Study design and population

Descriptive study, with a mixed quantitative-qualitative approach. It was conducted between November and December 2018 on WCA aged 15 to 49 years, residents of the district of Bagua, department of Amazonas. The district of Bagua is located in the northern jungle of Peru, at an altitude of 420 meters and has environmental characteristics that favor the presence of the Aedes aegypti vector ¹³.

For the quantitative approach, we developed a questionnaire based on the KAP survey on Zika and its complications for community settings by a multidisciplinary team of the World Health Organization (WHO) ¹⁴, which was made available for use in member countries. Since it is an instrument that has not been tested in the field, the WHO recommends the application of a pilot test. For our study, questions were selected according to the research objectives. The instrument was validated by four experts with experience in field epidemiology, epidemiological surveillance of congenital diseases and research. The review process included the evaluation of the questionnaire by using a rating card with six categories: sufficiency, congruence, wording, clarity-precision, relevance and pertinence of the items. A pilot test was also conducted in the city of Bagua Grande in the province of Utcubamba-Amazonas, with a non-probabilistic sample of 5% of the study sample (36 WCA), to adapt it to the context, improve the structure of the questions and determine the time required to fill out the instrument. At the beginning of the study, 40 questions were selected from the WHO survey that addressed the research objective. After review by the experts, five questions were ordered and reformulated. As a result of the implementation of the pilot test, three questions were removed, one question was added and the structure of question 19 was modified for better understanding. The final survey consisted of 38 questions, divided into four sections: sociodemographic data, knowledge, attitudes and practices; the average time to complete the survey was 15 to 30 minutes.

Subsequently, four focus groups were formed, using a semi-structured guide with 17 open-ended questions on perceptions of Zika. The average duration of each focus group was 60 to 120 min and was moderated by a professional with experience in qualitative research. The instrument was validated by expert judgment.

Sample and sampling

For the quantitative phase, we considered the estimated population of women aged 15-49 years in 2018 (6,862 WCA), published in the National Institute of Statistics and Informatics. An expected proportion of 50% (proportion of correct answers of knowledge and practices) was considered to obtain the maximum sample size, reliability level of 95%, margin of error of 5%, rejection rate of 0.1 and design effect of 1.8. The resulting sample of 721 women was calculated using Epidat 4.1 software (Xunta de Galicia- OPS).

The sampling was stratified by two-stage clusters, so a sample of subjects was selected for each sector of the district of Bagua (19 sectors). The first level unit was a random selection of blocks in each sector using the 2018 cadastral sketch of the District Municipality, proportional to the size of each cluster. The second level unit was the dwellings within each block and we randomly selected four dwellings per block. In each dwelling we sought for a WCA aged 15 to 49, if the subject was not found in the selected address, the next dwelling to the right was chosen.

For the qualitative approach, a non-probabilistic purposive sample of WCA who voluntarily agreed to participate in the focus groups was selected and the invitation was extended to all WCA during the application of the survey. The focus groups were formed according to their arrival; four groups were formed with a minimum of eight and a maximum of eleven WCA.

Data collection

The questionnaires were applied from November 26 to December 31, 2018. Previously, enumerators and supervisors were trained, in order to ensure the correct application of the instrument. There were twenty enumerators, distributed in each sector, and three supervisors who monitored six to seven enumerators in order to ensure the quality of the information collected. The survey was administered to WCA who were at home and who wished to participate in the study.

During the application of the survey each enumerator in charge of a sector made the invitation for the focus groups, seeking to include the entire rural and urban socioeconomic spectrum. From the 4th to the 7th of December 2018, four focus groups were carried out, each group had a moderator who used the semi-structured guide and led the focus groups. Likewise, there were two observers who recorded the field notes and the participants’ responses through a voice recorder.

Study variables

The quantitative survey included, in addition to the sociodemographic variables, 16 questions on knowledge, 9 questions on attitudes and 15 on practices. For the collection of qualitative data, stimulation questions were used for five topics: dissemination of information about Zika, knowledge about the disease, prevention of the disease, consequences for the pregnant woman and complications of the disease.

Analysis plan

For the descriptive quantitative analysis, we used absolute and relative frequencies and measures of central tendency and dispersion (mean and standard deviation) for the categorical and numerical variables, respectively. The statistical software Stata version 12 (Stata Corp LLC, USA) was used.

The qualitative analysis included the extraction of key quotes that were coded and grouped into five sections: Dissemination of information, knowledge about the disease, prevention of the disease, consequences in pregnant women and complications due to Zika. For the analysis, we used the grounded theory methodology, based on the analysis of the content of the responses, seeking to elaborate an integrating theory to explain the perception of each topic.

The quantitative-qualitative integration was carried out in the data interpretation phase, by using narrative integration with a constructive approach (weaving approach) ¹⁵. The integration followed the interpretation of the five sections, allowing to broaden, deepen and contextualize the study findings.

Ethical aspects

The study was approved by the Ethics Committee of the Hospital Nacional Dos de Mayo- Lima (evaluation 093-2018-CEIB- HNDM). All participants signed an informed consent form before the application of the survey and the focus group, after being informed of the purpose, risks and benefits of the research. Likewise, an informed consent form was used for underage participants. The data recorded in the instruments were anonymous in order to protect the participant’s identity and privacy.

Knowledge about the disease

Regarding knowledge, 86.3% (n=624) considered that it is possible to become ill with Zika; 35.6% (n=257) believed that it can cause a rash; 10.1% (n=73) that it can be transmitted through sexual intercourse and 2.2% (n=16) that it can be transmitted during pregnancy. A total of 97.1% (n=702) of the WCA would advise a patient with Zika to go to a health facility. Regarding practices, 94.2% (n=681) reported that if they had a rash, they would go to the health facility (Table 2).

In the focus groups, we found that Zika is perceived as “similar” to dengue and they consider that it “affects pregnant women”. Most of them relate transmission to the bite of the “mosquito”. However, some recognize transmission during pregnancy (Annex 1).

Dissemination of information about Zika

Regarding information on Zika, 85.8% (n=620) of the WCA received information more than a year ago; 41.1% (n=297) heard it on the radio; 34.3% (n=248) through talks by health personnel and 23.7% (n=171) on television. Of the total of participants, 68.5% (n=495) considered that the information received is still insufficient and would like to obtain more information on prevention 48% (n=347) and treatment 41.1% (n=297) Table 3. In the focus groups, participants indicated that information on Zika was broadcasted “fast” on radio and television. On the other hand, they indicate that other dissemination strategies should be considered (Annex 1).

Disease prevention

WCA believe that Zika can be prevented by using mosquito nets 60% (n=434) and covering water containers 53.4% (n=386); 3.6% (n=26) believe it can be prevented by avoiding sexual intercourse and 1.9% (n=14) by using a condom. Of the participants, 36.1% (n=261) considered that families are responsible for preventing Zika, 27.3% (n=197) that the health sector is responsible, 16.5% (n=119) that local governments and 27% (n=195) believe that everyone is responsible. Regarding practices, 74.4% (n=538) of WCA reported having taken some measure to protect themselves and 81.8% (n=591) to protect their family. Fourteen percent (n=101) reported that they kept the sachet of larvicide in the container and 7.9% (n=57) allowed the health brigades to enter their home. On the other hand, only 4.4% (n=32) used condoms, 1% (n=7) avoided sexual intercourse and 0.6%(n=4) received education within their families; 84.2% (n=609) considered that the health sector had taken preventive measures, 67.6% (n=489) through focal (larval) control. Of the WCA, 7.6% (n=55) consider that the local government has carried out activities, of which 7.3% (n=4) have coordinated with the local healthcare center (Table 4). In the focus groups, they considered that the health sector continues to do the “same thing”, they are suspicious of the impact of the new larvicide for focal control, they believe that spraying does not control the vector and “contaminates”. They perceive that the population is not “aware” of Zika prevention and give importance to education within the family and educational centers (Annex 1).

Consequences of Zika in pregnant women

Of the participants, 60.2% (n=435) believe that Zika causes risk of miscarriage, 30.2% (n=218) that it increases the risk of malformation in the newborn, and 19.2% (n=139) believe that they should not get pregnant in order to prevent Zika. Regarding practices, 31.7% (n=229) would choose to use condoms to prevent pregnancy, 62.8% (n=454) of WCA would go to prenatal controls if they were pregnant and with Zika and 98.3% (n=711) believe that they should be tested for Zika during prenatal controls (Table 5). In the focus groups, WCA believe that abortion would not be a choice. WCA perceive the concern and distress that a pregnant woman with Zika could suffer and the importance of psychological care (Annex 1).

Complications of Zika

Regarding complications, 38.7% (n=280) of WCA have heard of microcephaly, of which 87.1% (n=244) related it to zika; 82.1% (n=230) considered when the baby is born with a small head to be a complication of Zika. On the other hand, 5.5% (n=44) had heard about Guillain Barré, of which 52.5% (n=21) related it to Zika and 42.5% (n=17) considered that it causes difficulty in moving. Of the WCA, 34.7% (n=251) were concerned that Zika could cause disability to their babies; 75.1% (n=543) believed that the mother of a baby with a disability could suffer discrimination. Regarding practices, 58.7% (n=424) would use contraceptive methods to prevent complications; 2.6% (n=19) would take a child with a disability to a specialist or rehabilitation 1.9% (n=14) (Table 6). In the focus groups, WCA perceived that children with Zika are not necessarily born with malformations (Annex 1).