Tema relacionado con la salud






Resumen
El artículo explica un estudio que se realizó en Puerto Rico, sobre las creencias y prácticas de la comunidad sobre el dengue. Comienza estableciendo que el causante del dengue y sus variantes es el mosquito Aedes aegypti.
En Puerto Rico, el dengue es endémico y en ocasiones a resultado ser epidémico. La prevención comenzó en las Américas y el Caribe por programas militares que disminuyen los viveros de mosquito. Desde los 90’ el enfoque de la prevención ha sido enfocado en la eliminación de los viveros. Sin embargo, el acercamiento a las comunidades ha sido probado difícil pues continúa siendo un problema propagado.
El propósito del estudio explicado en el artículo es aprender como los mensajes y las intervenciones con la comunidad puedan ser mejorados y alcanzar practicas para prevenir el dengue a través de las residencias comunitarias.

El estudio fue conducido entre septiembre y octubre de 2003 en los municipios de Carolina, Guaynabo y San Juan. Se formularon 5 preguntas investigativas: (1) sExiste diferencia de creencias, actitudes y comportamiento acerca de la prevención del dengue por genero o por previo diagnostico de dengue? (2) sQué barreras afectan la adopción de prácticas de prevención del dengue? (3) sQué factores motiva la adopción de comportamientos de prevención? (4) sLos participantes comparten la misma opinión acerca de las estrategias de control del vector? (5) sLos participantes ven como convincente los mensajes de prevención para una audiencia especifica?
En los resultados se encontró que los problemas ambientales eran más importantes para las mujeresque para los hombres. Las mujeres entendían que los problemas se debían a la recolección insuficiente de basura por el gobierno, basureros ilegales, acumulación de gomas, falta de fumigación por el gobierno. Además las mujeres tenían más conocimiento acerca del dengue que los hombres. Los participantes que habían sido diagnosticados con dengue eran más conscientes de eliminar los criaderos de mosquitos. Las mujeres que no habían tenido diagnostico de dengue estaban más preocupadas por los efectos secundarios de los pesticidas como complicaciones respiratorias, que por eliminar los criaderos.
La mayoría de los participantes no sabía identificar el mosquito Adedes Aegypti. Los participantes entendían que a la problemática del dengue no le daban suficiente publicidad comparada con otras enfermedades.
En su conclusión, los autores establecen que las estrategias que motivarían a los residentes a implementar acciones para prevenir el dengue incluyen al gobierno supliendo agua potable a comunidades de poco acceso, ampliando el recogido de basura reduciendo el tiempo de recogido. También se deben implementar estrategias para el recogido de neumáticos de forma gratuita pues la comunidad no quiere pagar por un servicio de reciclaje. Los autores sugieren, utilizar los medios informáticos para campañas que eduquen sobre el dengue y el dengue hemorrágico y sus síntomas, diferenciándolos de otras enfermedades respiratorias o virales. Por último, el estudio sugiere que el gobierno exija educación continua para los profesionales de la salud referente al diagnóstico del dengue su tratamiento y prevención.
En mi opinión, el estudio el cual fue, a mientender, amplio no descubrió nada nuevo, excepto que puso de relieve que las mujeres se preocupan más por la salud colectiva mientras que por otro lado los hombres se preocupan más por la salud de individuo. Que el gobierno necesita mejorar el recogido de basura, el reciclaje de neumáticosž la orientación al público es de conocimiento general. Que se necesita utilizar los medios informáticos para llegar a las comunidades es sentido común. Entiendo se puede minimizar la pandemia y evitar una epidemia pero no me parece se pueda erradicar el problema pues por más cuidado que tenga la comunidad siempre existirán áreas imposible de supervisar por el hombre que se convierten en criaderos de mosquitos. No se puede evitar que llueva, ni que se empoce el agua, por lo cual se tiene que mantener la campaña de educación a la comunidad. Con lo que si concuerdo con el estudio es que se debe diferenciar la sintomatología del dengue de otras condiciones de salud para que la comunidad esté más alerta a los posibles peligros y este más dispuesta a buscar ayuda en los servicios de salud.
Intervenciones de Enfermería
La enfermera de la comunidad debe orientar sobre lo siguiente:
1. Educar sobre cuáles son los signos y síntomas del dengue.
2. Si las personas demuestran S/S indicarles no ingerir aspirina.
3. Educarles sobre medidas antipiréticas y animarles a buscar ayudad médica.
4. Recomendar el uso de mosquiteros, screenes y o repelentes de mosquitos.
5. Educarles sobre la eliminación de los criaderos de mosquitos.

Referencia:
Pérez-Guerra, C. L., Zielinski-Gutierrez, E., Vargas-Torres, D., & Clark, G. G. (2009). Community beliefs and practices aboutdengue in Puerto Rico. Revista Panamericana de Salud Pública, 25(3), 218-226. Recuperado el 1 de diciembre de 2011. Disponible en: https://search.ebscohost.com/login.aspx?direct=true&db=lth&AN=41562907&lang=es&site=ehost-live

Anejo:
218 Rev Panam Salud Publica/Pan Am J Public Health 25(3), 2009
Community beliefs and practices about
dengue in Puerto Rico
Carmen L. Pérez-Guerra,1 Emily Zielinski-Gutierrez,2
Danulka Vargas-Torres,1 and Gary G. Clark 1,3

Objective. In spite of long-term endemicity and repeated government and private efforts, effective,
sustained community participation for dengue prevention remains a challenge in Puerto
Rico. This study explored differences found in interviews conducted in 2001 in attitudes toward
dengue and its prevention by respondents’ gender and whether they had a prior dengue infection.
Findings may be used to develop messages to promote Aedes aegypti control practices.
Methods. From September to October 2003, 11 focus groups were conducted in San Juan,
Puerto Rico. Fifty-nine persons (35 women, 24 men), ≥18 years of age, who had been identified
through the Puerto Rico dengue surveillance system participated in the focus groups.
Analysis was based on grounded theory.
Results. Women considered dengue important because of its economic, emotional, and
health impact, and they were concerned more often than men about insufficient garbage removal
and water disposal. Participants with a previous dengue diagnosis were more concerned
about risk of the disease, were more knowledgeable about dengue and its prevention, and recommended
use of repellents more often than their counterparts without aprevious dengue
diagnosis. Barriers to sustained dengue prevention included misconceptions from outdated educational
materials, “invisibility” of dengue compared with chronic diseases, and lack of acceptance
of responsibility for dengue prevention.
Conclusions. Suggested strategies to motivate residents’ actions included working with
government agencies to address structural problems that increase mosquito populations, improving
access to information on garbage collection and water disposal through telephone hotlines,
increasing publicity and information about dengue by mass media campaigns, and educating
health professionals.
Dengue, health education, vector control, Puerto Rico.
ABSTRACT
Dengue and dengue hemorrhagic
fever (DHF) are acute febrile viral infections
caused by any of four dengue
viruses (1, 2). It is a mosquito-borne disease,
and the principal vector is Aedes aegypti.
In the past 20 years, dengue transmission
and the frequency of epidemics
have increased in the tropics and subtropics
of the Americas. Dengue is endemic
in Puerto Rico and epidemic
transmission occurs periodically. In
nonepidemic years, reported cases of
dengue range from about 3 400 to 7 000
per year (3). The highest period of disease
activity during the 1990s was the
1994 epidemic when 24 700 suspected
dengue cases were reported (4).
Key words
riginal / Original research
Pérez-Guerra CL, Zielinski-Gutierrez E, Vargas-Torres D, Clark GG. Community beliefs and practices
about dengue in Puerto Rico. Rev Panam Salud Publica. 2009;25(3):218–26.
Suggested citation
1 Dengue Branch, Division of Vector-Borne Infectious
Diseases, National Centerfor Zoonotic, Vector-
Borne, & Enteric Diseases, Centers for Disease Control
and Prevention, San Juan, Puerto Rico. Send
correspondence and reprint requests to: Carmen L.
Pérez-Guerra, Dengue Branch, Division of Vector-
Borne Infectious Diseases, Centers for Disease Control
and Prevention, 1324 Calle Cañada, San Juan,
Puerto Rico 00920-3860; telephone: (787) 706-2399;
fax: (787) 706-2496; e-mail: cnp8@cdc.gov
2 Division of Vector-Borne Infectious Diseases, National
Center for Zoonotic, Vector-Borne, & Enteric
Diseases, Centers for Disease Control and Prevention,
San Juan, Puerto Rico.
3 Current address: Mosquito and Fly Research Unit,
Center for Medical, Agriculture and Veterinary
Entomology, Agriculture Research Service, United
States Department of Agriculture, Gainesville, Florida,
United States of America.
Rev Panam Salud Publica/Pan Am J Public Health 25(3), 2009 219
Pérez-Guerra et al. • Beliefs and practices about dengue in Puerto Rico Original research
A. aegypti mosquito control in the
Americas and the Caribbean was initiated
through large, vertical, almost militaristic
programs that combined decreasing
the number of mosquito breeding
sites and use of insecticides. These government
programs were not sustainable
over the long term. Since the 1990s, the
theoretical focus for dengue prevention
shifted to community-based elimination
of mosquito breeding sites (5). These approaches,
however, have proven difficult
to put into practice. Today, dengue
is a widespread problem, with at least
35 countries in the Americas and the
Caribbean reporting dengue cases and
19 reporting DHF cases (6). The best approachesfor truly involving the general
population in dengue prevention are a
pressing concern.
In Puerto Rico, government efforts,
supported by the private sector (i.e., Rotary
International), have successfully educated
the public about the vector, the
transmission cycle, clinical symptoms,
and prevention methods (5, 7). These efforts
promoted household responsibility
in eliminating or controlling breeding
sites for A. aegypti and used insecticides
to reduce the adult mosquito population.
However, achieving sustained community
participation for dengue prevention
during periods of low disease activity
remains a challenge. We initiated a study
to learn how messages and interventions
might be improved to achieve sustained
dengue prevention practices among community
residents.
In 2001, group interviews were conducted
in four geographic areas of
Puerto Rico (7) to gather information
from residents that would help develop
more effective messages and
strategies to promote community involvement
in dengue prevention initiatives
and to augment residents’ adoption
of dengue prevention behaviors.
In that study, we found that men and
women had similar knowledge, attitudes,
and strategies about dengue prevention
regardless of their previous
dengue diagnosis. However, we found
differences by gender related to the
type of and most common production
sites (7).
This study was conducted to further
explore differences noted in 2001 interviews
in attitudes toward dengue and its
prevention by gender and to investigate
whether we find differences by previous
dengue infection.
MATERIALS AND METHODS
From September to October2003,4 we
conducted 11 focus groups in three municipalities
(Carolina, Guaynabo, and
San Juan) in the greater San Juan metropolitan
area. Focus group participants
from these municipalities were divided
according to gender and the presence or
absence of a previous laboratory-diagnosed
dengue infection. For each municipality,
we selected a random sample of
patients from the Dengue Branch of the
Centers for Disease Control and Prevention
(CDC) and the Puerto Rico Department
of Health (PRDH) dengue surveillance
system database who had a
positive IgM antibody test for dengue
from 1994 to 1999 and were > 18 years of
age. The potential participants identified
from the database were contacted by
telephone and invited to “participate in a
focus group about dengue prevention”
until five or more persons from each municipality
agreed to participate.
To recruit participants who were not
aware of having a previous laboratorydiagnosed
dengue infection, investigators
contacted the neighbor three houses
to the right of a participant with a previous
dengue infection. This neighbor was
invited to participate in the study if he
or she was > 18 years of age and had
no knowledge of a previous dengue infection.
Five or more persons in this
category from each municipality were
enrolled in the study. Each focus group
participant received a modest stipend for
travel costs.
We formulated five research questions:
(1) Are there differences in beliefs,
attitudes, and behaviors toward dengue
prevention by gender or previous dengue
diagnosis? (2) What barriers hinder the
adoption of dengue prevention practices?
(3) What factors willmotivate the
adoption of preventive behaviors? (4) Do
focus group participants share the same
opinions about the best strategies for
vector control programs as the participants
in the prior study? (5) What do
current focus group participants see as
compelling dengue prevention messages
for specific audiences?
The participants were also asked
their opinions about strategies proposed
by participants in the 2001 study for
the government to initiate to prevent
dengue (7). Dengue prevention methods
suggested by participants in the 2001
study included (1) house visits, (2) community
group discussions and orientations,
(3) development of community
groups, (4) implementation of laws and
fines for violators who keep A. aegypti
breeding sites at their residences, and (5)
a dengue educational media campaign.
A 14-item, open-ended question guide
was developed based on the research
questions described above and the guide
from the 2001 study (7). The 2001 question
guide was pretested with 10 members
of a church from Carolina. Modifications
were made to the 2001 guide to
address the new objectives of this study.
Before each focus group, informed consent
was obtained from each participant.
Groups of participants (average five persons)
were convened and their responses
to the 14-item question guide were annotated
and audio taped by the assistant
moderator, the third author (D.V.T.). The
focus groups were moderated by the
first author (C.L.P.G.) to ensure that all
participants expressed their opinions.
The term “grounded theory” refers to
a qualitative research method in which
a theory is developed from data. Responses
(data)are grouped in categories,
from which large themes or concepts
are identified. A content analysis with
grounded theory procedures was used
to analyze the data generated from the
focus groups and to answer the research
questions (8–10). Open coding analytical
procedures, which identified central categories
and subcategories for analysis,
were used. In addition, we used axial
coding in which the relation between
subcategories was determined. We compared
results from the focus groups with
the 2001 group interviews (7) and results
from other published research (11–20).
To enroll 20 dengue-positive focus
group participants, 135 telephone calls
were made. There was no response or the
phone was out of service for 42/135 (31%)
of the calls; 93/135 (69%) potential participants
were reached, and 45/93 (48%)
agreed to participate in a focus group. Ultimately,
only 20/45 (44%) attended one
of the focus group sessions and no information
was available about those who
did not participate. After the dengue-positive
patients had been reached by telephone,
44 neighbors, who had no recollection
of a previous dengue infection,
were visited; 39/44 (89%) agreed to par-
4 The protocol for this project was reviewed and approved
by the Centers for Disease Control and Prevention
Institutional Review Board protocol 3965.
220 Rev Panam Salud Publica/Pan Am J Public Health 25(3), 2009
Original research Pérez-Guerra et al. • Beliefs and practices about dengue in Puerto Rico
ticipate and all were present at the group
sessions. A total of 59 persons ≥18 years
of age—35 women and 24 men—participated
in the focus group sessions.
RESULTSAnalysis of the focus group participants’
responses resulted in the identification
of 7 large categories and 26 subcategories.
These results are presented
in Table 1 (categories) and Table 2 (subcategories),
with comparisons to the results
of the 2001 study (7). Current responses
differed by gender and history
of dengue diagnosis. For example, environmental
problems related to dengue
were more important for women than
for men. Women described these problems
as insufficient garbage collection
by the government and garbage disposal
in illegal dumps by the public, liquor
stores (which store containers for recycling),
and tire and auto repair shops (a
problem that men supported); mosquito
proliferation; and lack of fumigation
by the government. In addition, women
were more knowledgeable than men about
dengue.
Differences by gender were also seen
when participants discussed the perceived
severity of dengue. For women
with a previous dengue diagnosis,
dengue was serious because “there is
no vaccine” to prevent it, it has a “high
incidence” on the island, and it “causes
social, economic, job, family, and emotional
problems” for both the patient
and the government. Contrary to these
women, dengue was serious for men because
“people think it’s just a mosquito
bite” and are not aware of its severity.
That is, for women dengue is serious because
it is a widespread health problem
that affects many people, whereas for
men it is “serious” because it can cause
grave damage to an individual’s health.
Participants with a previous dengue
diagnosis, regardless of gender, were
more knowledgeable about dengue, its
symptoms,complications, and treatment
than participants without a previous
dengue diagnosis. Both men and women
took responsibility for decreasing the
number of breeding sites, although
women were seen as responsible for
breeding sites related to household domestic
activities and men were responsible
for tires, cars, and rubbish (Table 3).
All focus group participants indicated
that dengue can be prevented by avoiding
and eliminating “stagnant water” or
containers with water, but there were
some differences by gender and history
of previous dengue diagnosis. Women
with a previous dengue diagnosis thought
that dengue could be prevented by
“avoiding mosquito egg [laying],” while
women with no prior history of dengue
reported that they added drops of chlorine
to stored water and surroundings.
Women, regardless of previous dengue
diagnosis, mentioned fumigation and
using insecticides inside the house for
preventing dengue, whereas men with a
previous dengue diagnosis mentioned
using repellents for dengue prevention.
Women without a previous dengue diagnosis
were more likely than women
with a previous dengue diagnosis to
voice concern about fumigation and
its effect on health (e.g., spraying pesticides
may cause respiratory complications
such as asthma in their children).
Participants had divided opinions
when discussing the first four prevention
strategies recommended by participants
from the 2001 study. House visits were
not seen as appropriate because it was
believed that residents usually do not
have time to receive visits and reject visits
for selling, religious, or educational
purposes. Moreover, they expressedthe
opinion that the population of Puerto
Rico is too large for the PRDH to conduct
these house visits.
However, some participants thought
that house visits with distribution of educational
materials and a demonstration
of how to locate and discard containers
with mosquito larvae was the best strategy,
especially if health department staff
and community volunteers conducted
the visits. They explained that PRDH
staff have knowledge about the problem
and the volunteers will give a friendly
approach to the visit.
Some participants saw community
group discussions, orientations, and
health fairs with educational materials as
the best strategy, while others thought
that few people would attend these
activities.
The implementation of laws and fines
was not seen as a good strategy by almost
all men, contrary to men from the
2001 study who suggested implementing
fines for people who keep mosquito
production sites on their property. However,
most women in this study supported
fining violators and said that
these fines should be applied after house
visits and that violators should be monitored
at least once.
The following government actions by
type of container were suggested: (1) de-
TABLE 1. Categories as identified in transcriptions of 2001 group interviews and 2003 focus groups conducted in Puerto Rico
Category 2001 2003
a DHF, dengue hemorrhagic fever.
1
Most important biological, psychological, and social problems
faced by participants in their communities
Knowledge about dengue and DHFa and their prevention
Attitudes about dengue and DHF and their prevention
Community behaviors related to dengue and DHFIdeas to encourage the adoption of dengue prevention behaviors
Design of a dengue prevention mass media campaign
Most important environmental problems faced by participants in
their communities
Knowledge about dengue and DHF and their prevention
Mosquito breeding sites described most frequently by participants,
their function, and person responsible
Attitudes toward dengue and DHF and their prevention
Current personal behaviors practiced by participants to prevent
dengue
Specific actions suggested by participants to avoid potential
breeding sites
Government strategies discussed by participants to motivate the
adoption of dengue prevention behaviors among the population
Rev Panam Salud Publica/Pan Am J Public Health 25(3), 2009 221
velop a law to enforce fees for tire recycling
like the one developed for car oil,
develop an educational program for tire
recycling, and create a telephone hotline
for discarded tire pickup; and (2) develop
a hotline or information group to
educate the community about regulations
for tire recycling and coordinate collection
services.
Similar to the 2001 study, focus group
participants recommended an educational,
mass media campaign as a government
strategy to supplement the
above activities. Participants believed that
the campaign should include (1) distribution
of educational materials in public
places such as supermarkets, beaches,
restaurants, churches, and health centers;
(2) coordination among government
agencies and the inclusion of school children
to take information about dengue to
TABLE 2. Subcategories as identified in transcriptions of 2001 group interviews and 2003 focusgroups conducted in Puerto Rico
Subcategory 2001 2003
a DHF, dengue hemorrhagic fever.
1
Most important problems in the community Waste
Most important health problems in the community Lack of maintenance of abandoned houses, buildings, and green areas
Definition of dengue Mosquitoes
Definition of DHFa Lack of fumigation
Dengue and DHF symptoms Dengue definition, symptoms, treatment
Relationship between Aedes aegypti and dengue DHF definition, symptoms, treatment
Relationship between Aedes aegypti and garbage and containers with water Aedes aegypti relation to dengue
Aedes aegypti breeding sites in their communities Aedes aegypti relation to garbage
Definition of “important problem” Aedes aegypti relation to containers with water
Definition of “prevention” Breeding containers
Definition of “garbage” Container function
Ideas about dengue Person responsible for container
Responsibility for eliminating and controlling breeding sites Participant’s perception of dengue
Current personal and household behaviors for preventing dengue Responsibility for eliminating and controlling Aedes aegypti breeding
sites
Specific actions to eliminate Aedes aegypti breeding sites Eliminating stagnant water
Strategies to be implemented by government to promote dengue Cleaning breeding sites and surroundings
prevention
Evaluation of previous dengue prevention campaigns Changing water
Messages to motivate target audiences Pouring chlorine into water
Best spokesperson Fumigation
Best media Using repellents
Best time Visiting physicians when suspecting dengue
House visits
Community group discussions
Development of dengue prevention communitygroups
Implementation of laws and fines
Education campaign for community and physicians
TABLE 3. Most common breeding sites described by participants, their function, and person responsible, Puerto Rico, 2003
Container Function Person Responsible
Tires Replacement Men
Retained until carted Tire shops
Flower pots/dishes, flower vases, water plants Decoration Women
> 1-gallon containers Garbage thrown in yard Women
Milk/soda plastic containers Water plants Women
Buckets/pails Wash cars Men
Mop Women
Laundry Women
Water plants Women
Store water Women
Reserve parking spaces Women and men
Trash cans (industrial/house) Retain garbage until collected by sanitation services Industry/condominium management, women
Old cars Replace damaged auto parts Auto repair shop owners
Retained because of lack of information about collection services Men
Rubbish (washing machines/refrigerators/ Retained until collected by sanitation services or thrown in Householders/senior residents
dead animals) illegal dumps
Clogged drainage No function Residents/government
Rivers/lagoons with garbage Used as illegal dumps Residents/government
Puddles/high vegetation No function No person/agency responsible
Pérez-Guerra et al. • Beliefs and practices about dengue in Puerto Rico Original research
222 Rev Panam Salud Publica/Pan Am J Public Health 25(3), 2009
Original research Pérez-Guerra et al. • Beliefs and practices about dengue in Puerto Rico
their homes; (3) development of a dramatic
and fear-provoking public service
announcement (PSA) including dengue
definition, prevention methods, and
shocking testimonials that would be
aired frequently throughoutthe year;
(4) development of a video showing the
mosquito, its breeding cycle, most common
breeding containers, prevention
methods, and symptoms and treatment
of dengue and DHF; and (5) education of
physicians about dengue diagnosis and
treatment. Messages should be delivered
mostly by television and newspapers
distributed island-wide and regionally.
For program spokespersons, participants
generally preferred people who had suffered
from dengue and represented the
audience responsible for the container
that produced mosquitoes on the property.
Women preferred that PRDH officials
send general prevention messages
but also suggested that entertainers do it,
while men preferred community leaders.
The same three key themes obtained
in the 2001 study (7) were also found in
the content analysis of transcripts from
the current study and thus confirmed
earlier results. The first theme, misconceptions
about dengue and its vector, included
participants’ description of the
A. aegypti mosquito, the potential breeding
habitats and the type of water where
the mosquito breeds, and “cleaning” as a
central concept for dengue prevention. It
also involved the confusion of dengue
with the common cold and other similar
viral illnesses. The second theme, the
“invisibility” of dengue, emphasized the
limited discussion of dengue as a health
problem in the mass media compared
with chronic illnesses. The third theme,
responsibility for dengue prevention,
presented the importance of individual
and government responsibility to control
dengue. The issues described under
these three themes summarize the main
barriers for dengueprevention.
Misconceptions about dengue
prevention
Almost all focus group participants
demonstrated correct knowledge about
transmission, symptoms, and treatment
of dengue and DHF; container conditions
conducive to mosquito breeding;
and potential breeding containers. Still,
most participants had incorrect knowledge
about the physical description of
A. aegypti, confusion about the type of
water and place where the vector mosquito
breeds, and information that many
people confuse dengue with a cold.
These misconceptions influenced participants’
attitudes and practices to prevent
dengue. First, an incorrect description
of the vector mosquito means, as
participants said, that they failed to recognize
mosquitoes inside their residences
as those that transmit dengue
and may confuse it with other mosquitoes,
thus not perceiving their risk of becoming
infected with a dengue virus.
Participants also thought they were incapable
of avoiding mosquitoes and thus
dengue, because mosquitoes are everywhere
and are difficult to control, contrary
to the fact that if community members
eliminate or control potential
breeding sites it is possible to reduce
A. aegypti abundance indoors. Although
most people recognized the need to
eliminate accumulated or uncovered
water to prevent dengue, some perceived
it as a useless effort since mosquitoes
are always present. Participants saw
mosquitoes as part of the daily life of
Puerto Ricans, for which they use repellents,
insecticides, and screens with
moderate success. For them, the effective
strategy against mosquitoes is periodic
fumigation by government.
Second, misconceptions aboutthe
“type” of water also influenced the attitudes
and practices of participants, as
most associated clear or clean water only
or dirty water only with A. aegypti. Participants
thought that if they did not have
this specific kind of water, they would
not have the vector mosquito and, therefore,
did not recognize the need to eliminate
any water present in a container to
reduce the presence of A. aegypti.
Third, while half the participants
named bodies of water with garbage as
places where A. aegypti can breed, the
other half said that it can also breed in
high vegetation and humid places with
puddles, regardless of the presence or absence
of garbage. Consequently, they believe
it is difficult to eliminate the mosquito
and dengue given the ubiquitous
humid places and vegetation (Table 3).
Fourth, “cleanliness” was seen as
central to dengue prevention as participants
emphasized cleaning the premises,
surroundings, containers, and conducting
“collective cleanups” to prevent
mosquito breeding. Although it is accurate
that cleaning potential containers
will prevent the mosquito from breeding,
participants’ understanding that a
“clean” or orderly house is free from
A. aegypti is not necessarily correct since
containers with larvae may still be present
but not visible or disorderly (7). For
this reason, people might not realize that
they are breeding mosquitoes and potentially
increasing their risk of exposure to
dengue. Such was the case of a female
participant who did not identify with the
filthy yard in a PSA because her yard appeared
“clean” but, after having DHF
she found that plates to collect excess
waterunderneath the flower pots in her
yard had mosquito larvae.
Fifth, participants also said that the
general population and some health professionals
confused dengue with a common
cold and other respiratory diseases.
Puerto Ricans typically do not consider
colds to be serious and rarely seek medical
treatment for cold symptoms. Since
dengue and cold signs and symptoms are
similar at the onset, people do not feel
threatened and do not seek diagnosis
and treatment in a timely manner. When
doing so, they feel frustrated, even in
DHF cases, by the treatment they receive
from hospitals and physicians, the lack of
diagnosis, and the delay in receiving laboratory
test results. Participants of both
genders insisted that physicians and
health professionals in emergency rooms
are “uninformed” and “needed orientation”
to diagnose and treat dengue.
“Invisibility” of dengue
Similar to 2001 study participants (7),
focus group participants indicated that
dengue was given little publicity and
importance by the population and the
government compared with other—particularly
chronic—diseases. Female participants
defined the concept of an “important
problem” as a situation that is
presented in the newspapers and on television
news programs. Participants said
that, because of its limited presence in
the media, dengue is not seen as a health
priority; therefore, people minimize its
importance and they do not feel at risk
of contracting it. Although participants
considered dengue a serious problem,
no dengue PSAs emphasizing control
measures for potential breeding sites are
routinely broadcast; hence, people are
not aware oftheir consequences. In contrast,
private companies have promoted
the use of insecticides and repellents
only during dengue season. Moreover,
Rev Panam Salud Publica/Pan Am J Public Health 25(3), 2009 223
participants said that dengue cases are
not recognized by the government for
political reasons (7), “which reacts with
fumigation only when many people get
sick.” For these reasons, participants
said that the population does not eliminate
A. aegypti breeding sites.
Responsibility for dengue prevention
Concurring with results from the 2001
study (7), responsibility for dengue prevention
also emerged as the third theme
and was a central concept identified by
focus group participants to motivate the
population to take preventive actions.
Participants agreed that the population
was responsible for practicing behaviors
to prevent dengue (Table 4), but they
also demanded “active participation by
the government.”
Besides fumigation, participants expected
the government to solve problems
with the infrastructure and public
services related to dengue prevention.
For example, they insisted on improving
potable water services, enhancing waste
and rubbish collection services, and establishing
better strategies for tire collection
and recycling. Fees for taking refuse
to the landfill by the private sector were
not acceptable to many participants, as
they view waste disposal as the government’s
responsibility. These fees for
waste disposal were barriers to the
proper disposal of waste and prevention
of breeding sites.
The government’s lack of involvement
in maintaining public buildings, green
areas, and water service werebarriers to
community-wide dengue prevention.
When public buildings and green areas
are not maintained, people use them as
illegal dumps. People also store water in
their houses because water services are
inadequate.
Additionally, participants expected
the government to continue educating
the public about the mosquito vector and
its breeding sites, dengue and its symptoms,
and diagnosis and treatment of
dengue. They expect the government to
suggest behaviors to prevent A. aegypti
breeding throughout the year, rather
than only during “dengue” season. Participants
also advised using island-wide
and regional newspapers and the radio
to inform the public about localized outbreaks
instead of ignoring or hiding the
problem for political purposes.
DISCUSSION
The purpose of this study was to identify
differences in knowledge, beliefs, attitudes,
and practices about dengue prevention
in focus groups with men and
women with and without a prior dengue
infection and to compare the differences
with those found in the 2001 study (7).
While there were few differences between
the two studies, those that existed were
interesting. New barriers mentioned in
this study involved the payments and
fees required for recycling and waste collection
and the perception of health professionals’
lack of knowledge about how
to diagnose and treat dengue.
However, participants from both studies
reiterated that a collective response
was needed to prevent dengue, since it is
a problem generated by both the government
and the community. Whereas the
2001 study participants developed a list
of the four best strategies for dengue prevention(7), the focus group participants
agreed that none of those four would be
the best strategy to promote the adoption
of preventive behaviors but that a
strategy integrating all four could help
increase awareness of dengue prevention.
Instead, they suggested developing
telephone hotlines to improve tire,
waste, and rubbish pickup and eliminating
payment and fees to dispose of rubbish
in landfills.
Another difference was that women
participants in the 2001 study supported
fumigation by the government as the principal
strategy to prevent dengue, while
some women without a previous dengue
diagnosis from the focus groups questioned
its effectiveness and feared that
it could be harmful to their health. No
major differences were found between
2001 study participants and those from
this study when their knowledge, beliefs,
attitudes, and practices were compared.
We found that differences by gender
did exist. Compared with men, women
thought dengue was a serious disease
because of the burden and impact to
society. Men thought it was serious
because of an individual’s lack of perceived
health risk. Women also were
TABLE 4. Specific actions suggested by participants to avoid potential breeding sites,
Puerto Rico, 2003
Potential breeding site Suggested action
Tires Recycle
Plant flowers in them
Store them in dry places
Store them in plastic bags
Call municipality for pickup
Flower pots with dishes Eliminate dishes
Eliminate flower pots
Eliminate water from dishes
Pour small amounts of water into plants
Pour chlorine and chemicals into water in dishes
Put newspaper in dishes to absorb excess water
Pour soil indishes
Punch holes
Flower vases Change water every day
Add chemical to water
Water plants Plant them in soil
Buckets and pails Check and clean them
Store them upside down
Eliminate water
Store them in dry places
Clean and cover them
Trash cans Cover them
Throw garbage away every day
Punch holes
Clean them with chlorine
Milk gallons Store them in dry places
Store them upside down
Swimming pools in construction Cover them with plastic
Rubbish Store in dry places until truck comes
All containers Recycle
Check for and eliminate stagnant water
Pérez-Guerra et al. • Beliefs and practices about dengue in Puerto Rico Original research
more concerned about infrastructure
problems potentially contributing to increased
dengue transmission. In addition,
women were seen as responsible
for most breeding sites related to domestic
activities, while men were responsible
for tire and rubbish removal.
Most of these findings are consistent
with the cultural values and the social
norms of Puerto Rico. Although many
men actively participate in domestic and
health issues, society continues to perceive
women as responsible for the
household and the health of family members.
In addition, many women in Puerto
Rico are single mothers and household
heads. These findings suggest that compelling
messages about dengue prevention
need to target men’s and women’s
issues differently and directly.
Disparities by history of a previous
dengue diagnosis revealed that participants
with a previous dengue diagnosis
were more concerned about other people’s
risk of contracting dengue and were
more knowledgeable about dengue and
about effectiveprevention practices than
participants without this life experience.
Participants with a previous dengue diagnosis
also supported the use of repellents
to avoid mosquito bites—and hence
dengue—more than their counterparts.
For these reasons, it is important to consider
testimonials using people with a
previous dengue diagnosis as spokespersons
for educational campaigns.
The CDC had promoted the use of repellents
for tourists visiting dengue endemic
areas including Puerto Rico and
for other mosquito-borne diseases such
as West Nile virus. In the past, private
companies in collaboration with government
agencies financed the preparation
and production of educational materials
including preventive practices for specific
breeding sites. This collaboration
was partially discontinued because it
was thought that the materials sent contradictory
messages to the population
(e.g., avoiding bites by using chemicals
versus getting rid of mosquito breeding
sites) and the issue of including brand
names was complicated for government
agencies. Rather than avoiding this issue,
the appropriate use of repellents
and insecticides can be promoted as a
strategy complementary to the primary
strategy of eliminating breeding sites.
Similar barriers to dengue prevention
were found among participants from
this study and from the 2001 study (7). In
summary, the lack of importance given
to dengue limits the public’s interest in
carrying out dengue prevention actions.
For participants, the lack of importance
given to dengue was reflected by the
lack of government involvement in solving
underlying infrastructure problems
associatedwith dengue transmission,
the lack of publicity about dengue, and
the lack of fumigation.
Gubler and Clark (5) identified the lack
of planned urbanization and inadequate
potable water and waste disposal services
as infrastructural problems contributing
to dengue transmission. The lack of
involvement by the community was reflected
by the community’s perceived low
risk of contracting dengue, the inability of
the population to differentiate A. aegypti
and effectively avoid it, and the lack of
knowledge to recognize the type of water
where A. aegypti breeds and to differentiate
dengue symptoms in contrast to those
caused by colds and other viral diseases
that are not considered to be life-threatening
to the population.
Lloyd et al. (18) found that for residents
in Mérida, Mexico, it was important
to explain the presence of other mosquito
species after conducting dengue
prevention activities in order to get the
community to sustain them.
Panagos et al. (19) also found that twothirds
of residents surveyed in Grenada
could name mosquitoes as dengue vectors
but could not identify A. aegypti,
making it difficult to implement control
measures.
Entomologic studies have also demonstrated
that A. aegypti develops in containers
with standing water and organic
material that gets darker over time (12),
a fact that participants did not know.
The confusion about the type of water
and the distorted description of the mosquito
may come from earlier educational
materials that showed an enlarged image
of the mosquito or a cartoon and demonstrated
containers with clean water.
These materials make it difficult for the
public torecognize A. aegypti in their
households and to look for potential
breeding sites (7). The CDC recently developed
educational materials that included
real visuals of the mosquito that,
although enlarged, specified its real
measurements in addition to the various
types of water where it breeds.
Previous studies in Brazil (11), Colombia
(14), the Dominican Republic (15, 16),
Mexico (18, 20), and Puerto Rico (7, 17)
also found that participants confused
dengue with other febrile and respiratory
illnesses that are not considered serious
health problems by participants and are
not related to mosquitoes. Hence, participants
did not take prevention actions to
avoid a dengue illness. Also, Claro et al.
(13) analyzed 11 published articles related
to knowledge, attitudes, and practices
about dengue in various countries
and found that the association of dengue
with milder febrile, respiratory, and viral
illness resulted in a lack of concern by the
population. The association of dengue
with other febrile diseases also reduced
the association between the mosquito
vector and dengue.
The consistency between this study
and the 2001 study gives us confidence
that these views cover many of the important
barriers to dengue prevention in
Puerto Rico. Furthermore, similar results
were found in research conducted in
other dengue endemic countries (11–21).
However, qualitative research findings
cannot be generalized since the selected
samples do not represent the entire population.
In addition, underrepresentation
of participants with a previous dengue
diagnosis could have biased our results.
CONCLUSIONS
On the basis ofparticipants’ responses,
the strategies that would motivate
residents to implement dengue prevention
actions include the integrated
involvement of government agencies improving
potable water services in communities
with reduced access, enhancing
waste collection services by reducing
waiting periods for pickup, and providing
telephone numbers to improve access
to information about these services.
Proactive actions could also include establishing
better strategies for tire collection
and recycling and offering carting
and recycling for free. While the
community does not want to pay for
these services, they accept a municipality
tax of 1% that was implemented in
Puerto Rico in 2006. A percentage of this
tax could be used for these infrastructure
improvements.
Although participants demonstrated
concern about the feasibility of conducting
island-wide house visits, this activity,
supplemented with educational materials,
could be implemented during localized
outbreaks in specific communities
with the collaboration of community
224 Rev Panam Salud Publica/Pan Am J Public Health 25(3), 2009
Original research Pérez-Guerra et al. • Beliefs and practices about dengue in Puerto Rico
Rev Panam Salud Publica/Pan Am J Public Health 25(3), 2009 225
Pérez-Guerra et al. • Beliefs and practices about dengue in Puerto Rico Original research
groups and health officials. A mass media
campaign through island-wide and regional
newspapers, television newscasts,
and radio programs could also complement
this effort and address knowledge
gaps about dengue and its prevention.
This media campaign would also increase
publicity and informationabout dengue,
making it a visible priority for the government
and the community.
Compelling campaign messages must
contrast dengue and DHF symptoms
and their differences from other respiratory
and viral diseases and should emphasize
the symptoms that should trigger
persons to seek medical attention
to avoid complications. PSA and educational
materials should also include specific
prevention practices directed to the
member of the household that relates
to the container or the function it plays
in the household. Information about
dengue incidence, outbreaks, and outbreak
locations should be published in
the media. Moreover, since dengue is a
reportable disease by law in Puerto Rico,
the government could require continuing
education programs for health professionals
to refresh their knowledge
about dengue diagnosis, treatment, and
prevention.
The CDC Dengue Branch and PRDH
have a passive, laboratory-based surveillance
system for dengue that identifies
outbreaks and their geographic location
(22). In addition, the PRDH has a response
protocol for use during epidemics
that covers community alerts and education,
diagnosis, medical treatment,
and hospitalizations (22, 23). This protocol
has been disseminated in newspapers
and newscasts when necessary and
could be used for the development of educational
materials.
To evaluate the government practices
suggested by focus group participants,
we are conducting a community project
that uses home visits and the participation
of community leaders to control and
prevent dengue. During the household
visit, a dengue educational brochure is
discussed and a survey of theyard is
conducted to teach homeowners how to
identify and discard A. aegypti breeding
sites. In addition, we are conducting a
content analysis of newspaper articles to
better understand the social construct of
dengue presented by the most widely
read newspapers in Puerto Rico. Also
planned are health care provider interviews
to assess knowledge about dengue
in Puerto Rico and its diagnosis and
treatment.
Disclaimer. The findings and conclusions
in this report are those of the authors
and do not necessarily represent
the views of the CDC or the Agency for
Toxic Substances and Disease Registry.

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Manuscript received on 16 November 2007. Revised version
accepted for publication on 14 October 2008.
Original research Pérez-Guerra et al. • Beliefs and practices about dengue in Puerto Rico

Objetivo. Apesar de la prolongada endemia y los reiterados esfuerzos gubernamentales
y privados, la participación efectiva y sostenida de la comunidad en las tareas
de prevención del dengue sigue siendo un reto en Puerto Rico. A partir de entrevistas
realizadas en 2001 se analizaron las diferencias en las actitudes hacia el
dengue y su prevención según el sexo de los encuestados y sus antecedentes de haber
sufrido esta enfermedad. Estos resultados pueden servir para desarrollar mensajes dirigidos
a promover prácticas de control de Aedes aegypti.
Métodos. Entre septiembre y octubre de 2003 sesionaron 11 grupos focales en San
Juan, Puerto Rico. Participaron 59 personas (35 mujeres y 24 hombres) de 18 años o
más, identificados a través del sistema de vigilancia de dengue de Puerto Rico. El análisis
se basó en la teoría fundamentada o inductiva.
Resultados. Las mujeres consideraban importante el dengue por su impacto económico,
emocional y sanitario y más mujeres que hombres estaban preocupadas por la
insuficiente recolección de basura y disposición de aguas residuales. Los participantes
con diagnóstico previo de dengue estaban más preocupados por los riesgos de la
enfermedad, conocían más sobre el dengue y su prevención y con mayor frecuencia
aconsejaron el uso de repelentes que sus pares sin diagnóstico previo de dengue.
Entre las barreras para la prevención sostenida del dengue estaban: conceptos erróneos
por materiales educativos obsoletos, la “invisibilidad” del dengue en comparación
con las enfermedades crónicas y la falta de aceptación de responsabilidad por la
prevención del dengue.
Conclusiones. Las estrategias sugeridas paramotivar la acción de los residentes
comprenden: trabajar con las agencias gubernamentales para resolver los problemas
estructurales que incrementan las poblaciones de mosquitos, mejorar el acceso a la información
sobre la recolección de basura y la disposición de las aguas residuales mediante
líneas telefónicas de asistencia directa, aumentar la propaganda y la información
sobre el dengue mediante campañas por los medios masivos de información y
educar a los profesionales de la salud.
Dengue, educación en salud, control vectorial, Puerto Rico.

RESUMEN
Creencias y prácticas
comunitarias relacionadas
con el dengue en Puerto Rico
Palabras clave
226 Rev Panam Salud Publica/Pan Am J Public Health 25(3), 2009
Las pautas presentadas en esta publicación subrayan el hecho de que el dengue es un
problema vinculado principalmente con el saneamiento del medio domiciliario. Los vectores
más importantes del dengue, Aedes aegypti y Aedes albopictus, se pueden controlar mediante
maniobras físicas y sin el uso excesivo de sustancias químicas. A diferencia de los antiguos
programas centralizados y de estructura vertical, estas pautas hacen hincapié en las distintas
formas de transferir a la comunidad la responsabilidad, capacidad y motivación que
requieren el control y la prevención del dengue.
La presente publicación, que ha sido preparada por 18 representantes de siete países de las
Américas y varios funcionarios de la OPS, todos expertos en el tema tratado, ocupa un lugar
crítico en la lucha contra el dengue y constituye un instrumento indispensable para profesionales
de la salud que participan en el control de vectores.