Role of Primary Care Providers
in Dengue Prevention and
Control in the Community:
Practitioners’ and Local Laypersons’
Perspectives in Dhaka, Bangladesh
(Prepared for presentation at the EFPC Conference on “Balancing Primary and
Secondary Care Prevention for More Integration and Better Health Outcomes”,
Istanbul, Turkey, 9-10 September, 2013
Parnali Dhar-Chowdhury, C. Emdad Haque, and Suman Meyur
Natural Resources Institute, University of Manitoba, Canada and
Department of General Surgery, KPC Medical College & Hospital, Kolkata, India
Dengue Disease Burden in Cities of
Bangladesh – Dhaka and Others
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Dhaka, the capital of Bangladesh, 16th
largest city (15.4 million population in
2012) of the world
Estimated to grow to about 20 million
(2020), making it the world’s third
largest city
Population growth =~7%
Attracts some 300-400 thousand new
migrants/year
Dengue Trends in Dhaka: Facts
from Reality
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Asymptomatic nature of dengue
(known as Dhaka fever) since 1964
Fig. 1: Dhaka : Total number of reported dengue cases by
year (n = 22,705).
First major outbreak in 2000 with
5,551 hospitalized cases (93 deaths)
Short term (2000-2008) trend
reveals short cyclical pattern –
reasons are unknown
Generally, limited knowledge of
dengue vector distribution and
density, disease risk perception,
and circulating serotypes
Fig:. 2: Dhaka: Total number of reported dengue
cases, by month, 2000-2008 (n = 22,705)
Clusters of dengue cases, superimposed on a map of
the population density in wards
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A. agypti abundance is
correlated with population
density
Rate of reporting to govt.
PHC facilities is common
among low SES; high SES to
private PHC units
A sense of complacency is
high among high SES
Studies on the Role of PHC in
Dengue Prevention and Control in Southeast Asia
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Scott Halstead (1984) – strategies in
the developing world: PHC worker’s
role in educating the patient and
community on preventive measures
(e.g., control A. aegypti)
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Example of level of awareness –
1962 Bangkok, Thailand case when
dengue infection rates exceeded
40% of the locals, less than 1% of
foreigners acquired dengue
antibody due to not storing water
In Malaysia, K.T. Ang et al.
(2010) interviewed 236 patients
admitted in hospitals.
83.9% sought treatment at a PC
96-98% patients reported that
PC practitioners had not given
them any advice on preventive
measures to be taken even
though 52% has been told they
could be having DF
Studies on the Role of PHC in
Dengue Prevention and Control in Southeast Asia
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F. Haire et al. (2003) found
similar pattern in Malaysia, and
concluded that “good knowledge
not necessarily lead to good
practice”.
Relevant studies in Taiwan and
Singapore focussed on HCPs’
knowledge on dengue fever.
Linda K. Lee et al. (2011) have
found significant variations in
clinical practice of PC physicians
by practice setting as well as by
age group.
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Similarly, Taiwanese research by T.S.
Ho et al. (2013) registered
noticeable variation in knowledge of
dengue disease among HCPs in
medical centres and other settings.
Physicians scored higher than nurses
on questions about infectious agents,
common symptoms, behaviour of
disease vectors, and epidemic area.
Nurses do better in answering the
question about notification timing by
law than physicians.
Overall, correct rate for notification
timing question is still low (25%).
Objectives and Methodology
Objectives
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To examine the role of
PHC providers in
preventing and
controlling DF and DHF
To assess the status of
KAP among PHC
providers
Methodology
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Two PRA (Participatory Rural
Appraisal) tools were applied –
FGD (Focus Group Discussion)
and Key Informant Interviews
(KII)
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Advantages:
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-Rapid assessment
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-individual and group KAP
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-both quantitative and
qualitative aspects
- cost effective
Focus Group Discussion
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3 FGDs
-Lay persons: randomly
selected 15 from 3 Wards
- 25 nurses and health care
practitioners
- 8 physicians representing
diverse clinics and hospitals
6 KIIs
PHC System in Bangladesh
4 hierarchical levels
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RURAL
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Community Clinics
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18,000 total – 1/6000 persons
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Union sub-centres: 1362
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URBAN
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Ministry of Local Government and
Cooperatives
Private sector urban primary health
project
NGO run projects
Dhaka Medical Hospital Dengue Ward
Findings
Lay Persons
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PHC units are providing access to
low SES community members
Information on dengue
prevention and control through A.
aegypti control is not given by
PHC units
Most low SES community
members cannot afford to
continue with secondary HC and
hence drop out rate high (>50%)
Nurses and health care practitioners
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Health care practitioners
are well aware of dengue
virus transmission process
through A. aegypti
Due to shortage of NS1
kits, services to local
community members are
constrained
Physicians working at PHC Units
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Communication on prevention
and control through mosquito
control and monitoring patients is
not considered as part of
professional responsibilities
Due to demographic and
socioeconomic pressure,
opportunities to follow up on
patients at community sub-centre
level are limited
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High drop out rate is caused by
multiple factors:
- high cost of diagnostic tests – more
than Tk. 2500: >60% cannot afford
- obstacles to internodal linkages
due to traffic congestion in large
cities
Inadequate facilities for preparing
platelet when transfusion is needed
Conclusions
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PHC units have demonstrated
significant success in
immunization, maternity health;
however, communication
regarding dengue prevention
and control is not provided
Contrary to Thailand and
Singapore, physicians at PHC
units are unlikely to be involved
with dengue prevention and
control communications
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Great potential for training
nurses and health
practitioners/technicians to
provide such services
Integrated health care system
need to be developed by
encompassing infrastructure
development, high-tech
communications, and local
community empowerment.
Institutions:
International Centre for Diarrh Disease,
Bangladesh (icddr,b)
North South University (NSU), Dhaka,
Bangladesh
Population Services and Training Centre (PSTC),
Bangladesh
Public Health Agency Canada (PHAC)
Government:
Ministry of Health & Family Welfare, Govt. of
Bangladesh
Funding Agencies:
IDRC-CRDI, Canada
IDRC Doctoral Research Award
Manitoba Health Research Council (MHRC)
Graduate Fellowship
University of Manitoba (UM)
Looking to the future.........