Approaches to Community Prevention of West Nile Virus Infection

1. Approaches to Community Prevention of West Nile Virus Infection Emily Zielinski-Gutierrez, DrPH Behavioral Scientist Division of Vector-Borne Infectious Diseases Centers for Disease Control & Prevention

2. Outline • A little health education and behavior change theory • A national perspective on WNV trends • Some statistics on WNV protective behaviors • Some barriers & opportunities for prevention • Lessons from Colorado and elsewhere

3. Health communication/ behavior change theory

4. Lots of different theories • Theory of Reasoned Action • How people decide to take a certain action • Health Belief model • A person’s behavior can be predicted based upon issues such as perceived susceptibility, perceived severity when making a decision about a particular behavior concerning theirhealth.(Glanz, Lewis, & Rimer, 1990). • Transtheoretical model/Stages of Change • Precontemplation/ contemplation/ preparation/ action/ maintainence • Fear Appeals Theory • Some would agree, some not – fear can motivate OR lead to rejection and inaction. • And many more http://www.uky.edu/~drlane/capstone/health/

5. One Theoretical Basis Risk Communication and Education Risk Perception Environmental Factors MediaDisease history Local ecology Demographic factors Socio-cultural factors e.g. language, age, Income, gender, education Risk Assessment Action

6. Barriers to Action Facilitating Factors for the Action Desired Action Knowledge & Attitudes

7. Communication with other strategies can: Change human behavior Overcome barriers and systemic problems Health Communication can: • Increase knowledge • Increase awareness • Prompt action • Demonstrate skills • Influence attitudes • Refute myths DHHS/NIH/NCI: Making Health Communication Programs Work

8. Health communication questions with West Nile virus • What prevention measures are people using to avoid WNV infection? • What are possible reasons that people are not using prevention measures? • What communication activities and other interventions might increase use of personal & household prevention? • How can communication makes prevention measures more “actionable”/feasible?

9. Plan for the result you want • Outcomes: • Knowledge about transmission, about risk, about repellents, about prevention • Attitudes about personal risk, support of prevention, etc. • Impact: • Behavior: e.g. increased repellent use, installation of screens • Disease reduction: A challenge to measure for WNV/mosquito borne disease • Lots of variables ecological and otherwise, serosurveys a huge expensive effort…can use surveillance data for some questions

10. Message + receiver ≠ behavior change • A message w/o supporting context often insufficient • There are reasons that people don’t do things that would otherwise seem to make reasonable sense… find out what those reasons are… and address them in your campaign. • If there are significant obstacles (income or poor housing, for example) information alone isn’t often going to be enough to counter that alone.

11. WNV trends

17. A bigger and bigger problem # Cases # Deaths # States w/ human cases 1999 62 7 1 2000 21 2 3 2001 66 9 10 2002 4071 279 39 states +DC 2003 * 9306 240 45** states+DC *As of March 3, 2004. Numbers will change. **No human disease reports in 2003 in WA, OR, ME, HI, AK

18. This year… • 0ver 9000 human cases reported in the US* • Severe disease = more than 2700 (30%) • West Nile Fever = more than 6300 (~68%) • Only about ~25% of all cases in 2002 were Fever • Other/unknown = about 163 (2%) * 2003 cases reported to CDC, as of 3 March 2004

19. Who gets sick from West Nile? • All ages: 1 mo.–99 years • Fever cases tend to be young/middle age adults • Severe disease and deaths tend to be people over 50, and especially over 70 • Kids do get sick, but pretty rarely. • Intrauterine infection is possible when a pregnant woman gets infected, but the extent to which this occurs and the health effects on the infant are not yet known. * 2003 cases reported to CDC, as of 19 November 2003

20. Percent of Reported West Nile Virus Cases Classified as West Nile Fever, United States, 2003 Percent of Cases 0-24 25-49 50-74 75-100 * Reported as of 1/29/2004

21. WNND County Level Incidence per Million, United States, 2002* Incidence per million .01-9.99 10-99.99 >=100 * Reported as of 4/15/2003

22. WNND County Level Incidence per Million, United States, 2003* Incidence per million .01-9.99 10-99.99 >=100 *Reported as of 1/20/2004

23. Human WNV Disease Incidence, by Age Group and Clinical Category, United States, 2003* * Reported as of 1/30/2004 * *Entire US population

24. Prevention: Who’s doing what?national statistics

25. When it’s warm in your area, do you… • Nationwide: those who report they always/usually… • 43.9% look for household standing water • 37.6% apply {any} insect repellent • 28.5% avoid the outdoors due to mosquitoes • 23.9% wear long pants/sleeves 74.5% doing at least one of the above. * Healthstyles national survey, data licensed from Porter-Novelli, conducted July-Aug 2003

26. If it’s repellent, is it DEET? • 40.3% of respondents have repellents containing DEET in the household (another 26.8% not sure) • It’s not DEET for everyone: • Only 59.3% of repellent “users” confirmed having DEET in the household • Other respondents do have DEET, but they don’t use it much • 44.6% of those have DEET in the household said that they did NOT always/usually use repellent

27. Regional and Demographic Differences in Repellent Use

28. Jul-Aug 2003

29. West North Central region: 38% in 2002, 49% in 2003 Mountain region: 23% in 2002, 33% in 2003 East South Central region: 39% in 2002 49% in 2003 Red = Regionw/more than 10% increase in “Always/Usually Use Repellent” between 2002-2003

30. Age & Repellent Use Bad News:Repellent use (largely) decreases with age p < .000; n= 4034

31. Age and DEET in household • Highest age categories may be associated with having children at home

32. Race/ethnicity • Significant differences in having DEET in household by race/ethnicity (p<.000) • “White” respondents most likely to have DEET (44.3%), other respondents less so (<33%)

33. Household income • Poorer people in this sample were less likely to report having DEET-based repellent in the household. p<.000, n=4008

34. Education • Education level directly related to having DEET in household (p<.000) • Non HS graduates <30%, college graduates approaching 50% have DEET • Relationship to income bears further attention

35. Barriers and Opportunities

36. The “Why”: Qualitative Complementing Quantitative • Qualitative research to examine KAP and behavioral factors • 2003: Focus group discussions (~12 total) in higher and lower transmission areas [Larimer (high) and El Paso (low) counties]. Data on Cook County forthcoming. • 2002: 16 focus groups in Louisiana • Topics: • Risk perception • Attitudes twd mosquitoes, repellents, spraying • Information sources and shortcomings • Views on responsibility for prevention

37. Barriers: Questions about DEET • Reported infrequent/no use of DEET-based repellents in wk before group • Many cited their own sensory experience using repellent • smell, feel (“sticky”) • skin reactions, “sensitive skin,” I just can’t use that stuff • Strong, though often vague, beliefs and feelings about safety of DEET • Attribute brain damage, nerve damage, danger to kids • Often described by consumers as “something I heard somewhere… read somewhere” • Desire for more data, but resources for detailed info often unclear

38. More on repellents • Permethrin never mentioned • Use of any repellent on clothing rarely discussed • Very little awareness of details about repellent • DEET % strength unclear • Little about “hierarchy” of alternatives • Alternative repellents • “They wouldn’t have come up with the other types if there weren’t something wrong with DEET.” • Colorado way less interesting than Louisiana • Skin-So-Soft & the Avon ladies • Trust in “natural” products (regardless)

39. It’s not all about knowledge or about the bug spray • The decision to obtain/use repellent is only partly a function of knowledge about WNV, knowledge about prevention, or attitudes toward products. • Assessments of risk • Temporal, geographical, control/fear/outrage • Perceived impact of prevention efforts • Would any of these steps make a difference? • Individual cost-benefit analysis • What is it costing me to take these preventive measures? (not just $)

40. Conceptual Framework Risk perception was affected by locally- and personally-defined intensity of WNV transmission. Some factors that combine to define local intensity of transmission include: • - personal knowledge about disease • - perception of local ecology • - type and credibility of information sources • - local government intervention

41. Personal knowledge about disease Information Sources Actions of local government Local ecology Locally-defined intensity of transmission

42. Intense WNV Human Disease 2002 & 2003 ME WA VT MT ND MN NH OR NY MA WI ID SD RI Population perceives limited mosquito infestation Limited experience w/ & some resistance to mosquito control Risk perception linked to info from community groups WY MI PA NJ CT IA NE OH DE IN NV IL UT WV VA CO CA KS MO MD KY NC TN OK AZ SC NM AR GA AL MS TX LA FL Long history of mosquito infestations and nuisance Experience with and general support for mosquito control as a public service Risk perception linked to info from community groups Includes Fever and neuroinvasive disease as reported to CDC > 200 human cases 2003 > 200 human cases 2002 > 200 human cases both years

43. Risk: personal knowledge of disease • Knowing some who was ill • Increased recognition of WNV Fever cases during 2003*, more residents knew of someone infected • Concern about severity of Fever • Not the same impact as ND, but people missed school, work, described prolonged headache ache and fatigue • “No one told us it was going to be this bad.”

44. Defining Risk:disease & age • No one is “old.” • Perspective: participants > 60 y.o. pointed out their experience with other illnesses • Lived through polio • I had malaria and I figured I must be immune • Risk roulette for younger people: • “One of my younger neighbors, he thought that he ought to go ahead and get it so he would build up an immunity…”

45. Personal view of disease: fear and control • Concern fueled by sense of powerlessness • felt that personal options were limited • “I can’t spend time outside anymore” • Risk may seem ‘unquantifiable’ to general public • hard to make decisions about prevention--what to do, what to give up • Difficulty conceptualizing how a single mosquito bite can be fatal or life-changing

47. Defining Risk: Local Ecology • “No mosquitoes here” • Public lacks history of dealing with mosquitoes as a nuisance or makes qualitative comparisons to Midwest/elsewhere • “I just don’t see where all these mosquitoes can be coming from…” • Home as “Safe Zone” • Don’t use repellent when “just in the backyard”… some disinclination to regard home as dangerous • “Most of us [retirees] who are living here are so happy to be in this particular environment that we think we’ve got it made and… we’re kind of invulnerable to any sort of thing.”

48. Defining Risk: perception of ecology/local geography • “Hyper-localization” of risk • Desire to quantify exactly where and when the risk exists • People try to downgrade their risk – e.g. that dead bird was 3 blocks from here… • “We hear about the deaths… I wish they would go into a bit more history [of where they were bit.]”

49. Defining Risk: use of outdoors • The culture of outdoor recreation • Golfing, fishing, walking, gardening • Neighborhood visiting in PM (cities, south) • Resources • People without air-conditioning have a v. different relationship to outdoors • Age/quality/preferences in housing stock • Again western states very different than South and Midwest

50. Defining Risk: Info sources • People get most of information from media • Passive • Subject to the vagaries of how issues are covered – to what makes the “front page” • Respondents suspicious… media “hypes everything” • “I think there was confusion over how much is this really a problem and how much is media hype?” • Public’s inherent distrust (or at least ambivalence) regarding the media affected level of concern