This is the first exploratory study that evaluated the level of knowledge regarding the diagnosis, management, and prevention of dengue among physicians from different regions of Peru during the 2023 outbreak. The majority of participants (78.8%) had at least 70% of correct answers. In a national context, a 2016 study conducted in the province of Lambayeque, Peru, found that 69% of doctors obtained an average of 9 to 16 correct answers, which was considered to be a good level of knowledge (Paico-Romero et al., 2019). Dengue is a well-known disease among doctors in Peru, as it is an endemic disease in several provinces, such as Lambayeque (Paico-Romero et al., 2019; WHO, 2023b). In an international context, there are some studies that reveal a high level of knowledge related to dengue. For example, a pre-symposium survey in Florida (Doblecki-Lewis et al., 2016) showed physicians scoring an average of 74.3% on dengue-related questions. In Tanzania, Saringe et al. (Saringe et al., 2019) found that 74.1% of healthcare workers possessed good dengue knowledge, with a mean score of 43.6 (considered good if ≥ 40). Additionally, a multi-country study revealed that Bangladesh, India, and Malaysia had the highest dengue knowledge scores (16.9, 18.03, and 18.46, respectively), while Turkey scored lower (11.7) (Koonisetty et al., 2021). These studies suggest that the good knowledge could be due to the constant dengue cases presented in those areas, a situation similar to Peru.
In the multivariate analysis, it was found that reading the current Peruvian clinical practice guidelines for dengue management was positively associated with obtaining a score ≥ 70%. These results are in agreement with those reported by Handel et al. (Handel et al., 2016), who assessed KAP about dengue infection in health personnel in Machala, Ecuador, and found a higher score in workers who were more familiar with the 2009 WHO dengue guidelines. In both studies, clinical practice guidelines were used as a reference to perform the respective knowledge questionnaire. Furthermore, the importance of knowledge of clinical practice guidelines, whether international or local, lies in the fact that they reduce unjustified variation in practice and improve the quality of medical care (Panteli et al., 2019). This premise is reinforced by the fact that, in 2022 in Peru, according to an analysis of medical records of dengue deaths, there was evidence of a lack of adherence to the 2017 Clinical Practice Guideline for the care of dengue in Peru by the health personnel who attended the patients (Ministerio de Salud del Perú, 2023f). Therefore, it is important to know the local clinical practice guidelines to avoid unfavorable outcomes in the care of patients with dengue.
Our study also found that physicians who treated at least one dengue case in the last 3 months had a higher prevalence of knowledge ≥ 70% compared to those who did not. Ruberto et al. (Ruberto et al., 2019) found similar results. In their study, the doctors who had heard about the increasing number of dengue cases in Sonora, Mexico, had higher prevalence of good knowledge compared to those who did not. These results may suggest that doctors who frequently treat dengue cases or who learned about the increase in the number of cases were more likely to have had to research and update their knowledge about the pathophysiology, diagnosis, and treatment to manage cases or prepare for the possible arrival of cases at their health centers.
Differences in dengue knowledge scores by geographic location have been previously compared in physicians from endemic and non-endemic countries (Giang et al., 2021; Koonisetty et al., 2021; Tomashek et al., 2014). However, this study divided respondents according to macroregions within the same country, and despite the fact that the Eastern macroregion tends to have the highest number of cases and is considered a dengue endemic area (Ministerio de Salud del Perú, 2023g), in the multivariable analysis, living in this macroregion was negatively associated with obtaining a score ≥ 70%. Similarly, physicians in dengue-endemic countries such as Taiwan and Puerto Rico were found to have lower scores on their dengue knowledge surveys (Ho et al., 2013; Tomashek et al., 2014). This is contradictory, as physicians from endemic areas, who treat more dengue patients in their daily clinical practice, are expected to have higher scores on dengue knowledge tests (Doblecki-Lewis et al., 2016). Nevertheless, the results of this study are inconclusive because doctors from the Eastern macro-region accounted for only 19.2% of the sample. We believe this variation should be studied further with a larger sample.
We also found that physicians who clearly expressed their viewpoint on whether the MINSA provided adequate training for healthcare personnel, whether in agreement or disagreement, showed a higher level of knowledge regarding dengue compared to those who remained neutral on the issue. Physicians who agreed probably believed they had received adequate training by MINSA on dengue and therefore might have felt more confident in diagnosing and treating dengue. This premise is consistent with the results of a study conducted by the Florida Department of Health, where a significant increase in self-confidence in recognizing dengue cases was reported, with assessment scores increasing from a pre-test mean score of 4.1 to a post-test mean score of 7.0 out of 10 (Doblecki-Lewis et al., 2016). In cases of disagreement, participants may have received different training sessions from MINSA, enabling them to compare and provide an opinion on this matter; however, there are no studies for evaluating dengue clinical management programs offered by MINSA. In an international context, the Secretary of Health of Puerto Rico presented a training course on dengue management from the Dengue Branch of the CDC and evaluated physicians' perceptions of the impact of the course on medical practice in their hospitals. All respondents noted positive changes and appreciated the content and importance of the course (Han et al., 2016). Therefore, conducting studies to evaluate the training programs offered by healthcare institutions is crucial for enhancing the practices in managing dengue fever and preventing deaths (Srisawat et al., 2022).
Regarding knowledge gaps in our population, it was noticed that less than a half of the participants (49%) correctly identified the feeding time behavior of Aedes Aegypti during the early morning and early evening. Divergent results were found across different studies in the literature. Higher rates of correct answers were reported in Ethiopia, Iran, and Ecuador, with percentages of 79% (Mohammed Yusuf and Abdurashid Ibrahim, 2019), 75.7% (Nikookar et al., 2023), and 75% (Handel et al., 2016) respectively. In contrast, lower percentages were found in a study in Taiwan 27.1% (Huang et al., 2011). While in our study, the percentage falls within the mid-range of correct responses when compared to other studies, it underscores the need for continued efforts to enhance this concept. Having a good knowledge of Aedes biting behavior is important for physicians, due to its implications for preventive measures. Also, we found that almost 60% of the physicians were aware of the existence of the dengue vaccine, similar results were found in Bhutan (Tsheten et al., 2021) where 58.8% of the participants were aware of the dengue vaccine and its indication for the population aged ≥ 9 years. Despite these results, there are factors that may reduce the vaccine applicability in the Peruvian medical practice such as the need for greater resources (The Lancet Infectious Diseases, 2018), the requirement for laboratory testing, and limitations in conducting adequate trials (Hassan et al., 2021). However, the Peruvian National Institute of Health continues to work in collaboration with other countries to obtain and implement the vaccine (Instituto Nacional de Salud, 2023), so it is expected that this situation will improve in the future.
Perception related to management of dengue fever in Peru
In the perception domain, 47.9% of the participants disagreed with the premise that the MINSA is adequately training physicians on dengue during the current outbreak. We think that the poor management of the COVID-19 pandemic in Peru could have undermined the credibility of the Peruvian government (vaccinagate, deaths) among physicians (Colegio Médico del Perú, 2021). Other important findings were that 50.7% of participants disagreed with the premise that MINSA is adequately implementing prevention and vector control measures and 63.2% of participants disagreed with the premise that MINSA has the necessary resources to address dengue cases in the current outbreak. This is possibly attributable to the unstable government which has become a feature of Peruvian politics, such chaos has filtered through to ministries, with the country having six health ministers in the past 2 years (Daniels, 2023), making it difficult to establish political health measures according to the population ́s necessities. Besides, the conjunction of rainy conditions, substantial precipitation, and flooding in Peru, intensified by the presence of Cyclone Yaku (the first cyclone recorded in the country in four decades) in March 2023, provided an ideal setting for the recent dengue outbreak in the nation (Sanjeet Bagcchi, 2023). On the other hand, we found that 71.3% of the participants felt that the MINSA should implement vaccination against dengue in the country. Although there are some countries in Latin America where the dengue vaccine is approved, such as Brazil using Dengvaxia and Qdenga vaccines (Agência Nacional de Vigilância Sanitária - Anvisa, 2023), and Argentina the Qdenga vaccine in response of 2023 outbreak (Ministerio de Salud de Argentina, 2023), the Peruvian government is evaluating whether to acquire the vaccine against dengue by 2024 (Picón Quedo, 2023). It is crucial to urge the use of dengue vaccine in the country in order to mitigate the impact of future outbreaks.
Limitations and strengths:
There are some limitations to our study. Our sample was not fully representative of the entire population of physicians in Peru. Since the study was based on an online survey, only physicians with Internet access were able to participate, resulting in a selection bias. Also, non-probability sampling was used to enroll participants, making it difficult to extrapolate the results. Another limitation was the possibility of dishonesty in answering the questions, a factor that could not be completely excluded due to the lack of supervision of the participants during the survey. Despite these limitations, the present study is the first to assess physician knowledge and perception of dengue in the current outbreak in Peru. In addition, our study involved a sample of all macro regions of Peru to better understand the differences between each macro region.