In October 2003, an outbreak of the potentially-fatal dengue fever began in the <?xml:namespace prefix = st1 ns = "urn:schemas-microsoft-com:office:smarttags" />Torres Strait which infected 278 people, killing one of them. Simultaneous outbreaks in Cairns and Townsville have infected 78 and 58 people respectively, with both outbreaks ongoing.
The dengue mosquito only breeds around homes close to its human food source, not in swamps or lagoons. The disease can be controlled be eliminating mosquito breeding sites around the home (such as pot plant bases) and by using insect repellent.
The challenge for Queensland Health is to convince people a) of the potential seriousness of the disease, given so few deaths in Queensland, and b) to get rid of breeding sites in their yard and use insect repellent. This is not a disease governments can control on their own - public education and action plays a vital role in preventing or stopping dengue outbreaks.
Given the unique situation of three simultaneous outbreaks to control, Queensland Healths Tropical Public Health Unit Network developed new public education campaigns which relied heavily on free publicity. While formal research and evaluation of the campaigns were limited by a lack of funding, media content analysis and householder surveys indicated a high level of awareness of the dengue outbreaks and good recall of the key message about getting rid of mosquito breeding sites.
In 1904-05, 94 <?xml:namespace prefix = st1 ns = "urn:schemas-microsoft-com:office:smarttags" />Brisbane residents died of dengue fever. Improved disease surveillance and control in the 20th century resulted in fewer outbreaks of the disease and Australia was considered dengue-free in the 1950s. However, the increase in international travel to North Queensland since the mid-1980s has seen the re-emergence of dengue, as travellers infected in other countries (such as Papua New Guinea and Indonesia) bring the disease in with them.
About a dozen cases are imported into the region every year via infected travellers, some of whom infect the local dengue mosquito population, starting local outbreaks. Since 1995, there has been at least one outbreak in the region every year. Since 1990, more than 2500 North Queenslanders have acquired dengue fever. As outbreaks become more common (see graph, Appendix A), more people are at risk of developing the fatal form of the disease dengue haemorrhagic fever (DHF) which can occur if someone is infected with more than one strain of the virus over a five or six-year period. In the 2003 wet season, and for the first time in recent history, North Queensland recorded three cases of DHF, one of whom died and two of whom required five weeks in CairnsBaseHospitals Intensive Care Unit.
In 2003-04, there were three simultaneous outbreaks in North Queensland in Cairns, Townsville and the Torres Strait. Facing this unique and challenging situation, Queensland Healths Tropical Public Health Unit developed a new public education program in Cairns, while routine education programs continued in Townsville and, to a greater extent, in the Torres Strait.
Dengue Blitz 04 was developed in conjunction with The Cairns Post, with support form the Cairns City Council. It was a 9-week campaign sponsored by The Cairns Post as a community service initiative to increase public awareness of dengue fever. A weekly Dengue Watch was published along with one or two articles a week on different aspects of dengue and outbreak prevention (see articles, Appendix A).
In the meantime, a publicity campaign in the Torres Strait was supplemented with limited press advertising, while flyers, brochures and pamphlets in the local language, Creole, were developed and printed in-house (see Appendix A).
The campaigns supported the work of Queensland Healths Dengue Action Response Team (DART), a mosquito surveillance and control unit which treats or eradicates mosquito breeding sites on properties in outbreak areas.
The Tropical Public Health Unit Network does not have a market research budget. Only limited formal research on community awareness of dengue fever has been conducted over the past 11 years.<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" />
A 1993 regional health survey included several questions relating to a television commercial about dengue fever prevention. Most respondents recalled seeing the ad, although recall of its key messages was mixed.
A household survey about dengue fever awareness was conducted by staff in 1995. Most respondents understood dengue was carried by mosquitoes and knew they should get rid of mosquito breeding sites around their home. Two-thirds indicated they would clean up breeding sites in their yard, with barriers to this behaviour including time, cost and laziness.
This research, and the observations of field workers over the years, suggested that while awareness of dengue was relatively high, more work needed to be done on encouraging behaviour change, especially given the continuing outbreaks.
Given time and resource constraints, no formal research was conducted immediately prior to the 2003-04 public education campaign. However, informal research included:
consultation with field workers (DART members) to gain an understanding of current public knowledge
consultation with staff in the <?xml:namespace prefix = st1 ns = "urn:schemas-microsoft-com:office:smarttags" />Torres Strait about effectively communicating dengue prevention messages to the local population
consultation with entomology and medical staff about the most important dengue prevention messages meetings with the local press about potential educational strategies
review of media content during previous outbreaks.
A short questionnaire on dengue knowledge was conducted by field workers in Cairns and the Torres Strait, as time permitted (see Appendix A). The results (noted later) helped frame the key messages during the latter part of the outbreaks, and will be used in development of communication strategies in future outbreaks.
As the dengue mosquito lives in the northern half of <?xml:namespace prefix = st1 ns = "urn:schemas-microsoft-com:office:smarttags" />Queensland, all North Queensland residents are at risk of the disease. However, the major outbreaks in 2003-04 were focussed on three populations, meaning the primary target audiences were:<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" />
- residents of Townsville, the Torres Strait and Cairns
- print and electronic media in these three locations.
Residents and media in the rest of North Queensland were secondary target audiences, because of the potential for dengue to spread to other locations.
Residents in outbreak areas were the primary audience, as their actions can help stop an outbreak.
Three different communication strategies were implemented, based on the extent of the outbreaks. With no dedicated communications budget, strategies relied heavily on free publicity. Two simple messages were developed for use in the campaign:
- get rid of breeding sites
- use insect repellent.
Communication strategies were based on those outlined in the Dengue Fever Management Plan for North Queensland. These included:
- regular media releases on the progress of the outbreak
- media conferences and phone interviews (both scheduled and on request).
These supplemented the face-to-face educational work done by the DART during field work.
<?xml:namespace prefix = st1 ns = "urn:schemas-microsoft-com:office:smarttags" />Torres Strait outbreak
Communication strategies included:
- regular media releases
- media conferences and phone interviews
- free community service announcements on Torres Strait radio
- press advertising, using images and local language
- in-house development, printing and distribution of fact sheets, flyers and brochures in Creole.
The extent of this outbreak prompted the deployment of a 19-person strong dengue intervention force which conducted intense mosquito surveillance and control on all properties on Thursday Island. This required extensive publicity to gain the cooperation of local residents.
Communication strategies included:
- regular media releases
- media conferences and phone interviews
- fact sheets for peak tourism bodies and consulates, and local businesses, developed and printed in-house
- the 9-week Dengue Blitz 04 campaign in The Cairns Post, a free campaign which featured a weekly Dengue Watch column (with details of hotspots, number of cases, common breeding sites, and a tip of the week), a kids colouring-in competition, and one or two articles a week on different aspects of dengue (worst breeding sites, patient interviews, local research, dengue-aware workplaces, gardening and health tips). All stories were branded with the Dengue Blitz 04 logo developed by the Post.
In addition to the above, the dengue TV commercial screened in all three centres, as it does every wet season. (The advertising schedule has been sponsored by Reckitt Benckiser, makers of Aerogard, for the past 10 years.)
Media content analysis<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" />
In the 12 months to July 2004, an in-house media content analysis revealed 289 mentions in the media concerning dengue fever.
Press articles about dengue were scanned for the two key messages. Of 126 articles, 90 (or 71%) included the message about breeding sites, while 24 (19%) included the message about insect repellent.
Early in the <?xml:namespace prefix = st1 ns = "urn:schemas-microsoft-com:office:smarttags" />Cairns campaign, 47 Cairns residents visited by DART members were surveyed, with the following results:
- 44 (93%) knew there was a dengue outbreak in Cairns
- 30 heard about it from the newspaper, 27 from TV, 17 from radio
- 42 (89%) knew they should get rid of breeding sites, 26 (55%) knew they should wear repellent
- 37 (78%) claimed they had done at least one of these things.
A questionnaire of 99 Torres Strait residents was done by field workers towards the end of the campaign, with the following results:
- 96 (97%) knew there was a dengue outbreak on TI
- 60 heard about it from family or friends, 58 from radio, 35 from the newspaper
- 93 (94%) knew they should get rid of breeding sites, 66 (67%) knew they should wear repellent
- 84 (85%) claimed they had done one of these two things.
The objectives were:<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" />
- to heighten public perception of the immediate risk and encourage people to eliminate mosquito breeding sites and use insect repellent
- to achieve 75 per cent recall of the two key messages.
The surveys in <?xml:namespace prefix = st1 ns = "urn:schemas-microsoft-com:office:smarttags" />Cairns and the Torres Strait indicated that a significant majority knew there were dengue outbreaks in their area (93% and 97% respectively). A significant majority knew they should get rid of breeding sites (89% and 94% respectively), while fewer people knew they should wear insect repellent (55% and 67%). In an effort to measure behaviour change, residents were also asked if they done one of these things 78% and 85% respectively claimed they had. Limited time and resources meant field workers could not always check these claims, but it has been identified as an issue to be included in future research.
The surveys indicate objective one was partially met, given the high level of awareness of the dengue outbreaks and the need to eliminate breeding sites. Objective two had mixed success most people recalled the message about breeding sites, but fewer recalled the message about insect repellent.
The final two objectives were:
- to ensure up-to-date information was available to the media and public
- to achieve publication of the two key messages in 50 per cent of media coverage.
During the three outbreaks, a total of 23 media releases were issued and six expert staff were available for interview. One information gap identified was the lack of a dengue web-site this is now under development.
There were 289 press or electronic media items about dengue in the 12 months to July 2004. Of 126 press articles, 90 (or 71%) included the first message, while 24 (19%) included the second message. This indicates that while objective 4 was met for the first message, it was not met for the second message. The household surveys also included a question on where people heard about the outbreak, and this information will help the unit target appropriate media in future outbreaks.
The limited research conducted during the 2003-04 outbreaks indicates the message about using insect repellent needs to be reinforced. While knowledge about mosquito breeding sites is much higher, field workers continue to find breeding sites - trying to change the high level of public knowledge about dengue into healthier behaviour will need to be a focus of future campaigns.
The lack of a budget for formal research hampered evaluation of the communication strategies implemented during the 2003-04 outbreaks. However, the large number of outbreaks and cases in the past two years has prompted the government to approve funding for formative research in 2004-05, so that a more comprehensive public education campaign using the resources and expertise of health promotion officers can support the work of the Tropical Public Health Units communications officer during future outbreaks.