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Approaches to Community Prevention of West Nile Virus Infection. Emily Zielinski-Gutierrez, DrPH Behavioral Scientist Division of Vector-Borne Infectious Diseases Centers for Disease Control & Prevention. Outline. A little health education and behavior change theory

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Approaches to community prevention of west nile virus infection l.jpg

Approaches to Community Prevention of West Nile Virus Infection

Emily Zielinski-Gutierrez, DrPH

Behavioral Scientist

Division of Vector-Borne Infectious Diseases

Centers for Disease Control & Prevention


Outline l.jpg
Outline Infection

  • A little health education and behavior change theory

  • A national perspective on WNV trends

  • Some statistics on WNV protective behaviors

  • Some barriers & opportunities for prevention

    • Lessons from Colorado and elsewhere



Lots of different theories l.jpg
Lots of different theories Infection

  • Theory of Reasoned Action

    • How people decide to take a certain action

  • Health Belief model

    • A person’s behavior can be predicted based upon issues such as perceived susceptibility, perceived severity when making a decision about a particular behavior concerning theirhealth.(Glanz, Lewis, & Rimer, 1990).

  • Transtheoretical model/Stages of Change

    • Precontemplation/ contemplation/ preparation/ action/ maintainence

  • Fear Appeals Theory

    • Some would agree, some not – fear can motivate OR lead to rejection and inaction.

  • And many more

  • http://www.uky.edu/~drlane/capstone/health/


    Slide5 l.jpg

    One Theoretical Basis Infection

    Risk Communication and Education

    Risk Perception

    Environmental Factors

    MediaDisease history

    Local ecology

    Demographic factors

    Socio-cultural factors

    e.g. language, age,

    Income, gender, education

    Risk Assessment

    Action


    Slide6 l.jpg

    Barriers Infectionto Action

    Facilitating Factors for the Action

    Desired Action

    Knowledge

    &

    Attitudes


    Health communication can l.jpg

    Communication Infectionwith other strategies can:

    Change human behavior

    Overcome barriers and systemic problems

    Health Communication can:

    • Increase knowledge

    • Increase awareness

    • Prompt action

    • Demonstrate skills

    • Influence attitudes

    • Refute myths

    DHHS/NIH/NCI: Making Health Communication Programs Work


    Health communication questions with west nile virus l.jpg
    Health communication questions with West Nile virus Infection

    • What prevention measures are people using to avoid WNV infection?

    • What are possible reasons that people are not using prevention measures?

    • What communication activities and other interventions might increase use of personal & household prevention?

      • How can communication makes prevention measures more “actionable”/feasible?


    Plan for the result you want l.jpg
    Plan for the result you want Infection

    • Outcomes:

      • Knowledge about transmission, about risk, about repellents, about prevention

      • Attitudes about personal risk, support of prevention, etc.

    • Impact:

      • Behavior: e.g. increased repellent use, installation of screens

      • Disease reduction: A challenge to measure for WNV/mosquito borne disease

        • Lots of variables ecological and otherwise, serosurveys a huge expensive effort…can use surveillance data for some questions


    Message receiver behavior change l.jpg
    Message + receiver Infection≠ behavior change

    • A message w/o supporting context often insufficient

    • There are reasons that people don’t do things that would otherwise seem to make reasonable sense… find out what those reasons are… and address them in your campaign.

    • If there are significant obstacles (income or poor housing, for example) information alone isn’t often going to be enough to counter that alone.


    Wnv trends l.jpg

    WNV trends Infection


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    A bigger and bigger problem Infection

    # Cases # Deaths # States w/ human cases

    1999 62 7 1

    2000 21 2 3

    2001 66 9 10

    2002 4071 279 39 states +DC

    2003 * 9306 240 45** states+DC

    *As of March 3, 2004. Numbers will change.

    **No human disease reports in 2003 in WA, OR, ME, HI, AK


    This year l.jpg
    This year… Infection

    • 0ver 9000 human cases reported in the US*

      • Severe disease = more than 2700 (30%)

      • West Nile Fever = more than 6300 (~68%)

        • Only about ~25% of all cases in 2002 were Fever

      • Other/unknown = about 163 (2%)

    * 2003 cases reported to CDC, as of 3 March 2004


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    Who gets sick from West Nile? Infection

    • All ages: 1 mo.–99 years

    • Fever cases tend to be young/middle age adults

    • Severe disease and deaths tend to be people over 50, and especially over 70

    • Kids do get sick, but pretty rarely.

      • Intrauterine infection is possible when a pregnant woman gets infected, but the extent to which this occurs and the health effects on the infant are not yet known.

    * 2003 cases reported to CDC, as of 19 November 2003


    Percent of reported west nile virus cases classified as west nile fever united states 2003 l.jpg
    Percent of Reported West Nile Virus Cases Infection Classified as West Nile Fever, United States, 2003

    Percent of Cases

    0-24

    25-49

    50-74

    75-100

    * Reported as of 1/29/2004


    Wnnd county level incidence per million united states 2002 l.jpg
    WNND County Level Incidence per Million, United States, 2002*

    Incidence per million

    .01-9.99

    10-99.99

    >=100

    * Reported as of 4/15/2003


    Wnnd county level incidence per million united states 2003 l.jpg
    WNND County Level Incidence per Million, United States, 2003*

    Incidence per million

    .01-9.99

    10-99.99

    >=100

    *Reported as of 1/20/2004


    Slide23 l.jpg

    Human WNV Disease Incidence, by Age Group and Clinical Category, United States, 2003*

    * Reported as of 1/30/2004

    * *Entire US population


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    Prevention: Category, United States, 2003*Who’s doing what?national statistics


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    When it’s warm in your area, do you… Category, United States, 2003*

    • Nationwide: those who report they always/usually…

      • 43.9% look for household standing water

      • 37.6% apply {any} insect repellent

      • 28.5% avoid the outdoors due to mosquitoes

      • 23.9% wear long pants/sleeves

        74.5% doing at least one of the above.

    * Healthstyles national survey, data licensed from Porter-Novelli, conducted July-Aug 2003


    If it s repellent is it deet l.jpg
    If it’s repellent, is it DEET? Category, United States, 2003*

    • 40.3% of respondents have repellents containing DEET in the household (another 26.8% not sure)

    • It’s not DEET for everyone:

      • Only 59.3% of repellent “users” confirmed having DEET in the household

    • Other respondents do have DEET, but they don’t use it much

      • 44.6% of those have DEET in the household said that they did NOT always/usually use repellent


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    Regional and Demographic Differences Category, United States, 2003*in Repellent Use


    Slide28 l.jpg

    Jul-Aug 2003 Category, United States, 2003*


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    West North Central region: Category, United States, 2003*

    38% in 2002, 49% in 2003

    Mountain region:

    23% in 2002, 33% in 2003

    East South Central region:

    39% in 2002

    49% in 2003

    Red = Regionw/more than 10% increase in “Always/Usually Use Repellent” between 2002-2003


    Age repellent use l.jpg
    Age & Repellent Use Category, United States, 2003*

    Bad News:Repellent use (largely) decreases with age

    p < .000; n= 4034


    Age and deet in household l.jpg
    Age and DEET in household Category, United States, 2003*

    • Highest age categories may be associated with having children at home


    Race ethnicity l.jpg
    Race/ethnicity Category, United States, 2003*

    • Significant differences in having DEET in household by race/ethnicity (p<.000)

      • “White” respondents most likely to have DEET (44.3%), other respondents less so (<33%)


    Household income l.jpg
    Household income Category, United States, 2003*

    • Poorer people in this sample were less likely to report having DEET-based repellent in the household.

    p<.000, n=4008


    Education l.jpg
    Education Category, United States, 2003*

    • Education level directly related to having DEET in household (p<.000)

      • Non HS graduates <30%, college graduates approaching 50% have DEET

      • Relationship to income bears further attention


    Barriers and opportunities l.jpg

    Barriers and Opportunities Category, United States, 2003*


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    The “Why”: Category, United States, 2003*Qualitative Complementing Quantitative

    • Qualitative research to examine KAP and behavioral factors

      • 2003: Focus group discussions (~12 total) in higher and lower transmission areas [Larimer (high) and El Paso (low) counties]. Data on Cook County forthcoming.

      • 2002: 16 focus groups in Louisiana

      • Topics:

        • Risk perception

        • Attitudes twd mosquitoes, repellents, spraying

        • Information sources and shortcomings

        • Views on responsibility for prevention


    Barriers questions about deet l.jpg
    Barriers: Category, United States, 2003* Questions about DEET

    • Reported infrequent/no use of DEET-based repellents in wk before group

    • Many cited their own sensory experience using repellent

      • smell, feel (“sticky”)

      • skin reactions, “sensitive skin,” I just can’t use that stuff

    • Strong, though often vague, beliefs and feelings about safety of DEET

      • Attribute brain damage, nerve damage, danger to kids

      • Often described by consumers as “something I heard somewhere… read somewhere”

      • Desire for more data, but resources for detailed info often unclear


    More on repellents l.jpg
    More on repellents Category, United States, 2003*

    • Permethrin never mentioned

    • Use of any repellent on clothing rarely discussed

    • Very little awareness of details about repellent

      • DEET % strength unclear

      • Little about “hierarchy” of alternatives

    • Alternative repellents

      • “They wouldn’t have come up with the other types if there weren’t something wrong with DEET.”

      • Colorado way less interesting than Louisiana

      • Skin-So-Soft & the Avon ladies

      • Trust in “natural” products (regardless)


    It s not all about knowledge or about the bug spray l.jpg
    It’s not Category, United States, 2003*all about knowledge or about the bug spray

    • The decision to obtain/use repellent is only partly a function of knowledge about WNV, knowledge about prevention, or attitudes toward products.

      • Assessments of risk

        • Temporal, geographical, control/fear/outrage

      • Perceived impact of prevention efforts

        • Would any of these steps make a difference?

      • Individual cost-benefit analysis

        • What is it costing me to take these preventive measures? (not just $)


    Conceptual framework l.jpg
    Conceptual Framework Category, United States, 2003*

    Risk perception was affected by locally- and personally-defined intensity of WNV transmission.

    Some factors that combine to define local intensity of transmission include:

    • - personal knowledge about disease

    • - perception of local ecology

    • - type and credibility of information sources

    • - local government intervention


    Slide41 l.jpg

    Personal knowledge about disease Category, United States, 2003*

    Information Sources

    Actions of local

    government

    Local ecology

    Locally-defined intensity of transmission


    Slide42 l.jpg

    Intense WNV Human Disease 2002 & 2003 Category, United States, 2003*

    ME

    WA

    VT

    MT

    ND

    MN

    NH

    OR

    NY

    MA

    WI

    ID

    SD

    RI

    Population perceives limited mosquito infestation

    Limited experience w/ & some resistance to mosquito control

    Risk perception linked to info from community groups

    WY

    MI

    PA

    NJ

    CT

    IA

    NE

    OH

    DE

    IN

    NV

    IL

    UT

    WV

    VA

    CO

    CA

    KS

    MO

    MD

    KY

    NC

    TN

    OK

    AZ

    SC

    NM

    AR

    GA

    AL

    MS

    TX

    LA

    FL

    Long history of mosquito infestations and nuisance

    Experience with and general support for mosquito control as a public service

    Risk perception linked to info from community groups

    Includes Fever and neuroinvasive disease as reported to CDC

    > 200 human cases 2003

    > 200 human cases 2002

    > 200 human cases both years


    Risk personal knowledge of disease l.jpg
    Risk: Category, United States, 2003*personal knowledge of disease

    • Knowing some who was ill

      • Increased recognition of WNV Fever cases during 2003*, more residents knew of someone infected

    • Concern about severity of Fever

      • Not the same impact as ND, but people missed school, work, described prolonged headache ache and fatigue

        • “No one told us it was going to be this bad.”


    Defining risk disease age l.jpg
    Defining Risk: Category, United States, 2003*disease & age

    • No one is “old.”

    • Perspective: participants > 60 y.o. pointed out their experience with other illnesses

      • Lived through polio

      • I had malaria and I figured I must be immune

    • Risk roulette for younger people:

      • “One of my younger neighbors, he thought that he ought to go ahead and get it so he would build up an immunity…”


    Personal view of disease fear and control l.jpg
    Personal view of disease: Category, United States, 2003*fear and control

    • Concern fueled by sense of powerlessness

      • felt that personal options were limited

      • “I can’t spend time outside anymore”

    • Risk may seem ‘unquantifiable’ to general public

      • hard to make decisions about prevention--what to do, what to give up

    • Difficulty conceptualizing how a single mosquito bite can be fatal or life-changing


    Defining risk local ecology l.jpg
    Defining Risk: Category, United States, 2003* Local Ecology

    • “No mosquitoes here”

      • Public lacks history of dealing with mosquitoes as a nuisance or makes qualitative comparisons to Midwest/elsewhere

        • “I just don’t see where all these mosquitoes can be coming from…”

    • Home as “Safe Zone”

      • Don’t use repellent when “just in the backyard”… some disinclination to regard home as dangerous

        • “Most of us [retirees] who are living here are so happy to be in this particular environment that we think we’ve got it made and… we’re kind of invulnerable to any sort of thing.”


    Defining risk perception of ecology local geography l.jpg
    Defining Risk: Category, United States, 2003* perception of ecology/local geography

    • “Hyper-localization” of risk

      • Desire to quantify exactly where and when the risk exists

        • People try to downgrade their risk – e.g. that dead bird was 3 blocks from here…

        • “We hear about the deaths… I wish they would go into a bit more history [of where they were bit.]”


    Defining risk use of outdoors l.jpg
    Defining Risk: Category, United States, 2003*use of outdoors

    • The culture of outdoor recreation

      • Golfing, fishing, walking, gardening

      • Neighborhood visiting in PM (cities, south)

    • Resources

      • People without air-conditioning have a v. different relationship to outdoors

      • Age/quality/preferences in housing stock

        • Again western states very different than South and Midwest


    Defining risk info sources l.jpg
    Defining Risk: Category, United States, 2003* Info sources

    • People get most of information from media

      • Passive

      • Subject to the vagaries of how issues are covered – to what makes the “front page”

    • Respondents suspicious… media “hypes everything”

      • “I think there was confusion over how much is this really a problem and how much is media hype?”

      • Public’s inherent distrust (or at least ambivalence) regarding the media affected level of concern


    Defining risk media and controversy l.jpg
    Defining Risk: Category, United States, 2003*media andcontroversy

    • Adulticiding in Larimer county became major and divisive distraction from other prevention messages

    • On the other hand it keep it in the forefront of people’s minds…

      Hard to know the sum effect

      of controversy.


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    Defining risk: Category, United States, 2003*Info sources

    • Some Hispanic residents reported hearing little to nothing about WNV in the media sources to which they were exposed

      • Some folks may be accessing Univision more than local media

    • “Worry fatigue”:

      • “… it felt like, OK, so this year it’s West Nile, last year was something and next year will be something else to be afraid of.”

    • All areas: People expressed interest in hearing from community representatives, relevant leaders, “people like them”

      • “I figured if it were really important my pastor would have mentioned it.” – urban LA resident


    Defining risk people look at what government is doing l.jpg
    Defining risk: Category, United States, 2003*people look at what government is doing

    • Mosquito Control actions can create controversy.

      • The decision to declare a public health emergency also was noted as influencing people’s concern over the issue.

  • Some question whether long-term mosquito control can lead to complacency among citizens and how to combat

  • Local gov’t actions can serve as trigger for citizens


  • Opportunities cues to action l.jpg
    Opportunities: Category, United States, 2003* Cues to Action

    • High profile repellent sales in retail locations triggered purchase

      • “[they] had [repellent] right when you walk in the door… we bought some right then, and I don’t know if I would have right then [otherwise]… I thought that was wise and caring.”

      • Approach to bring in private elements of the community

    • Hearing about & knowing people around them who were ill


    Opportunities l.jpg
    Opportunities Category, United States, 2003*

    • A minority of the US population is using repellent but most are doing something.

      • But important gaps related to population (age, SES) and possible geographic risk factors

      • The “something” might provide limited protection.


    Opportunities future steps l.jpg
    Opportunities/Future steps Category, United States, 2003*

    • “Socially market” repellents with greater savvy

      • DEET and more effective alternatives

      • Distribution points (where people already go)

      • Encourage industry to look at some of the things people really don’t like about DEET

      • Address safety straight on

    • Use the fact that nearly half the population already report looking for breeding sites

      • Encourage, and evaluate


    Opportunities future steps57 l.jpg
    Opportunities: Category, United States, 2003* future steps

    • Identify maintenance vs. emergency strategies

    • A lesson from the Avon ladies

      • Personal messages engage people on a different level than TV, a website or a flyers.

      • Who are your partners?


    Final opportunities l.jpg
    (Final) Opportunities Category, United States, 2003*

    • As WNV epidemiology and ecology evolve, messages must similarly evolve.

    • Local ecology and history w/ mosquitoes important in construction of risk

      • considered in adapting prevention efforts

    • Involve community groups and local officials in prevention messages and planning

      • Supplement media and health department personnel


    Thank you l.jpg
    Thank you! Category, United States, 2003*


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