Study setting

Iquitos is the most populated city of the Peruvian Amazon basin (population of 545, 000) [15] and is surrounded by the Amazon, Nanay, and Itaya Rivers, making it only accessible by air or water [16]. The main forms of employment in Iquitos are small businesses in the extractive industries (lumber, fishing, oil), farming, and tourism [17]. This study took place in the Punchana district—one of the four districts in Iquitos. It was selected because of its history of high Ae. aegypti population densities [6, 16], because Punchana has been previously identified as the district in Iquitos where dengue outbreaks start and having the highest dengue seroprevalence rates overall [6], and because of confirmed presence of Zika virus in this area [3, 4] There is no publication on this yet, but our dengue research team noted that the spatial and temporal progress of Zika transmission after its detection was very rapid in Iquitos (AC Morrison, personal communication, June 2018), and was similar to patterns observed after the introduction of a novel dengue serotype into the city [6, 16]. Since the emergence of Zika in Iquitos, surveillance programs have been put into place to combat the risks associated with infection. There are no cases to date of neurological disease in Peru as a direct cause of Zika, however surveillance remains critical [4, 18].

Study design

This was a qualitative study comprised of six focus group discussions (FGDs) conducted in June 2017. A focus group discussion guide was developed and applied by our research team (see Appendix A), all proficient or native Spanish speakers, and included a local coordinator from Iquitos to facilitate and ensure cultural understanding. Two of the co-authors (VPS and ACM) have been conducting dengue research in Iquitos for ~35 years combined, including a dengue knowledge, attitudes, and practices survey and FGDs exploring various aspects of dengue transmission and control in the context of Iquitos [5, 19, 20, 21]. The FGD guide was developed by local experts in our research team and focused on qualitatively exploring themes that are common in knowledge, attitudes, and practices (KAP) surveys regarding Zika virus [22, 23]. The main topics explored in the FGDs were: 1) knowledge of Zika transmission, symptoms, and treatment, 2) attitudes regarding Zika, including perceived risk for and severity of Zika, and 3) common preventative practices (e.g., use of repellents or condoms), and health messages received in the community regarding Zika. Because dengue and Zika viruses share a common vector and have similar symptoms, participants were also probed to compare characteristics of Zika and dengue fever symptoms and Aedes vector control campaigns in general. The Health Belief Model (HBM) was used to inform the focus group discussion guide, specifically the themes surrounding attitudes towards Zika, by focusing on perceived risk and severity; perceived risk represents a person’s perceived susceptibility of experiencing Zika virus, while perceived severity refers to the beliefs a person holds concerning the seriousness of Zika virus [24].

Recruitment

Because of our interest in focusing on women’s knowledge and preventive practices, particularly during childbearing years, and because women are more likely to discuss certain topics, such as family planning, in a single sex setting, only women were recruited for FGDs. Purposive sampling was used to recruit women from the Punchana district. This region was selected as there are affiliated research projects in this district and there is known dengue and Zika transmission. Women of prime childbearing years (20–35) were approached near their homes by a local field worker who has worked in this district before and invited those who met inclusion criteria of age and gender, and who were available at the time, to participate in the FGDs. Once enough women were recruited for the FGDs, recruitment stopped. The research team covered transportation costs to and from the FGD sites.

Data management and analysis

After reviewing the consent form and obtaining verbal consent from each participant, FGDs were audio recorded and later transcribed. There were also two note takers present at each FGD. After each session, the research team met to discuss and summarize the FGDs and compile the notes into one document. These notes were used alongside the transcripts throughout analysis.

A codebook was developed prior to data collection based on themes included in the guide. Once the team had reached saturation—the point where the same topics are emerging in each group [25, 26]–on the main themes being explored, the codebook was edited to reflect additional identified topics. Two researchers coded the discussions using Dedoose version 7.6.13, a web application for managing, analyzing, and presenting qualitative and mixed method research data [27]. Blind coding was used on every other transcription, and then compared, to ensure consistency in code application. Any differences were discussed and addressed before continuing with coding.

Ethics statement

This study was approved by the Institutional Review Board (IRB) of a local non-governmental organization, Asociación Benéfica PRISMA (CE1425.17), and Tulane School of Public Health and Tropical Medicine (#1040307). Since the FGD with each group of women would only be carried out once and there was no reason to document the participants’ names except if we used a written informed consent, the two IRBs approved the use of verbal consent for participants. Prior to starting the FGDs, all participants gave verbal informed consent to participate and to be audio-recorded. All participants were provided with a copy of the consent document, which included contact information for the IRBs and the PI of the project. All members of the research team completed human subjects training.

Knowledge of Zika virus transmission

All participants from all FGDs knew that infected mosquitos transmit Zika virus, but only one or two participants from each focus group knew that the dengue and Zika virus vector, Aedes aegypti, bites during the day. In fact, almost all respondents described the mosquito that transmits Zika to “sleep during the day” and “give problems at night.” Very few knew about the sexual transmission route: a few participants in three of the six FGDs mentioned this transmission mechanism. In one FGD, a woman suggested that Zika was transmissible through “sexual relations,” and the other women laughed and shook their heads in disagreement.

Knowledge of Zika symptoms

Almost all focus group participants correctly and consistently named the most common symptoms, including rash, mild fever, headache, joint and muscle pain, and red eyes. In all of the FGDs, participants distinguished Zika by its distinctive rash or “welts” made up of individual bumps grouped tightly together, which spreads all over the body. The rash was noted as the most common way to differentiate Zika from other similarly presenting illnesses in every FGD. These symptoms were frequently compared to those of dengue fever without prompting from the facilitators. One participant described the differences: “it was similar to dengue, but it was different, because it covers you in welts, it made you itchy and you felt a fever and the children could not sleep. That was the difference.” When asked about duration of symptoms, responses varied, ranging from 3 to 8 days.

Knowledge of treatment for Zika

When participants were asked to share their understanding of treatment for Zika, women mentioned that there “was nothing” that could be done and it was something “one has to fight with refreshments [keeping hydrated].” Despite this, two or three participants in each FGD mentioned “paracetamol and chlorphenamine” (anti-histamine) as a common remedy for Zika infection. The refreshments refer to juices from local fruits including malba (a local plant), lemon, and coconut, primarily used for keeping hydrated and reducing fever. Many participants in three of the six focus groups also discussed covering body surfaces with malba leaves to lower body temperature. Healthcare seeking was rarely reported. One participant went to the health post and was diagnosed with Zika, based on clinical signs, without a blood test. Another pregnant participant described regular blood draws to check for Zika as a part of her prenatal care. However, the majority of women felt that symptoms were primarily controllable by using home remedies and paracetamol (available without prescription) as listed above, and hence, seeking healthcare was not common.

Perceived risk of Zika

About half of the participants in each FGD knew someone who had experienced Zika virus infection; those who knew someone reported knowing this based on symptom recognition, most commonly the presence of the distinguishable rash. In Iquitos, some laboratory testing was done by the Instituto Nacional de Salud (National Institute of Health), but diagnosis was also provided at local health centers without a laboratory diagnosis. A women voiced that there had been “a lot of Zika” and they [she and fellow Iquitos residents] felt they were at risk of Zika, but “the truth is that here in this area, as it is a jungle area, we are already accustomed to it [Zika]” because “there will always be that little animal, the mosquito.” And that they had learned not to be afraid of Zika, “If we are afraid we will be self-conscious in the house: I cannot go out, I cannot go for a walk because Zika is everywhere.” The women explained that pressures of mosquito-borne illnesses, such as “going on a walk and suddenly feeling with discomfort that we can contract [Zika],” was not a lifestyle they wanted to face. The women appeared to acknowledge the risk of Zika infection, but chose not to live in fear of something they could not control. The fatalistic attitude expressed by the participants was also evident in their head nodding and strong agreement with each other, as noted by the notetakers.

Participants expressed more concern for vulnerable populations, such as children and pregnant women, at risk for contracting Zika virus. Women feared more for children than other family members due to their perceived weaker immune systems and higher susceptibility to high fevers and other symptoms of Zika. When prompted to discuss gender differences relating to Zika, two groups suggested that women were more at risk for mosquito bites than men because their “defenses are a little lower” and they spend more time at home, while men are generally in air conditioned rooms at work or in more rural areas with a lower presence of the Aedes mosquito. Although none of the participants reported knowing anyone with fetal complications from an infected pregnant mother, in five out of six FGDs, participants expressed concern for pregnant women exposed to Zika because of potential effects on fetal development including “small heads” and “missing limbs.” One pregnant woman said, “It mainly affects the babies and the pregnant mothers…. let’s say, if they get Zika, it can be risky for your baby. That is, it can be born with abnormalities.” There was awareness in five of the six groups of risks for developing fetuses, but no one mentioned neurological disorders associated with adults, such as Guillain-Barre syndrome.

Perceived severity of Zika

When asked about the severity of Zika compared to other febrile illnesses, including malaria, dengue, and chikungunya, all focus groups but one ranked Zika the least severe of all these febrile illnesses. Participants also stated that “malaria is the worst and can kill you” and “if you get malaria, it is worse than dengue and Zika.” The severity of Zika seemed to be ranked lowest on the spectrum of mosquito transmitted diseases in the community.

Zika prevention practices

The most common responses, stated in all six FGDs, regarding ways to prevent transmission of Zika virus were to use mosquito bed nets and to maintain general household cleanliness. Other reported methods used for mosquito prevention included use of mosquito coils and/or repellent, and emptying water containers to reduce breeding sites. One pregnant woman relayed the advice she had received at a talk at her local health post on preventing transmission of Zika, which included “not to have [sexual] contact without protection, to take care of ourselves, to sleep with a mosquito net, to have a clean house.” When prompted, nearly all FGD participants reported that they had not changed their individual or household preventative practices in response to the Zika outbreak. A few women in each FGD explained that preventative practices were meant for general mosquito elimination, not to target a specific vector borne disease.

Prevention of sexual transmission of Zika was only discussed if participants brought up the sexual transmission route. Within the three focus groups that named the sexual transmission route, only two women knew about the recommended waiting period of six months before initiating sexual contact with a Zika infected partner [8]. When prompted, most women reported condom use challenges due to their partners’ preferences: “they protest, but in the end they do it.” Women said that if they did use condoms, it was primarily for family planning purposes, not for prevention of sexually transmitted infections. One of the two pregnant participants reported avoiding unprotected sex during pregnancy, while the other pregnant participant was not taking any additional precautions to prevent viral sexual transmission during pregnancy. Within our FGD participants, the preferred family planning method was the injection, formally known as the Depo-Provera birth control injection. When asked about family planning, women reported that the conversations with their partners were “not easy.” Almost all women strongly reported that they did not want more children and that often children were unplanned.

Another Zika prevention method mentioned in every FGD was the use of insecticide, in the form of emergency fumigation campaigns, administered variably from year to year. These campaigns are run by the Dirección Regional de Salud (DIRESA, the regional Ministry of Health), who usually fumigate in the early morning hours when the family is typically at home. The main sentiments FGD participants expressed about the household fumigations was the poor efficacy of the insecticide, or as one said, “they might be spraying water, because instead of disappearing, the number of mosquitos are growing,” and the lack of engagement from the healthcare workers, who often didn’t have conversations with the families.

Health promotion regarding Zika

Participants reported that health education is not routinely provided alongside fumigation campaign activities. As one participant described “They don’t know how to share information. They speak quickly and leave.” Another participant described her desire, and the missed opportunity, to learn more:

“They are not going to the houses to teach prevention on how to avoid [Zika] or giving us ways to care for it in the house. For example, yesterday the dengue team came to fumigate. I thought they were also going to give me instructions on what Zika is, no? I … didn’t know what this was. I’m not informed about that.”

This desire was echoed by a number of participants who “would like to know more” about Zika prevention. Despite this, the consensus among most participants was that they felt reasonably well informed about Zika, and reported that they primarily relied on television, radio, and verbal and written information from health posts to inform themselves on this topic. Participants in all six focus groups had a very positive attitude towards health messaging in general and they described their media preferences for health information enthusiastically: listening to the radio or television while cleaning, and reading flyers at the health posts during appointments. When asked about who in the family tends to be informed on the topic of health, participants reported that “the women are more conscious because they have more responsibilities” for the health of their family and desired to know as much information as possible to prevent their household from infirmity.