Microsoft Word - 3-hashare Dr Yilmaz Public RTL 88 10 3 .doc Iranian J Arthropod-Borne Dis, (2009), 3(2): 12-17 R Yilmaz et al: Public Knowledge and Attitude… 12 Original Article Public Knowledge and Attitude toward Crimean Congo Hemorrhagic Fever in Tokat Turkey *R Yilmaz1, M Ozcetin1, U Erkorkmaz2, S Ozer1, F Ekici3 1 Department of Pediatrics, School of Medicine, Gaziosmanpasa University Tokat- Turkey 2 Department of Biostatistics, School of Medicine, Gaziosmanpasa University Tokat- Turkey 3 Department of Physiology, School of Medicine, Gaziosmanpasa University Tokat- Turkey (Received 24 Mar 2009; accepted 28 Oct 2009) Abstract Background: The World health Organization (WHO) declares Crimean Congo hemorrhagic fever (CCHF) endemic in Turkey. Despite the magnitude of problem, no documented evidence exists in Turkey, which reveals the aware- ness and practices of the country’s adult population regarding CCHF, its spread, symptoms, treatment, and preven- tion. This study was conducted to assess the level of knowledge, attitudes, and practices regarding CCHF in people visiting tertiary care hospital in Tokat, Turkey. Methods: This questionnaire based cross-sectional survey was conducted among patients’ relatives or guardians who admitted pediatric outpatient clinics during May-July 2008. The questionnaire was composed of 25 questions. Results: A total of 1034 respondents participated in the survey. Sufficient knowledge about CCHF was not found in 28.9% of the sample. Literate individuals were relatively better informed about CCHF as compared to the illiterate people. Television and radio were considered as the most important and useful source of information on the disease. Conclusion: We have found insufficient knowledge on CCHF in our population. It is thought to have no chance of success against a fatal disease such as CCHF, which has serious consequences, without the contribution of commu- nity. It is clear that there are important tasks for health, agriculture, and media sectors to improve public knowledge and awareness about CCHF. Keywords: Crimean Congo hemorrhagic fever, Public knowledge, Survey, Turkey Introduction Crimean Congo hemorrhagic fever (CCHF), that is endemic in over 30 countries around the Black Sea and in the Middle East and Africa, is a potentially fatal virus infection. CCHF virus is transmitted to humans by bites of infected ticks or direct contact with secretions or blood of infected animal or human (Williams et al. 2000). Many CCHF outbreaks have occurred in Tokat and other Anatolian cities since 2003 (Bakir et al. 2005, Gozalan et al. 2007). Changes in socioeconomic conditions and climate have increased animal and human migration, travel, the risk of bioterrorism and ecological deterioration. These factors may increase the spread of viral infections to new places and their incidence in endemic re- gions (Bakir et al. 2005). In endemic regions, persons including farmers, shepherds and veterinarians who are in occupational contact with livestock and wild animals, are in high-risk group (Flick and Whitehouse 2005, Vorou et al. 2005). Recreational activities such as picnic, track- ing in endemic areas also represent risk fac- tor for tick bite. Healthcare workers caring with CCHF patients are the second major group at risk for infection (Ergonul et al. 2007). Tokat is geographically located between the Black Sea and Central Anatolia. The cli- mate is suitable for ticks survive. The first cases of CCHF virus infection in Turkey was reported from this region (Bakir et al. 2005). *Corresponding author: Dr. Resul Yilmaz, E-mail: drresul@hotmail.com Iranian J Arthropod-Borne Dis, (2009), 3(2): 12-17 R Yilmaz et al: Public Knowledge and Attitude… 13 We studied the public knowledge and atti- tude toward CCHF at a tertiary care hospital in Tokat, where CCHF outbreaks have still been reporting since 2003 in every spring to early autumn. Materials and Methods This questionnaire based cross-sectional survey was conducted among patients’ rela- tives admitted to pediatric outpatient clinics during May-July 2008 in Gaziosmanpasa Uni- versity Medical Center in Tokat, Turkey. We offered the patients’ relatives to participate in the survey. If they agreed, informed consent was taken. A total of 1034 parent or guardian of child agreed to participate and completed the questionnaire. The questionnaire was composed of 25 questions. The first four questions were con- stituted to access demographic data; remains were for knowledge and attitude toward CCHF. It was self administered and in Turkish. To access the readability and applicability of the questionnaire, a pilot study was assessed on 50 respondents. Questions, which were confus- ing, were simplified. When respondent needed instruction, researchers helped to understand and fill in the questionnaire. We respected the confidentiality of respondents, data were recorded anonymously. Statistical Analysis The continuous variables were present- ed as mean and standard deviation. The cate- gorical variables were presented as count and percentage. Analyses were performed using commercial software (PASW ver. 18, SPSS Inc, Chicago, IL) Results A total of 1034 respondents participated in the survey. Mean age was 30.28±10.75 yr (range 18-84). Demographic information about respondents was given in Table 1. The sources of CCHF information is presented in Fig. 1. Participants thought Civil Society Organizations in Tokat informed, par- tially informed and did not informed the com- munity about CCHF n= 115 (11.2%), n= 344 (33.3%) and n= 575 (55.6%), respectively. Factors that could correlate with the source of CCHF information is shown in Table 1. Job and education were statistically signifi- cant factors that effects where they could get the information. Questions that measure public knowledge and preventive measures about CCHF and their answers are given in Table 2 and Table 3. 22.1% of participants did not have pic- nic. Remains had at least one picnic in a year and n= 635 (61.5%) point out CCHF af- fected their picnic habit. Table 1. Basic demographics of respondents n % Female 547 52,9 Gender Male 487 47,1 City 654 63,2 Town 287 27,8 Residence Village 93 9,0 Elementary+ Middle school 297 28,7 High School 261 25,2 Educational level University 476 46,0 Farmer 23 2,2 Retired 42 4,1 Tradesman 50 4,8 Worker 114 11,0 Housewife 220 21,3 Government Employee 274 26,5 Job Student 311 30,1 Iranian J Arthropod-Borne Dis, (2009), 3(2): 12-17 R Yilmaz et al: Public Knowledge and Attitude… 14 Table 2. The questions and answers of paticipants about CCHF n % The causative agent is A virus A bacteria Unknown Bioterrorism agent 652 98 130 138 67.1 9.5 12.6 14.9 Transmission to human by Ticks Close contact with patient Secretion of infected animals 802 65 138 77.6 6.3 13.3 Where were CCHF first emerged? Africa Russia Europe Turkey I don’t know 264 160 42 158 400 25.5 15.1 4.1 15.3 39.7 What kind of disease is CCHF? Not contagious but dangerous Common, dangerous disease Non remediable disease Fatal, contagious and dangerous 100 76 86 772 9.7 7.4 8.3 74.7 Is there a treatment for CCHF? Yes No I don’t know 538 329 167 52 31.8 16.2 Is there a vaccine against CCHF? Yes No I don’t know 152 579 303 14.7 56 29.3 What are the symptoms of CCHF? Fever Myalgia Headache Fatigue- Low appetite All 200 19 8 72 735 19.3 1.8 0.8 7 71.1 Who are at risk for CCHF infection Farmers- Shepherds Healthcare workers People who are visiting rural area All 278 12 48 735 26.9 1.2 4.6 71.1 When will symptoms appear after tick bite? Within 1-3 days At least 9 days In first month Longer than 1 month 579 390 47 18 56 37.7 4.5 1.7 Which season is CCHF common? Spring Summer Autumn 182 845 7 17.6 81.7 0.7 Can you eat your livestock’s meat if a tick bites it? We can eat its meat We cannot eat It has to destruct I do not know 157 201 382 294 15.2 19.4 36.9 28.4 Iranian J Arthropod-Borne Dis, (2009), 3(2): 12-17 R Yilmaz et al: Public Knowledge and Attitude… 15 Table 3. The questions and answers of paticipants about CCHF’s preventive measures n % What is the most effective method for prevention? Insecticide Minimizing the open area of the body Disseminating poultry Avoidance of areas where ticks are abundant Use of repellents 208 328 218 180 103 20.1 31.4 25.1 17.4 10 Who can remove embedded the tick? Their self Healthcare workers or doctors I don’t know: 8 1000 26 0.8 96.7 2.1 How do you remove the tick when it embeds your livestock or pet? Use of repellants Naked hand Wearing gloves and other protection materials I don’t know 323 18 493 200 31.2 1.7 47.7 19.3 Discussion The Gaziosmanpasa University Health Practicing Center is the only tertiary health care facility which accepts and gives care to the severe CCHF children patients in Tokat where the survey was conducted, no referral was needed (Yilmaz et al. 2009). We deter- mined that parents or guardians of these chil- dren were not aware of the seriousness of the disease. We wanted to emerge the knowledge and attitude towards CCHF in this population. Although all of the respondents were familiar with CCHF, vast majority of them pointed out CCHF transmission to human was by tick bites. One fifth of them marked close contact with infected patients and secretions of infected animals. These are not strange find- ings because Tokat is the first city where first CCHF cases were reported from here in Tur- key. Despite all the participants heard about CCHF, ¾ of them remembered CCHF to be contagious and dangerous disease. ¼ of them said it was not contagious. One third of the respondents did not know the causative agent. About 15% of the participants believed that CCHF virus was a biological war agent, coming from some for- eign countries. This result may be indicating that people consider new diseases are mostly biological war agent. “Tick disease” and CCHF are the cur- rently known two expression of CCHF in pub- lic. 2/3 of the participants showed adequate knowledge about the symptoms. There is no similar study about public knowledge and at- titude towards CCHF in English literature, so we did not compare our results. Half and 40% of participants specified CCHF symptoms would appear in 1-3 d and at least 9 d, re- spectively. It is compatible with literature group (Flick and Whitehouse 2005, Vorou et al. 2005). Although knowledge about symptoms was insufficient, knowledge about the treat- ment of CCHF was not clear. Half of the pa- tients considered there was no treatment or they did not know whether there was a treat- ment or not. Almost all the participants pointed out that they could remove the embedded tick at health care centers. Ticks can be removed by using tweezers to gasp the tick as close to the skin as possible (Sloan, 2009). Using fire, home remedies, alcohol or petroleum jelly can cause tick to regurgitate its guts contents to the bitten person’s or animal’s blood stream that increases the chance of CCHF infection Iranian J Arthropod-Borne Dis, (2009), 3(2): 12-17 R Yilmaz et al: Public Knowledge and Attitude… 16 or other tick born diseases (WHO fact sheet 208, 1998). Seventy percent of participants gave the correct answers how they remove the tick when it bites their livestock or pet, but only 15% of them recognized they can eat the meat of tick bitten livestock. Destructing the tick bitten livestock can bring a huge eco- nomical load on the farmers’ budget; farm- ers in our region mostly have low income. The most effective preventive measure is avoidance of areas where ticks are abun- dant. One fifth of participants gave right an- swer. If they want to go rural area where ticks are present, they can use repellants and/or they can wear trousers tucked in boots or socks and a long sleeved shirt tucked in at the waist (WHO fact sheet 208, 1998). When the participants were asked “What is the source of your information on CCHF?” They mostly pointed out media including radio- TV and newspapers. In literature, public knowl- edge and information on infectious disease mostly obtained from media (Itrat et al. 2008, Mossialos and Rudisill, 2009). Our study is consistent with these studies. Media can exag- gerate or oversee the situation. This behavior of media leads CCHF information is mostly inappropriate or wrong. There is a great re- sponsibility on media to transmit appropriate and right information on CCHF. Several studies have reported a higher socioeconomic status correlates with better knowledge score (McArthur et al. 2001, Winch et al. 2002). In the present survey occupation and education are associated with more knowl- edge about CCHF. Participants, who had high school or university graduate certificate, gave most accurate answers. Farmers in our re- gion have lower education and income than in farmers from western part of Turkey (Din- cer et al. 1996). These findings suggested that more effective programs, which would target farmers and low educated people for public knowledge, needed to be implemented. Four fifth of participants had a picnic at least once a year and they pointed out CCHF affected their picnic habit. Common (popular) infections, zoonotic disease affect people’s attitude. When an avian influenza outbreak occurred in Turkey in 2006, most of the people did not consume poultry prod- ucts (Cultu-Kantaroglu et al. 2007). In our survey, we determined people did not have picnic or postponed to winter or late autumn. The level of knowledge and attitude of community is important to get the highest sup- port from community before launching any disease control program (Singh et al. 2006). CCHF outbreaks have occurred every year since 2003 so it can be said that people from this area have a higher knowledge. Our survey is limited to a university hospital so these data cannot be generalized to rest of Turkey, where has different socioeconomic status and cul- tural background. Nationwide or sum of local studies can provide the accurate status of public knowledge and attitude towards CCHF. By using these data, ministry of health and min- istry of agriculture can easily establish the pro- gram of controlling the disease. In conclusion, we have found insuffi- cient knowledge in our population. It is thought to have no chance of success against a fatal disease such as CCHF, which has serious con- sequences, without the contribution of com- munity. It is clear that there are important tasks for health, agriculture, and media sectors to improve public knowledge and awareness about CCHF. Acknowledgements The authors are grateful to Gaziosman- pasa University Medical Faculty for their sup- port. The authors declare that they have no conflicts of interest. References Bakir M, Ugurlu M, Dokuzoguz B, Bodur H, Tasyaran MA, Vahaboglu H; Turkish CCHF Study Group (2005) Crimean- Iranian J Arthropod-Borne Dis, (2009), 3(2): 12-17 R Yilmaz et al: Public Knowledge and Attitude… 17 Congo haemorrhagic fever outbreak in Middle Anatolia: a multicentre study of clinical features and outcome meas- ures. J Med Microbiol. 54(Pt 4): 385-89. Bülent Dinçer, Metin Özaslan, Erdoğan Sa- tılmış. 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