title: A social-ecological analysis of community perceptions of dengue fever and Aedes aegypti in Machala, Ecuador.
abstract: BACKGROUND
  The growing burden of dengue fever and the lack of a vaccine or specific medical treatment have increased the urgency of the public health sector to identify alternative management strategies. A prevailing trend in Latin America has been a shift towards decentralized vector control programs with integrated management strategies, requiring significant intersectoral coordination, community engagement, and knowledge of the local social-ecological system (SES). Community perceptions and responses are a critical component of this system, since perceptions shape actions, and thus govern behavioral responses and acceptance of shifts in policy and management.
  
  
  METHODS
  We investigated perceptions, misconceptions, and local SES risk factors for dengue in high risk communities located at the urban periphery and center in Machala, Ecuador. We facilitated twelve focus group discussions with community members using semi-structured question guides and causal diagrams. Focus groups were recorded, transcribed, and coded to identify emergent themes using qualitative methods for theme analysis. To estimate the relative importance of the themes in each study area, we tabulated the number of focus groups in which each theme was present. Household surveys (n = 79) were conducted to further explore these themes, and we compared survey responses from the two areas using descriptive statistics.
  
  
  RESULTS
  We identified thirty biophysical, political-institutional, and community-household risk factors for dengue. People at the periphery identified a greater number of risk factors. Dengue control required considerable investment of time and resources, which presented a greater challenge for women and people at the periphery. Common misperceptions included confusion with other febrile diseases, lack of knowledge of transmission mechanisms, and misconceptions about mosquito behavior. People perceived that dengue control programs had been limited by the lack of inter-institutional coordination and lack of social cohesion.
  
  
  CONCLUSIONS
  There is a need for local, policy-relevant research that can be translated to strengthen the design, implementation, and evaluation of new dengue management strategies. This study contributes to a growing body of research in this area. Based on these findings, we identify key policy and management recommendations that will inform the ongoing transition to a decentralized dengue control program in Ecuador and other dengue endemic countries.
authors.affiliation: Center for Global Health and Translational Science and Department of Microbiology & Immunology, State University of New York Upstate Medical University, Syracuse, NY, USA. stewarta@upstate.edu.
authors.forename: Anna M
authors.initials: AM
authors.lastname: Stewart Ibarra
authors.forename: Valerie A
authors.initials: VA
authors.lastname: Luzadis
authors.forename: Mercy J
authors.initials: MJ
authors.lastname: Borbor Cordova
authors.forename: Mercy
authors.initials: M
authors.lastname: Silva
authors.forename: Tania
authors.initials: T
authors.lastname: Ordoñez
authors.forename: Efraín
authors.initials: E
authors.lastname: Beltrán Ayala
authors.forename: Sadie J
authors.initials: SJ
authors.lastname: Ryan
mesh_terms: D000328:Adult; D000330:Aedes; D000818:Animals; D003153:Community Health Services; D003715:Dengue / Q000382:microbiology / Q000517:prevention & control*; D004484:Ecuador; D005260:Female; D017144:Focus Groups; D006801:Humans; D007303:Insect Vectors / Q000502:physiology*; D008297:Male; D009032:Mosquito Control / Q000379:methods; D012307:Risk Factors; D012959:Socioeconomic Factors; D011795:Surveys and Questionnaires