Factors influencing the knowledge, attitude, and practices of police personnel toward dengue fever in Kathmandu, Nepal

Abstract Objective Dengue fever is a significant public health problem in Nepal, and police personnel are considered to play a crucial role in preventing and controlling dengue fever. This study aimed to assess the factors that influence the knowledge, attitudes, and practices of police personnel toward dengue in Kathmandu, Nepal. Methods The study design was a descriptive cross‐sectional study among 422 police personnel, where data were collected using self‐administered questionnaires. Bi‐variate analysis and multivariate analysis were used to examine the association between sociodemographic factors and environmental factors with knowledge, attitude, and practices of dengue. Results The study found that the knowledge, attitude, and practice toward dengue prevention was 58%, 46%, and 75%, respectively. The study found that family history of dengue (AOR = 2.78, 95% CI = 1.38‐5.6), owning bed nets (AOR = 2.13, 95% CI = 1.04‐4.35) and having covered water storage containers (AOR = 2.99, 95% CI = 1.74‐5.13) were associated with higher odds of knowledge on dengue. Having family history of dengue (AOR = 2.45, 95% CI = 1.24‐4.87) and the presence of broken glasses or discarded plastic bottles in the house (AOR = 2.07, 95% CI = 1.93‐5.36) were associated with attitude on dengue. Knowledge on dengue was associated with higher odds of attitude (AOR = 3.3, 95% CI = 2.09‐5.36) and practices (AOR = 3.21, 95% CI = 1.93, 5.36). Conclusion The study identified specific factors associated with knowledge, attitude, and practices toward dengue prevention. The study concluded that regular training and awareness‐raising activities are needed to improve their knowledge, attitudes, and practices toward dengue.


| INTRODUCTION
Dengue is a health problem globally.It is an Arboviral disease and one of the most common public health threats, neglected viral disease in the tropics and subtropics.People once infected with the dengue virus can get immunity lifelong but there is no cross protective immunity.It is worldwide distributed in the tropics, 390 million people infected with dengue every year and only 96 million people manifest with the symptoms. 1Aedes aegypti and Aedes albopictus mosquitoes are the main vectors of the disease.The distribution of A. aegypti is predominantly increasing in the tropics because of the urbanization and the increment of the biodegradable product like as plastic and the tier, where larva of the mosquito can find the habitat. 2,3Person can get dengue virus four times in his lifetime.Changing environment and global warming, huge increasing mosquitoes and case number are challenging to face the epidemic for the upcoming years. 4athmandu Valley has registered a huge spurt in dengue cases, 12 654 people infected with dengue as of September 4, 2002. 5Hospitals in the Kathmandu Valley have reported a massive surge in dengue cases.Knowledge toward emerging infectious organisms and mechanism of transmission is essential to prevent from spreading of dengue diseases. 6,7Lack of knowledge and practice about dengue lead to high risk of disease spreading causes increasing morbidity among police personnel of Kathmandu Valley.Also, the police barracks were favor for the dengue transmission and mosquito proliferation.Moreover, Ministry of Health and Population to seek the help of police to combat dengue outbreak spread in 42 districts of the country that may risk to be infected with dengue.
Lack of effective mosquito control; demographic changes including uncontrolled urbanization often accompanied by substandard housing, poor water supplies, and inadequate sewage and waste management; increase in travel and commerce; and poor public health infrastructure are risk for dengue fever. 8,9In Nepal, dengue is a rapidly emerging disease.The number of cases increased rapidly with the data of mortality in all provinces at the end of the rainy season. 10,11Loss of duty days and erosion of the mission capability in combatants are underestimated.Due to their job nature and station in the barracks, they are more vulnerable to get infected with the disease.
Thus, in order to improve and design sustainable public health interventions for dengue throughout the police personnel of Nepal, with people having different socioeconomic and cultural backgrounds, it is essential to recognize and understand the people's knowledge, attitude, and practices (KAP) on dengue virus and its vectors. 7,12,132][13] Furthermore, none of the previous studies were conducted among police personnel that may be risk of dengue.To our knowledge, there is no previous population based study done among police personnel to assess knowledge, attitude, and practice to dengue fever, as this is an important effort in designing anti dengue intervention programs.And also, the police personnel have a gap of knowledge and understanding of the causes, transmission, and preventive practice of the dengue which impacts on health and combat readiness among police personnel.Therefore, this study was focused on knowledge, attitude, and practice and its associated factors toward dengue fever and the study helped to effective preventive intervention of police personnel related to dengue.The study is useful for the police personnel to evaluate and plan to increase knowledge and perception related to dengue fever in terms of prevention and control of the disease.Assist the police personnel in the study areas to develop appropriate health education methods to improve army personnel's knowledge.

| METHODS
A descriptive cross-sectional study was conducted to identify the knowledge, attitude, and practice regarding dengue fever among police personnel of Kathmandu valley.With standard formula, the police personnel size of 411 police personnel estimated; given that the margin of error alpha (α) = 0.05, prevalence = 0.05, the confidence level is = 95%, design effect = 1.5, and the non-response rate = 5%.There were 10 police barracks in the Kathmandu valley and among them, 411 police personnel were selected by systematic random sampling.Self-administrated questionnaire was used for data collection adapted from different literatures [11][12][13] and consultation with experts.Data collection tool consisted of five parts.Part I dealt with sociodemographic information, Part II dealt with environment factors, Part III dealt with information on dengue knowledge including causative agent, transmission, Part IV dealt with attitude on dengue, and Part V dealt with practice on dengue prevention.Knowledge, attitude, and practice score was obtained by summing up the responses of each item of subscale to derive the composite value out of a possible total score of 20 for knowledge, seven for attitude, and none for practice.Knowledge was defined as "adequate" or "inadequate," attitude and practice were defined as "good" or "poor" based on a 70% cut-off point.Bi-variate analysis (Chi-squared test and Independent t-test) was used to examine the association between sociodemographic factors, environment factors with knowledge, attitude and practice regarding dengue among police personnel.A P-value less than .05was considered as statistically significant.Initially, explanatory determinants were included in the model one at a time to examine their univariate relationship with the outcome and variables that were significant in the univariate analysis at P-value <.20 were fitted in the multivariate analysis.Multivariate analysis with all independent variables entered at the same time was completed to adjust for the effect of confounding and adjusted OR and 95% CI were computed.Multicollinearity was checked among the variables, and there was no significant collinearity (variance inflation factor 1-2).The Hosmer-Lemeshow test was performed to test the goodness-of-fit of the multivariate logistic regression model, and the model was found to be a good fit (P > .05).All statistical analyses and graphs for this study were conducted using the R program.Ethical clearance was obtained from Nepal Police Hospital, Institutional Review Committee of Nepal Health Research Council for this study with registration number IRC 06/2079.

| RESULTS
followed by females (11.7%), and the mean age was 31.8 years (SD = 9.7 years).The majority of the police personnel were Hindu (93.4%), and the remaining police personnel belonged to Buddhist (3.9%) and other (2.7%) religions.In terms of caste, the largest group was Janajatis (38.7%), followed by Dalits (25.8%),Upper Caste Groups (15.8%),Madhesi (9.5%), and Others (10.2%).The mean number of family members was 5.9 (SD = 2.3).In terms of education, the majority of the police personnel had proficiency level certificate and above (57.4%),while the remaining police personnel had SEE/SLC and below (42.6%).The majority of the police personnel owned a bed net (91.2%), and most of them did not have a history of dengue among family members (87.6%).Regarding household-related factors, most of the police personnel had a good drainage system inside their household (73%), natural light inside the house (88.8%), and regular water supply (90.5%).However, many police personnel had stored water in containers (37.5%), and some of these containers were not covered tightly (26.8%).The majority of the police personnel had flower vases in their house (66.4%), while a smaller proportion had discarded tires around the house (18%) or broken glasses/discarded plastic bottles inside the house (23.1%).Similarly, the majority of the police personnel lacked garbage disposal nearby their house (62.5%), while the remaining police personnel had such facilities nearby.
Figure 1 shows the Venn diagram showing the knowledge, attitude, and practice on dengue prevention among police personnel.It was found that knowledge of dengue fever was 58%, attitude of dengue fever was 46%, and practice of dengue fever prevention was 75%.About 34% of police personnel had knowledge and attitude on dengue; 49% of police personnel had knowledge and practice on dengue; 49% of police personnel had attitude and practice on dengue.About 31% of police personnel had knowledge, attitude, and practice on dengue prevention.
Table 2 shows the factors associated with knowledge on dengue among police personnel in both bivariate and multivariate analysis.Table 2 presents the number and percentage of participants with inadequate and adequate knowledge of dengue, as well as the P-values, crude odds ratios (COR), and adjusted odds ratios (AOR) with their respective 95% confidence intervals (CI).In the bivariate analysis, several factors were significantly associated with knowledge of dengue, including gender, history of dengue among family members, good drainage system inside the household, the water storage containers were covered tight, and the availability of public water taps nearby.These factors were further analyzed in the multivariate analysis, and the adjusted odds ratios were presented.The results of the multivariate analysis showed that the history of dengue among family members, ownership of a bed net, and having covered water storage containers remained significantly associated with knowledge of dengue after being adjusted with other factors.The results show that females had higher odds of having knowledge on dengue fever compared to males, although this difference was not statistically significant after adjusting for other factors (adjusted odds ratio [AOR] = 1.89, 95% CI = 0.92-3.88).Having a history of dengue among family members was significantly associated with higher odds of having knowledge on dengue fever (AOR = 2.78, 95% CI = 1.38-5.6).Ownership of a bed net and having covered water storage containers were significantly associated with higher odds of having knowledge on dengue fever (AOR = 2.13, 95% CI = 1.04-4.35and AOR = 2.99, 95% CI = 1.74-5.13,respectively).Table 3 provides the results of bivariate and multivariate analyses of factors associated with attitude toward dengue among police personnel.In the multivariate analysis, after adjusting for other factors, history of dengue among family members, broken glasses or discarded plastic bottles were present in the house, and knowledge on dengue remained significantly associated with attitude toward dengue.Having a history of dengue among family members was significantly associated with higher odds of having good attitude on dengue fever (AOR = 2.45, 95% CI = 1.24-4.87).Broken glasses or discarded plastic bottles were present in the house were significantly associated with higher odds of having attitude on dengue fever (AOR = 2.07, 95% CI = 1.93-5.36).Knowledge on dengue was associated with a good attitude on dengue prevention, the police personnel who had knowledge on dengue had a higher attitude of dengue, with an AOR of 3.3 (95% CI: 2.09-5.36).
Table 4 provides the results of bivariate and multivariate analyses of factors associated with practice toward dengue among police personnel.In the multivariate analysis, after adjusting for other factors, water storage containers were covered tight, presence of flower vases in the house, knowledge on dengue, and attitude on dengue remained

| DISCUSSION
To our knowledge, it is the first study among police personnel to determine knowledge, attitude, and practice toward dengue prevention and its associated factors among police personnel in Kathmandu valley.The study found that the knowledge of dengue fever was 58%, attitude of dengue fever was 46% and practice of dengue fever prevention was 75%.2][13] The reasons for inadequate knowledge on dengue fever can be due to various reasons, including cultural beliefs, lack of awareness, and ineffective communication strategies.Studies identified that people may not be aware of the signs and symptoms of dengue, its mode of transmission, and the importance of preventive measures, due to a lack of health education and ineffective communication strategies. 7,13,14However, the practice of dengue prevention was comparatively high due to the availability of preventive measures, the fear of contracting dengue, and government and public health interventions.
The availability of preventive measures such as mosquito repellents, bed nets, and insecticides can encourage people to practice dengue prevention.When people have access to effective preventive measures, they are more likely to use them.As a result of dengue outbreaks in 2019 with high mortality, 5,14,15 there has been a substantial increase in practice on dengue prevention and treatment options.The fear of contracting dengue motivates people to practice dengue prevention.When people are aware of the risks associated with dengue and the potential consequences of contracting the disease, they are more likely to take preventive measures.Government and public health interventions such as campaigns to raise awareness, the distribution of mosquito nets and repellents, and the implementation of mosquito control measures were on rise during the outbreaks.
The study also found that police personnel with a history of dengue among family members were more knowledgeable and attitude toward dengue fever than those without such a history. 4,16This could be because those who have experienced the disease among themselves, and their families are more likely to be aware of the symptoms and preventive measures.They are likely to have a higher level of knowledge and attitude toward the disease due to their personal and family experience and the impact it has had on their lives. 10,13They may develop a heightened awareness of the importance of preventing and controlling the disease and use proactive measures to reduce their risk of contracting the disease again, such as using mosquito wearing protective clothing, and eliminating mosquito breeding sites around their home.Having personal and family experience with dengue fever can also increase empathy and understanding toward others who have been affected by the disease.
Ownership of bed nets was associated with higher knowledge on dengue fever as consisted with similar studies. 17,18The police personnel were aware that owning a bed net can help prevent dengue fever by reducing the exposure of individuals to the mosquitoes that transmit the virus.Bed nets are an effective tool for preventing mosquito bites, which can lead to the transmission of dengue. 19nowledge and practice on environment factors associated with dengue was strong predictor with knowledge, attitude, and practice on dengue prevention. 8,20,21Having covered water storage containers were significantly associated with higher odds of having knowledge on dengue fever and broken glasses or discarded plastic bottles were present in the house were significantly associated with higher odds of having attitude on dengue fever.Understanding the environmental factors that contribute to dengue transmission is essential for effective prevention strategies. 20These factors include standing water, poor sanitation, and inadequate waste management, which provide breeding sites for mosquitoes.Knowledge of these factors enables individuals and communities to take steps to eliminate mosquito breeding sites and reduce the risk of dengue transmission. 8,9Knowledge alone is not sufficient; individuals and communities must take action to prevent the spread of dengue. 22This includes measures such as removing standing water from their surroundings, using mosquito repellents, and wearing protective clothing.By practicing these behaviors, individuals and communities can reduce the risk of dengue transmission and protect themselves and others from infection. 8,22he study found that police personnel who were more knowledgeable about dengue had a more positive attitude toward dengue. 7,13This finding is consistent with the notion that knowledge is an important predictor of behavior change.Studies have shown that people who have a good knowledge of dengue are more likely to use mosquito repellents, wear protective clothing, and clean up mosquito breeding sites. 7,10-14Furthermore, individuals who have a high level of knowledge about dengue are more likely to seek medical help early and reduce the risk of complications. 12,13ttitudes toward dengue prevention are shaped by factors such as beliefs, social norms, and cultural practices. 23eople who have a good understanding of dengue and have positive attitudes toward prevention are more likely to take action to prevent the disease. 10,11,16In contrast, individuals who lack knowledge or have negative attitudes toward dengue prevention are less likely to take preventive measures, which can lead to an increased risk of dengue transmission.
The association between knowledge, attitude, and practice is essential for effective dengue prevention and control. 13,168][19] Effective preventive practices require the integration of knowledge and positive attitudes toward dengue prevention. 9,20everal studies have examined the relationship between knowledge, attitude, and practice and dengue prevention and control.For example, studies conducted in Nepal 7,12,13 and India [18][19][20] found that people who had a high level of knowledge about dengue were more likely to use mosquito repellent and clean up mosquito breeding sites.People who had positive attitudes toward dengue prevention were more likely to take preventive measures, such as using mosquito repellent and cleaning up mosquito breeding sites. 17,18,23These findings highlight the importance of knowledge, attitude, and practice of dengue prevention in dengue prevention and control.
There are some limitations to this study that should be taken into account when interpreting the results.Firstly, the study relied on self-report measures, which are subject to response bias and social desirability bias.Participants may have been reluctant to report certain behaviors or thoughts due to social norms or stigma.Secondly, the study was cross-sectional, meaning that it captured a snapshot of participants' experiences at one point in time and not possible to establish causal relationships between variables or to determine the direction of the observed relationships.

| CONCLUSION
In conclusion, the study found that the level of knowledge and attitude toward dengue prevention among police personnel in Kathmandu valley was low, but the practice of dengue prevention was comparatively moderate.The availability of preventive measures, fear of contracting dengue, and government and public health interventions contributed to this.Personal and family experience with dengue fever, ownership of bed nets, and knowledge of environmental factors associated with dengue were also associated with higher levels of knowledge, attitude, and practice toward dengue prevention.Knowledge, attitude, and practice are all essential for effective dengue prevention and control, and their integration is necessary.Effective preventive practices require individuals and communities to take action to prevent the spread of dengue, including measures such as removing standing water, using mosquito repellents, and wearing clothing.It is recommended that health education campaigns be conducted to increase awareness and knowledge about dengue fever.The campaigns should be designed in a culturally appropriate manner and should utilize effective communication strategies.Therefore, it is recommended that efforts be made to improve environmental hygiene and sanitation, and to educate the public on the importance of eliminating mosquito breeding sites.
1 Venn diagram showing the knowledge, attitude, and practice of dengue prevention.T A B L E 2

Characteristics Knowledge on dengue P-value COR (95% CI) AOR (95% CI) Inadequate Adequate Number (172.42%) Number (239.58%)
T A B L E 2 (Continued)T A B L E 3 Factors associated with attitude on dengue among police personnel in bivariate and multivariate analyses.

Characteristics Attitude on dengue P-value COR (95% CI) AOR (95% CI) Poor Good Number (224.54%) Number (187.46%)
Factors associated with practice on dengue prevention among police personnel in bivariate and multivariate analyses.
T A B L E 3 (Continued) T A B L E 4