Perceptions on dengue among residents of a brazilian border municipality

Background and Objectives: Approaches based on knowledge of the population constitute an important tool to guide the development of appropriate and effective strategies to control and prevent outbreaks of dengue. The objective of this study was to identify the perceptions about the knowledge, occurrence and control activities of dengue fever among the residents of Ponta Porã municipality, Mato Grosso do Sul state, Brazil/Paraguay border. Method: A qualitative-quantitative study was conducted from November to December 2016 in a population sample of residents in the urban area of the city. For the data collection, 383 residents were interviewed, whose content analysis was performed using the Collective Subject Discourse technique. Results: The speeches disclose coherence between the information disseminated by dengue control campaigns and the knowledge of the population about the disease. The population’s own accountability for the occurrence of dengue was observed. The interviewees showed dissatisfaction with the dengue control actions developed by the municipal government, mainly regarding their intensity, regularity and continuity. Conclusions: Most of the interviewees know what dengue is, are aware of its form of transmission and know how its control is carried out.


INTRODUCTION
Considering that approximately three billion people are at risk of contracting the infection, dengue is now considered the world's most important vector-borne viral disease, with an estimated 390 million infections (96 million symptomatic ones) and 20,000 deaths reported annually. 1 In 2016, more than 2.38 million cases of the disease were reported in the American continent. 2 In Brazil, dengue fever has been occurring continuously since 1986, interspersed with epidemic outbreaks. Between 2010 and 2016, more than 7.5 million cases were reported, highlighting the recent epidemics of 2015 and 2016, with 1.6 and 1.5 million cases, respectively. 3 Regarding the magnitude of the disease in Brazilian borders, between 2007 and 2009 dengue was among the diseases of compulsory notification, the second most significant one in these localities, second only to malaria. 4 The actions aimed at fighting dengue are carried out in Brazil in accordance with the guidelines of the National Dengue Control Program (PNCD, Programa Nacional de Controle da Dengue), which has been operating since 2002. 5 Among the municipalities considered to be priorities for the PNCD are those at Brazil's international borders, as they are considered receptive to the introduction of new disease serotypes. The program has ten components, comprising operational actions of integrated, entomological and environmental surveillance; patient care; health education, communication and social mobilization; training of professionals; social and political support and monitoring, and evaluation. However, the effectiveness of these interventions depends on the continuity, coverage and, above all, the adoption of preventive measures by the population. The population behavior regarding dengue prevention is influenced by individual and collective perceptions about the risk of the disease, mediated by the daily life experiences and by cultural elements. 6 Thus, when one thinks about an intervention in health education, it is necessary to consider people's previous knowledge and perspective on the subject. Approaches based on the population's knowledge constitute an important tool to guide the development of appropriate and effective strategies to control and prevent dengue outbreaks. 7 Considering that in municipalities located on the borders the cultural practices, specific of each territory, are mixed with those used in the frontier territories, the propositions of educational interventions constitute a greater challenge in these localities. Because of these motivations and the frequent mobility of cross-border individuals, it is important to implement special surveillance and control strategies.
In this sense, the objective of this study was to identify people's perceptions about knowledge, occurrence of the disease and control actions related to dengue in a border town, by evaluating the municipality of Ponta Porã, state of Mato Grosso do Sul, Brazil, located on the border with Paraguay. This choice, for consideration purposes, was due to the direct contact of its territory with the international border and because it is a priority municipality for the Dengue Control Program in the state of Mato Grosso do Sul, Brazil.

METHODS
This is a quantitative, descriptive and exploratory study carried out from November to December 2016 in a population sample of residents in the urban area of the Ponta Porã municipality, located in the south of the state of Mato Grosso do Sul, on the border of Brazil and Paraguay.
The municipality, with has an area of 5,330,448 km², has an estimated population of 88,164 inhabitants, 80% of which reside in the urban area. 8 The city of Ponta Porã is separated by a street (the International Avenue) from the city of Pedro Juan Caballero (the capital of the Amambay department), in Paraguay.
In order to calculate the sample size, we considered for the urban population of Ponta Porã, a 50% incidence of dengue, a sampling error of 5% and a 95% confidence interval, resulting in a minimum sample of 383 participants. This total was distributed proportionally to the registered population in each of the five census sectors of the municipality used by the Brazilian Institute of Geography and Statistics (Instituto Brasileiro de Geografia e Estatística -IBGE).
The systematic sampling technique was used, by dividing the number of households of each sector by the number of sample subjects of each sector, and the value obtained was considered the interval between the households. A draw was made between the number 1 and the interval value obtained in each sector, to establish the casual start of household sampling, in order to maintain the randomness.
Two interviewers, previously trained on the subject, carried out the interviews in the selected households, using a semi-structured script consisting of two parts: the first addressing questions about the residents' profile (age, gender and schooling) and the second with guiding questions (highlighted, in the Results section, as the title of the tables), which addressed the knowledge about dengue, the practice and habits of prevention and the evaluation of the control actions developed by the government. For the guiding questions, more than one answer was admitted per interviewee. Only one person was interviewed in each household.
The inclusion criteria were: age ≥ 18 years, of both genders, and agreement to participate in the study. The mean duration of the interview was fifteen minutes. The interviews were fully recorded, as a strategy to put the interviewees more at ease to answer them and to speed up the data collection, and the interviews were fully transcribed for subsequent analysis.
The Discourse of the Collective Subject (DCS) technique was used to assess the collected data, which is a proposal for the organization and tabulation of qualitative verbal data obtained from statements. 9 The basic methodological procedure requires the identification of the central ideas (CI) in the interviewees' discourses about the established question. The interviewees' discourses may contain one or more CI. For each established CI, key expressions are assigned, so that it becomes possible to group the key expressions of similar meaning into categories of responses. Synthesis-discourses are then constructed using the material of the CI key expressions, in the first person singular, which are the DCS. 9 The analysis of the discourses was performed using the DSCsoft software (improved

RESULTS AND DISCUSSION
Of the 383 assessed individuals, 62% were aged between 18 and 44 years, and most of them were women (62.9%). This profile of respondents has also been found in other studies on the population's knowledge about dengue. 11,12 Regarding education, 51.4% of the interviewees had more than Elementary School level, and 17 individuals were illiterate.
The results of the survey applied to the interviewees will show their central ideas and the proportion obtained for each of these CI presented as tables. The most frequently shared CI for each formulated question, that is, the one with the greatest intensity and high amplitude, will be presented as DCS. However, the discussion refers to all the obtained discourses. Table 1 shows the six CI created for question 1: "What is dengue for you?" and the proportion obtained for each of them. The interviewees showed they knew what dengue was.
Most of them recognize dengue, in a simple or qualified manner, as a disease (74.8%). Those who qualify the disease, associate it with its vector, (prevalent CI), i.e., the Aedes aegypti mosquito; and associate dengue to the sensation it causes, the effects on the body and/or the fear of its fatality; and with the lack of care.   The three CI that were most often shared among the interviewees regarding this question, associated dengue prevention with vector control. It is possible that the explanation for this attitude is the same as in the previous question, when the population mistook the disease for its vector: educational campaigns focused on the control of the vector breeding sites.
According to the common sense, preventing the disease is understood as eliminating the mosquito. 16 An analysis of the content of printed materials on dengue showed that most of them (88%) focused on the physical control, by dealing with the containers or possible breeding sites. 17 According to the authors, this transfer of information that is simply of biological nature, contributes to a reductionist view of the disease by the population, in which the breeding sites determine the presence of the vector, which, in turn, determines the occurrence of the disease.
It can be observed that only 3.9% of respondents' answers mention the repellent as a way to prevent dengue. It should be noted that materials used in the campaigns contain scarce information on individual and household protection against mosquito bites. Collective socioenvironmental measures should always be intensified and supplemented by individual protection measures. Therefore, we highlight the need to instruct the population about such procedures.
The population's perception regarding the occurrence of dengue in Ponta Porã allowed the disclosure of seven Central Ideas (Table 3). One of the factors that can be identified as responsible for the lack of effective commitment by the population are the dengue vector control actions carried out vertically, with the municipality being in charge of reproducing the practices prescribed in the official manuals. 16 Local knowledge and practices are not incorporated into the control strategies, that is, the specificities of each locality are not considered when planning the activities, a situation that has specific delineations in border areas.
Border cities somehow naturally integrate and create a type of a third space, which generates a new society, with their own cultural and ethnic values and traits, particular and specific languages of that locality, presenting a different identity from that of the rest of the country. 19 Knowing and taking into account the specificities of these regions is important to support the discussion and formulation of the most adequate dengue prevention and control actions and, consequently, to stimulate the population's participation in vector control.
The second most shared CI among the studied population associates the occurrence of There is a tendency, which is no less important, to blame the "other", manifested through the idea that it is the neighbor's and Paraguay's fault, as shown by CI "C" and "E".
This transfer of responsibility has also been identified in another study. 21 The interviewed population tends to reproduce what Valla considers to be one of the most harmful effects of the inefficiency of public services in Brazil: the blaming of the victim. 22 According to the author, the government individualizes the question of fighting the vector by directly blaming the mosquito that transmits the disease and, indirectly, the population for the occurrence of the disease. In border areas, the international neighborhood is another element that can be blamed by the population and the government for the failure to control the disease.
When asked if they are satisfied with the dengue control actions carried out by municipal government, the variables Yes (49.6%) and No (47.9%) are practically equivalent in the respondents' answers, although the most prevalent CI is negative regarding those actions (34.3%) ( Table 4). Another important aspect was valuing the technical and educational work of dengue control agents, as shown in CI "C", similar to that recorded in another study on the users' perception of basic care on dengue. 25 Even without the continuity desired by the population, the actions of these agents have positive impacts that remain in the (un)conscious of the local residents. These are sporadic actions, but with high visibility and produce instant results.
The evaluation of the studied population's degree of satisfaction with the dengue control actions developed by the municipal government constitutes an important indicator to be considered in the planning of actions.
Based on the analysis of the DCS of the interviewees, it is possible to conclude that the majority knows what dengue is, is aware of its form of transmission and how the control is performed. However, one can perceive a reproduction of the popular TV campaigns, of which background aims to frighten, to blame and to place the responsibility on the population.
The interviewees recognized their own negligence regarding the fight against dengue as the main motivation for its occurrence, without disregarding the government's inefficiency and negligence. They showed dissatisfaction with the dengue control actions developed by the municipal government, mainly regarding the intensity, regularity and continuity of these actions.
The results suggest the need for adjustments in the communication, education and social mobilization practices. It is necessary to establish a dialogue, using appropriate techniques and languages, so that the population can receive reliable information that makes sense for their reality. It is necessary to set aside the episodic information campaigns, to promote training ones. Considering that is a frontier municipality, where cultural hybridization is a reality, it is extremely important that the agents assigned to implement such practices know and consider the values and beliefs of this border population.
Finally, communication, education and social mobilization practices must be associated to a set of intersectoral actions. Improvements in urban infrastructure can reduce the risk of dengue.