A Qualitative Research Study on Needs, Attitudes and Practices Related to Pregnancy Prevention, Abortion Care, Pregnancy Care, and Care for Children Affected by Zika Virus

This research study aims to explore the needs, attitudes and practices of women, men and healthcare service providers related to pregnancy prevention, abortion care, pregnancy care, and care for children affected by Zika Virus. The study uses a qualitative approach based on structured interviews and includes ethical considerations. The sample size is 270 participants and the results are reported in percentage form.

A Qualitative Research Study
to explore the needs, attitudes and practices
of
women, men and healthcare service providers
related to
pregnancy prevention, abortion care, pregnancy care,
and care for children affected
by
Zika Virus

Table of Contents
1. Introduction (2 – 5)
1.1 Background
1.2 Diagnosis
1.3 Indian Scenario
1.4 Need for Research
2. Research Methodology (6)
2.1 Problem Statement
2.2 Aim of the research
2.3 Sampling Method
2.4 Research Design and Technique
2.5 Ethical Consideration
3. Research Analysis (7-11)
4. Conclusions (12)
5. Recommendations (12)
6. References (13)
Appendix 1: Questionnaire (14)
6.1
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1. INTRODUCTION AND BACKGROUND
1.1 Background
Zika virus is an arthropod-borne flavivirus transmitted by mosquitoes. Clinical signs of Zika
virus infection can be acute onset low-grade fever with rash, notably small joints of hands and
feet, or conjunctivitis (non-purulent). Congenital Zika virus infection is associated with
anomalies such as congenital microcephaly (along with other developmental problems among
infants born to women infected during pregnancy), Guillain-Barré syndrome, myelitis, and
meningoencephalitis (Besnard M et al. 2016).
Since its detection in Brazil in 2015, Zika virus has emerged as a growing concern, it is endemic
in parts of Africa, has been reported in South East Asia and there is an ongoing Zika virus
outbreak in the Americas, the Caribbean, and the Pacific.
1.1.1 Microcephaly
The World Health Organization (WHO), the United States Centers for Disease Control and
Prevention, and other scientific groups have concluded that the Zika virus can cause
microcephaly. In some cases, congenitally infected offspring of women with first or second
trimester Zika virus infection have a normal head circumference at birth but subsequently
develop microcephaly in the first year of life. Definition of microcephaly given by WHO is:
Occipitofrontal circumference (head circumference) greater than two standard deviations below
the mean or less than the third percentile based on standard growth charts for sex, age, and
gestational age at birth.
1.1.2 Adverse Pregnancy Outcomes
Adverse pregnancy outcomes include miscarriage, stillbirth and impaired fetal growth.
1.1.3 Pregnancy Management
There is no specific treatment known to cure ZIKV infection. Its management includes rest and
fluids intake to prevent dehydration and medicines are administered to relieve pain and fever.
The World Health Organization (WHO) has issued initial guidance for infected persons and their
families. Ultrasound is the major screening method for congenital Zika virus infection. Magnetic
resonance imaging is more sensitive for diagnosis of fetal brain abnormalities. In women
infected early in pregnancy, ultrasound findings associated with fetal infection may be detected
as early as 18 to 20 weeks of gestation but are usually detected in the late second and early third
trimesters of pregnancy. The United States Centers for Disease Control and Prevention (CDC)
suggest fetal ultrasound examination every three to four weeks to look for signs of congenital
Zika virus infection and monitor fetal growth in pregnant women with laboratory evidence of
recent Zika virus infection. If the ultrasound report shows something not normal, amniocentesis
for diagnosis of fetal infection should be considered.
1.1.4 Delivery
Timing and route of delivery are determined according to routine obstetric policies and
standards. The appropriate location for delivery should be decided by late third trimester
Breast Feeding
Transmission of Zika virus through breast milk has not
been reported [42], although the virus has been detected
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Breast Feeding
Transmission of Zika virus through breast milk has not
been reported [42], although the virus has been detected
Breast Feeding
Transmission of Zika virus through breast milk has not
been reported [42], although the virus has been detected
Breast Feeding
Transmission of Zika virus through breast milk has not
been reported [42], although the virus has been detected
Breast Feeding
Transmission of Zika virus through breast milk has not
been reported [42], although the virus has been detected
1.1.5 Breast Feeding
There are no reported cases of transmission of Zika virus through breast milk, although the virus
has been detected in breast milk in some studies (Blohm GM et al, 2018).
1.2 Diagnosis
The diagnosis of Zika virus infection should be suspected in individuals with typical clinical
manifestations and relevant exposure (residence in or travel to an area where mosquito-borne
transmission of Zika virus infection has been reported, or unprotected sexual contact with a
person who meets these criteria) The differential diagnosis of Zika virus infection includes:
Dengue fever, Chikungunya, Parvovirus, Rubella, Measles, Leptospirosis, Malaria, Rickettsia
infection, group A Streptococcus. Health care providers should screen pregnant woman for
possible exposure to Zika virus. Mother has one or more of the symptoms or she is residing in or
travelled to an area where mosquito-borne transmission of Zika virus infection has been reported.
Serum and urine are the primary diagnostic specimens; whole blood is an approved specimen for
some nucleic acid tests. For individuals presenting more than 14 days after persistent symptoms,
blood and urine tests for detection of Zika virus RNA should be performed. Any positive result
establishes a diagnosis of Zika virus infection and in such cases no further testing is done.
Negative results do not exclude the chances of infection and Zika virus serologic test should be
done. The diagnostic approach is different in pregnant and non-pregnant women because Zika
virus RNA can persist longer in a pregnant woman's serum and because of the potential for
congenital infection. The risk of transmission to unborn child is there throughout the pregnancy
in both symptomatic and asymptomatic mothers.
1.2.1 Prevention
It is suggested that pregnant women should not travel to areas where mosquito transmission of
Zika virus is well acknowledged. Protective measures should be taken to avoid mosquito bite as
well as sexual transmission of the virus, stick to specific directions regarding blood donation and
standard infection precautions. No vaccine is there for prevention of Zika virus infection, but a
vaccine is under development.
1.3 Indian Scenario
Since 2013, with the first reported Zika virus (ZIKV) outbreak in the Marquesas Islands and its
subsequent spread to Brazil in May 2015, health agencies in India have been on alert and kept a
watch on the Zika situation in India. There is an anticipation that ZIKV outbreak in India is
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possible due to presence of the vector-Aedes aegypti mosquitoes and the susceptible host. On
May 15, 2017, the Ministry of Health and Family Welfare, Government of India, reported three
laboratory-confirmed cases of ZIKV disease from Bapunagar area, Ahmedabad, Gujarat, India.
Before this declaration, India was in WHO category-4 (virus may be present, but no notified
cases documented), but with these three confirmed cases, India has shifted to WHO category-2.
With recent confirmation of more Zika cases from different parts of India, concerns over
spreading awareness and prevention of spreading of disease is required.
As evident from the present cases, Zika may not be a recent introduction in India. In 1954,
National Institute of Virology (NIV), Pune (then Virus Research Centre), had tested samples
from Bharuch district, which showed ZIKV antibody detection in 16.8 per cent of the samples.
However, due to high cross-reactivity of ZIKV with dengue virus (DENV) and other
flaviviruses, it was difficult to confirm Zika virus infection in India based on serology. Cases
detected did not reveal any travel history to ZIKV endemic region, suggesting that the ZIKV is
not a recent introduction into the country.
It is difficult to confirm Zika infection (out of acute phase of 4-5 days) by serology, due to a very
high cross-reactivity with DENV. In such a situation, performing serology is not advised where
high false positivity will create panic. At present, only a few commercial serology kits are
available. It is difficult to ascertain whether there will be congenital disabilities in children born
to ZIKV-infected women or with history of infection. It is so far not feasible to screen all
asymptomatic pregnant women by molecular tests. Now, that the presence of ZIKV in the
country is confirmed, microcephaly may be made a notifiable disease in the country to indirectly
estimate the burden caused by ZIKV.
1.4 Need for Research
Research is required to understand the ZIKV natural cycle in India and several questions need to
be addressed. The virus has lived a ubiquitous life for decades in tropical and equatorial zone and
has also not shown any dramatic evolutionary mutations, but the vector biology and pathogenesis
of the ZIKV need to be better understood. Zika and microcephaly screening should ideally be
made mandatory for pregnant women in collaboration with hospitals and laboratories across the
country, which will help us know the burden of ZIKV in India.
These mosquitoes breed throughout the year especially in stagnant water sources, but the density
is very high during monsoon because of availability of more breeding sites. High humidity and
optimal temperature support them in laying eggs every 3-4 days. The most effective and long-
term preventive and control measure for Ae. aegypti as recommended by the authorities is source
reduction which requires community participation.
Thus, to estimate the extent of ZIKV impact in India, a long-term surveillance network, active
participation of the concerned health authorities and communities is needed.
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Figure 1. WHO Zika Virus Research Agenda Implementation Framework
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2. RESEARCH METHODOLOGY
2.1 Problem Statement
Based on previous studies, it is observed that ZIKV, when first discovered, was a relatively
benign disease. Currently more studies are being conducted on this subject and link of ZIKV
with microcephaly and Guillain-Barré syndrome has been established by many scientists. There
is a great amount of medical research regarding ZIKV is available but caring science research on
the topic is still lacking to some extent. As the treatment options are very limited, the focus lies
mostly on prevention and control of the infection before it spreads more. Therefore, there is a
need for qualitative studies to explore the needs, attitudes and practices of women, men and
healthcare service providers related to pregnancy prevention, abortion care, pregnancy care, and
care for children affected by ZIKV.
2.2 Aim of the research
To study the attitude and practices of people towards ZIKV disease.
2.3 Sampling Method
Before the study started, a contact in India was established, the contact person was informed
regarding the purpose of study and a variety of men, women and health professionals above the
age of 18 years were interviewed. The participants who were not able to provide written consent
and who did not align with the aim of the study were tried to be excluded. Research was
conducted at accessible houses, colleges and health centres. Most current available Census Data
from the year 2011 was used to estimate the number of households in the sampling frame.
Randomisation of sampling is used so that the bias can be reduced, this is a method based on
positivist paradigm.
2.4 Research Design and Technique
For this study, a qualitative approach based on structured interviews was used. Qualitative
interviews are a suggested method to conduct research based on people’s living experiences,
attitudes and practices. Research questions (Appendix 1) were asked from the people
participating in the study after taking their written consent. Analysis of the responses is done
using qualitative approach and representation using tables is included. The responses collected in
hard copy were entered in electronic form and with the help of Microsoft excel tool, data
analysis was done. Based on the analysis, results are reported in percentage form and conclusion
is drawn from it.
2.5 Ethical Considerations
The ethical consideration in qualitative research helps to ensure that the research is thorough and
accurate (Thomas & Magilvy, 2011). E. Thomas & Magilvy,2011 lists four ethical principles
that are of importance while conducting research on this level which includes freedom, integrity,
confidentiality and anonymity of the participants. While conducting the research, the participants
were informed with the aim of the study and that they are not under any obligation to answer.
Written consent was taken from the participant before asking research questions. The
information provided by the participants will be handled with care and the data will be used for
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the ongoing study only. It will not be used for anything else and will not be kept for future
studies.
3. RESEARCH ANALYSIS
Many households, colleges and health centres were approached for the structured interviews. A
total of 270 participants gave full response to the questions asked in the interview.
3.1 Demographics
Characteristics of the sample
Sample Size, N = 270
Table 1
Age No. of Individuals
18-28 yrs. 40
28-38 yrs. 110
38-48 yrs. 80
48 yrs. and above 40
Total 270
3.2 Reported Number of Pregnant Women
Pregnant women are at a very high risk of getting infected by ZIKV and therefore protecting
them should be at the top in the priority list. Studies have shown that ZIKV infection during
pregnancy is the cause of congenital malformations in unborn baby, including microcephaly and
other severe brain defects, and other adverse outcomes. This question was included to have an
idea on the number of pregnant women and their responses. 5.5 % of the respondents were
pregnant (Table 2).
Table 2
Gender No. of Individuals
Male 120
Female 149
Pregnant, if Female 15
3.3 ZIKV HEALTH COMMUNICATION
The purpose of including questions based on health communication of ZIKV was to determine
how people are acquiring information about the disease, which sources of are most relevant for
people to spread ZIKV awareness, and what additional information needs to be circulated.
Question - Which sources gave you information about ZIKV?
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Table 3
Information Source No. of Individuals
Radio/Television 149
Internet 57
Newspaper 15
Social Media 12
Relatives 7
Others 13
No Answer 17
Total 270
Most people get information about the disease and its prevention from television and radio
(around 55 % of the respondents). Internet is the other prominent source, newspaper, social
media etc are also referred by few respondents. Around 6% respondents did not choose any
source. Those who marked others as their response, mentioned government sources, magazines,
journals etc to name a few as the source which gave information about ZIKV (Table 3).
Question-What additional information would you like to receive regarding the ZIKV
disease?
Table 4
Additional Information Needed No. of Individuals
Signs and Symptoms 123
Prevention 69
Treatment Options 31
Cause 24
Risks 19
No Answer 3
Any Other 1
Total 270
Most of the respondents wanted to receive additional information about ZIKV signs and
symptoms (45.56%) and prevention (25.56%), some wanted to get information about the
treatment options (11.48%), cause (8.9%), and risk category (7%) (Table 4). One person who
marked other wanted to know the long-term effects of the disease.
3.4 KNOWLEDGE REGARDING ZIKV
Prevention methods should be adopted by the population primarily to avoid the risk of getting
ZIKV infection especially the pregnant women and small children need extra care. Therefore, the
questions regarding knowledge of ZIKV infection and mosquito prevention methods used by
people were included in the questionnaire.
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Importance of ZIKV knowledge
Question - Do you think ZIKV is an important issue?
Table 5
Response No. of Individuals
Yes 223
No 32
No Answer 6
Don't Know 9
Total 270
82.59% respondents believe that ZIKV is an important concern whereas 11.85% stated “No”, 3%
“don’t know” and 2% “no answer” as their opinion. (Table 5).
Mode of transmission, risks of disease and symptoms
Question- Which are the different modes of transmission of ZIKV?
For this question, respondents were asked to mark all possible options as per their knowledge.
Table 6
Mode of transmission No. of Responses
Mosquito Bite 189
Sexual Transmission 45
Passed from mother to child 23
Others 0
Don't know 40
No Answer 3
63% response was for mosquito bite, sexual transmission mode had 15% response whereas only
7.6% response was reported for it can pass from mother to child (Table 6).
Prevention Methods
Question-Is there a vaccine for ZIKV?
Table 7
Responses No. of individuals
Yes 24
No 177
Don't Know 64
No Answer 5
Total 270
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65.9% of individuals were aware that no vaccine is available for ZIKV, 23.7% said they “don’t
know” whether ZIKV vaccine is available or not (Table 7).
Question-What are the symptoms of ZIKV infection?
Table 8
Responses No. of Individuals
Fever 109
Headache 26
Other 39
Don't Know 96
Total 270
Regarding the symptoms of ZIKV disease, 40% respondents stated “fever”, 35.5% accepted that
they “don’t know”. (Table 8). In addition, 14.4% participants reported “other” symptoms, which
were not correct, for example, AIDS. Very few people responded with other common ZIKV
symptoms such as: pain in joints, rash and conjunctivitis. Rarely people reported that a person
infected with ZIKV might not show any such symptoms.
Question- If a pregnant woman has ZIKV disease, what are the risks for her unborn baby?
Respondents were asked to give multiple options if they are aware of more than one risks.
Table 9
Response No. of Individuals
Microcephaly 23
Abnormality in development 81
Other 38
Don't know 163
Most people recorded abnormality in development of unborn baby whose mother is affected by
ZIKV as a risk, only 7.5% responses were for microcephaly (Table 9). Other risks stated by the
respondents include miscarriage, premature birth, brain damage, zika infection.
The Government of India has published an advisory with the prevention and control measures
which includes:
 Guidelines on Zika Virus Disease from Ministry of Health and Family Welfare
 Guidelines on Integrated Vector Management for Control of Aedes Egypti mosquitoes
 Fact sheet on Zika Virus Disease
 Vector management for Mosquito
Prevention Measures mentioned in the guidelines are as follows:
 No vaccines exist to prevent Zika Virus Disease
 Prevent Zika by avoiding mosquito bites
 Wear full sleeves shirts and pants
 Sleep under mosquito net
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 Sleep in places with window screens or mesh
 Once a person has been infected he/she is likely to be protected from future infection.
Question-What actions can you take to be protected from ZIKV?
Respondents were asked to give multiple measures which they are aware of.
Table 10
Prevention Measures No. of Responses
Mosquito Repellent 160
Cover and clean items that hold water 190
Wear long sleeved shirts/pants 41
Spray or fumigate home 70
The most frequent actions taken by participants as protection measure from ZIKV were: to use
mosquito repellent, cover and clean items that hold water, wear long sleeved shirts/pants and
spray fumigate home (Table10).
Access to treatment/prevention
Question-Have you accessed resources from your local health department regarding
prevention from ZIKV infection?
Table 11
Response No. of Individuals
Yes 24
No 246
Total 270
91% respondents stated that they have not accessed local health department resources regarding
ZIKV prevention (Table 11).
4. CONCLUSIONS
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Urban Indians are receiving ZIKV information from various sources, most popular being
radio/television and internet, newspapers, social media, and family has also been informative for
some of them. There are some additional sources which people have referred in the study like the
local health department and family doctor. Many people accepted that they are not accessing
local health department ZIKV resources.
Most Indians stated ZIKV to be an important issue considering the risks known to them but have
moderate knowledge of all the modes of disease transmission. Most of them appropriately
understand mosquito bites as a mode of transmission but they are not aware of the fact that ZIKV
can cause birth defects in the babies born to those mothers who were infected with ZIKV during
pregnancy. However most of Indians are not aware of the term microcephaly. Some of the
respondents reported sexual transmission as a mode of ZIKV infection. Furthermore, interview
responses indicated that people are not fully aware of all the signs and symptoms of the disease
in question. Individuals wanted to get additional information about the symptoms, prevention,
and treatment of ZIKV infection.
5. RECOMMENDATIONS
Awareness regarding mode of transmissions of ZIKV should be the focus of programs,
especially Indians are not aware that this disease can be transmitted from pregnant mother to her
child. Also, they are not fully aware of the risks caused to the unborn baby if the mother is
ZIKAV infected.
Government should telecast advertisements mentioning the details of the disease as most of the
Indians are referring to television/radio for information.
People should be advised to go through the advisory published by Government of India for
prevention and control of ZIKV.
People are advised to avail the facilities provided by Health Department for vector management.
Government should identify strategies to ensure that the citizens and other stakeholders get
accessibility to accurate mosquito management information and can utilise the prevention
methods available to them.
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References
Blohm GM, Lednicky JA, Márquez M…. Alberto E Paniz-Mondolfi. Evidence for Mother-to-
Child Transmission of Zika Virus Through Breast Milk. Clinical Infectious Diseases. Available
at: https://academic.oup.com/cid/advance-article/doi/10.1093/cid/cix968/4782287 (Volume 66,
Issue 7, 19 March 2018, Pages 1120–1121)
Besnard M, Eyrolle-Guignot D, Guillemette-Artur P, Lastere S, Bost-Bezeaud F, Marcelis
L….Mallet HP.Congenital Cerebral Malformations and Dysfunction in Fetuses and Newborns
following the 2013 to 2014 Zika Virus Epidemic in French Polynesia. (Euro Surveillance 2016)
Centres for Disease Control and Prevention (CDC). Zika Virus: Transmission and Risks.
[Online]. [Atlanta (GA)]: CDC; [revised 2017]. Available at:
https://www.cdc.gov/zika/prevention/transmission-methods.html
Ministry of Health and Family Welfare, National Guidelines for Zika Virus disease. Available at:
https://mohfw.gov.in/media/disease-alerts/national-guidelines-zika-virus-disease
New York City Department of Health and Mental Hygiene. Zika virus. Available at:
https://www1.nyc.gov/site/doh/health/health-topics/zika-virus.page
Silverman, D. (2000). Doing qualitative research: A practical handbook.
London, Thousand Oaks, New Delhi: Sage Publications.
Thomas, E., & Magilvy, J. K. Qualitative rigor or research validity in qualitative research (2011).
Journal for Specialists in Pediatric Nursing, 16(2),151-155.
World Health Organization. Zika: Strategic Response Framework & Joint Operations Plan
January-June 2016; 2016. Feb 2016.
World Health Organization. WHO Zika Q&A; 2017. Available at:
http://www.who.int/features/qa/zika/en/.
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APPENDIX 1: QUESTIONNAIRE
Questionnaire to study people attitude and practices towards ZIKV
Date (MM/DD/YY) …………………..
Q-1 Age
□ 18-28 yrs. □ 28-38 yrs. □ 38-48 yrs. □ 48 yrs. And above
Q-2 Gender
□ Male □ Female
Pregnant (If, female) □ Yes □ No
Questions regarding Zika Virus health communication
Q-3 Which sources gave you information about ZIKV?
□ Family □ Relatives □ TV/Radio □ Internet □ Social Media □ Newspaper
□ Others, please specify …………….
Q-4 What additional information would you like to receive regarding the ZIKV disease?
□ Signs and Symptoms □ Cause □ Risks □ Treatment Options □ Prevention
□ Any Other, please specify …………….
Questions regarding your knowledge of ZIKAV
Q-5 Do you think ZIKV is an important issue ?
□ Yes □ No □ Don’t Know
Q-6 Which are the different modes of transmission of ZIKV?
□ Mosquito Bite □ Sexual Transmission □ Passed from mother to child
□ Others, please specify ……………
Q-7 Is there a vaccine for ZIKV?
□ Yes □ No □ Don’t Know
Q-8 What are the symptoms of ZIKV infection?
□ Fever □ Headache □ Don’t know
□ Others, please specify ………………..
Q-9 If a pregnant woman has ZIKV disease, what are the risks for her unborn baby?
□ Abnormality in development □ Microcephaly □ Don’t Know
□ Others, please specify ……………….
Q-10 What actions can you take to be protected from ZIKV?
□ Mosquito Repellent □ Wear long sleeved shirts/pants □ Cover and clean items that hold water
□ Spray or fumigate home □ Use of Condom/abstain from sex
□ Others, please specify …………….
Q-11 Have you accessed resources from your local health department regarding prevention from ZIKV infection?
□ Yes □ No
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