{'fraction_non_alphanumeric': 0.03969213853765805, 'fraction_numerical': 0.02611324903793293, 'mean_word_length': 5.098223265169293, 'pattern_counts': {'":': 0, '<': 4, '<?xml version=': 0, '>': 2, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
A cross-sectional survey of knowledge, attitude, and practices toward dengue fever among health workers in a tertiary health institution in Sokoto state, Nigeria

Introduction: Dengue fever (DF) has become a disease of public health concern. It is a mosquito-borne virus infection caused by one of the four serotypes of the dengue virus, and the disease is prevalent in the tropical and subtropical regions of the world, with a global burden in the Americas. Yearly, about 390 million cases of new infection are estimated to occur. Aims of the Study: This study was aimed atdetermining the knowledge, attitude and practices regarding dengue fever amongst health workers in a tertiary health institution in Sokoto state , Nigeria. Methods: A descriptive cross-sectional study was carried out at the Usmanu Danfodiyo University Teaching Hospital, Sokoto, among 367 health-care workers who had worked in the hospital for at least 1 year before the study were selected using a systematic sampling method. Data were collected by trained resident doctors using a standardized, pretested questionnaire and analyzed using SPSS version 20 with a significance set at P > 0.05. Results: There was high awareness (95.1%) among the respondents, with seminars and lectures in school as the most familiar information sources. A more significant proportion, 87.8%, 93.2%, and 76.6%, of the respondents had adequate knowledge, positive attitude, and appropriate DF practice, respectively. Nurses and laboratory scientists had higher practice scores compared to other health-care workers (P = 0.016). Conclusion: Capacity building of health-care workers, especially the primary care physicians on surveillance, proper diagnosis, and treatment, is needed to avoid missing cases or misdiagnosis of cases, especially in developing and underdeveloped countries with limited health resources care service delivery.


Introduction
Dengue fever (DF) has become a disease of public health concern-the most important arboviral infection globally. [1] It is a mosquito-borne viral infection caused by one of the four serotypes of the dengue virus. [2] The disease is prevalent in the tropical and subtropical regions of the world. [2][3][4] It has been estimated that around 50% of the world population lives in areas where the disease transmission is favorable. [5,6] The global burden is seen in the Americas region with annual 1.5 million cases, and around 3 million cases of the disease were reported in 2019 by the Pan America Health Organization. [7,8] Africa is A cross-sectional survey of knowledge, attitude, and practices toward dengue fever among health workers in a tertiary health institution in Sokoto state, Nigeria another region with notable cases, [1] and currently, the disease is endemic in 128 countries. [9][10][11] Yearly, about 390 million new infection cases are estimated to occur, [12] more than estimated by the WHO. [9] Aedes aegypti and Aedes aldopicus transmit DF-the two mosquitoes responsible for transmitting the disease among humans. [2] DF can develop into a severe form of infection called dengue hemorrhagic fever and can lead to severe complications and even death. [1] There are two main types of dengue diseases, DF and dengue hemorrhagic fever, and infection due to a particular serotype confers immunity against it; however, an individual can still be infected by other serotypes. [13] Currently, there is no vaccine neither specific treatment for the disease; therefore, controlling the mosquito vectors is critical in the prevention of the disease [14,15] In Nigeria, the first case of dengue was isolated in the 1960s, but the disease is not among the list of reportable cases in Nigeria, [16] despite the number of diagnosed fevers of unknown cause. A seroprevalence of 30.8, 17.2, and the recent report of 73 among febrile patients have been reported. [17][18][19] Knowledge, attitude, and health-care workers' practices on the disease are critical for early diagnosis and disease prevention, especially by family physicians who are usually the first contacts for patients. [20,21] The purpose of the current study is to assess the knowledge, attitude, and practices regarding DF among health-care workers (HCWs) in a tertiary health institution in Sokoto, northwestern Nigeria. It is hoped that this will further deepen the study subjects' knowledge and help identify gaps for further interventional studies.

Study Area and Design:
A cross-sectional descriptive study design was carried out among health workers at the Usmanu Danfodiyo University Teaching Hospital (UDUTH), located within Sokoto city. UDUTH is a tertiary health center and serves as a referral center to many hospitals from Nigeria's northwestern region.

Study population and Eligibility:
The study population comprises health workers (doctors, pharmacists, laboratory scientists, and nurses) who had worked in the hospital for at least 1 year before this study and came in contact with patients from time to time (inclusion criteria).
Sample Size and Sampling Technique: A sample size of 367 was calculated for the study based on an assumption of 35% from a previous study [22] who had adequate knowledge of the disease. The various health workers' list was obtained from the institution's staff officer, and study subjects were selected proportional to size using a systematic sampling method.
Data Collection and Analysis: Participants' knowledge, attitude, and practices regarding DF that were assessed using a standardized pretested semistructured questionnaire consisting the questions on knowledge, attitude, and practice were administered by trained research assistants. Consent was obtained from the participants before the application of the instrument. Sociodemographic characteristics were also collected. The questionnaires were checked for completeness and entered into SPSS version 20 for subsequent analysis. Mean, standard deviations, proportions calculated, and logistic regression analysis were conducted to identify the relationships among the interests' variables. Correct responses to each question on knowledge and practice attract one mark and zero for incorrect answers, and a cut-off score of >60% was considered for adequate knowledge and appropriate practice. Similarly, concerning attitude, a correct response to strongly agree or agree was given a score of 1, while any response to strongly disagree, disagree, or not sure was awarded 0 scores. The attitude scores were finally graded as a percentage, with ≥60% being positive attitude. The level of significance was set at P < 0.05.

Ethical approval
The approval to conduct the study was granted by the Research and Ethics committee of the Usmanu Danfodiyo University Teaching hospital. Participation was voluntary, and all the information collected from the respondents was treated with uttermost confidentiality. Before the data collection, informed consent was obtained from the respondents.
More than 90% (347) of the respondents heard of DF, with seminars and lectures in school being the commonest sources of information regarding the disease. However, less than half 167 (48.1%) had experience in reporting suspected DF cases.
The majority of the respondents, 309 (84.0%), knew DF is transmitted when mosquito bites and more than half 208 (56.7%) knew Aedes mosquito as the responsible vector for the transmission of the disease. A total of 144 (44.4%) of the subjects knew that ponds and rivers are breeding grounds for the vector. The majority of the respondents (75.4%) knew that DF could be spread from human to human. They also knew that fever 341 (94.7%), nausea and vomiting 331 (93.8%), bleeding 325 (91.3%), headache 329 (94.3%), rash 257 (75.4%), and abdominal pain 275 (79.5%) are symptoms of DF [ Table 2].
Almost all the respondents were knowledgeable about the vector characteristics. However, 141 (46.1%) of the respondents knew that the vector frequently bites during the morning and daytime 175 (55.2%) [ Table 3].
There were some misconceptions concerning the treatment of DF as only a third 116 (34.0%) felt that patients with the   Table 4].
The sociodemographic variables had no significant impact on years of experience and overall (graded) knowledge of HCWs regarding the disease. Less than half (45.0%) of the respondents with adequate knowledge had ≥10 years of experience, and this was statistically significant (P = 0.011) [ Table 5].
The association between respondents' cadres and overall DF knowledge was significant (P < 0.001). Consultants, resident doctors, house officers, pharmacists, and nurses had higher knowledge scores than the laboratory scientists.
The majority of the respondents opined that DF is a serious illness 275 (78.2%) but can be prevented, 233 (66.6%) and there is a need for treatment, and hospitalization 224 (65.9%) and 246 (73.7%) agreed that any community with suspected symptoms should seek for medical advice. Almost all 330 (93.2%) respondents had a positive attitude toward DF. The majority (76.2%) of the subjects strongly believed that DF is a serious health problem and were of the strong belief that they were at risk of contracting the illness; similarly, a greater proportion (65.7%) believed that the government has a responsibility in ensuring that the vector breeding places are adequately controlled.
Overall, 330 (93.2%) of the study subjects had a positive attitude toward the illness. However, no significant relationship was seen between the sociodemographic variables, including years of experience and overall (graded) attitude of HCWs regarding DF. Nurses had higher attitude scores compared with laboratory scientists, and this was statistically significant (P = 0.025) [ Tables 6 and 7].
The majority of the respondents, 269 (76.6%), had appropriate practice concerning DF. However, about half 160 (48.6%) of them would admit patients with DF without warning signs,  Contd...
importance. Our study investigated the knowledge, attitude, and practice of DF among HCWs in Sokoto. As shown in the data, and similar to another study carried out in Abidjan, Cote de'Ivoire, [24] more than half (54.8%) of the respondents were below 35 years of age, the active period of life with high chances of exposure to the outside environment. As expected, males constituted the majority (60%) of the study subjects, and this agrees with the findings of Tan et al.; [21] however, similar studies conducted in Tanzania and Quebec, Canada, showed female preponderance. [25,26] Our study's male dominance may not be unconnected with the low female school enrollment and our study area's sociocultural milieu. [27] Similar to another study elsewhere, [24] it was observed from our study that more than half (57.3%) of our respondents were nurses who also constituted the majority of the health workforce in the teaching hospital, but in contrast with other studies where doctors were the majority. [26,28,29] Our study's findings showed that less than half (42%) of the study subjects had more than 10 years of working experience as health  Tables 8 and 9].
Most 48 (70.6%) of the respondents with inappropriate practice had <10 years of experience and this was statistically significant (c 2 = 5.82, P = 0.018). Nurses and laboratory scientists had higher practice scores compared with other health professionals, and this was statistically significant (P = 0.016) [ Table 10].

Discussion
DF is a global infection of public health importance, endemic in about 128 countries with an estimated prevalence of 3.9 billion. [12,23] HCWs, especially family physicians being the gatekeepers on health issues and first contacts with patients, are the core workforce expected to change this trend. Their overall operational capacity in dealing with DF is therefore of paramount  workers. Ekra et al. found a lower figure of 31% amongst their subjects. [24] In contrast to our findings, higher figures (51% and 65%) were observed in other studies elsewhere. [26,28] The majority of our study subjects (95.1%) were aware of DF before now; varying levels of awareness ranging from 34.5% to 77% had been recorded in previous studies. [30][31][32] The high level of awareness amongst our study subjects compared with the other studies may not be unconnected with the fact that our study was amongst HCWs while the other studies were in the general population with varying levels of awareness as observed in the findings.
The commonest source of information on DF by our respondents was through hospital seminars and training during outbreaks, especially on other hemorrhagic fevers. This is in agreement with the findings of Ekra et al. in Abidjan, Cote d'Ivoire. [24] The study revealed that most of the respondents had good knowledge of causes, spread, and DF symptoms with a score of 75% and above. This is not unexpected considering the background of the study subjects and the fact that working in a tertiary health and training institution exposes them to continuing medical education in the form of seminars and clinical meetings. However, lesser knowledge scores were reported among health workers in Tanzania and residents of Westmoreland, Jamaica. [25,33] In contrast to our findings, higher scores were reported from Pakistan and India. [34,35] On the knowledge of the HCWs on prevention and vector characteristics, more than 80% were quite knowledgeable; however, more than half (55.2%) of the respondents knew that the vector bites during the daytime. This is higher than the findings from the study of Kajeguka and his    with high knowledge [40] and other studies with low knowledge levels from India, Pakistan, Thailand, and Jamaica. [32,33,[40][41][42][43][44] Furthermore, it was observed from our study that the majority of our subjects expressed a positive attitude toward DF. Studies elsewhere observed similar positive attitudes, although not as high as observed in this study. [33,40,40,45] The proportion of respondents that showed a positive attitude toward DF is not surprising, although it has been shown that good knowledge about DF could translate to positive attitudes. [46] On the overall graded practice of preventing DF, most study subjects (76.6%) had appropriate practices. This is in agreement with findings from other studies elsewhere. [45,47] On the other hand, some other studies observed varying practice levels from 49.6% to 57.3%. [36,38,40] The difference between our study and these other studies may not be unrelated to the fact that ours was among health workers while these others were from community-based studies. The health workers are usually the first contacts of patients in all health facilities; therefore, the perception of being at risk of infection, frequent training, and continuous provision of information, education, and communication invariably strengthen good practices. Although education plays an essential role in enhancing good practices, it has been observed that education alone cannot be correlated with knowledge. [33] It is therefore not surprising that nurses in our study had better practice than other health workers. Ekra et al. observed similar findings from their study. [24] In terms of correlates of overall graded knowledge and attitudes of the HCWs, there was no statistically significant association between sociodemographic variables, including years of experience. However, in terms of practice, HCWs colleagues in Tanzania, [25] where only 26.3% of the participants knew that the mosquitoes that transmit DF are daytime biters. Similarly, other studies observed good knowledge of the transmission by Aedes mosquitoes. [36][37][38] Findings from our study showed that the knowledge of DF treatment was good, with 67.7% of the participants scoring 75% and above; however, Kajeguka et al., [25] in 2017, reported over treatment of malaria in the absence of diagnosis. Another study by Nguyen and his coresearchers revealed missed opportunities by primary health physicians to improve dengue prevention through communication. [39] Overall, the majority (87.8%) of our respondents had adequate knowledge of the cause, transmission, treatment, and prevention of DF. This contrasts with other studies that found only 10.3% with more than 10 years' experience were two times more likely to have fair practice compared with others. The overall knowledge score of DF between respondents' cadres was found significant (P < 0.001) among consultants, resident doctors, house officers, pharmacist, and nurses and had a higher knowledge score than the laboratory scientist probably due to the few numbers of cases seen or wrong laboratory investigation and diagnosis. Nurses had a significant higher attitude score compared with laboratory scientists (P = 0.025); however, nurses and laboratory scientists had significant higher practice scores compared with other health professionals (P = 0.016), and this could be due to safety precautions adopted, especially by these cadres of HCWs to limit exposure and contact with suspected patients and samples.

Summary
Findings from our study indicated that the respondents had high awareness about DF with seminars and lectures in school as the commonest sources of information. A greater proportion of the respondents had adequate knowledge, a positive attitude, and appropriate DF practice, respectively. The need to increase sensitization of HCWs on attitude and practice of DF prevention is timely and essential considering the population at risk globally and the impact of population growth, urbanization, and climate change. Surveillance, proper diagnosis, and treatment are needed to avoid missing cases or misdiagnosed cases, especially in developing and underdeveloped countries with limited resources in terms of health-care service delivery. Communicating the regular geographical distribution and global burden to alert HCWs is equally essential. The need to develop programs and activities aimed at capacity development of HCWs, especially the primary health-care physicians, to avoid missing or misdiagnosed cases of DF is critical.

Financial support and sponsorship
Nil.

Conflicts of interest
There are no conflicts of interest.