# Presentation: 780260

**Fourth National Conference on **
**West Nile Virus in the United States**
- February 10, 2002 - New Orleans, Louisiana
**Emily C. Zielinski-Gutierrez, DrPH**
- Centers for Disease Control and Prevention
- Division of Vector-Borne Infectious Diseases

**Barriers and Facilitating Factors to West Nile Virus Personal Prevention**

## Questions

- To what extent are people employing personal prevention measures against West Nile virus infection?
- What are possible reasons (barriers) that people are not using personal prevention measures?
- What interventions or activities might increase use of personal prevention measures?

## What are people currently doing about WNV?

## “When the weather is warm in your area...”

- 34% always/usually use insect repellent
- 34% usually/always check for & remove standing water around household
- 30% usually/always avoid spending time outdoors b/c of mosquitoes
- 21% always/usually wear long sleeves/pants

- Porter Novelli Healthstyles Survey, July-Aug 2002

## “During this past summer...” 

- 45% of respondents took *some* precaution to avoid mosquito bites
- 31% used a mosquito repellent containing DEET
- 21% used Skin-So-Soft or citronella as a repellent
- 16% replaced/repaired window screens

- Survey by Harvard School of Public Health, Nov 2002

## What barriers to prevention did we find during fieldwork in Louisiana?

## Field research examining barriers to prevention 

- July-September 2002
- LA-OPH in collaboration w/ CDC
- 16 focus groups across Louisiana, including:
- New Orleans, Slidell, Hammond, Monroe, West Monroe, Natchitoches, rural areas near Morgan City and a rural area south of Houma.
- African-American, white and Native-American residents

**Natchitoches Senior Center**

## Knowledge (and Beliefs)

What do people know about WNV? 

Is what people believe about DEET a barrier? 

- What do people know about WNV?
- Is what people believe about DEET a barrier?

## What do people know about WNV? 

- 92% know mosquitoes transmit the disease
- However, 47% of respondents believe can get WNV from drinking infected water
- 53% replied that can contract WNV through contact w/ dead birds

- Survey by Harvard School of Public Health, Nov 2002

## What people know/think about repellent use

- Question which repellents contain DEET:
- labels say *N,N-diethyl-m-toluamide*
- People know that they *should *use repellent
- yet most reported _**not**_ having used repellent  last time they were outdoors or with regularity the week before the focus group

## More ideas about repellent use

- Limited concern about safety or toxicity issues associated with DEET – in Louisiana.
**Likely to be very different in other areas.**
- Question DEET use on children, but concerns generally indistinct

- Commonly cited reasons for not using repellent:
*“**I just don’t think of it” *
*“**It’s not convenient when I need it” *
- Hassle factor of bathing self and kids

## Risk Perception:
Not a problem here, 
not a problem for me

- Not a problem here,
- not a problem for me

## Are people worried about WNV? 

- ~30% concerned they/someone in family may “get sick from West Nile virus” in the next 12 months

- Survey by Harvard School of Public Health, Nov 2002

## Who is at risk? 

- Risk can be perceived as _very_ local
- Risk is influenced by media coverage
- Some saw 2002 WNV outbreak in Louisiana as primarily “white” b/c of area affected

*“...**Black people and white people live relatively separate lives here, so they keep saying Covington or somewhere in Mandeville, and I wonder is it just white people dying? ...” * African-American Woman in New Orleans

## Who is at risk? 

- Few identify older people or persons over age 50 as being at higher risk for severe disease
- most cite concern about children
- Very little knowledge about asymptomatic WNV infection

## Financial and Resource Constraints

## Resource Issues: repellent

- Respondents were quite aware of the cost of the products and where prices were better
- Very few cited the cost of repellent as a problem
- though some stated *“it could be if you used it all the time”.*

## Staying indoors from dusk-dawn

- Resource issues:
*Not everyone has* *air-conditioning*
*Small/poor quality housing may guide one’s decision to be outdoors (space, temperature)*
*Inadequate housing may mean that risk is not entirely reduced indoors*

**Social and Cultural Factors**

**Perceived Efficacy of Prevention**

- Do people see risk as related to other, perhaps uncontrollable, factors in local environment?

## Outdoors as “social space”  
Evening is the reasonable time to be outside in many climates 
Neighborhood and cultural patterns guide people’s use of the outdoors to visit, observe/monitor the area

*Evening is the reasonable time to be outside in many climates *
*Neighborhood and cultural patterns guide people’s use of the outdoors to visit, observe/monitor the area*

*“...**My neighbors sit out. Nine pm at night and my neighbors are sitting outside. I like my neighborhood because of that.”**  *Woman in New Orleans

**Staying indoors from dusk-dawn**

**Notes:**
People want to know what’s going on in their area. 

## May conflict w/ physical activity recommendations 
Potentially high social cost to heed this message
Baseball games cancelled, HS football
Potential confusion regarding efficacy of other steps
Isn’t repellent enough at night? 

- Potentially high social cost to heed this message
- Baseball games cancelled, HS football
- Potential confusion regarding efficacy of other steps
*Isn’t repellent enough at night? *

**Staying indoors from dusk-dawn**

**Notes:**
What’s a bigger problem in Louisiana, obesity or WNV? 

## Why is this a problem now? 

- Mosquitoes: a threat or a nuisance?
- shifting definitions
- People ask why mosquitoes are ‘suddenly’ a problem?
*“**What’s different about the mosquitoes?”*
*“**This wasn’t a problem when we were coming up.”*

## Why is this a problem now?

**Why is this a problem now?**

- WNV seen as a short-term problem, people want to “get back outdoors”
- paradigm of Emerging Infectious Disease not always meaningful for the general public
- The (not entirely negative) legacy of DDT, especially in the South
*any* outbreak of mosquito-borne disease risks being seen as a “failure” of taxpayer-funded service

## Who’s job is prevention? 

**Who’s job is prevention?**** **

*Who *is responsible for mosquito control often unclear
- City Hall? Parish?
- Rarely can residents identify the agency that carried out mosquito control
- Little knowledge in the community about how mosquito control is conducted
- Perception of biased service delivery can exist as rationale for targeted adulticiding unclear

## Understanding Prevention

- Raised question of personal protection as a “compensatory behavior”
- Complex and complementary nature of mosquito abatement and personal prevention rarely clear or explicit

## So, what do we do? 

## Current educational efforts

- Largely focused on info through news media and electronic sources (Internet), supplemented with print materials.
- Current tendency to treat knowledge as the most important barrier to preventive action.
- There _are_ gaps, but knowledge isn’t enough.

**Notes:**
Acknowledge that there are other activities happening, and we want to know about them. 

## Behavior Change: Role for Community-Based Prevention Activities

- Focus groups emphasized need to receive  information ‘personally’
- Not just officials – get people talking, neighbors etc.
- People expect to hear important messages from local sources

*“...**Well, I figured if it were really important, then our Mayor would have said something.” *woman in focus group

## Role of Community-Based Prevention 

- Ouachita Parish Multi-Service Center – program to assist older residents with screen repair
- What are resources in local communities to carry out activities like this?

## Summary: future of WNV prevention & behavior change?

- Increase targeting
- Reaching persons over 50
- Take into account the resource and financial barriers to prevention
- Better convey how mosquito control functions
- Include role of activism
- Advisory council for Mosquito Control Boards?
- Advocacy to establish programs where non-existent

- Work with repellent manufacturers to address convenience issues (?)
- Messages/interventions should stress role for multi-level actions
- repellent + source reduction + avoiding mosquitoes + mosquito control...
- Establish specific actions in Phased Response Plan tied to surveillance data
- Need for evaluation!

**Summary:**** future of WNV prevention & behavior change?**

## Thank you. 

**Thank you. **

- Special acknowledgement
** ****Karen Kelso**, LA Office of Public Health and staff of Regional Offices
**Elisabeth Gleckler**, **Charlotte Colvin**, **Mary Ann Seday, Chiho Suzuki,** Tulane School of Public Health and Tropical Medicine and **Sandy Johnson**, Tulane Graduate School
-  Ouachita Parish and St. Tammany Parish Mosquito Abatement programs and other community organization throughout LA that helped facilitate focus groups