Content uploaded by Md. Siddikur Rahman
Author content
All content in this area was uploaded by Md. Siddikur Rahman on Sep 19, 2020
Content may be subject to copyright.
ORIGINAL ARTICLE
Trans R Soc Trop Med Hyg 2020; 0:1–9
doi:10.1093/trstmh/traa093 Advance Access publication 0 2020
Climate change and dengue fever knowledge, attitudes and practices
in Bangladesh: a social media–based cross-sectional survey
Md. Siddikur Rahman a,∗, Ajlina Karamehic-Muratovicb, Mahdi Baghbanzadehc, Miftahuzzannat Amrina,
Sumaira Zafard, Nadia Nahrin Rahmane, Sharifa Umma Shirinaf, and Ubydul Haqueg
aDepartment of Statistics, Begum Rokeya University, Rangpur, Rangpur 5400, Bangladesh; bDepartment of Sociology and
Anthropology, Saint Louis University, St. Louis, MO, USA; cData Analytics division, Zarrin Jam Marina, Tehran, Iran; dAsian Institute of
Technology, Bangkok, Thailand; eDepartment of Mass Communication and Journalism, Bangladesh University of Professionals, Dhaka,
1216 Bangladesh; fDepartment of Mass Communication and Journalism, University of Barishal, Bangladesh; gDepartment of
Biostatistics and Epidemiology, University of North Texas Health Science Center, North Texas, Fort Worth, TX 76107, USA
∗Corresponding author: Tel: +8801711339573; E-mail: siddikur@brur.ac.bd
Received 24 April 2020; revised 15 July 2020; editorial decision 21 August 2020; accepted 26 August 2020
Background: Bangladesh experienced its worst dengue fever (DF) outbreak in 2019. This study investigated the
knowledge, attitudes and practices (KAP) among university students in Bangladesh and significant factors asso-
ciated with their prevention practices related to climate change and DF.
Methods: A social media–based (Facebook) cross-sectional KAP survey was conducted and secondary data of
reported DF cases in 2019 extracted. Logistic regression and spatial analysis were run to examine the data.
Results: Of 1500 respondents, 76% believed that climate change can affect DF transmission. However, partic-
ipants reported good climate change knowledge (76.7%), attitudes (87.9%) and practices (39.1%). The corre-
sponding figures for DF were knowledge (47.9%), attitudes (80.3%) and practices (25.9%). Good knowledge and
attitudes were significantly associated with good climate change adaptation or mitigation practices (p<0.05).
Good knowledge, attitudes and previous DF experiences were also found to be significantly associated with good
DF prevention practices (p<0.001). There was no significant positive correlation between climate change and DF
KAP scores and the number of DF cases.
Conclusions: Findings from this study provide baseline data that can be used to promote educational campaigns
and intervention programs focusing on climate change adaptation and mitigation and effective DF prevention
strategies among various communities in Bangladesh and similar dengue-endemic countries.
Keywords: adaptation, climate change, control, dengue, early warning system, prevention
Introduction
Dengue fever (DF) is a climate-sensitive mosquito-borne viral
infection that has emerged as a major public health burden.
Globally there are an estimated 390 million dengue infec-
tions per year1and despite a risk of infection existing in 129
countries,270% of the actual burden is in Asian countries.1
Approximately half of the world’s population is currently at risk,
especially in countries with tropical and subtropical climates,
including Bangladesh.3DF can be caused by any of the four
dengue virus (DENV) serotypes and climate change is affect-
ing the infection and transmission of the virus, which occurs via
the bite of two species of female Aedes mosquitoes (A. aegypti
and A. albopictus).4Rainfall, temperature and humidity affect
the growth, survival and feeding behaviour of these dengue vec-
tors and climate change have contributed substantially to their
spread.4
Dengue is not new in Bangladesh and its epidemiology has
been a concern since the first outbreak was reported in 2000.3
After the first official outbreak, the number of hospitalized DF
cases was between >3000 and 7000 in the years 2002, 2004,
2015, 2016 and 2018.3However, this number jumped to 101 354
cases in 2019.5In 2019, dengue outbreaks in Bangladesh sur-
passed all previous annual records. There are several possible rea-
sons for this unprecedented increase in DF cases. Climate change,
unplanned rapid urbanization and construction, high popula-
tion densities, suboptimal vector control programmes and the
© The Author(s) 2020. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene.
All rights reserved. For permissions, please e-mail: journals.permissions@oup.com
1
Downloaded from https://academic.oup.com/trstmh/advance-article/doi/10.1093/trstmh/traa093/5905887 by guest on 19 September 2020
M. S. Rahman et al.
struggling healthcare system in Bangladesh further increase the
risk of dengue outbreaks. For example, several macrolevel risk
factors, including overpopulation, uncontrolled urbanization and
poor waste management, play prominent roles in the emergence
of DF in Bangladesh.6Furthermore, the uneven distribution of
piped water supply and drainage and adequate sewage disposal
can affect DF transmission as well.7
Bangladesh is one of the most vulnerable countries to the
adverse impacts of climate change,8with strong seasonal vari-
ations and heavy monsoon rainfall.9The heavy monsoon peri-
ods are responsible in part for the high seasonality of DF in
Bangladesh, with an increased incidence during the monsoon
season.10 Furthermore, there is also an increasing trend of
climate-related extreme events (tropical cyclones, storm surges,
floods and droughts) over the last 50 y.11 Climatic variability with
geographical spread and periodic outbreaks of DF poses a serious
threat to public health in Bangladesh.6,12
Since there is no licensed vaccine or prophylaxis available for
DF, behavioural impact programs are particularly effective for
DF control and prevention.13 The increasing incidence of DF in
Bangladesh highlights the importance of health behaviours and
attitudes about the virus contributing to its prevention. Protec-
tive behaviours and attitudes regarding DF may be enhanced
by studies addressing the knowledge, attitude, and practices
(KAP) relating climate change to DF. ‘KAP surveys are represen-
tative of a specific population to collect information on what is
known, believed, and done in relation to a particular topic and are
the most frequently used study tool in health-seeking behaviour
research’.14 The majority of the focus of dengue KAP research has
been area-based and conducted in several countries, except for
some studies conducted at the university level.13,15 ,16 Thus far,
no study has been conducted addressing dengue KAP among
university students in Bangladesh. University settings have the
potential to become disease hotspots, with active transmission
of agents and a negative impact on large communities due to
the close social contact, divergence of student behaviour from
non-student populations and permeability of universities’ bound-
aries and groups.13,17 Therefore assessment of climate change
and its association with DF was conducted to determine the KAP
level of university students in Bangladesh and to provide evidence
for future educational interventions in communities such as
this one.
Materials and methods
Study participants and design
Using Facebook, a cross-sectional KAP survey was conducted
across 16 public universities located in 14 distinct districts in
Bangladesh (see Supplementary Figure 1), so that a wide range
of universities and areas of Bangladesh would be represented.
The selected universities were chosen randomly from each divi-
sion (at least one) to make the sample more representative of
all geographic parts of Bangladesh. Using the snowball sam-
pling method,18 whereby participants were gradually identified
and invited to participate via both private and group chats and
encouraged to invite other friends to take part in the study, a
sample of 100 students was targeted from each university. A
total of 1560 surveys were completed, with a response rate of
97.5%, but due to unusable and/or significant missing data, 60
questionnaires were not included in the final analysis. Thus the
results of this study are based on the data from a total of 1500
respondents.
Written consent was sought via Facebook from all the selected
participants through private and group chats. Messages were
sent to consented students with a link to the survey and accom-
panying instructions. Participants were assured that the informa-
tion they provided would be kept confidential and the analysis
included only de-identified information. Responses to the survey
were screened to ensure that only currently enrolled students
and internet users were included in the analysis.
Instrument and data collection
The online survey using a self-administered questionnaire (see
Supplementary File 1) was conducted from September 2019 to
January 2020. The concept of climate change and its connec-
tion to DF was also presented in the questionnaire. The ques-
tionnaire was developed using several well-established, previ-
ously validated and employed scales and measures that were
adapted for this study.19–23 Before conducting the main study,
the questionnaire was pretested with 50 students and the reli-
ability of the questionnaire was determined by Cronbach’s α.In
the pilot sample, Cronbach’s αcoefficients of overall KAP domains
were 0.71, which indicates reasonable internal consistency.24
Data used in the pretest were not included in the final analy-
sis. Data on sociodemographic factors along with KAP regard-
ing climate change and DF were collected. Publicly available sec-
ondary data of reported DF cases of 2019 were collected from
the Directorate General of Health Services, Mohakhali, Dhaka,
Bangladesh.5
Data management and statistical analysis
The study asked a total of 49 questions, 23 of which were knowl-
edge related (climate change, 8; DF, 15), 15 were attitude related
(climate change, 10; DF, 5) and 11 were practice related (climate
change, 4; DF, 7). Each question was scored on a scale of 0–1,
with scores of 0, 0.5 and 1 representing incorrect/poor, moderate
and correct/good answers for knowledge and practices, respec-
tively. For attitudes, scores likewise included 0, 0.5 and 1, the
answers representing positive, moderate and negative/not sure,
respectively. Total knowledge scores were calculated by sum-
ming scores across knowledge questions for each participant.
Participant knowledge was assessed as good or poor based on an
80% cut-off point of total knowledge score.25 Thesamemethod
was separately applied to the sections on attitude and practices.
Covariates were assessed for statistical significance through χ2
testing or Fisher’s exact test, where appropriate. Significant vari-
ables in univariate analysis (p≤0.25) were used for multivariate
logistic regression analysis to determine the predictors of the KAP
domain.26 Odds ratios (ORs) and 95% confidence intervals (CIs)
were estimated using logistic regression models. Spatial analy-
sis was performed for the distribution of district-wise reported
DF cases and average KAP scores. Data were entered and anal-
ysed using RStudio (version 1.1.456; RStudio, Boston, MA, USA)
and ArcGIS (version 10.7; Esri, Redlands, CA, USA).
2
Downloaded from https://academic.oup.com/trstmh/advance-article/doi/10.1093/trstmh/traa093/5905887 by guest on 19 September 2020
Transactions of the Royal Society of Tropical Medicine and Hygiene
Tab le 1. Correct knowledge/awareness regarding climate change and dengue fever among university students in Bangladesh (N=1500)
Correct knowledge
Knowledge components n (%) 95% CI
Climate change
Have heard about climate change 1490 (99.3) 98.8 to 99.6
Believe that climate is changing 1488 (99.2) 98.6 to 99.6
Have good understanding and awareness about climate change 569 (37.9) 35.5 to 40.4
Biggest local climate change problem in Bangladesh
Increase in extreme weather (more heat/very cold/heavy or torrential rainfall) 1416 (94.4) 93.1 to 95.5
River bank erosion 1341 (89.4) 87.7 to 90.9
Floods 1352 (90.1) 88.5 to 91.6
Droughts 1088 (72.5) 70.2 to 74.7
Believe that changes in climate can affect numbers of vectors and dengue transmission 1142 (76.1) 73.9 to 78.2
Dengue fever (DF)
Have good understanding and awareness about DF 658 (43.9) 41.4 to 46.4
Transmission and spread
DF is caused by a virus 1268 (84.5) 82.6 to 86.3
Dengue virus has four serotypes 670 (44.5) 42.2 to 47.2
A person is vulnerable/can get dengue more than once 1052 (70.1) 67.8 to 72.4
Dengue is spread through mosquito bites 1423 (94.9) 93.7 to 95.9
A. aegypti and A. albopictus are the vectors of dengue 740 (49.3) 46.8 to 51.9
Symptoms and signs
Fever 1476 (98.4) 97.7 to 98.9
Headache 1355 (90.3) 88.8 to 91.8
Joint pains 1353 (90.2) 88.6 to 91.6
Muscle pain 1252 (83.5) 81.5 to 85.3
Pain behind the eyes 994 (63.3) 63.8 to 68.6
Nausea/vomiting 929 (61.9) 59.5 to 64.4
Most frequent bite time of Aedes mosquitoes (day time) 1271 (84.7) 82.8 to 86.5
Vector morphology
Identifying Aedes mosquitoes 1077 (71.8) 69.5 to 74.0
Have white spots on their legs 1078 (71.9) 69.6 to 74.1
Results
Sociodemographic characteristics
Of the 1500 respondents included in the final analysis, 64.8%
were male. The mean age of the respondents was 21.9 y
(standard deviation 1.95). Seventy seven percent of the stu-
dents were from the undergraduate/honours level and 33% from
the masters level. The respondents represented different facul-
ties, but most were affiliated with science (30.9%), followed by
arts and social science (30.7%), engineering and earth science
(14.3%), biological and health science (14.2%) and business stud-
ies (9.9%). The majority of respondents (42.7%) reported their
family income as <20 000 Bangladeshi taka and the majority
were from rural areas (56.5%). Furthermore, most of the par-
ticipants reported to have never been personally infected by DF
(83.7%) but were familiar with the recent 2019 dengue epidemic
in Bangladesh. Further data on the demographic and socio-
economic characteristics of the respondents are presented in
Supplementary Table 1.
Correct knowledge/awareness of respondents on
climate change and DF
Almost all of the respondents reported having heard about cli-
mate change (99.3%) and believed that the climate is chang-
ing (99.2%). Most reported their greatest concern regarding local
climate change to be the increase in extreme weather (94.4%),
followed by floods (90.1%) and riverbank erosion (89.4%). Two-
thirds (67%) of participants believed that climate change affects
the expansion of dengue vectors and DF (Table 1). A major-
ity of the participants correctly perceived only two transmis-
sion modes of DF, including DF caused by a virus (84.5%) and
mosquito bites (94.9%). Less than 50% of the respondents knew
about the dengue virus serotypes and vectors (A. aegypti and A.
albopictus). As for correct knowledge of DF symptoms, fever
was the most common known symptom (98.4%), followed
by headache (90.3%), joint pain (90.2%) and muscle pain
(83.5%). Nearly two-thirds of the respondents knew that pain
behind the eyes (63.3%) and nausea/vomiting (61.9%) were
3
Downloaded from https://academic.oup.com/trstmh/advance-article/doi/10.1093/trstmh/traa093/5905887 by guest on 19 September 2020
M. S. Rahman et al.
Tab le 2. Positive attitude or opinions regarding climate change and dengue fever among university students in Bangladesh (N=1500)
Positive attitude
Attitude components n (%) 95% CI
Climate change
Climate change and more spread of DF is an extremely serious problem 893 (59.5) 57.0 to 61.9
Climate change is causing more DF in my area 892 (59.5) 56.0 to 61.9
Media should take a leading role in raising awareness about the impact of
climate change and dengue risk reduction issues
1391 (92.7) 91.3 to 93.7
Need for better awareness and knowledge on climate change 1458 (98.1) 97.3 to 98.7
Need more knowledge and education programs on climate literacy
(adaptation and mitigation capacities)
1416 (94.4) 93.1 to 95.5
Need more knowledge and education programs on early warning systems
(flood/drought) and its health impact on DF
1399 (93.5) 91.9 to 94.5
Want to receive update information about climate change and DF (global and
local)
1331 (88.7) 87.1 to 90.3
Preferred mode of receive update information about climate change and dengue risk
News media (Television/radio/newspaper) 1448 (96.5) 95.5 to 97.4
University education 1219 (81.3) 79.2 to 83.2
Social media (Facebook/Twitter/YouTube/Instagram etc.) 1452 (96.8) 95.8 to 97.6
Dengue fever (DF)
Need for better awareness and knowledge on DF 1435 (95.7) 94.5 to 96.6
Need more knowledge and education programs on symptoms and treatment
of dengue haemorrhagic fever
1372 (91.5) 90.0 to 92.8
Need more knowledge and training programs on effective vector control
strategies
1308 (87.2) 85.4 to 88.8
We can reduce dengue risk due to climate change 987 (65.8) 63.3 to 68.2
The government should take immediate action to mitigate dengue risk that
may spread due to climate change
1205 (80.3) 78.3 to 82.3
the general signs or symptoms of DF. Regarding the vec-
tor morphology, 71.9% of the respondents reported that they
knew how to identify Aedes mosquitos. Additionally, the major-
ity (84.7%) knew that these mosquitos are daytime biters
(Table 1).
Positive attitudes or opinions of respondents regarding
climate change and DF
Most of the respondents (59.5%) agreed on the seriousness of the
climatic connection to the rapid spread of the DF problem and its
extreme effect in their area (Table 2). Thus 92.7% of the respon-
dents appreciated the role of media in raising awareness regard-
ing climate change and DF risk reduction and prevention. Nearly
98% of participants reported that they needed more knowledge
on climate change, especially adaptation and mitigation capaci-
ties related to climate change (94.4%) and early warning systems
(93.5%) for flood/drought and its impact on DF. Most respondents
said that they would like to receive updated information regard-
ing climate change and DF (88.7%) and chose social media (Face-
book, Twitter, YouTube, Instagram; 96.8%) followed by main-
stream media (television, radio, newspaper; 96.5%) as a preferred
mode of communication. For DF risk mitigation, the majority of
the respondents showed a positive attitude towards the need for
better awareness and knowledge (87.2%) and more educational
programs on symptoms and treatments of DF (91.5%), including
additional training on vector control strategies (87.2%). Most of
the respondents believed that DF risk reduction due to climate
change is possible (65.8%) and that the government should play
a leading role (80.3%) in this process (Table 2).
Good practices (behaviours) of respondents about
climate change and DF
Only 21.9% of respondents took extra actions to adapt to the
impact of climate change (floods, droughts, storms) (Table 3).
Most of the respondents (59.5%) had climate-resilient house-
hold practices regarding the spread of DF due to climate change.
The majority of the respondents (91.5%) used communication
tools (internet, mobile phone, television) to inform themselves
about climate change and to obtain up-to-date information on
a daily basis as a preventive measure against the spread of DF
due to climate change (82.3%). The most common good prac-
tices among respondents included disposing of water-holding
containers (90.8%), followed by the use of mosquito repellent
and mosquito nets (89.5%), cleaning up garbage/trash (87.9%),
4
Downloaded from https://academic.oup.com/trstmh/advance-article/doi/10.1093/trstmh/traa093/5905887 by guest on 19 September 2020
Transactions of the Royal Society of Tropical Medicine and Hygiene
Tab le 3. Good adaptation and preventive practice against climate change and dengue feveramong university students in Bangladesh (N=1500)
Good practice
Practice components n (%) 95% CI
Climate change
Took more climate resilient household practices for increased risk of climate change and DF 892 (59.5) 56.0 to 61.9
Took extra actions to lessen the impact of climate change (floods, droughts, storms, etc.) 328 (21.9) 19.8 to 24.0
Use media (internet/mobile phone/television) to read/watch/listen to stories on climate change 1373 (91.5) 90.0 to 92.9
How often listen/read/watch stories on climate change practices and dengue risk reduction
Every day 1235 (82.3) 80.3 to 84.2
Sometimes 254 (16.9) 15.1 to 18.9
Never use 11 (0.7) 0.4 to 1.3
Dengue fever (DF)
Took extra precautions for mosquito control practice following the last dengue epidemic 748 (49.9) 47.3 to 52.4
Steps to prevent mosquito breeding during a dengue outbreak
Dispose of water-holding containers such as tires, parts of automobiles, plastic bottles, cracked pots, etc. 1362 (90.8) 89.3 to 92.2
Clean up garbage/trash 1319 (87.9) 86.2 to 89.5
Use insecticide sprays to reduce mosquitoes 1074 (71.6) 69.3 to 73.8
Use window screens and bed nets 1208 (80.5) 78.5 to 82.5
Use mosquito repellent and mosquito net when sleeping 1343 (89.5) 87.9 to 91.0
Health-seeking behaviour regarding DF
Go to hospital 1132 (75.5) 73.2 to 77.6
Go to a community health worker 58 (3.9) 3.0 to 4.9
Go to a private provider 84 (5.6) 4.5 to 6.8
Get medication from the pharmacy 145 (9.7) 8.2 to 11.2
Wait for the fever to go away 81 (5.4) 4.3 to 6.6
window screens and bed nets (80.5%) and insecticide sprays
to reduce mosquitoes (71.6%). The majority of respondents
(75.5%) choose hospitals as health-seeking behaviour regarding
DF (Table 3).
Spatial distribution of DF cases and average KAP scores
Fewer DF cases were reported in 2019 in the northern districts of
Bangladesh than in its central or southern districts (Figure 1A).
Figure 1B–G illustrates the spatial distribution of cases reported
in each district with the average KAP scores of individuals from
each of the districts. There is no significant correlation between
climate change KAP scores and the number of cases in the dis-
tricts. However, at the α=0.05 significance level, there is a signifi-
cant negative correlation of −0.28 between the DF practice score
and the number of DF cases reported (Figure 1G).
Demographic and socio-economic factors, knowledge
and attitudes associated with good climate change and
DF preventive practice (behaviours)
KAP regarding climate change adaptation and mitigation prac-
tices were statistically significant (p<0.05) among male com-
pared with female respondents, as well as among those with
good knowledge or attitudes compared with those respondents
without good knowledge or attitudes. Male participants had
lower odds (Table 4) of having good practice regarding adapt-
ing to climate change (OR 0.73 [95% CI 0.58 to 0.93]) compared
with females (Table 4). Increased odds of having good practices
regarding climate change were also identified among partici-
pants with good knowledge (OR 1.44 [95% CI 1.1 to 1.87)] and
a good/positive attitude (OR 3.28 [95% CI 2.17 to 4.96]) com-
pared with participants with poor knowledge or negative atti-
tudes (Table 4).
Respondents who have good knowledge of DF (OR 1.69 [95%
CI 1.33 to 2.15]) had 1.69 times higher odds of having good DF
prevention practices compared with those respondents with poor
knowledge (Table 4). Respondents having positive attitudes (OR
2.48 [95% CI 1.73 to 3.56]) had higher odds of having good pre-
vention practices regarding DF compared with respondents with
poor knowledge (Table 4). A significant statistical difference was
found for DF control/mitigation practices between the respon-
dents who suffered from DF compared with those that did not.
Participants who suffered from DF (OR 1.55 [95% CI 1.33 to 2.11])
were more likely to have good DF prevention practices compared
with those with no previous history of DF exposure. The study
did not find any significant impact of the area of specialization,
level of income or environment (rural/urban) on good climate
change and DF preventive practice (behaviours) (see Supplemen-
tary Tables 2–3).
5
Downloaded from https://academic.oup.com/trstmh/advance-article/doi/10.1093/trstmh/traa093/5905887 by guest on 19 September 2020
M. S. Rahman et al.
Figure 1. (A) Reported dengue cases, (B) climate change knowledge, (C) climate change attitude, (D) climate change practice, (E) dengue knowledge,
(F) dengue attitude and (G) dengue practice scores among university students in Bangladesh.
Discussion
Rapid assessment of health education is necessary for targeted
interventions against emerging infectious diseases, including DF.
This study used a Facebook-based approach to carry out a rapid
assessment of health education needs after the 2019 dengue
outbreak in Bangladesh.
The findings of the study demonstrate that good knowledge
and attitudes are crucial for good climate change adaptation or
mitigation and DF prevention practices. Students were knowl-
edgeable of DF signs and symptoms, which correlates with the
results of a previous study conducted in Malaysia.13 Findings like
these underline the importance of adequate community knowl-
edge to recognize disease that will in turn cause them to seek
prompt remedial measures.27 Although 94.9% of participants
reported that they know DF spreads through mosquito bites,
only half of the participants (49.3%) knew that A. aegypti and A.
albopictus are responsible for DF transmission. Most of the stu-
dents correctly reported that the Aedes mosquito is a day biter.
This finding is important for the adequate adoption of protection
strategies at specific bite times.
Most of the students were deemed to need additional knowl-
edge and education on climate change and DF, particularly on
early warning systems (flood/drought) and its health impacts on
DF, symptoms and treatment of dengue haemorrhagic fever and
effective vector control strategies. An early warning system for
DF is meant to predict outbreaks and prevent DF cases by aid-
ing timely decision making and deployment of interventions.28
Providing information to improve knowledge on climate-based
warning systems is especially effective for DF control and pre-
vention. Universities are key settings for health promotion, so
understanding factors that influence the practice of DF preven-
tion within a university community are important.29 Moreover,
approximately half of the student population in Bangladesh are
commuters who frequently travel between their homes and the
university, raising the risk for disease transmission. The capac-
ity for infectious disease control and prevention may need to be
strengthened to meet the increasing challenge of climate change
in Bangladesh.
This study found that social media (Facebook, Twitter,
YouTube, Instagram, etc.) was the preferred source of informa-
tion (96.8%), followed by news media (television, radio, newspa-
per) and university education, regarding climate change and DF.
The use of social media can play a vital role in the dissemina-
tion of information about adaptation and mitigation measures
for climate change, as well as monitoring and preventing DF. In
developing countries, use of the internet and social media has
become increasingly popular, especially among young people.30
For example, use of the internet increased from 42% in 2013–14
to 64% in 2017–18, while the use of online social networking has
increased from 34% to 53% during the same period in emerging
economies and developing countries.30 Since university students
come to study from different parts of the country, knowledge-
able university students can be employed to create awareness
on the impact of climate change on DF among the general pub-
lic. Health awareness seminars should be planned by academic
6
Downloaded from https://academic.oup.com/trstmh/advance-article/doi/10.1093/trstmh/traa093/5905887 by guest on 19 September 2020
Transactions of the Royal Society of Tropical Medicine and Hygiene
Tab le 4. Univariate and multiple logistic regression analysis showing significant predictors of good climate change adaptation (behaviours) and
dengue prevention practice (N=1500)
Predictors Univariate OR (95% CI) p-Value Multivariate adjusted OR (95% CI) p-Value
Climate change adaptation practice
Sex <0.001 <0.05
Fema le 1 1
Male 0.67 (0.54 to 0.83) 0.73 (0.58 to 0.93)
Climate change knowledge <0.001 <0.001
Poor 1 1
Good 1.62 (1.25 to 2.09) 1.44 (1.1 to 1.87)
Climate change attitude <0.001 <0.001
Poor 1 1
Good 3.69 (2.46 to 5.55) 3.28 (2.17 to 4.96)
Dengue prevention practice
Dengue knowledge <0.001 <0.001
Poor 1 1
Good 1.76 (1.39 to 2.22) 1.69 (1.33 to 2.15)
Dengue attitude <0.001 <0.001
Poor 1 1
Good 2.52 (1.77 to 3.59) 2.48 (1.73 to 3.56)
Previous dengue experience <0.05 <0.001
No 1 1
Yes 1.46 (1.08 to 1.96) 1.55 (1.13 to 2.11)
institutions to educate students about DF. Printed and electronic
media administered by healthcare providers should be used
to disseminate knowledge and awareness.16More importantly,
proper communication and coordination between different enti-
ties working on climate change and DF and the local communi-
ties to recognize key constraints/practical difficulties in DF man-
agement are required. Likewise, community-based approaches
in countries such as Bangladesh are more likely to work and be
successful. A plethora of studies on modern public health efforts
have demonstrated that improvements in public health at the
community level have the best chance at reducing the health
needs of a community, and infectious diseases likewise.31 Vigilant
disease and vector surveillance, preventive practice and commu-
nity health promotion programs will be required to address the
threat of DF in the future. Further efforts are required to adapt
to climate change and to curb the impacts of climate-sensitive
infectious diseases on human health.28
This is the first study looking at the KAP regarding climate
change and DF in dengue-endemic countries. Information from
this study will be useful to determine the community’s needs
for necessary prevention and control strategies of DF due to cli-
mate change. The cross-sectional study design provides a snap-
shot of the KAP of the selected university students and the
results may not be generalizable and representative of all uni-
versity students in Bangladesh. There are 46 public universi-
ties in Bangladesh, but we considered only 16 universities as
our sample due to time and budget limitations. The insignifi-
cant associations of sociodemographic factors with DF preventive
practices could be partly explained by the homogeneous sociode-
mographic characteristics of the sample. A comparison of the
other studies presented serious challenges because the studies
varied in sample size and study area. Other studies used differ-
ent factors for the leading cause of dengue, such as sociode-
mographic upheavals causing urbanization problems. Most of
the studies were community-based and more heterogeneous
in terms of the sociodemographic characteristics of the sample
than the current study. With regard to generalizability, the results
of this study are mostly applicable to universities in Bangladesh.
The study findings are also difficult to generalize due to the limita-
tions inherent in the snowball sampling technique, such as deter-
mining the sampling error or making inferences about a popula-
tion based on a sample. There are also concerns about whether
the findings can be generalized to populations at large, particu-
larly rural populations, or tertiary educational institutions in other
countries with different cultural backgrounds.
Conclusions
This study provides useful information for capacity building in uni-
versity settings for climate change adaptation, DF control and
prevention as specific to Bangladesh. Since most of the univer-
sity students use social media and communication tools, namely
Facebook, mobile phones and radio/TV, rigorous and targeted
campaigns by public health authorities through social, electronic
and print media can ultimately play a crucial role in improv-
ing knowledge and control measures regarding climate change
and DF. Future threats from DF can be reduced by improving
7
Downloaded from https://academic.oup.com/trstmh/advance-article/doi/10.1093/trstmh/traa093/5905887 by guest on 19 September 2020
M. S. Rahman et al.
preventive practice behaviours regarding climate change adap-
tation and DF prevention through an interdisciplinary approach
involving community participation, media and government.
Therefore university-based educational programs regarding cli-
mate change and DF should be advocated to encourage com-
munity participation in DF control.
Supplementary data
Supplementary data are available at Transactions online.
Authors’ contributions: MSR, UH and AKM conceived the study design.
MSR and MA prepared the dataset. MSR carried out the analyses. MB
helped with the figure production. MSR wrote the original draft and all
authors reviewed, edited and approved the final manuscript. MSR and UH
are guarantors of the paper.
Acknowledgments: The researchers are very grateful to everyone who
participated in the study and Afsana T. Prima, Murad Hossain, Mowri Dhali,
Afroza Begum, Selim Mondol, Yeasmin N. Sweety, Shahajada Mia, Mahbub
A. Rakib and Arman H. Chowdhury for helping with the data collection and
technical assistance. We would also like to give special thanks to Noah C.
Peeri for his comments and insights on the manuscript.
Funding: UH was supported by the Research Council of Norway (grant
281077).
Competing interests: None declared.
Ethical approval: Not required.
Data Availability: None.
References
1 Bhatt S, Gething PW, Brady OJ, et al. The global distribution and burden
of dengue. Nature. 2013;496(7446):504–7.
2 Brady OJ, Gething PW, Bhatt S, et al. Refining the global spatial limits
of dengue virus transmission by evidence-based consensus. PLoS Negl
Trop Dis. 2012;6(8):e1760.
3 Mamun MA, Misti JM, Griffiths MD, et al. The dengue epi-
demic in Bangladesh: risk factors and actionable items. Lancet.
2019;394(10215):2149–50.
4 Rocklöv J, Tozan Y. Climate change and the rising infectiousness of
dengue. Emerg Top Life Sci. 2019;3(2):133–42.
5 Directorate General of Health Services. Daily dengue status report.
Dhaka, Bangladesh. 2019. Available from: https://www.dghs.gov.bd/
images/docs/Notice/2019/dengue/Dengue_20191231.pdf [accessed
3 April 2020].
6 Mahmood BAI, Mahmood S. Emergence of dengue in Bangladesh a
major international public health concern in recent years. Environ Res.
2011;2(3):35–41.
7 Banks N. A tale of two wards: political participation and the urban poor
in Dhaka city. Environ Urban. 2008;20(2):361–76.
8 Al-Amin AKMA, Akhter T, Islam AHMS, et al. An intra-household anal-
ysis of farmers’ perceptions of and adaptation to climate change
impacts: empirical evidence from drought prone zones of Bangladesh.
Climatic Change. 2019;156(4):545–65.
9 World Health Organization, Regional Office for South-East Asia. Com-
prehensive Guideline for Prevention and Control of Dengue and
Dengue Haemorrhagic Fever. New Delhi: World Health Organization
Regional Office for South-East Asia; 2011.
10 Sharmin S, Glass K, Viennet E, et al. Interaction of mean temper-
ature and daily fluctuation influences dengue incidence in Dhaka,
Bangladesh. PLoS Negl Trop Dis. 2015;9(7):e0003901.
11 Shahid S, Wang X-J, Harun SB, et al. Climate variability and changes
in the major cities of Bangladesh: observations, possible impacts and
adaptation. Region Environ Change. 2016;16(2):459–71.
12 Dhar-Chowdhury P, Paul KK, Haque CE, et al. Dengue seroprevalence,
seroconversion and risk factors in Dhaka, Bangladesh. PLoS Negl Trop
Dis. 2017;11(3):e0005475.
13 Lugova H, Wallis S. Cross-sectional survey on the dengue knowledge,
attitudes and preventive practices among students and staff of a pub-
lic university in Malaysia. J Community Health. 2017;42(2):413–20.
14 World Health Organization. Advocacy, communication and social
mobilization for TB control: a guide to developing knowledge, atti-
tude and practice surveys. Available from: http://whqlibdoc.who.
int/publications/2008/9789241596176_eng.pdf [accessed 13 April
2020].
15 Rosli WRW, Rahman SA, Parhar JK, et al. Positive impact of educational
intervention on knowledge, attitude, and practice towards dengue
among university students in Malaysia. J Public Health. 2019;27:461–
71.
16 Bota R, Ahmed M, Jamali MS, et al. Knowledge, attitude and perception
regarding dengue fever among university students of interior Sindh. J
Infect Public Health. 2014;7(3):218–23.
17 Van D, McLaws M-L, Crimmins J, et al. University life and pandemic
influenza: attitudes and intended behaviour of staff and students
towards pandemic (H1N1) 2009. BMC Public Health. 2010;10:130.
18 Baltar F, Brunet I. Social research 2.0: virtual snowball sampling
method using Facebook. Internet Res. 2012;22(1):57–74.
19 Nigatu AS, Asamoah BO, Kloos H. Knowledge and perceptions about
the health impact of climate change among health sciences students
in Ethiopia: a cross-sectional study. BMC Public Health. 2014;14:587.
20 Woodward A, Smith KR, Campbell-Lendrum D, et al. Climate change
and health: on the latest IPCC report. Lancet. 2014;383(9924):1185–
9.
21 Wu X, Lu Y, Zhou S, et al. Impact of climate change on human infec-
tious diseases: empirical evidence and human adaptation. Environ Int.
2016;86:14–23.
22 Zaki R, Roffeei SN, Hii YL, et al. Public perception and attitude towards
dengue prevention activity and response to dengue early warning in
Malaysia. PLoS One. 2019;14(2):e0212497.
23 Rosli WRW, Rahman SA, Parhar JK, et al. Positive impact of edu-
cational intervention on knowledge, attitude, and practice towards
dengue among university students in Malaysia. J Public Health (Berl).
2019;27:461–71.
24 Taber KS. The use of Cronbach’s alpha when developing and
reporting research instruments in science education. Res Sci Educ.
2018;48:1273–96.
25 Dhimal M, Aryal KK, Dhimal ML, et al. Knowledge, attitude and
practice regarding dengue fever among the healthy population of
highland and lowland communities in central Nepal. PLoS One.
2014;9(7):e102028.
26 Harapan H, Rajamoorthy Y, Anwar S, et al. Knowledge, attitude,
and practice regarding dengue virus infection among inhabitants of
8
Downloaded from https://academic.oup.com/trstmh/advance-article/doi/10.1093/trstmh/traa093/5905887 by guest on 19 September 2020
Transactions of the Royal Society of Tropical Medicine and Hygiene
Aceh, Indonesia: a cross-sectional study. BMC Infect Dis. 2018;18(1):
96.
27 Khun S, Manderson L. Community and school-based health education
for dengue control in rural Cambodia: a process evaluation. PLoS Negl
Trop Dis. 2007;1(3):e143.
28 Tong MX, Hansen A, Hanson-Easey S, et al. Perceptions of capacity for
infectious disease control and prevention to meet the challenges of
dengue fever in the face of climate change: a survey among CDC staff
in Guangdong Province, China. Environ Res. 2016;148:295–302.
29 Lugova H, Wallis S. Cross-sectional survey on the dengue knowl-
edge, attitudes and preventive practices among students and staff
of a public university in Malaysia. J Community Health. 2017;42(2):
413–20.
30 Poushter J, Bishop C, Chwe H. Social media use continues to
rise in developing countries but plateaus across developed ones.
Pew Research Center. 19 June 2018. Available from: https://www.
pewresearch.org/global/2018/06/19/social-media-use-continues-to-
rise-in-developing-countries-but-plateaus-across-developed-ones/
[accessed 5 September 2020].
31 Blumenthal DS, DiClemente RJ. Community-Based Participatory
Health Research: Issues, Methods, and Translation to Practice. New
York: Springer; 2013.
9
Downloaded from https://academic.oup.com/trstmh/advance-article/doi/10.1093/trstmh/traa093/5905887 by guest on 19 September 2020
