working with vector control staff, develop an
action plan for transmitting the messages to
the target audiences and develop evaluation
strategies.
Periodic monitoring will ensure that messages
continue to be effective and will allow for
appropriate adjustments in the communications
strategy.
Social science contributions to
dengue prevention programs
Use of evaluation results should improve
program efficacy and eventually result in:
- incorporation of the action into the routine
activities of the individual or household
(behavioral change) and
- institutionalization of social science and
communication practices into effective and
sustainable dengue prevention programs
(behavioral change).
Community reaction to dengue
prevention messages
• Lack of knowledge- There is no
“problem”
• Recognition of problem- Problem of
others
• Knowledge/acceptance of problemLack skills to resolve the problem
• Skilled community- Not motivated
• MOTIVATED COMMUNITY=>
Prevention and control of dengue!!
Community Participation
• First, must educate the public in the
basics of dengue, such as:
• Where the mosquito lays her eggs
• The link between larval and adult
mosquitoes
• How mosquitoes transmit DEN viruses
• General information about dengue
symptoms and treatment
• We are seeking behavior change, not
just an educated populace.
Skills Deficit
• Knowledge is not sufficient to
produce behavior change!!
• People may lack the skills (skills
deficit) necessary to carry out the
recommended behaviors
(elimination of some larval habitats)
• Need to address this skills deficit
Barriers and Motivation (I.)
• Knowledge combined with skills still
may not be sufficient to change
behavior
• Need to understand what barriers may
prevent the desired behavior, and
what factors may motivate people to
take the desired action
• Barriers and motivating factors vary in
different regions
Barriers and Motivation (II.)
• Structural factors
• laws regarding Aedes aegypti habitats
• Environmental factors
• lack of potable water, need to store water
• inadequate solid waste disposal
• Attitudinal factors
• beliefs: causes, treatment, prevention of
febrile illnesses
• Community factors
• community history and structure
• other priority problems in the community
Cues for
Dengue Preventive Behaviors
• People need reminders when they
are learning a new behavior
• Behavioral cues are prompts or
signals to remind the person to
engage in the desired behavior
Cues: Feedback
• Use regular feedback of entomologic and
epidemiologic data
• Every time someone receives the
information, it can serve as a reminder to
act
• If the data indicate control activities are
successful, they serve as positive
reinforcement
Cues: Presence of Adult Mosquitoes
• Idea to promote:
• Person sees adult mosquito
• Asks, “Where did it come from?”
• Immediately searches for larval
habitats
• Eliminates or controls all potential
habitats found
Cues: Rainfall
• Associate rainfall with the creation
of larval habitats
• Remind people to look for larval
habitats after it rains (e.g., after
tropical storms)
• Encourage people to eliminate
habitats created by rainfall
Personal Protection
• Make sure window and door
screens are secure and without
holes. If available, use airconditioning.
• When possible, wear long sleeves
and pants for additional
protection.
Personal Protection
Repellents
• Use repellent on your skin following label
instructions.
• Registered repellents (CDC recommended)
 DEET and Picaridin
• Unregistered repellents (EPA acceptedminimal risk to public health)
 Oils: citronella, cedar oil, geranium,
peppermint, and soybean.
Challenges for Prevention
• Achieve active community involvement
• Solicit input from the community in the
earliest stages of program planning
• Encourage community ownership
• Programs that emphasize telling
communities what to do, without
involving them or taking their views into
account, are not likely to be effective
• True community participation is key to a
successful dengue prevention program!
Acknowledgments
Sharon M. Hudson, Ph.D.
Linda S. Lloyd, Dr.P.H.
Carmen L. Perez, Ph.D.
Emily Zielinski-Gutierrez, Dr.P.H.
[email protected]