J Arthropod-Borne Dis, Dec 2022, 16(4): 340–349 S Firooziyan et al.: Predictors of … 340 http://jad.tums.ac.ir Published Online: Dec 31, 2022 Original Article Predictors of Dengue Preventive Practices Based on Precaution Adoption Process Model among Health Care Professionals in Northwest of Iran Samira Firooziyan1,2, Roya Sadeghi3, Maryam Sabouri4, Azar Tol3, Ehsan Rikhtehgar5, Behrouz Fathi2,6, *Mohammad Mehdi Sedaghat1 1Department of Medical Entomology and Vector Control, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran 2Urmia Health Center, Disease Control Unit, Urmia University of Medical Sciences, Urmia, Iran 3Department of Health Education and Promotion, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran 4Department of Health Education and Promotion, School of Public Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran 5Urmia Deputy for Health Affairs, Urmia University of Medical Sciences, Urmia, Iran 6Assistant professor, Health economics and management department, Public health school, Urmia, Iran *Corresponding author: Prof Mohammad Mehdi Sedaghat, E-mail: sedaghmm@tums.ac.ir (Received 16 June 2022; accepted 30 Nov 2022) Abstract Background: Dengue fever as a mosquito-borne disease, has rapidly spread due to climate change, globalization, and human behavior. Iran is prone to dengue fever, as its vector recently has been found in the country. This study aimed to assess predictors of dengue preventive practices based on Precaution Adoption Process Model (PAPM) factors in West Azerbaijan province, northwest of Iran. Methods: This cross-sectional study conducted on 405 health professionals of communicable disease sector who were interested in study participation. Data-gathering instrument was an online researcher-made questionnaire consisting of demographic characteristics (11 items), questions based on PAPM, and dengue preventive practices (85 items). Content validity and reliability of the instrument, content validity ratio, content validity index, and Cronbach α were utilized, respectively. Descriptive, analytical, and regression analysis using SPSS and STATA were examined. Results: Regression analysis revealed that awareness of appropriate actions for dengue prevention was a stronger pre- dictor of preventive practice in borderline and appropriate categories (β= 4.09, p< 0.001) and (β= 4.42, p< 0.001), re- spectively. Among factors of PAPM, beliefs about precaution effectiveness and difficulty in borderline (β= 1.04, p= 0.04) and appropriate (β= 1.12, p= 0.03) groups had direct and significant relation with dengue preventive practice. Conclusion: The highest mean score of beliefs about hazard likelihood and severity factor was related to dengue pre- vention. Therefore, theory-based interventions that address beliefs about precaution effectiveness and difficulty can lead to assistance in acting. To improve dengue preventive practices, a well-designed promotive intervention that addresses associated factors in a context-specific manner is essential. Keywords: Preventive practices; Dengue fever; Precaution adoption process model (PAPM); Health professionals Introduction Dengue is a viral mosquito-borne disease endemic in tropical and subtropical regions, transmitted by the bite of Aedes mosquito vec- tors (Aedes aegypti and Aedes albopictus). Cli- mate change, globalization and trade, urbani- zation, travel, and human behavior have led to the spread of dengue fever and its vectors to human communities (1–3). Dengue is a rapidly spreading arboviral disease, its incidence has increased 30-fold over the past 50 years while the vectors Ae. aegypti and Ae. albopictus have expanded their Copyright © 2022 The Authors. Published by Tehran University of Medical Sciences. This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International license (https://creativecommons.org/licenses/by- nc/4.0/). Non-commercial uses of the work are permitted, provided the original work is properly cited. http://jad.tums.ac.ir/ mailto:sedaghmm@tums.ac.ir https://creativecommons.org/licenses/by-nc/4.0/ https://creativecommons.org/licenses/by-nc/4.0/ J Arthropod-Borne Dis, Dec 2022, 16(4): 340–349 S Firooziyan et al.: Predictors of … 341 http://jad.tums.ac.ir Published Online: Dec 31, 2022 geographical distribution. The disease is now endemic in 128 countries across Africa, the Americas, the Eastern Mediterranean region with several outbreaks occurring in Pakistan, Yemen, and Saudi Arabia(4–5). A virus of the Flaviviridae family causes dengue. Four dis- tinct, but closely related, serotypes of the virus cause dengue. The symptoms differ in young- er children and those who have the disease for the first time (3, 6). Presentation varies, ranging from no symp- toms to a mild fever to severe dengue hemor- rhagic fever and dengue shock syndrome may threaten human life (7). The ailment presents high fever accompanied by frequent headaches, nausea, skin rashes, enlargement of lymph nodes, pain behind eyes, severe muscular, bone and joint pains, epitaxis along with leukocytopenia i.e. reduction in white blood cells count. Den- gue Fever (DF) is also characterized as bone break fever or bone crush fever due to severe pain in joints and bones (5). Mild DF causes fever above 40 °C, headache, rashes, eye pain, vomiting, swollen lymph nodes, and muscle and joint pain. DF in severe situation can cause ecchymosis, hematemesis, severe ab- dominal pain, nosebleeds and bleeding in the mouth, permanent nausea, pulmonary, cardiac and hepatic problems, hypertensive shock, and death. It to DF diagnose is difficult because of symptoms similar of many diseases with those of DF (8). The global burden of dengue is not well recognized, but its epidemiological patterns are affecting both human health and the health economy (3). Annually, about ∼50 million den- gue infections and ∼500,000 individuals are hospitalized with dengue hemorrhagic fever mainly in Southeast Asia, the Pacific, and the Americas (9). Mortality and morbidity of se- vere dengue are reported at 20 percent approx- imately (10). There is no specific treatment for dengue fever for the infection, and manage- ment is only supportive care (6). According to the WHO, dengue control is technically feasible with coordinated interna- tional technical and financial support for na- tional programs (6). Preventive and vector con- trol interventions aim to reduce dengue trans- mission, thereby decreasing the incidence of the infection and preventing outbreaks of the disease. Primary prevention includes wearing protective clothing to reduce skin exposure, using mosquito repellents, using mosquito traps and nets, installing screens on doors and win- dows, eliminating unnecessary container habi- tats that collect water, and covering water stor- age containers with a fine mesh. These actions presented the most effective factors in dengue prevention and control (3, 6, 9). Public health system preparedness has a very important role to decrease morbidity and mortality of dengue fever, especially during epidemics. Knowledge, attitude and belief of health professionals are very crucial in this regard (11). Precaution Adoption Process Model (PAPM) is a stage model of health behavior, which derives from social learning theory and the health belief model also the PAPM has been generally used for health behavioral change in different issues such as wearing seat belts, using condoms, weight management, prevent- ing smoking and following treatment plans (12). This model attempts to clarify how a per- son make a decision to take an action and how decision translate into action (13). The PAPM was chosen as a theoretical framework for this study because it offers a more detailed stage, especially the early stages from awareness to decision regarding health-related behaviors. Factors of PAPM consisted of awareness (Me- dia messages about the hazard and precaution, communications from significant others, and personal experience with hazard), beliefs about hazard likelihood and severity, beliefs about personal susceptibility, beliefs about precau- tion effectiveness and difficulty, perceived so- cial norms and assistance in acting (14). In the Covid-19 pandemic, increasing den- gue cases happened due to disruptions in the http://jad.tums.ac.ir/ https://www.sciencedirect.com/topics/medicine-and-dentistry/arthralgia https://www.sciencedirect.com/topics/medicine-and-dentistry/leukopenia J Arthropod-Borne Dis, Dec 2022, 16(4): 340–349 S Firooziyan et al.: Predictors of … 342 http://jad.tums.ac.ir Published Online: Dec 31, 2022 pathogen-host-vector relationship reasoned by changes in individual behaviors in response to COVID-19. Lockdowns and social distancing policies could spread dengue in an endemic area. This situation could limit coverage of dengue preventive programs and delay the medical management of both diseases due to co-infection and misdiagnosis (15). It is well noted that medical staff and health workers working in health centers in endemic areas need regular training and consistent supervi- sion to improve their knowledge of the pre- vention and care of dengue patients (16). West Azerbaijan province is in the north- west of Iran with some points of entry, which makes the province susceptible to dengue fe- ver. The points of entry in the province in- clude Urmia International Airport, Razi Rail- way border, and five land border entry and exit points. For the first time, this study aimed to assess predictors of dengue preventive prac- tices based on (PAPM) factors among health care professionals in West Azerbaijan Prov- ince in 2022. Materials and Methods This cross-sectional study was conducted on 405 health professionals through an online questionnaire. Health professionals employed in the communicable disease sector in health centers affiliated to West Azerbaijan Province and willing to study participants included in the study. Ethical approval was obtained from the Research Ethics Committees of the Na- tional Institute for Medical Research Devel- opment (IR.NIMAD.REC.1400.027). Online consent was obtained from respondents before participation in this study. All identities of the respondents were kept anonymous, and the information in this study was kept confiden- tial. The self-administered questionnaire was in Persian, the national language of Iran. An explanation of the nature and purpose of the study was presented on the first page of the online instrument. The questionnaire used in this study was a researcher-made with two parts. The first part consists of demographic characteristics and work-related variables; age, sex, marital sta- tus, job profile, work history, educational lev- el, workplace, information about dengue dis- ease, and the source of obtaining information related to dengue collected in this part of the questionnaire (10items). In the second part of the questionnaire items were based on PAPM factors including staging definition, awareness of disease symp- toms, types of disease transmission, preven- tion, breeding places of vectors and vector con- trol, beliefs about personal susceptibility, be- liefs about hazard likelihood and severity, be- liefs about precaution effectiveness and dif- ficulty, perceived subjective norms and assis- tance in carrying out an action related to den- gue prevention and items of preventive prac- tices (85 items). The range score of this part of the questionnaire was zero to 24 and scor- ing was based on a five-point Likert from ab- solutely agree to absolutely disagree (0–4) and a three-point Likert as yes, no, or do not know. Based on achieved scores in the PAPM questionnaire, the total score was divided into three parts inappropriate, borderline, and ap- propriate. This classification was performed based on zero to 100. This instrument was de- veloped through literature review and experts’ opinions. At first, one hundred questions re- lated to dengue preventive practices were de- veloped. Ten experts in medical entomology and vector control, and health education and promotion revised this version. In the second stage, a revised instrument based on five- and three-point Likert was developed. To assess the content validity of the re- vised instrument, qualitative and quantitative methods were used. In the qualitative method, experts were asked to evaluate using appro- priate words and scoring the items. Feedback was gained then a final revised instrument was developed. To assess content and the validity of the instrument, Content Validity Ratio (CVR) http://jad.tums.ac.ir/ J Arthropod-Borne Dis, Dec 2022, 16(4): 340–349 S Firooziyan et al.: Predictors of … 343 http://jad.tums.ac.ir Published Online: Dec 31, 2022 and Content Validity Index (CVI) were uti- lized. CVR upper than 0.62 and 0.79 based on ten experts’ opinions were approved, respec- tively (17). To assess face validity, thirty health professionals filled out the questionnaire and evaluated the instrument in terms of proper words, grammar, simplicity, and understand- ing. In this assessment, CVR were calculated at 0.97. Reliability was confirmed using Cronbach α (0.7) (18). The study questionnaire was completed by thirty eligible health care professionals with two weeks interval and α was calculated at 0.89 in total. Reliability of staging definition, awareness about dengue, beliefs about per- sonal susceptibility, beliefs about hazard like- lihood and severity, beliefs about precaution effectiveness and difficulty, perceived subjec- tive norms and assistance in carrying out an action related to dengue prevention, and items of preventive practices were calculated 0.73, 0.74, 0.71, 0.87, 0.93, 0.77, 0.87, 0.74, and 0.78 respectively. Descriptive, analytical such as Kruskal-Wallis H test and Mann-Whitney U (using a nonparametric test based on the abnormality of data) and regression analysis using SPSS version 25 and STATA was per- formed at a significant level that was set less than 0.05. Results Study results presented that 48.4 percent (n= 196) were in the age range 36–45 with mean years old. The mean ± standard devia- tion age of the participants was 38.5±7.4. About half (49%) of the participants have 11– 20 years of work history. More than half of the study participants were female (53.8%, n= 218). Among demographic variables, educa- tion level revealed significant relation with dengue preventive practices (p= 0.03) (Table 1). Figure. 1 represented 85.9 percent of the participants who had heard about dengue and 67.9 percent of the participants who decided to adopt dengue prevention practices (Fig. 1). The mean prevention practices score of participants was 20.03±2.48 out of 24. Among factors of PAPM, beliefs about hazard likeli- hood and severity (20.40±3), and beliefs about precaution effectiveness and difficulty (17.93 ±2.92) had higher mean and SD. Awareness about the definition of vector breeding places among types of awareness including disease symptoms, types of the disease transmission, prevention, and vector control was higher (5.72±2.64) out of 24 (Table 2). After assessing normality of data, regres- sion analysis using inter method variables eval- uated by the Uni variate method, variables with sig< 0.1 enter the analysis, and others are excluded (Table 3). Results of regression analysis revealed that awareness of appropriate actions for dengue prevention was a stronger predictor of dengue preventive practices in borderline and appro- priate categories (β= 4.09, p< 0.001) and (β= 4.42, p< 0.001), respectively. Among factors of PAPM, beliefs about precaution effective- ness and difficulty in borderline (β= 1.04, p= 0.04) and appropriate (β= 1.12, p= 0.03) cate- gories had direct and significant relation with dengue preventive practices, respectively (Ta- ble 4). http://jad.tums.ac.ir/ J Arthropod-Borne Dis, Dec 2022, 16(4): 340–349 S Firooziyan et al.: Predictors of … 344 http://jad.tums.ac.ir Published Online: Dec 31, 2022 Table 1. Characteristics analysis of participants in this study (n= 405) P value Mean Rank Number (%) Groups Variables 0.35 211.27 140 (34.6) 21–35 Age (yrs.) 195.66 196 (48.4) 36–45 207.09 69 (17) above 45 0.92 203.44 218 (53.8) Female Sex 202.48 187 (46.2) Male 0.55 201.76 349 (86.2) Married Marital status 210.71 56 (13.8) Unmarried 0.58 194.77 106 (26.2) Health workers Job profile 203.13 225 (55.6) Health professionals 211.23 60 (14.8) Doctor 227.93 14 (3.5) Another job 0.03 259.06 8 (2) Up to diploma Level of education 180.85 78 (19.3) Diploma 207.01 319 (78.8) Academic degree 0.53 209.69 152 (37.6) 1–10 Work history(yrs.) 198.99 201 (49.6) 11–20 195.22 52 (12.8) Above 20 0.79 199.52 308 (76) Urmia City 213.44 16 (4) Piranshahr 209.04 12 (3) Poldasht 221.89 18 (4.4) Mako 212.66 51 (12.6) Another cities in the province 0.31 204.43 290 (71.6) Rural Health Center Workplace 194.09 100 (24.7) Urban Health Center 234.77 15 (3.7) Another health sites 0.27 206 324 (80) Yes Have information about dengue disease 191 81 (20) No 0.23 146.50 32 (7.9) Continuous education Source of information 172.73 75 (18.5) Academic education 173.75 56 (13.8) Media 157 161 (39.8) Workshop *T test for quantitative variables and ANOVA for more than two sample groups Table 2. Descriptive analysis of PAPM factors and dengue preventive practices (n= 405) Minimum Maximum Mean± (SD) Groups Variables (0, 5) 2.55±1.46 Staging definition (0, 6) 4.72±1.64 Disease symptoms Awareness (0, 5) 2.63±1.35 Type of Transmission (0, 5) 3.59±1.25 Prevention (0, 9) 5.72±2.64 Breeding places (0, 4) 3.51±1.01 Control actions (0, 16) 11.23±2.24 Beliefs about personal susceptibility (0, 24) 20.40±3.95 Beliefs about hazard likelihood and severity (3, 20) 17.93±2.92 Beliefs about precaution effectiveness (0, 20) 8.87±3.90 Beliefs about precaution difficulty (4, 20) 15.89±3.83 Perceived subjective norms (6, 20) 13.23±3.35 Assistance in carrying out the action (0, 21) 20.03±2.48 Preventive practices http://jad.tums.ac.ir/ J Arthropod-Borne Dis, Dec 2022, 16(4): 340–349 S Firooziyan et al.: Predictors of … 345 http://jad.tums.ac.ir Published Online: Dec 31, 2022 Table 3. Multivariate regression analysis of preventive practices among the study participants (n= 405) P value ICC** 95% Β* Groups Variables Upper Bound Lower Bound 35–21 ־ ־ ־ ־ Age (yrs.) 0.36 0.84 -0.3 0.26 36–45 0.53 1.06 -0.55 0.25 > 45 Female Sex ־ ־ ־ ־ 0.93 0.54 -0.59 0-.02 Male Married Marital status ־ ־ ־ ־ 0.38 1.05 -0.4 0.32 Unmarried Up to diploma ־ ־ ־ ־ Level of education 0.07 0.18 -3.48 -1.65 Diploma 0.65 1.48 -2.34 -0.43 Academic degree *Linear regression coefficient **Intraclass Correlation Coefficient Table 4. Multivariate regression analysis of preventive practices among study participants (n= 405) Variables Groups Grouping by score Β* ICC** 95% P value Lower Bound Upper Bound Staging definition 1 (0,1) - - - - 2 (2) 0.19 -0.51 0.89 0.59 3 (3–5) 0.27 -0.37 0.92 0.4 Awareness Disease symptoms 1 (0–4) - - - - 2 (5) 0.01 -0.57 0.61 0.94 3 (6) 0.03 -0.56 0.62 0.91 Type of Transmission 1 (0–1) - - - - 2 (2) 0.06 -0.62 0.75 0.84 3 (3–5) -0.15 -0.82 0 .50 0.64 Prevention 1 (0–3) - - - - 2 (4) 0.13 -.35 0.63 0.58 3 (5) -0.2 -.81 0 .41 0.52 Breeding places 1 (0–4) - - - - 2 (5–7) 0.03 -0.52 0.59 0.9 3 (8–9) 0.33 -0.29 0.96 0.29 Control actions 1 (0–1) - - - - 2 (2–3) 4.09 2.91 5.27 0.001 3 (4) 4.42 3.24 5.60 0.001 Beliefs about personal susceptibility 1 (0–10) - - - - 2 (11–12) 0.33 -0.17 0.84 0.19 3 (13–16) 0.16 -0.47 0.81 0 .60 Beliefs about hazard likelihood and severity 1 (0–17) - - - - 2 (18–23) 0.34 -0.32 1.01 0.31 3 (24) 0.36 -0.49 1.21 0.40 Beliefs about precaution effectiveness 1 (3–15) - - - - 2 (16–19) 1.04 0.32 1.75 0.004 3 (20) 1.12 0.38 1.86 0.003 Beliefs about precaution difficulty 1 (0–7) - - - - 2 (8–9) 0.87 -0.50 0.67 0.77 3 (10–20) 0.27 -0.25 0.81 0.30 Perceived subjective norms 1 (4–14) - - - - 2 (15–18) 0.04 -0.51 0.61 0.86 3 (19–20) -0.33 -1.006 0.34 0.33 Assistance in carrying out the action 1 (6–11) - - - - 2 (12–14) 0.42 -0.11 0.96 0.12 3 (15–20) 0.22 -0.38 0.84 0.46 *Linear regression coefficient **Intraclass Correlation Coefficient http://jad.tums.ac.ir/ J Arthropod-Borne Dis, Dec 2022, 16(4): 340–349 S Firooziyan et al.: Predictors of … 346 http://jad.tums.ac.ir Published Online: Dec 31, 2022 Yes, 85.9 Yes, 29.6 Yes, 32.8 Yes, 39 Yes, 67.9 No, 14.1 No, 70.4 No, 67.2 No, 61 No, 32.1 0 20 40 60 80 100 Have you heard of dengue fever? I have never thought about dengue fever prevention practices I have not yet made a decision on preventive practices I have decided on preventative measures for dengue fever but have… I have decided to implement dengue fever prevention practices Fig. 1. Percentage stages of change of dengue prevention practices Discussion Dengue is one of the most important ar- thropod-borne viral diseases with widespread distribution in the tropics and subtropics (3). Iran is at risk of transmission of DF disease due to the presence of the main vector Ae ae- gypti, changing rainfall and floods pattern that increases Aedes mosquito larvae habitats, as well as the spread of DF in some countries of the region, including Pakistan and Yemen (19). This study aimed at assessing predictors of dengue preventive practices based on PAPM factors among health care professionals in West Azerbaijan Province. It is important to note that there was a limited study about dengue and health education and promotion models/ theo- ries which affected to discuss results of the present study in PAPM factors. Among socio-demographic factors, the on- ly level of education had a significant and di- rect relation with dengue preventive practices. This result was in the line with Wong et al. (20), their results approved that religion, level of education, and the job had a significant as- sociation with dengue preventive practices. Chanyasanha et al. (21) reached a similar con- clusion; they revealed that age, religion, fami- ly income, education, knowledge, and attitude were associated with preventive practices (21). The present study confirmed the findings of the study results of Guard et al. (22) about the significant association of knowledge, attitude, and preventive practice (KAP) regarding den- gue infection among community residents in endemic areas. This result demonstrated that knowledge and awareness among different ed- ucated individuals could vary. It seems that health promotion activities should purpose at raising awareness at the community level on the importance of combining mosquito bite pre- vention with the elimination of breeding sites in and around high-density residence locations (23). The present study confirmed that aware- ness about the appropriate breeding places of vectors had the highest mean score in compar- ison with other related awareness; this finding is directly in line with previous findings with http://jad.tums.ac.ir/ J Arthropod-Borne Dis, Dec 2022, 16(4): 340–349 S Firooziyan et al.: Predictors of … 347 http://jad.tums.ac.ir Published Online: Dec 31, 2022 Sarfraz et al. study (24). From the results, awareness of appropriate actions for dengue prevention was a stronger predictor of dengue preventive practices in borderline and appro- priate categories respectively. This finding ties well with Wong et al. (20), showing the im- portance of sufficient information of partici- pants about dengue, many people had ade- quate knowledge of dengue fever and mosqui- toes, but understanding of the important rela- tionships among mosquitoes, human behavior, and disease transmission was sub-optimal. Re- sults of a qualitative assessment of community beliefs and practices about dengue revealed that participants had suffered from DF and were iden- tified through the surveillance system. Also, participants with previous dengue diagnosis were more concerned about risk of the disease, had better knowledge about disease prevention (25). In another study, Shuaib et al. (26) demon- strated that individuals well informed regard- ing taking self-protection actions using den- gue prevention methods. One of the most im- portant measures in dengue virus transmission reduction is the interruption of host-mosquito contact. Individuals should cover the limbs by wearing full length pants, trousers, and full sleeved clothes. Mosquito repellents or lotions as conventional measures must be utilized to protect and avoid mosquito biting during day- time hours. Furthermore, coils, electric vapor mats, trap lights, insecticide treated nets and curtains and so forth should be used to pre- vent direct contact with mosquitoes (5). Among factors of PAPM, beliefs about precaution effectiveness and difficulty in bor- derline and appropriate categories had direct and significant relation with dengue preventive prac- tices. In accordance with our findings, Siddiqui et al. (27) showed that providing health messag- es in interventional programs considering reg- ular environmental sanitation can be helpful and would benefit in reducing the number of den- gue mosquito vectors in residential places. It seems practical and sustainable efforts are a necessity to tailor behavioral changes in health education and promotion interventions through appropriate mass media and commu- nity clean-up campaigns among communities to dengue control in endemic areas. This study had some limitations. Although this study tried to sample to reflect the charac- teristics of health care professionals employed in health centers of West Azerbaijan Prov- ince, the study findings cannot be generalized to all health care professionals in Iran. Fur- thermore, the study findings showed important associations among study variables, but the findings obtained from cross-sectional survey data with self-reported instruments cannot clar- ify causal-effect relationships between PAPM factors and the variables. This study had a nov- elty that explained predictors of dengue pre- ventive practices based on PAPM factors among health professionals. Conclusions Based on study results, the highest mean score of beliefs about hazard likelihood and severity factor related to dengue prevention, providing theory-based interventions that ad- dress beliefs about precaution effectiveness and difficulty related to assistance in acting might be beneficial. To improve dengue pre- ventive practices, well-designed promotive in- tervention programs that address the associ- ated factors in a context-specific manner are essential. Practical efforts should be conduct- ed to raise awareness about dengue transmis- sion and develop community-based sustaina- ble vector control programs involving both the public and private sectors. Acknowledgements Research reported in this publication was supported by Elite Researcher Grant Commit- tee under award number [4000586] from the National Institute for Medical Research De- velopment (NIMAD), Tehran, Iran. http://jad.tums.ac.ir/ J Arthropod-Borne Dis, Dec 2022, 16(4): 340–349 S Firooziyan et al.: Predictors of … 348 http://jad.tums.ac.ir Published Online: Dec 31, 2022 Ethical considerations The study was approved by the Ethical Committee of the National Institute for Medi- cal Research Development (NIMAD), Tehran, Iran, ethic no. IR.NIMAD.REC.1400.027. Conflict of interest statement The authors declare there is no conflict of interests. References 1. Ebi KL, Nealon J (2016) Dengue in a chang- ing climate. Environ Res. 151: 115–123. 2. Wesolowski A, Qureshi T, Boni MF, Sundsøy PR, Johansson MA, Rasheed SB, Engø- Monsen K, Buckee CO (2015) Impact of human mobility on the emergence of dengue epidemics in Pakistan. Proc Natl Acad Sci USA. 112(38): 11887–1192. 3. Guzman MG, Gubler DJ, Izquierdo A, Martinez E, Halstead SB (2016) Dengue infection. Nat Rev Dis Primers. 2(1): 1– 25. 4. Rasheed SB, Butlin RK, Boots M (2013) A review of dengue as an emerging di- sease in Pakistan. Public Health. 127: 11–17. 5. Tahir U, Khan UH, Zubair MS (2015) Wolbachia pipientis: A potential candi- date for combating and eradicating den- gue epidemics in Pakistan. Asian Pac J Trop Med. 12: 989–998. 6. Thai KTD, Nishiura H, Hoang PL, Tran NTT, Phan GT, Le HQ, Tran BQ, Nguyen NV, de Vries PJ (2011) Age-Specificity of Clinical Dengue during Primary and Secondary Infections. PLoS Negl Trop Dis. 5(6): e1180. 7. Khetarpal N, Khanna I (2016) Dengue fever: causes, complications, and vaccine strategies. J Immunol Res. 2016: 1–14. 8. Dehghani R, Kassiri H (2021) A review on epidemiology of dengue viral infection as an emerging disease. Research J. Pharm. and Tech. 14(4): 2296–2301. 9. Guzman M, Alvarez M, Halstead SB, Artsob H, Buchy P, Farrar J, Gubler DJ, Hunsperger E, Kroeger A, Margolis HS, Martínez E, Nathan MB, Pelegrino JS, Simmons C, Yoksan S, Peeling RW (2010) Dengue: a continuing global threat. Nat Rev Microbiol. 8(12 Suppl): S7–S16. 10. Nanaware N, Banerjee A, Mullick Bagchi S, Bagchi P, Mukherjee A (2021) Den- gue virus infection: a tale of viral ex- ploitations and host responses. Viruses. 13(10): 1–20. 11. Jayawickreme K, Jayaweera D, Weerasinghe S, Warapitiya D, Subasinghe S (2021) A study on knowledge, attitudes and prac- tices regarding dengue fever, its preven- tion and management among dengue pa- tients presenting to a tertiary care hos- pital in Sri Lanka. BMC Infect Dis. 21 (1): 1–14. 12. DiClemente RJ, Crosby R, Kegler MC (2009) Emerging theories in health pro- motion practice and research. John Wiley and Sons. New Jersey. 13. Porche DJ (2004) Public and community health nursing practice: A population- based approach. SAGE Publications, CA. 14. Glanz K, Rimer BK, Viswanath K (2008) Health behavior and health education: theory, research, and practice:4th Edition John Wiley and Sons, San Francisco, CA. 15. Wiyono L, Rocha ICN, Cedeño TDD, Mi- randa AV, Lucero-Prisno III DE (2021) Dengue and COVID-19 infections in the ASEAN region: a concurrent outbreak of viral diseases. Epidemiol Health. 43: 1–5. 16. Tsheten T, Clements AC, Gray DJ, Gyeltshen K, Wangdi K (2021) Medical practitioner’s knowledge on dengue management and clinical practices in Bhutan. PLoS One. 16(7): 1–15. 17. Lawshe CH (1975) A quantitative approach to content validity. J Pers Psychol. 28 (4): 563–575. http://jad.tums.ac.ir/ J Arthropod-Borne Dis, Dec 2022, 16(4): 340–349 S Firooziyan et al.: Predictors of … 349 http://jad.tums.ac.ir Published Online: Dec 31, 2022 18. George D, Mallery P (2019) IBM SPSS statistics 26 step by step: A simple guide and reference: 16th Edition, Routledge, New York. 19. Khoobdel M, Jonaidi Jafari N (2016) Dengue fever, an old arboviral disease threatening the Persian Gulf region and southern Iran. J Mil Med. 18(2): 181–183. 20. Wong LP, Shakir SMM, Atefi N, Abu- Bakar S (2015) Factors affecting dengue prevention practices: nationwide survey of the Malaysian public. PLoS One. 10 (4): 1–16. 21. Chanyasanha C, Guruge GR, Sujirarat D (2015) Factors influencing preventive be- haviors for dengue infection among house- wives in Colombo, Sri Lanka. Asia Pac J Public Health. 27(1): 96–104. 22. Guad RM, Mangantig E, Low WY, Tay- lor-Robinson AW, Azzani M, Sekaran SD, Sim MS, Azizan N (2021) Develop- ment and validation of a structured sur- vey questionnaire on knowledge, attitude, preventive practice, and treatment-seek- ing behaviour regarding dengue among the resident population of Sabah, Malay- sia: an exploratory factor analysis. BMC Infect Dis. 21(1): 1–11. 23. Elsinga J, Schmidt M, Lizarazo EF, Vin- centi-Gonzalez MF, Velasco-Salas ZI, Arias L, Burgerhof JGM, Tami A (2018) Knowledge, attitudes, and preventive practices regarding dengue in Maracay, Venezuela. Am J Trop Med Hyg. 99(1): 195–203. 24. Sarfraz MS, Tripathi NK, Tipdecho T, Thongbu T, Kerdthong P, Souris M (2012) Analyzing the spatio-temporal relation- ship between dengue vector larval den- sity and land-use using factor analysis and spatial ring mapping. BMC Public Health. 12: 1–19. 25. Panagos A, Lacy ER, Gubler DJ, Mac- pherson CN (2005) Dengue in Grenada. Revista panamericana de salud pública. 17(4): 225–229. 26. Shuaib F, Todd D, Campbell-Stennett D, Ehiri J, Jolly PE (2010) Knowledge, attitudes and practices regarding dengue infection in Westmoreland, Jamaica. West Indian Med J. 59(2): 139–146. 27. Siddiqui TR, Ghazal S, Bibi S, Ahmed W, Sajjad SF (2016) Use of the health belief model for the assessment of public knowledge and household preventive practices in Karachi, Pakistan, a dengue- endemic city. PLoS Negl Trop Dis. 10 (11): 1–15. http://jad.tums.ac.ir/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6085811/ https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=21132094 https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=21132094