Different Domains of Dengue Research in Malaysia: Comparison
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Please note this is a comparison between Version 2 by Jason Zhu and Version 1 by Hamed Taherdoost.

The systematic review provided some useful insights into recommendations for the control of dengue infection in Malaysia. The efforts of translating knowledge into appropriate attitude and preventive practices regarding dengue should be conducted into more sustainable strategies by the active engagement of communities, inculcation of positive culture, improvements of health campaign, and co-operation with faith-based organisations to spread awareness on dengue prevention and control measures.

  • dengue
  • Malaysia
  • survey
  • knowledge
  • attitude

1. Introduction

At present, dengue fever is considered a major public health concern in Malaysia, contributing to a high rate of morbidity and mortality [10][1]. However, the exact number of dengue cases in Malaysia is under-reported [11][2] partly due to the rapid population growth and the influx of a large number of foreign workers [12][3].
Malaysia is a multiethnic country with different cultures and traditions, consisting of Malay, Chinese, Indian, Orang Asli (mostly inhabiting in West Malaysia), and indigenous people of Sabah and Sarawak (e.g., Kadazan-dusun, Bajau, Iban, and Bidayuh). Over the years, the influx of foreign migrants has added to the diverse ethnicities, traditions and socioeconomic status of the country. Although the government imposed higher levies on skilled migrants [13][4], there have been recent amendments to this policy, whereby levies are also offered to skilled migrants for permanent residence or even citizenship. Apart from this, massive immigration was fastened to strengthen certain political parties [14][5]. This situation has created diverse populations merge of local and foreign cultures in Malaysia, further leading to complex inter-relationship in dengue transmission [15][6]. For example, statistics have reported that large numbers of unauthorised foreign migrants (locally simply known as “PATI”) in Sabah state, predominantly from the Philippines and Indonesia [16[7][8],17], could predispose a higher spread of dengue in this region.
Based on the abovementioned circumstances, the Vector-Borne Disease Control Programme under the Ministry of Health [18][9] has been implemented to formulate a dengue control programme, including surveillance and control, public education and inter-agency collaboration with community participation. Additionally, extensive research studies in various fields, such as epidemiological surveillance, laboratory diagnostic [19][10], clinical management, and entomological surveillance [20][11], have been conducted. In these research studies, various types of questionnaires have been designed to assess various domains, such as knowledge, attitude, and practice (KAP), treatment-seeking behaviour, relationship of health belief model (HBM) construct and health behaviour towards dengue, and perception towards dengue vaccine and complementary medicine (CAM) use for dengue.
Despite this, the collective scopes of these studies have never been discussed. The accuracy of findings from questionnaire-based studies is a matter of concern, as the extent of results’ accuracy largely depends on the reliability of the tools or questionnaires used in the study [21][12]. In this regard, a systematic review of questionnaire-related dengue studies is required to highlight the reported findings in this area, assess the validity and reliability of the questionnaires used in research, as well as draw broad conclusions.

2. Knowledge, Attitude, and Practice towards Dengue Infection

Overall, the analysis in this review showed that the respondents had sufficient KAP regarding dengue in Malaysia. The level of KAP is comparable to other studies conducted in Southeast Asia countries, including the Philippines [82][13], Indonesia [83][14], Thailand [84][15], and India [85][16]. One of the reasons for the comparable findings could be due to the occurrence and mortality of dengue in these tropical countries that affect their knowledge level [83][14]. As a consequence, a tremendous effort by the health department in Malaysia is essential for controlling dengue, especially in areas where the disease has been the most severe. One of the efforts that could be implemented is health education campaigns might lead to an increase in knowledge regarding dengue as reported in Myanmar [86][17] and Indonesia [87][18].
Nonetheless, it should also be noted that this review demonstrated that the Malaysian population had adequate knowledge of dengue infection per se on signs and symptoms. Some common problems in lacking dengue knowledge are misconceptions of dengue transmission (e.g., breed in dirty water, preferred biting time, and identification of typical symptoms of dengue) [48[19][20],77], treatment or prevention. Presumably, the respondents could not state typical symptoms of dengue because they neither personally experienced the disease nor witnessed a case from a close relative or member of the community or due to lacking regular awareness programmes on dengue infection in their area. This presumption is consistent with earlier cross-sectional studies in Indonesia [88][21] and India [89][22] that could lead to failure in controlling the infection and a delay in medical intervention. Moreover, this situation might be worsening by lacking the knowledge of the vector’s habit, behaviour and life cycle as reported in this review. In fact, other similar studies have also expressed the same, such as Thailand [90][23]. Many studies have reported several factors associated with dengue knowledge, suggesting a role of both health authorities and community residents in spearheading dengue prevention program.
In this review, most respondents demonstrated a good attitude, reflecting that they had perceived risk of dengue and supported dengue control. In addition to the similar associated factors affecting attitude towards dengue as reported in other countries, this finding might also be partially influenced by the local Malaysian culture of trying to please any guests because the surveys were conducted by self-administered (63.2%), face-to-face interviewer (33.3%), and phone call interview (3.5%) using a structured questionnaire, indicating possible cultural influence as reported in a study in Nepal [91][24].
In Sabah, the rising incidence of severe dengue has been reported in two main eastern districts, namely Tawau and Sandakan [92][25]. Interestingly, these regions are mostly associated with illegal migrants from the Philippines and Indonesia [93][26]. It could be partly due to sociocultural factors, including human movement patterns, whereby these populations lived in a poor condition that is suitable for dengue infection. However, no study has been conducted to compare KAP between locals and migrants in Malaysia; thus, it would be interesting to assess these populations, as reports have associated migrants with the transmission of infectious diseases [94][27].
Another interesting finding in this review is that despite a significant association between knowledge of dengue and attitude towards Aedes mosquito control, some studies have reported that good knowledge and good practice may be unparallel. However, other studies have reported similar levels of association [95[28][29],96], with few others citing positive association [97,98][30][31]. Although the exact factor that inhibits the translation of dengue knowledge to preventive practice is unknown, researchers hypothesised several major factors based on the rationale and analysis of the reviewed articles. Firstly, this situation could be due to the lack of regular and continuous awareness programmes conducted in the area that leads to discrepancies in their attitude or preventive practices. Secondly, an effective practice towards dengue prevention might be affected by traditional beliefs and culture of a certain ethnicity. For instance, it has been shown that rural Malay ethnic living in a traditional lifestyle spent large amounts of time in and around the house, resulting in positive attitudes towards the elimination of mosquito breeding sites [48][19]. Furthermore, people may resist household or personal practices to control the vector and considering that it is the responsibility of the government. A recent study indicated that the impact of uncontrolled and intensified deforestation on increased dengue cases in Sabah due to sylvatic spillage of dengue virus [92][25], suggesting further investigation could focus on specific demographic factors and land-use contributing to dengue breeding.
The review provides several important steps in dengue prevention and control. Firstly, future dengue awareness campaigns should be targeted at communities in both endemic and non-endemic areas throughout Malaysia. Secondly, the process of transformation related to their traditional beliefs on health requires continuous processes and integrated cooperation between government (e.g., Health Departments and Department of Occupational Safety and Health of Malaysia), non-government organisation, district office, head of the village (ketua kampung in Malay language), and Village Development and Security Committee (Jawatankuasa Kemajuan dan Keselamatan Kampung in Malay language). Thirdly, active participation and effective communication should be fostered when conducting regular voluntary communal works, aiming to motivate and strengthen a healthy lifestyle, such as the integration of appropriate dengue prevention practices. Besides, in this sort of setting, conventional education campaign to increase dengue awareness is useful, but the programme materials need to be evaluated on a routine basis, including health messages content, as well as training of personnel to deliver educational messages. In fact, a study in Cambodia [99][32] revealed that the content of the materials in health pamphlets was not always practical or effective in preventing mosquito bites, leading to difficulty in knowledge translation to the communities. In addition, when designing health pamphlets regarding dengue, the level of literacy and cognitive understanding of the concerned population should be considered and incorporated in the final product [100][33]. Lastly, ingrained and negative habits are difficult to discourage with plain knowledge sharing. Perhaps more personal and practical approaches in the health education programmes are required to stimulate behavioural change, including co-operation with faith-based organisations, particularly in rural areas, in Malaysia.

3. Treatment-Seeking Behaviour

Despite the importance of immediate treatment-seeking behaviour upon dengue infection, only a few studies have been conducted in Malaysia. Similar patterns of treatment-seeking behaviour have been demonstrated in Myanmar [101][34] and Venezuela [102][35], reflecting a lack of awareness of the need for immediate medical attention for dengue. This situation could be caused by several factors, including: (i) misconception that dengue is easily curable without progression to further complications, and this intention is worrying; (ii) poor transportation amongst rural populations in certain states of Malaysia, such as Sabah and Sarawak; (iii) poor healthcare services, such as poor ambulance response time in case of emergency, lack of facilities, and low skills of health care providers, that lead to lack of confidence among community residents [103,104,105][36][37][38] could partly explain the reason for a delay in treatment-seeking behaviour among Malaysian population; and (iv) dependency to symptom-relief-based supporting therapy, especially over-the-counter medication like paracetamol [106][39].
The findings in this review suggested several recommendations to improve the dengue treatment-seeking behaviour. Firstly, comprehensive information on dengue should be included in health education at all levels in the community, including school-aged children [61][40], regarding the critical of seeking immediate treatment through raising awareness on the importance of early attendance to health centres. This recommendation is vital to populations at higher risk of dengue infection, such as “sociodemographic-deprived” and history of dengue hospitalisation, due to the fact that they are prone to a higher risk of clinical complications, such as severe dengue, and even death. Besides, home-based treatment, such as the use of paracetamol or traditional medicines, needs to be assessed for efficacy and safety as it is widely perceived and experienced as efficacious for treating dengue in Malaysia, especially among rural populations [107][41]. This is because a multi-centre randomised controlled trial demonstrated that the use of standard-dose paracetamol in dengue infection increased the incidence of transaminase elevation in the liver and clinical complications, such as gastric haemorrhage and acute kidney injury [108][42].

4. Acceptance of Diagnostic and Preventive Treatment

Based on a study by Yeo et al. (2018) (40), the rate of dengue vaccine acceptance in a subset of the Malaysia population was lower than a similar study in Bandung, Indonesia (88.4% vs. 95%) [109][43]. This information on dengue acceptance is important as one of the criteria that World Health Organisation (WHO) recommends for vaccine implementation in a population [110][44]. However, further study is warranted to assess the strength of the country’s current immunisation system and the characteristics of the vaccine itself.
Overall, this review showed that the level of acceptance towards diagnostic or preventive treatment, such as dengue vaccine, bacteria (Wolbachia) as a vector for dengue control, and self-test diagnostic kit for dengue, was significantly associated with the level of dengue knowledge. Theoretically, people with higher dengue knowledge are more aware of any information, including the benefits of vaccination, limitations of treatment, and the importance of early dengue detection, such as using a home self-use kit. Similar association has also been demonstrated in other infectious diseases, such as the human papillomavirus vaccine [111][45] and influenza [112][46].
Additionally, the acceptance of a hypothetical dengue vaccine was significantly associated with their attitude towards vaccination practice in Malaysia, suggesting a need to improve their attitude as it has a more discernible effect on increasing vaccine acceptance. Similar findings have been reported in the Indonesian population [109][43]. Furthermore, a study in Indonesia [113][47] demonstrated the importance of parental acceptance on the school children’s vaccination programme as reflected in national coverage of the Expanded Programme of Immunisation (EPI) vaccination (>90% amongst infants and school children). It has been reported that other populations also adopted a similar attitude towards vaccination against other infectious diseases, such as human papillomavirus [114][48], influenza A virus subtype H1N1 [115][49], rubella, and measles [116][50]. Furthermore, the acceptability of the dengue vaccine is also associated with trust in public health institutions, vaccination programmes, and health institutions, making them accept the vaccine rooted in the controversial vaccine experience as shown by the Philippines population [117][51].
Given the aforementioned situation, it is therefore deemed essential to increase public health trust by any means via incorporation of community participation, health promotion programme, and informal social networks in disseminating public health messages. Interesting findings in a unique Malaysia multi-ethnicity country showed the importance of ethnicity in the acceptance of a hypothetical dengue vaccine [41][52]. It is possible that the differences are not due to ethnicity per se but due to other sociodemographic characteristics, such as age, gender, level of education, or occupation. The disparities across the three main ethnic groups in the use of dengue home test kits if available would be interesting to investigate further.

5. CAM as Dengue Treatment

It was reported that a high number of dengue patients in the central region of Peninsular Malaysia depend on complementary medicine (85.3%), which is similar to the East Coast of Peninsular Malaysia (84.6%) [107][41]. Interestingly, the reported prevalence rate was found lower in an earlier study involving all states in Malaysia (69.4%) [118][53], Japan (76%) [119][54], South Korea (ranged 29% to 83%) [120][55], and Singapore (76%) [121][56]. The variations in the prevalence may be due to one or multiple factors, including methodological criteria of assessment (e.g., age of the population examined, locality of the studied region and CAM definition) and the purpose of using CAM for health maintenance rather than for treating illness.
According to the review findings, the use of CAM, such as papaya leaf extract (Carica papaya), was increased amongst dengue patients, particularly among rural populations due to economic and geographical constraints [122][57]. Similar findings have been shown in other populations in Indonesia [123][58], the Philippines [124][59], and India [125][60]. Clinical studies have reported the beneficial effects of C. papaya on dengue patients by improving their platelet counts, reducing inflammatory reactions [126][61] and maintaining the stability of the haematocrit level [123][58]. Arguably, this finding did not correlate with life-threatening complications of dengue infection, such as plasma leakage and shock syndrome [127][62]. Therefore, the use of C. papaya is limited as acute and temporary dengue management for rural populations while waiting for transportation to receive hospital management. Similarly, the use of isotonic drink did not reduce dengue severity other than giving supportive effects helping dengue patients to regain energy. In view of diabetes, it may endanger the life of a diabetic patient infected with dengue due to its high sugar content [128][63] if over-consumed.
With the advancement of molecular techniques, a more comprehensive study on the association of different genes in determining other roles of C. papaya is warranted in order to justify the value of conducting a dengue awareness campaign on CAM in Malaysia. Alternatively, leaves extract of C. papaya has been demonstrated to have larvicidal activity against mosquito Aedes, the primary dengue vector for dengue infection, suggesting an ideal approach for vector control programme [129][64]. Although reports have concluded that the administration of C. papaya is safe [130][65], further study is required to elucidate its mechanistic action in providing alternative or adjuvant therapy to dengue patients.
Lastly, the analysis in this review also discovered that an association between the use of CAM and higher level of education, which is consistent with another local study among dengue patients in the northeast region of Peninsular Malaysia [107][41]. This finding may be due to the fact that they are more aware of dengue complications, making them search for health supplements to complement the treatment received in the hospital. Similar findings were also reported in other populations [120][55].

6. HBM Construct Association with Dengue Prevention Practices

HBM constructs can be utilised to predict people’s behaviour or why people take action to control or prevent a specific illness or disease. They can guide the plan of dengue interventions and the development of an effective awareness or targeted educational programme in Malaysia. However, only six out of 57 studies in this review considered HBM constructs and not all of them correlate to attitude and practices.
Multiple studies have indicated that the practice of protective behaviours is more dependent on the beliefs based on HBM constructs. Although only one study correlated the HBM constructs with prevention practices, the perceived barriers and perceived susceptibility constructs of the HBM were significantly related to prevention practices [62][66]. People with lower perceived barriers were significantly related to higher dengue prevention practices [62][66]. To perform dengue prevention effectively, it is imperative to eliminate barriers hindering actions against dengue. For instance, a qualitative study conducted amongst the Indonesian population [131][67] demonstrated the importance of clarifying appropriate action and promoting positive effects on performing dengue vector control to reduce persistent dengue transmission. Similar to cancers, another study among female students in Botswana, Southern Africa, showed that misconception could act as a barrier to breast cancer screening [132][68], indicating the importance of identifying and reducing perceived barriers through interventional programmes to correct health misinformation.
In addition, people with lower perceived susceptibility to dengue were less possible to carry out dengue prevention practices, most probably due to Orang Asli are either not aware of the serious consequences of dengue fever or never experienced themselves. Previous studies have revealed that if action is expected to occur, the individual perceives the susceptibility of having the illness [133][69]. A recent study in the dengue-endemic city Karachi, Pakistan [134][70] showed that perceived threat was significantly associated (p = 0.000–0.007) with acquiring information on dengue knowledge among populations as compared to low intensity to acquire knowledge on dengue in a non-endemic area of dengue in Malaysia [33][71]. This finding is important because it is a prerequisite for population stratification based on risk levels, personalise risk based on a person’s characteristics or behaviour, making perceived susceptibility more consistent with individuals’ actual risk or specify consequences of risks and conditions.
In this review, only one study related HBM concepts with attitude, and they found that the highest satisfactory attitude was in the perceived benefit concept [26][72]. Hence, this study highlighted that health education, campaigns and knowledge of dengue fever were highly required and essential in order to improve preventive practices among communities, particularly Orang Asli. It was further suggested that health messages and education awareness campaigns should be prepared in accordance with HBM constructs.
Based on the above, it is noted that HBM plays an important role and should be used as the predominant theory-driven intervention strategies to reduce dengue. However, in interpreting the relationship of HBM constructs as a conceptual guiding framework for health behaviour intervention, caution must be exercised when drawing a conclusion as HBM has some limitations. One example is that HBM does not account for environmental factors that may prevent an individual from practising the desired preventive practices, including poor infrastructure, bad sanitation, and inadequate water supply experienced by community residents. Thus, it is essential for the government and private sectors to work co-operatively providing facilities to remove the barriers in conjunction with behavioural change interventions of the community for sustainable dengue prevention and control.

7. Awareness and Utilization of Clinical Practice Guidelines (CPG)

The Ministry of Health in Malaysia has adapted the CPG prepared by the WHO for managing dengue, with evidence of good awareness by clinicians. Despite quantitative survey evidence on a high level of dengue awareness regarding CPG amongst medical doctors in Malaysia [53][73], the study showed differences amongst medical practitioners in public and private health facilities. It could be explained that medical doctors in public health facilities are younger, thus they are more likely to look for guidance in managing their patients. Comparatively, those working as private health practitioners tend to undermine their well-experienced clinical practice in managing their patients.
Nonetheless, several studies in other countries [135,136,137][74][75][76] have demonstrated that the recommendations stated in the CPG are impractical in some clinical settings, including limitations in consulting time, lack of resources, lack of attention to the logistics of implementation, or lack of detail on particular patient groups. Due to this, the adaptation of ‘local’ guidelines in public health facilities with highly dengue admission rate has been reported, which generally advocated fixed regimes of fluid management with limited resources [138][77].
Although public facilities continuously conduct training to their staff regarding CPG to enhance their awareness and implementation, the use of standard CPG could result in a problematic situation in a patient requiring more tailored fluid regimes. Therefore, the final decision on the implementation of guidelines in routine patient management should be evaluated thoroughly to maximise the benefits to the patients. Importantly, providing guidelines in clinical settings should be in line with the emerging model of translational science in healthcare, which integrates translational research and effectiveness a novel and timely evidence-based revision [139][78] for maximal benefit of the patients.

8. Sources of Information on Dengue

In this review, the analysis showed that most Malaysians obtained information regarding dengue from mass media, such as television, radio, and newspaper, suggesting that this platform is important in disseminating dengue-related information to raise better awareness. Additionally, more audiences are increasingly engaging with online social media, including Facebook, Instagram, Twitter and other smartphone dating applications. The obtained dengue-related information could be utilised for health promotion and would be a promising method due to relatively inexpensive, convenient accessibility and a fast approach. However, astoundingly, over 72% of Malaysian national ground territory seemingly has near-zero telecommunication coverage, with a major void even in the central Malaysian peninsula [140][79], that could create information barriers. Moreover, one should be aware of the fact that not all the information accessible through social media is credible.
Recent studies have suggested that dengue outbreaks are increasing in rural settings of Sabah due to urbanisation and deforestation [92][25], thus increasing dengue awareness and preventive practices are urgently needed in this area. An effective method of delivering dengue information in rural areas would be a community-based health education delivered by nearby health center outreach activities and health campaigns as demonstrated amongst rural population in Cambodia [99][32]. However, the outcome from the previous study recommended that a more persuasive approach, such as modelling of performing the desired behaviours or relating their personal sufferings due to their attitude and practices, should be incorporated in health education as it could form better confidence amongst respondents [141][80]. Additionally, health education could be conducted by healthcare providers to provide dengue-related speeches in formal or non-formal religious lecture sessions in religious centres, such as mosques, churches, or temples, as it has been shown to provide a similar opportunity for increasing dengue awareness in Indonesia [83][14].
Surprisingly, this review showed that healthcare providers demonstrated a lower function as a source of attaining dengue-related information amongst respondents. This issue merits a further examination, as they are considered as the frontliners that highlight the importance of prompt treatment of dengue patients. This finding is opposed to a study in Aceh, Indonesia, that healthcare providers had been cited as a major source of information on dengue [83][14]. The contradicting finding could be due to patients perceived trustworthiness and acceptance of healthcare services as reported in Uganda, Africa [142][81]. Plausibly, the Communications for Behavioural Changes (COMBI) programme on dengue prevention implemented by Health Departments and developers at construction sites to promote dengue awareness and prevention failed to achieve desired behavioural impact among community [143][82], which may be due to lacking respectful and supportive patient-provider interactions.

9. Lack of Evidence in the Questionnaire’s Reliability and Validity

Validity and reliability are very important to measure the accuracy and consistency of research tools, particularly questionnaires. However, their measure is not regularly conducted among healthcare researchers in developing countries. The reliability of a questionnaire is usually measured using a pilot test. Moreover, the reliability could be assessed in three major forms, including test-retest reliability, alternate-form reliability and internal consistency reliability. It is important to take note that some studies have mentioned that a pilot study has been carried [36,38,53,57,67][83][84][73][85][86]; however, the findings of the pilot study were not reported.
In regard to validity, many subtypes of validity are available, such as face, content, criterion, and construct validity [144][87]. In fact, all questionnaire studies should report at least the minimum internal consistency coefficient of Cronbach’s alpha values [21][12]. For an exploratory or pilot study, it is suggested that reliability should be equal to or above 0.60. In this review, most articles neither report the findings of the pilot study nor of the questionnaire pre-test. Although reliability is important for the study, it is not sufficient unless the validity of the study is provided [21][12]. In other words, it is crucial for a questionnaire to include a validity index [145][88]. Thus, the underlying construct of the items in a newly developed questionnaire should be analysed by factor analysis [146][89] to predict the discriminant and convergent validity. However, only one study was found in this review had carried out the factor analysis [75][90]. The reliability, content and construct validity of the questionnaire should be carefully examined. It is crucial to harmonise and validate the content of all structured questionnaires, with the aim of reducing the heterogeneity of findings and obtaining quality results based on the questionnaire used for data collection [121,147][56][91].

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