Awareness and Health-Seeking Behaviour Regarding Japanese Encephalitis in Kurnool: A Cross-Sectional Study

Introduction

Japanese encephalitis (JE) is one of the serious vector-borne viral encephalitis diseases found worldwide, particularly in Asia, the Western Pacific countries, and Northern Australia. Over three billion individuals live in the JE epidemic and/or endemic countries. In India, JE was first recognized via a serological survey in the 1950s. The first JE outbreak was reported in West Bengal in 1973, followed by reports in the southern, eastern, and western states of India.¹

Andhra Pradesh is one of the southern states of India where JEV activity has been recorded since the mid-sixties and Kurnool is the worst affected district in this state.² The national estimate of the incidence rate of JE was 1.14 cases during 2007-2011 and 1.08 cases per 1,000,000 population during 2013-2021, based solely on reported secondary public health data.³

Despite growing concerns over the emergence of JE, it remains poorly understood, mainly because the problem has been approached in a compartmentalized manner, with human health, animal health, policy design and implementation being examined in isolated silos.⁴ In this regard, a study was conducted to evaluate the awareness and health-seeking behaviour among the public related to JE. The aim of this study was to determine the level of awareness and health seeking behaviour related to JE among the residents of Sriramnagar, Kurnool and to identify the barriers to awareness and health-seeking behaviour within the community.

Materials and Methods

This cross-sectional study was conducted at UHTC, Sriramnagar, Kurnool. The sample size was calculated based on the assumption that 50% of the population have basic awareness and good health-seeking behaviour towards Japanese encephalitis, and we arrived at a sample size of 100 individuals from the community. Simple random sampling technique was used to collect samples. The study was conducted during July - August 2024. All residents of Sriramnagar, residing in that area for more than six months were considered for the study. Individuals not willing to participate, and those residing for less than six months in the selected locality were excluded from the study. Data were collected through a pre-tested, semi-structured questionnaire, and analyzed using MS Excel. Relevant non-parametric tests like Chi Square test, and measures of central tendency were used to assess the data. These tests were done using MS Excel version 16 and SPSS version 26.

Results

Demographic details of the study population are mentioned in the following table (Table 1).

The awareness level of the residents was assessed by assigning scores based on their responses. Seven questions were asked with response options of ‘yes’ or ‘no’. A score of 1 was assigned for each ‘yes’ response and a score of 0 was assigned for each ‘no’ response. Two questions relating to population at risk and the mode of spread of disease were asked, and correct answer was given a score of 1. One question relating to the source of information was asked, and a score of 1 was given for the response of health workers, while the remaining options were given a score of 0. The purpose of this question was to assess the effectiveness of health workers in raising awareness about JE. The score of 75% and above was considered excellent awareness, a score between 50 to 74.9% was considered good awareness, a score of 25 to 49.9% was considered average awareness and a score of below 24.9% was considered poor awareness. The questions used to assess the awareness are given in Table 2.

The results suggest that the overall awareness of the residents regarding JE was average (45.9%). While health workers and newspapers play a major role in spreading awareness (78%), there should be more focus on encouraging the public to take up JE vaccination and other preventive measures to prevent the spread of JE and other vector borne diseases. About 60% of the respondents were aware of Japanese encephalitis and its severity. While there was a positive response regarding the broad symptoms of viral diseases, 70% of them did not know about the specific symptoms of JE. Regarding the preventive measures, most of the respondents had a basic idea about the prevention of viral diseases and the vector-borne mode of transmission; however, only 23% of them were aware of specific preventive measures, like protection against mosquito bites, control of stray pigs and maintaining proper water hygiene, etc.

Regarding the awareness about vaccination for JE, only 44% of the subjects were aware of JE vaccination for children and adults. Among those aware, only 52.28% had administered at least one dose of the JE vaccine to their children. The remaining subjects had either not yet vaccinated their child/children because they were under nine months of age, or were hesitant to administer the vaccine. This explains the low vaccine coverage rate (47.72%). Among the upper middle class, the vaccine coverage rate was high when compared to the upper lower and lower middle classes (Table 3).

Health-seeking behaviour was assessed through a set of questions which were qualitative in nature and each question was individually analyzed to determine the health-seeking behavior of the community.

Regarding their health-seeking behaviour, majority (78%) of the respondents cited lack of awareness as a barrier to seeking timely healthcare (Figure 1). Fifty eight percent of the households felt the need for better information and awareness campaigns, while 22% sought financial support to access healthcare and 20% expressed the need for more accessible healthcare facilities (Figure 2). The average distance from their household to healthcare facility was around 2.5 km, ranging between 2-4 km. The preferred mode of transport was a two wheeler (47%). About 30% of the subjects were willing to visit a hospital in case of developing symptoms of viral fever or JE in specific, while 70% were willing to visit any doctor in a private care/clinic, or seek traditional healers, and 6% of them chose to practice various home remedies for the cure (Figure 3).

Discussion

To the best of our knowledge, this is the first study conducted to evaluate the attitudes and health-seeking behaviour of residents in an urban field practice area regarding JE. In this context, our findings are relevant to other viral or vector-borne diseases, like malaria, dengue fever and other related illnesses.

In our study, 77% of respondents had a very limited knowledge about the preventive measures of vector borne diseases, particularly JE. This finding is similar to a study conducted by Ahmad et al., involving health workers as the study population.⁵

Duval P et al., observed that the knowledge and practices are influenced by the socioeconomic status of respondents, and the educational level was noted to be a key factor.⁶ In our study, upper middle class demonstrated better awareness regarding vector borne diseases in general, compared to the lower middle and upper lower class of the community.

In the present study, 78% of the respondents identified ‘unawareness’ as the major obstacle to the prevention of vector borne diseases, reflecting the fact that a major proportion of the population remain ignorant of information regarding vector borne diseases, such as mosquitoes, their breeding habitats, and preventive measures, which is similar to the study findings of Mobin M et al.⁷

In order to reduce JE incidence in the community, focus on an intensified education program is necessary to sustain high vaccine coverage in the community, as 58% of our study population expressed the need for better information, education and awareness campaigns to engage the community, which is similar to the findings of Kyaw PP et al.⁸

Although higher levels of education is usually associated with higher immunization coverage in less-developed countries, as noted in the study by Halder SC et al., there is a relative hesitancy towards vaccination among the educated sections of the society.⁹ Our study reflects this with only 44% of the respondents being aware of the JE vaccine, and among them, only around 51% administered at least one dose to their children.

Additionally, vaccine hesitancy was found to be more in upper lower and lower middle class compared to upper middle class. The high levels of education in Dutch parents was identified as one of the determinants of a negative attitude towards having their child vaccinated, as per the study conducted by Hak E et al.¹⁰

As per the study conducted by SJ Omman et al., the parental vaccine hesitancy rate toward the child JE vaccine was 84.3%.¹¹ While in our study, the vaccine hesitancy rate was found to be around 47.72%, despite the fact that awareness of JE vaccine among the residents was only 44%. Thus, the hesitancy towards the JE vaccine among the parents of vaccine-eligible children was higher compared to hesitancy toward other vaccines included in the National Immunization Schedule of India.¹²

Conclusion

The role of health workers is significant in creating awareness among the public, as observed in this study. However, there is a need for awareness campaigns related to vector borne diseases and JE in particular, since Kurnool is an endemic area. The public must be educated on the importance of maintaining hygienic practices and implementing effective mosquito control methods.

The health workers should also focus on encouraging JE vaccinations among the public. It is mandatory to administer JE vaccine in the endemic areas under the universal immunization program. Those aware of the vaccine have taken it, but the issue stands at creating awareness among the public and eradicating the fears and doubts the public have regarding vaccination. There should be more vaccine drives conducted for JE vaccination, especially during the pre-monsoon and monsoon seasons, in order to increase awareness and educate the public about the vaccination campaign and to address any doubts they have regarding the potency or effectiveness, or the side effects related to the JE vaccination administration. The healthcare workers must be well trained and equipped with educative tools like charts and posters, banners, hoardings and placards that can be displayed at the site of immunization, providing necessary information about various vector borne diseases, their mode of transmission and the various preventive measures that can be undertaken at the community level.

There is a dire need to regularly engage the public to encourage timely hospital visits and access to healthcare. They must be made aware of the early signs and symptoms of various vector borne diseases and their preventive measures. If the preventive measures fail, they should be aware of when to seek healthcare, and understand the consequences and severity of various vector borne diseases if the treatment is delayed.

Conflicts of Interest

The authors had no conflict of interest throughout this research.

Acknowledgements

We would like to thank our Institution and the Principal Dr. Chitti Narsamma for giving us an opportunity for conducting this research. We would also like to thank the Ethics Committee for approving this study and for providing inputs related to this study.