article: Dengue Fever presents a significant and growing burden of disease to endemic countries, where children are at particular risk. Worldwide, no effective anti-viral treatment has been identified, thus vector control is key for disease prevention, particularly in Peru where no vaccine is currently available. This qualitative study aimed to explore the perceptions of dengue control in caregivers’ of children under 5 years in Peru, to help direct future mosquito control programmes and strategy. Eighteen semi-structured interviews were conducted in one health centre in Iquitos, Peru. Interviews were audio-recorded, transcribed and translated by an independent translator. Data were analysed using an inductive thematic approach. Three core analytic themes were interpreted: (1) awareness of dengue and its control, (2) perceived susceptibility of children, rural riverside communities and city inhabitants, and (3) perceived responsibility of vector control. Participants were aware of dengue symptoms, transmission and larvae eradication strategies. Misconceptions about the day-time biting behaviour of the Aedes aegypti mosquito and confusion with other mosquito-borne diseases influenced preventative practice. Community-wide lack of cooperation was recognised as a key barrier. This was strengthened by attitudes that the government or health centre were responsible for dengue control and a belief that the disease cannot be prevented through individual actions. Participants felt powerless to prevent dengue due to assumed inevitability of infection and lack of faith in preventative practices. However, children and rural communities were believed to be most vulnerable. Perceptions of dengue control amongst caregivers to under 5’s were important in shaping their likelihood to participate in preventative practices. There is a need to address the perceived lack of community cooperation through strategies creating a sense of ownership of community control and enhancing social responsibility. The belief that dengue cannot be prevented by individual actions in a community also warrants attention. Specific misconceptions about dengue should be addressed through the community health worker system and further research directed to identify the needs of certain vulnerable groups.
  Dengue fever (DF) remains the most rapidly spreading mosquito-borne viral disease in the world and it has caused more human morbidity and mortality than any other arbo-viral infection [1,2]. It currently infects 390 million people each year [3]. Dengue fever has presented an acutely difficult and progressive public health challenge in Latin America, as it has increased in prevalence, severity and spread throughout the region [4,5]. In Peru, over half the population live in areas at risk of the disease since it re-emerged in 1984 after 30 years of successful vector eradication [6]. This re-emergence has been attributed to: rapid growth and migration of urban populations, and limited resources directed towards dengue control [6]. Climate change, extreme poverty and poor water supply leading to household water storage have further compounded these effects by increasing the habitation sites of the mosquito, which now populates 17 of the 25 departments in Peru [6]. Dengue viruses are transmitted by female mosquitoes of the Aedes genus which are wide-spread in tropics and sub-tropics [7,8, 9]. Dengue has been a particular health threat to children living in endemic areas [10] since young children are particularly susceptible to dengue haemorrhagic fever [1,11]. Ninety percent of cases of DHF occur in infants under 5 years of age, where there is a 2. 5% risk of fatality [12]. The situation regarding a vaccine against dengue remains complex. Although a vaccine has undergone Phase III clinical trials and is recommended for use in endemic areas, it is not registered for use in young children [13]. Since no effective anti-viral treatment exists globally, and no vaccine is currently available in Peru, mosquito control is the foundation of dengue prevention nationwide [4,14]. Control strategies against the Aedes aegypti vector may also have the combined effect of enhancing protection from other diseases transmitted by the mosquitoes, such as zika and chikungunya. In dengue-endemic countries, control focuses on community and household mosquito eradication strategies. In the Peruvian Amazon, the city of Iquitos is endemic for DF and experiences frequent outbreaks [15]. The inaccessibility of drinking water in homes leads to the use of water storage containers [16], which provide a breeding site for the Aedes aegypti mosquito. In Iquitos, health promotion messages are broadcasted via radio, television and roadside billboards. These predominantly focus on symptom recognition and household eradication of breeding sites through cleaning the house and care or removal of containers that collect water (buckets, tubs, tyres for example) [17]. The local health authority further streamlines control strategies through case-by-case fumigation, larvicide water treatments, home inspections and community education [6]. According to the World Health Organisation, dengue control needs improvement to alleviate its significant burden of disease to endemic countries [18]. Further research is required to target dengue control in areas at risk. To date, few qualitative studies have explored perceptions and experiences around dengue control worldwide, but these have identified certain issues such as misconceptions, confusion with other febrile diseases, the “invisibility” of dengue and lack of responsibility in control methods [19–25]. In Iquitos, dengue-related research has concentrated on studies of epidemiology and entomology [26–28]. A recent survey evaluated community knowledge and practices [29], highlighting the misconception that Aedes aegypti bite during the night-time and the subsequent incorrect use of mosquito bed nets. Although informative, the nature of the survey did not allow researchers to explore in depth why misunderstandings exist or how preventative practices are influenced by perceptions. A recent qualitative study performed in Northern Peru and one Peruvian focus group study included within a WHO report found that people may consider vector control to be a lot of work, with reservations about the efficacy of interventions. [17,30] However, as far as the authors are aware, there have been no other published qualitative studies in Peru which have explored this topic [31], highlighting an important gap in the knowledge base, particularly in this region [32,33]. This novel qualitative study sought to better understand the interrelated social and individual factors that determine perceptions, experiences and practices of dengue control, in caregivers of children under 5 years (a term which describes biological parents, step/foster/adoptive parents, wider family members and will be used from this point forward) to an at-risk group. Further understanding of caregivers’ thoughts and actions around DF can help to inform and direct future mosquito control programmes and strategy in the Peruvian Amazon.
  Ethical approval was gained from the University of Birmingham Internal Ethics Review Committee (Ref: 2015-6/C1/DK/11) and the Institutional Ethics Committee of Research at the Department of Health, Loreto (Constancia No: 001-CIEI-DRSL-2016). This pragmatic exploratory study was undertaken in the San Juan health centre in Iquitos, north-eastern Peru. The health centre serves 32,848 people in the southern district of the city and offers free state-funded health consultations under the Seguro Integral de Salud (SIS) system for those who qualify as either ‘poor’ or ‘very poor’. Residents who do not qualify for support are still able to access the health centre but a fee is incurred. The power of a purposive sample lies in the intentional selection of participants defined as ‘information-rich’ [34]. This embraces the importance of individual views to best answer a research question concerning personal perceptions and practices [34]. Participants were purposively selected based on the following eligibility criteria: (i) caregiver to a child under 5 years of age, (ii) aged over 18 years and (iii) living in Iquitos. Following each interview, participant demographics were entered into a database to facilitate exploration of which characteristics (differing in age, gender, level of education and dengue experience) were missing from the sample. Cases with these characteristics were then purposively sought to ensure a maximum variation sample [35]. Recruitment was undertaken during the ‘wet season’ in February 2016, where the Aedes aegypti vector may be more abundant due to higher levels of rainfall [36]. Eligible participants were identified by clinicians and they were then approached by lead author (AF) with support from an interpreter who explained the study and provided participant information sheets. The reason for participant attendance at the health centre was not recorded. It was made clear that participation was voluntary and would not affect the care participants received at the health centre. Semi-structured interviews followed a topic guide developed using existing, albeit limited, literature [19–25] and discussion within the research team (S1 Topic Guide). The first two interviews were deemed pilots, due to difficulties with the topic guide and translational discrepancies. After this, the topic guide was revised and translation difficulties addressed before the final eighteen interviews. An iterative process allowed inclusion of novel ideas, until no new concepts were presented and data saturation was achieved [37]. Interviews were conducted in English and Spanish using real-time interpretation [38] between the researcher, interpreter and participant. Two interpreters were used throughout the data collection; the first interpreter was present for five interviews and the second present for 15. Both interpreters were English language students at the university in Iquitos, with experience interpreting in clinical environments. Although acknowledged that use of one interpreter is preferable, efforts were made to ensure the similarity between interviews by briefing the second interpreter on the issues arisen from the pilot interviews and thoroughly practising interview questions. Informed written consent was obtained before each interview which took place in a private room in the health centre. Interviews were audio-recorded and field notes taken. The spoken Spanish was transcribed into English by the researcher and a translator who had experience translating medical projects. Cultural context and the meaning behind colloquialisms were discussed with the researcher to support analysis. A translation lexicon was developed to establish conceptual equivalence [39]. An independent translator reviewed a random sample of two transcripts to assess the quality of translation. Minimal discrepancies between translations were noted, thus no changes were made. Data were analysed using Braun and Clarke’s [40] inductive thematic analysis method to identify and interpret themes. An iterative approach was employed, where a constant comparison method ensured data analysis was undertaken in parallel with data collection [41]. Immersion in the data was ensured through repeated reading and familiarisation of the transcripts. Initial codes and themes were generated and a coding rationale produced, with support of NVivo software. Thematic mind maps were developed and themes reviewed using quotes from the text and interviews as a whole. To improve the credibility of analysis, five of the most data rich transcripts were independently coded by a second analyst (EB). Differences and similarities were evaluated and additional interpretations incorporated into the coding framework. Themes were discussed between the analysts and further reviewed by the research team (LJ, GW) which sought to enrich interpretations and reduce bias presented by a single analyst [42]. A reflexive approach to analysis was employed, where notes were made throughout the analytical process to acknowledge the potential impact of research bias [43]. Continued communication between the lead author (AF) and Peruvian clinicians (GMS) clarified cultural misunderstandings and minimised the risk of cross-cultural bias in interpretation and analysis [39].
  Eighteen interviews formed the final analysis dataset, of which equal numbers were male and female. The average age of the sample was 32 years (range 21 to 56 years). Seven participants reported having suffered DF themselves. A demographic summary of the participants is presented in Table 1. The average length of interviews was 36 minutes (range 24–51 minutes). Three core analytic themes and eight subthemes (Fig 1) were interpreted within the data: (1) awareness of dengue and its control, (2) perceived susceptibility of children, rural riverside communities and city inhabitants and (3) perceived responsibility of vector control. The overarching theme of responsibility runs through each narrative and exists in three interlinked but separate dimensions: (i) external responsibility, (ii) community responsibility, (iii) personal responsibility.
  It is important to acknowledge the strengths and limitations of the study. The strength of this study lies with the important feedback and insight it provides in the ongoing control of dengue fever and the influence of current health campaigns to community and individual perceptions in an endemic region. However, the qualitative nature requires findings to be interpreted with caution, particularly if generalising the conclusions beyond the sample explored. Qualitative studies are limited by the use of a relatively small number of participants and cannot be considered representative [34]. It is important to consider this when applying the findings to caregivers to children under 5 years who live in similar endemic situations. Furthermore, in cross-language qualitative research, the use of translators and interpreters may impact the findings [39]. Braun and Clarke emphasise the importance of deriving meaning from words and data [65], therefore use of an interpreter and translator may have impacted analysis by increasing the risk that meaning was lost in translation. Steps were taken to avoid this potential bias of misinterpretation [39]. Interviews were piloted, a translation lexicon was created and two transcripts were externally validated. Moreover, the benefits of a local interpreter included useful insights into the meaning behind responses and increased cooperation from participants who seemed more relaxed and willing to participate in in depth discussion with a member of their community. In retrospect, a further limitation to the study may be the absence of deeper exploration into the conflation presented in the interviews between dengue and other arbo-viral diseases. Further questioning about the different types of mosquitoes known by participants, as well as distinct control methods, may have proved useful when discussing appropriate recommendations to improve vector control. Likewise, the findings from this study would have been further enriched by closer examination of the individual motivators or barriers to performing protective household practices. Further research may aim to better explore these two limitations. Finally, the impact of the lead author (British, female medical student) conducting cross-cultural research must be acknowledged. Culture is defined as a set of distinctive features of a social group [66] thus, as an outsider to the community, preconceptions and values of the principal researcher may have influenced data interpretation and analysis. The potential effect of this was minimised through support with interpretation from the wider research team, to ensure cultural understanding and the use of multiple coders and analysts to reduce the risk of researcher bias. This study contributes to the understanding of perceptions and experiences that influence dengue control amongst caregivers of children under 5 years in an endemic setting. Specific misconceptions around dengue transmission and confusion with other diseases, such as malaria, need to be addressed. In terms of disease control, the lack of community cooperation in mosquito prevention was perceived as a key barrier. This social phenomenon was intensified by attitudes that the government and health centre were responsible for dengue control and the belief that the disease cannot be prevented through individual actions. There is a need to address these perceptions through targeted campaigns encouraging individual and community empowerment in dengue control.
summary: Dengue fever is the most rapidly spreading mosquito-borne viral disease in the world and is a significant international health problem. It is endemic in the Peruvian Amazon and since there is no available vaccine or effective treatment, mosquito control is key. This novel study used qualitative interviews to explore the perceptions and experiences of dengue control in caregivers’ to children under 5 years, to help inform future Peruvian mosquito control programmes. Findings suggested that caregivers had basic knowledge about dengue, but that misconceptions around the mosquito itself and confusion with other diseases (like malaria) influenced people’s protective practice. Furthermore, participants felt powerless to prevent dengue since the invisible mosquito, perceived ineffective prevention methods, and rural riverside environment made the disease seem inevitable. Despite this, children and rural riverside communities were identified as most vulnerable groups. Key findings suggested a lack of community cooperation in mosquito prevention due to an attitude that the government and health centre were responsible for disease control, and the belief that dengue cannot be prevented through individual actions alone. These were important barriers to community mosquito prevention efforts. The findings from this study provide novel insights into how perceptions of dengue control can impact prevention in an endemic country.
keywords: invertebrates
  medicine and health sciences
  behavioral and social aspects of health
  sociology
  tropical diseases
  social sciences
  parasitic diseases
  animals
  research design
  human families
  neglected tropical diseases
  infectious disease control
  insect vectors
  research and analysis methods
  public and occupational health
  infectious diseases
  aedes aegypti
  dengue fever
  qualitative studies
  disease vectors
  insects
  arthropoda
  mosquitoes
  biology and life sciences
  viral diseases
  species interactions
  malaria
  organisms
title: "We need people to collaborate together against this disease": A qualitative exploration of perceptions of dengue fever control in caregivers' of children under 5 years, in the Peruvian Amazon