Community knowledge, attitude and practices on mosquitoes and mosquito-borne viral diseases in Kinshasa, Democratic Republic of the Congo

Background Mosquito-borne viral diseases (MBVD) are among the important human and animal health threats globally. Gaining insights on behaviours and practices of local population on MBVD can improve understanding of socio-demographic and cultural factors to be addressed in intervention packages. This study was carried out to explore community knowledge, attitudes and practices regarding mosquito and MBVD in Kinshasa, the Democratic Republic of the Congo (DRC). Methods A cross sectional survey involving heads of household was carried out in Kinshasa, DRC, between January and April 2019. Information on socio-demographic characteristics, knowledge, attitudes and practices on mosquito and MBVD was collected through a questionnaire. Data analysis was performed using Epi Info 7 software. Results A total of 1,464 individuals were involved in the study. Of these, 69% were under 44 years of age, 60.7% were females and the majority (90.2%) were educated. One-third of the houses had insect window screens, 61.2% had open garbage cans, 33.4% had outdoor water storage units, 25.1% had stagnant water collection and 22.5% water containers. The majority (80.3%) of the respondent mentioned polluted water bodies as the main mosquito breeding places. Yellow fever (86.6%) was the most commonly known MBVD. Overall, 12% of the respondents knew that mosquitoes are vectors of these viruses. Majority of respondents (72.5%) felt to be at risk of contracting MBVD. Drainage and blocked draining water channels, dirty, agriculture, house and road construction, animal rearing and automobile garages were associated with mosquito abundance. Health professionals, family member, radio/television and/or school/university were the main source of information. Cleaning environment (58%) and/or use of insecticides (25%) were the main measures implemented in controlling of mosquitoes. Mosquito net ownership (87.4%) and use (67%) were high. Conclusion Most of the residents of Kinshasa had limited knowledge on the roles of mosquitoes in the transmission of pathogenic viruses in both humans and animals. Raising awareness and educational sessions are essential in empowering the community on the correct attitudes and practices in order to effectively manage the risk posed by MBVD.


Introduction
Mosquitoes transmit different pathogens that affect human and animal health and impact negatively on food security and socio-economic wellbeing [1][2][3][4]. In addition to malaria and lymphatic filariasis, mosquitoes are vectors of several viruses. The most important mosquito-borne viral diseases (MBVD) include Yellow fever, Zika, Dengue, Chikungunya, Rift valley fever and West Nile virus [5]. These infections are mostly transmitted by Aedes mosquitoes. Transmission of MBVD to humans and animals includes multifaceted processes; which are influenced by mosquito and viral genetics, environmental, socio-demographic and anthropological factors [6,7].
For effective interventions, in addition to knowledge on biomedical aspects of the diseases, information on socio-anthropological aspects is equally important. It is critical to explore different local socio-cultural and demographic driving factors of MBVD in order to design appropriate interventions. In the current context of increasing insecticide resistance, limited vaccine options and lack of curative resources; integrated approach based on community and individual participation are inescapable for the prevention and control of MBVDs.
There is limited information on community knowledge, attitude and practices (KAP) on mosquitoborne viral diseases in Sub-Saharan Africa, which bears the one of the largest burden of MBVDs [8].
Studies outside Africa have shown that KAP on MBVD varies widely across populations and countries [9][10][11][12]. Inadequate knowledge is a significant barrier for appropriately empowering local communities and individual interventions against MBVD. Lack of or inadequate community knowledge is likely to be an obstacle in adopting of specific prevention and control measures against some specific mosquito species and MBVD [13]. Indeed, mosquito species express different biting behaviour and breeding preferences.
In DRC, climatic and ecological conditions are optimal for almost all major MBVD of public health importance. The country is known to be at high risk of YFV transmission, morbidity and mortality [14].
More than 400 people died during the yellow fever outbreak that occurred between 2016 and 2017 [7,15]. Kinshasa, the capital city, has experienced four chikungunya outbreaks during the past two decades [16][17][18]. Recently, reports on Dengue occurrence have increased [17,[19][20][21], presence of Zika virus (ZIKV) has been documented [21] and the overall sero-prevalence of Rift Valley fever virus (RVFV) has increased [22]. To date, Aedes albopictus has been reported in Kinshasa [23]. These threats of MBVD are not only to the local population but also to visitors to DRC. For instance, the majority of Chikungunya virus infections in Belgium between 2007 and 2012 were imported from DRC [24] and recently, a Japanese traveller returning from DRC was diagnosed with DENV [25]. The evidence of West Nile virus (WNV) were documented in Kinshasa among dogs, horses and mosquitoes [26][27][28]. In the context of inadequate resources for control, there is an immediate need to increase community awareness on MBVD in DRC. This study was therefore carried out to determine community knowledge, attitudes and practices on mosquito and MBVDs in Kinshasa, DRC.

Study area and design
In this cross-section study, a questionnaire survey was conducted in four districts in Kinshasa, the capital city of DRC, between January and April 2019. Kinshasa has 24 communes (municipalities) grouped into four districts and each commune is divided into neighbourhoods. It has an estimated of 11,855,000 urban population [29]. The head of household or his representative was systematically selected from neighbourhoods to guarantee a good coverage of geographical, demographic and socio-economic profiles of the population.
The questionnaire was developed in English, translated in French and administered by face-to-face interview in either Lingala or French depending on the language proficiency of the respondent. The questionnaire contained both closed and opened questions with possibility for the respondent to provide more than one answer. The questionnaire and covered information related to sociodemographic characteristics of respondents,, knowledge about mosquito (breeding places, activities, behavior, vector role, control measures) and MBV diseases; attitudes and practices towards mosquito and MBVD.

Data Analysis
The data were entered into Microsoft Excel spreadsheet and statistical analysis was performed using Epi Info software Version 7 (CDC, Atlanta). Summary of statistics were presented as frequencies and proportions in Tables or figures. Results Socio-demographic and environmental characteristics A total of 1,464 participants were involved in the study. Of these the majority (60.7%) were females.

Knowledge
The majority of respondents stated that stagnant and drain polluted water (80.3%) and garbage (35%) were the major mosquito breeding sites. As regards to mosquito biting time, 39% considered mosquitoes to bite during the night, 31% during sundown while 30.5% stated anytime of the day (Table 3). Yellow fever was the most frequently (86.6%) mentioned mosquito-borne viral disease.
Regarding knowledge on the role of mosquito in spreading zoonoses, about four fifth of respondents were unaware that mosquito can transmit pathogens to animals or exchange pathogens between animals and animals ( Table 4). Out of 348 respondents who were aware about the role of mosquito in zoonosis transmission, 39.0% were not able to mention any zoonosis while about 14% mentioned zoonosis not vectored by mosquito (trypanosomiasis, rabies), 5% stated Ebola and inappropriately 34% answered malaria (Table 4) were mentioned by only a few respondents (Table 3).

Attitudes and perceptions
Approximately, three quarters (72.5%) of the respondents were aware about impact of mosquitoes on their daily life. Most (60.7%) respondents reported being bitten by mosquitoes outdoor in their home places, fewer at recreational places or work places and half of respondents responded were bitten indoors. In all, 44.6% respondents were regularly bitten and 31.2% reported sometimes. Overall 90% of participants were bitten during the dark (sundown 36%, night 53%); fewer reported mentioned to be bitten during the day (7.0%). When asked about activities associated with mosquito abundance, 21% mentioned drainage and blocked draining water channels, 17.7% dirty, 14% farming activities, 10% house/road construction, 7.7% animal rearing and automobiles garage (Table 5).
Most participants (72.9%) perceived that they were responsible in the prevention and protecting themselves and their household against mosquito and MBVD, but only 37.3% were aware about their responsibility at community level. They perceived that mosquito and MBVD control and prevention to be the responsibility of the health authorities and national Government ( Table 6).
The most familiar sources of information about MBVD were health professional/hospital (40.2%), their relatives or family members (26.1%) and mass media such as radio or television (25.3%); school/university (17.7%). Church, megaphone public announcement, Government announcement, newspapers, internet, telephone short messages were less common source of information of respondents (Table 5).
Practices regarding vector control Slightly above half (58.6 %) of the respondents reported cleaning environment, one quarter use of insecticides, another one quarter reported emptying garbage containers and emptying of flowers pots (11%) as the measures undertaken to reduce mosquito abundance around their homes. The draining of standing water was mentioned by 16.3% of respondents and garbage by 11.3%. Covering of water source, drinking water and/or storage containers was stated by only 10.4% of respondents.
As regards to measures undertaking to reduce or avoid mosquito bites, a large proportion of the  (Table 7).

Discussion
The present study explored the level of community KAP with regard to mosquitoes and mosquitoborne viral diseases in Kinshasa, DRC. The focus was on Aedes-borne viruses which represent an imminent worldwide threat for human and animal health. Although majority of respondent reported that were frequently been bitten by mosquitoes either outdoors or indoors; most of them stated mosquito activities were more intense from sundown to night. Only a few participants knew about daily activity of mosquitoes. High proportion of study participants felt more concerned by health Nevertheless, majority of respondents in the current study were unaware about vector role of mosquitoes in spreading pathogens to animals and their involvement. Although majority of study participants have heard about an Aedes-transmitted virus, yellow fever and some few on chikungunya, Zika and dengue; the majority of them did not know that these viruses are transmitted to human by mosquitoes. Democratic Republic of the Congo has experienced four chikungunya and four yellow fever outbreaks during the recent 2 decades [16][17][18][38][39][40][41], this could be the reasons that majority of the respondents were aware of the diseases.
The lack of knowledge on the role of mosquito in spreading virus in both humans and animals could explain some contradictory attitudes, behaviours and practices noted among study participants.
Similar observations have been reported in Jamaica, where the population had poor knowledge of MBVD and poor prevention practices [42]. Contrary in Belize more than 85% of the respondents confirmed that DENV, ZIKV, CHIKV, and YVFV are viruses transmitted by mosquitoes and that they were regularly draining standing water or use insecticides to control mosquitoes [2]. Similar observation has been reported in Colombia, USA and China where the majority of the population were positively involved in source reduction preventive practices [12,43,44].
The appropriate knowledge of MBVD can empower individual to make some effort to prevent or control MBVD in their properties instead of waiting for government intervention. The poor knowledge about mosquito-borne disease has also been reported for RVF in Kenya, Tanzania, and Sudan [1,35,36]. The lack of knowledge is driving MBVD in new areas and leads to loss of life and economic losses [1,36]. The high level of dirty, multiple fortuitous markets, higher demographic pressure, inadequate urbanization of Kinshasa Metropolitan are suitable conditions to support Culex mosquito, main vector of WNV and RVFV [45][46][47]. In DRC, currently RVFV activities are increasing [22] and evidence of WNV in domestic dogs and horses have been documented from Kinshasa [27,28].
Regarding the number of household rearing either domestic or livestock animals in this study area, there is also urgent need to raise awareness of population about the role of mosquito in spreading zoonosis.
Participants in current study were less aware about how their involvement as local population can boost controlling mosquito and MBVD in their community. The study participants perceived that they had only the duty for self-protection and for their own household but they not responsible for local community mosquito prevention and control. Similar observations have been reported in a study in Western Australia [48]. These positive attitudes of trusting in government action offer an opportunity for decision-makers and health actors to maximize their educational activities in this community and to get closer to population through its local structures. Even practically, the respondents did not perceive the responsibility of local community and their role as source of information. It is important that the population perceive that control of mosquito-borne diseases does not only have to rely on individual or household protection but also at the community level. Strengthening co-operation between neighbouring households can also serve as an information channel to improve the knowledge levels of this study population. The financial problem was mentioned as main hindrance in taking action against mosquitoes for the majority of study population. This could be the reason that the majority of study participants would resort less to struggling measures that incur expenditures.
Once the health risk is perceived as real threat and priority, population can run to transfer their knowledge into action [13]. But embracing of protective behaviours is a multi-factorial procedure influenced by socio-economic and cognitive factors [49]. In general, household expenditure on protective measures using chemical is high [2,3]. So, in low income region it is better to emphasize on environment measures which are more accommodated, simple to implement and very effective too.
Simple action of removing garbage and domestic use containers can reduce over 90% of larvae abundance and putting window screen, closing door can contribute to avoid over 80% of mosquito adults in homes [13]. Social mobilization and communication programs including modern channels should be developed with all national, local partners and community leaders. The integration of awareness-raising activities on the prevention and control of mosquito-borne diseases should be encouraged in church, school and university programs to educate the church followers, students and use them as multipliers.

Conclusions
The findings of this study indicate that the population of Kinshasa lives in an environment conducive for the proliferation of mosquitoes and spread of mosquito-borne diseases. However, the overall community knowledge regarding MBVD was poor both in terms of mosquito biology, prevention and control. Therefore, there is an urgent need to introduce multiple education programs to raise their awareness and improve their knowledge. Particular emphasis should be placed on environmental sanitation, as it is essential to encourage this population to invest themselves in the hygiene of their living environment, since it is also within their reach. Availability of data and materials All data generated or analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests
There are no competing interests.

Funding
This study received financial assistance through a scholarship from the Government of the United Republic of Tanzania from World Bank WB-ACE II Grant PAD1436.
Contributions KMM designed the study, conducted the field works, performed statistical analysis and prepared the manuscript for publication; LM assisted in developing study questionnaire, revised critically the manuscript; RW assisted in developing study questionnaire, study design and participated in writing the manuscript; JZ participated in study design and conducted the field work, FKL participated in field and assisted in writing the manuscript; GM participated in study design and revised the manuscript; SIK participated in designing the study, assisted in developing study questionnaire. All authors read and approved the final version of the manuscript.