Gary G. Clark, Ph.D. Mosquito and Fly Research Unit CMAVE, ARS, USDA Gainesville, Florida The Important Role of Social Sciences in the Prevention of Dengue: Controlling Mosquitoes Produced in Containers * June 19, 2014

 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) Presentation topics

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

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 Plant trivets Bromeliads Plastic containers Abandoned swimming pool

And what they found near the residence of the second case Sweep of area yielded larvae- On the rooftop next door Fountain Bird bath Light fixture Bromeliads

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. These “containers” then became the focus of what the Keys MAD wanted community residents to eliminate or control

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 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? 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) They help us:

Knowledge-based approach versus behavior-based approach People lack knowledge People seek benefits and evaluate the pros and cons of their decisions Everyone needs the same Audience is segmented information based on its needs and special characteristics Technical information Messages are simple > non-participatory format easy to understand; provide skills; and persuade/motivate Focus on knowledge Focus on behavior change

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).

Lack of knowledge- There is no “problem” Recognition of problem- Problem of others Knowledge/acceptance of problem- Lack skills to resolve the problem Skilled community- Not motivated MOTIVATED COMMUNITY=> Prevention and control of dengue!! Community reaction to dengue prevention messages

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 air- conditioning. 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 accepted- minimal 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.