Practical steps of intervention design in dengue fever prevention: Interventional mapping approach

Abstract

Background and aims:

Dengue fever is a viral disease that is also called bone-breaking fever, this disease is transmitted to humans by the mosquito. The aim of this research is a framework for dengue prevention: designing educational and behavioral interventions using intervention mapping.

Methods:

In this research, the practical steps of the dengue fever prevention intervention were carried out with the intervention mapping approach in six steps. In the first step, needs assessment was done through literature review, semi-structured in-depth interview and checklist. In the second step, the matrix of change objectives was designed. After selecting intervention methods based on theory and practical applications, and producing program components and materials, the intervention was implemented and evaluated.

Results:

The results of first stage of the model showed 54% did not know the time of Aedes aegypti mosquito bite and 57% of the participants stated that they would choose to install nets among the options for preventing Aedes aegypti mosquito bites in the second stage, a matrix of behavior change goals was designed. In the third step, intervention strategies were identified, and in the fourth step, program components were identified. In the fifth and sixth steps, the implementation and evaluation of the dengue fever prevention program was designed at the individual, family and social levels.

Conclusion:

The intervention mapping approach ensures the transparency of all intervention components and it provides a useful approach for developing behavior change interventions.

Introduction

Over the past 50 years, humans have witnessed the emergence or spread of diseases transmitted through invasive Aedes aegypti mosquito., such as dengue, chikungunya, and Zika. ¹ Due to the creation of widespread epidemics, deaths, disability and the emergence of destructive economic and social effects and environmental consequences in human societies, these diseases are very important in terms of public health. ² The spread of these diseases in the world can be largely attributed to the increase in trade and international travel; Inefficient implementation of vectors control programs, incorrect methods of household water storage, unfavorable waste management, lack of effective community participation and insufficient political will. ³ Another important reason for this increase is climate change and global warming in recent years. ⁴ The Eastern Mediterranean region of the WHO has recently witnessed several outbreaks of dengue and chikungunya diseases. ⁵

Dengue fever (DF ) is a viral disease that is also called bone-breaking fever, this disease is transmitted to humans through a mosquito called Aedes aegypti mosquito. The symptoms of this disease include headache, back pain and backache, usually severe fever and in some cases itching and rash in different parts of the body. This disease is vector-borne. The mosquito needs regular meals to mature its eggs and Completes the cycle by biting a healthy human and transmits the disease. ⁶

In recent decades, the incidence of dengue fever has increased dramatically worldwide; so that the cases reported to World Health Organization have increased from 505,430 cases in 2000 to 5.2 million cases in 2019. ⁷ As of the beginning of 2024, more than 10 million dengue cases and more than 5000 dengue-related deaths have been reported from 80 countries/regions; and the most cases worldwide have been reported from the PAHO (Pan American Health Organization) region, so that more than 9 million cases reported by PAHO in 2024 are double the number of cases reported in 2023. ⁷ Considering that the dengue fever vaccine is not widely available to prevent this disease self-care practices are among the most effective preventive measures, educating people about ways to prevent this disease is one of the effective ways to promote Public health is, which requires model-based targeted education.^8,9 Because theories and models help to understand the mechanisms of behavior change.^10,11

One of the planning approaches of health promotion programs is intervention mapping. This approach provides a framework for identifying behavioral determinants based on theory and environmental causes, this six-step approach: needs assessment, goal matrix design, selection of intervention methods, production of intervention program components and materials, planning for implementation and evaluation, allows planners to make effective decisions in each of the planning stages.^10,11 The aim of the research is to demonstrate a planning process to improve dengue prevention activities in the community, not entomological interventions or the goal of mosquito control (Figure 1).

Figure 1.

Dengue transmission cycle.

Methods

The current research describes a study in which the operational steps of dengue fever prevention intervention are designed with intervention mapping approach. In this study, which was conducted from April 2024 to June 2024, before starting the design of the intervention process, a participatory planning team (provincial health officials, representatives of the group to fight against infectious diseases, focal point of entomology, neighborhood health volunteers, beneficiaries and health education professionals) was formed to ensure the participation of influential people for social listening and the intervention plan was drawn in the following order and announced to the provincial health center for implementation.( In the study, the task of the participatory team is to promote and develop an approach in which everyone who has a stake in the program has a say. Staff from the organization that administers it, members of the target population, community officials, interested citizens, and individuals from the organizations involved should all be invited to the conversation and have their voices heard.)

Step 1: Needs assessment

The first stage of intervention design is needs assessment, at this stage, needs assessment is defined to identify the difference between what is and what should be, ¹² which was conducted through literature review (21 articles related to the topic in the last 5 years and documents published by the World Health Organization), semi-structured in-depth interviews with stakeholders, health volunteers, people and completion of the checklist (24 questions). The validity of questionnaire was determined by two methods of face validity and content validity, which confirmed by experts of health education and promotion, Entomologist, Infectious diseases. The total content validity index (CVI) in the “relevancy,” “simplicity,” and “clarity” respectively equals 83.7, 93.9, and 91.7. The reliability of the questionnaire further evaluated through internal consistency (α = 0.81) and test retest (r = 0.8). This checklist was completed for participants who were interested in participating in the study. At this stage, semi-structured in-depth interviews were conducted with 11 citizens, 15 health care workers and 15 influential health volunteers (people’s representatives) for social listening and collecting opinions about dengue fever prevention strategies, barriers and facilitators, in the qualitative phase of the study primary participants were selected through purposive sampling. Before the interviews, research questions were developed by reviewing the literature and using the opinions of consultants, medical staff, and faculty members in face-to-face meetings and a meeting (list of questions). Also, in order to accurately determine the predictors of fever dengue prevention health behavior, a checklist of 24 questions was completed for 566 citizens (The inclusion criteria for the study were: age over 18 years and willingness to cooperate, and the exclusion criterion was determined as unwillingness to cooperate.).

questions pre-designed were:

Are people familiar with dengue fever and ways to prevent it?

What measures can you suggest to control and prevent dengue fever?

And other research questions were asked in accordance with the answers provided.

Step 2: Designing the objectives matrix

The main tool for drawing up the intervention map is the behavior change goals matrix. (Behavior change goals specify what needs to be done to achieve the main goals.) The process of creating the change goals matrix was designed based on the assumption that what are the behavioral and environmental factors affecting the health problem? (These assumptions are determined using a literature review, the results of the first stage, and the participation of the participatory planning team) and finally the final program matrix is designed.

Step 3: Selection of intervention method

The third step describes the initial design of the program to be implemented. This step includes building the general idea of the program, the components and the effective parts and the order of their implementation; or in other words, the answer to this question is: Who should be used in which part of the program? At this stage, the messages and how to spread them and the methods for changing determinants were determined according to the target population and local culture of each place.

Step 4: Production of program components and content

 If the plans of the program are not suitable for the local culture, the designed project will not be successful. In the intervention mapping approach, the participatory planning team determines the causes related to the health problem, and what needs to be changed was determined, and in the third step, the draft program was prepared. The native culture of the place was determined for the training of the target group. Three points were implemented in the design of this step: preparation of suitable educational content, accessibility to the content, determination of the reading level of the audience, and finally the final messages were determined and selected to be published in the community. The stage of assessing the appropriateness of the message and content with the audience was carried out by the pre-test.

Step 5 and 6: Implementation and evaluation of the program

The intervention program was designed in 10 regions of Ardabil city. Interventions were developed at individual, family (interpersonal) and social levels. At first, the slogan “To prevent the reproduction of the Aedes aegypti mosquito, we should remove the stagnant water around our homes and places of residence” was determined for the intervention program and the responsibility of all the program presenters was determined. The intervention at the individual level included education based on the collected evidence, motivational messages, distribution of posters, booklets and motion graphics playback in neighborhood virtual space groups with the cooperation of each neighborhood’s health volunteer. Intervention at the environmental level included coordination to improve the environment and collective programs with the cooperation of relevant organizations. Also, the health volunteers of each neighborhood were responsible for collecting false news and rumors that were spread among the people.

Results

Step 1: Needs assessment

After carrying out the needs assessment and evaluating the results of the completed checklists of 566 citizens, the most important health behaviors related to the prevention of dengue fever were asked according PRECEDE-PROCEED model, including predisposing factors (awareness - attitude - self-efficacy - risk perception), enabling factors (policies) and reinforces (social support) were determined according to the aim of the study, a program was developed for the predisposing factors phase

The results of the 24-question checklist assessment showed that the study population was predominantly female (63.2%) with a mean age of 36 ± 3.62 years. Most participants were married (87.6%), more than half of the participants (54.8%) lived in low-rise apartments, and most participants had a high school diploma or higher (81.5%), and 89% of the participants had heard of dengue fever at least once, but 28% of the participants did not know the difference between the bite of a common mosquito and the Aedes aedes mosquito in dengue transmission. (54%) did not know the time of bite of the Aedes aedes mosquito, and the majority considered it the same as other mosquitoes. And (44.7%) were aware that the dengue virus can infect a person multiple times. Twenty-four percentage had not received any education on ways to prevent dengue fever and (30%) said that the educational materials published were not understandable to the general public (the educational content provided by health care providers and other sources was not clear and practical) and the results showed that people received their health information in this regard from the internet - television and health workers, respectively. Fifty-one percentage of people did not consider themselves at risk of being bitten by Aedes aedes mosquitoes. Most participants had screens on doors and windows in their homes or workplaces. (57%) of participants, respectively, said that they would choose to install screens as a means of preventing aedes mosquitoes. Also, 88% considered insecticides to be very effective in killing mosquitoes.

Also, given that the results of the present study are a needs assessment report and a roadmap for initiating interventions, they can be a guide for researchers and planners, so the research team decided to publish the results of these stages more quickly. In the following, we publish the results of the intervention section and the evaluation of the before and after results, which are based on the results of the present study and will be implemented within the study area for 1 year.

Step 2: Designing the matrix of goals

At this stage, performance goals were determined based on the expected outcomes of the program. Then, for validation, the collaborative planning team was used to review and modify performance goals; and finally, the matrix of change goal was set. The matrix was validated by the research team, which reviewed other relevant studies (21 articles related to the topic in the last 5 years and documents published by the World Health Organization; Table 1).

Table 1.

Matrix of behavior change goals.

Perception of risk	Self-efficacy a	Attitude b	Awareness c	Functional goals
Citizens should state the consequences of not following health tips related to mosquito bite prevention. Citizens should prioritize the implementation of dengue prevention behaviors.	Citizens should be confident in their ability to eliminate mosquito spawning and breeding places near their residences. Citizens should be confident in their ability to implement ways to prevent Aedes aegypti mosquito bites.	Citizens should consider dengue fever disease as important. Citizens should be curious about dengue fever and its related matters. Citizens should be interested in attending the training classes.	Citizens learn about dengue fever. Citizens should know the causative agent of dengue fever and its symptoms. Citizens should name the ways of transmission of dengue fever. Citizens should know the groups at risk of dengue fever.	Citizens should be familiar with dengue fever disease.
.Admins of high-profile channels and journalists should state the dangers and consequences of not following health tips related to mosquito bite prevention.	Admins of high-profile channels and journalists should be confident in their important role in informing. Admins of high-profile channels and journalists should be confident in the importance of their role in reducing the false beliefs of the society regarding dengue fever and its transmission ways.	Admins of high-profile channels and journalists consider dengue fever as an important health problem. Admins of high-profile and high-profile channels and journalists are interested in attending training classes. Admins of high-profile channels and journalists interested in periodic and regular publication of educational content about dengue fever should show interest.	Admins of popular channels and reporters define dengue fever. Admins of popular channels and reporters should state the causative agent of dengue fever and its symptoms. Admins of high-profile channels and journalists should name the ways of transmission of dengue fever. Admins of high-profile channels and journalists should get to know the groups at risk of dengue fever	.Admins of popular channels and journalists should participate in training sessions held in health centers on the prevention of dengue fever.
The employees of the health system should explain to their clients the risks and consequences of not following the health tips related to the prevention of mosquito bites.	Health system employees should be confident about their important role in teaching ways to prevent dengue fever	Health system employees should actively participate in disseminating dengue fever educational materials The employees of the health system follow up the citizens’ compliance with health tips by calling and using media messages.	-----------------	Health system employees should encourage people to observe health behaviors related to dengue fever.
The provincial officials should announce the risks and consequences of not following the health tips related to mosquito bite prevention to the influential organizations.	The provincial officials should be confident about their important role in controlling dengue fever.	The provincial officials are interested in cooperating with the health center regarding the control of dengue fever.	The provincial officials should familiarize themselves with dengue fever, ways of transmission and prevention.	The provincial officials should cooperate with the local health center in implementing ways to prevent dengue fever.

^aA person’s belief in their abilities to organize and carry out a range of activities required to manage different circumstances and situations.

^bAny expression of opinion about an object, a person, or an event that contains a judgment and evaluation (regardless of whether it is positive or negative) is called an attitude.

^cIt is the ability to become wise and understand or gain knowledge from events.

Step 3: Selection of intervention method

At this stage, theoretical methods and their practical applications were selected to address the change goals. For example, to change the awareness of the audience, awareness-raising methods were used in accordance with the meta-theoretical model and personalization of risk (precautionary process model), which is done by using entomology and health education experts.

To change the attitude, the method of repeated exposure and persuasive communication derived from the model of social cognitive theory and diffusion of innovation was determined, Local leaders, local health volunteers, and online campaigning were used for persuasive communications.

Also, to understand the risk, the Precaution Adoption Process Model (PAPM) was chosen to design the intervention, this model has seven stages (unaware of the potential issue-unengaged by issue-undecided about acting-decided not to act-decided to act-acting-maintenance)

The verbal persuasion method is based on the derivatives of the theory of social cognition and public commitment (spontaneous behavior theory) and was determined to increase the self-efficacy of the audience. In the following, the methods of behavior change and their practical applications are explained in (Table 2).

Table 2.

Theory-based methods, application program and program components.

Practical applications a	Components and materials of program	Methods (related theory)	Determinants b
Poster preparation, Motion graphics, Paint motion, logotype, Infographic, Booklet and Information campaign. Inviting entomologists and health education specialists to radio and television to radio and television	Introduction of authoritative sources and databases approved by the Ministry of Health	Raising awareness (Trans Theoretical Model) Risk personalization (Precaution Adoption Process Model)	Awareness
Inviting influential people Setting up meetings in the neighborhood interview	Advice and persuasion by media and experts Peer group formation	Repeated exposure (social cognitive model) Persuasive communication (innovation diffusion theory)	Attitude
Holding provincial campaign with people’s participation Introduction of successful people in controlling the ways of transmission of dengue fever in their place of residence and daily life	Holding a campaign with a clear slogan and a dedicated logo	Verbal persuasion and modeling (social cognition theory) General commitment (spontaneous behavior theory)	Self-efficacy
Role playing The use of health threatening educational videos	Holding a campaign Setting up local meetings	Risk personalization (Precaution Adoption Process Model)	Perception of risk

^aIt is an activity that is done to reduce the determinants of behavior change.

^bThis refers to the determinants of behavioral and environmental outcomes.

Step 4: Production of program components and content

At this stage, the components and content of the program were designed and produced according to the needs of the audience and the participatory planning team identified the most suitable channels for implementing the intervention. According to the results of the needs assessment, adolescents and youth age group were mostly the audience of cyberspace. Housewives were more interested in training through podcasts and audio training while doing housework and the elderly used more television and radio. According to these results, the compiled contents were provided to the target group through appropriate channels and in order to ensure that the messages and information are clear and understandable to the target audience, the messages were made available to the citizens and the items that needed to be corrected were rewritten. Finally, the intervention program was developed with the presence of stakeholders and the executive team for 3 months.

Step 5 and 6: Implementation and evaluation of the program

Impact evaluation was determined based on the general goal and specific objectives of the study and using the completed tools in the needs assessment stage. The general goal of the program was improving the awareness and behavior of citizens regarding ways to prevent dengue fever, that due to the time limit, the final evaluation of the program is done by the same study group with delay and the results will be published in the next studies.

Discussion

This research was carried out with the aim of developing and designing practical interventions in the prevention of dengue fever disease by using the intervention mapping approach. The intervention mapping approach guides planners more precisely for each decision about program development. ¹³ The intervention mapping planning approach has been used to develop other programs and has been evaluated in achieving better results.^14,15

The results of the present study showed that the intervention mapping planning approach is suitable framework and step-by-step guide for developing a systematic, theory- and evidence-based program. The intervention mapping approach provides a usable and practical guidance for developing health promotion programs for use by other planners in other places. ¹⁶

 Also, intervention mapping encourages planners to collaborate with stakeholders in achieving better results in adopting and implementing programs ¹⁷ and intervention adherence.^18,19 Intervention mapping is helpful and flexible despite its time-consuming and complex nature. ¹⁵ In the study by Ziapour et al., who used an intervention mapping approach for Brucellosis, the results showed that this approach can draw a comprehensive map for effective interventions with the cooperation of the public and authorities. ²⁰

Intervention mapping provides a useful approach for developing behavior change interventions and converting theories into practice. ²¹ This approach is a turning point that prevents the formation of ineffective educational and intervention programs, because most of the interventions are provided in the form of general education, without needs assessment and participation. The results of this study lead to the development of a practical intervention program to increase the sensitivity to dengue fever disease, the ways of its transmission and prevention with the participation of people and organizations based on theory and evidence^15–19

Therefore, identifying the determinants of a behavior and choosing appropriate strategies will help health policy makers to design and implement targeted interventions.^21,22 As a result, it is important and necessary to educate people to visit the doctor early and diagnose the disease in order to prevent more complications and deaths caused by dengue fever. It is necessary for educational interventions to target the awareness of dengue fever among all members of the society through mass media, especially those who live in remote areas and villages and these educational messages should be sent through mass media such as television and radio advertisements.^21–24

In the end, it seems that it is necessary to design educational programs about the signs and symptoms of dengue fever, so that, after that, immediate treatment can be done to prevent death from dengue fever. It is also necessary to increase community participation to eliminate mosquito breeding places and increase campaigns to increase responsibilities toward neighborhood cleanliness to facilitate prevention measures among the community.^11,25-27 It is suggested that the Ministry of Health and governments provide precautionary measures and more cost-effective ways to prevent mosquitoes and dengue fever.

Limitations and strengths

Although the intervention design process using intervention mapping was useful, it is a time-consuming and challenging task. On the other hand, all the information obtained from the interview was provided in self-report form; therefore, there may be a bias toward socially desirable responses and behaviors. It is suggested that future studies use other community-based methods with larger sample sizes. Despite these limitations, the present study provided useful results that will guide government administrators and policymakers in formulating programs and activities to initiate dengue prevention. It is necessary to conduct more community-based studies among the community to educate about dengue. Since mass media is one of the main sources of awareness and education transmission, therefore, it is necessary to install more billboards and advertisements in the suburbs and remote areas emphasizing the seriousness of dengue fever.

Conclusion

From the findings of this study, several conclusions with important implications for dengue prevention efforts can be drawn. Using the intervention mapping approach helps develop a theory- and evidence-based program, systematic, identifying outcomes, practical goals and change, determinants, methods of theoretical change and practical application, transparency of all intervention components, development of interventions, behavior change, translation of theory into practice, dissemination and evaluation. Health and education programs should focus on identifying behavior determinants, selecting appropriate strategies for behavior change, especially in rural areas and places where mosquitoes are more prevalent. It is also suggested that managers and policymakers: 1—Subsidized mosquito nets to prevent bites, 2— Enhanced public awareness campaigns in remote and underserved areas, 3—Large-scale national strategies to apply intervention mapping for dengue prevention and control.