Introduction
As of May 2, 2017, the U.S. Virgin Islands (USVI), comprising St. Thomas, St. John, and St. Croix, had reported 1,021 probable or confirmed cases* of Zika virus disease in its population of approximately 100,000;[1] 222 symptomatic and asymptomatic pregnant women in the USVI had tested positive for Zika virus. In January 2016, USVI Department of Health (USVI DOH) initiated Zika response measures, including surveillance, vector control, and a communications program. Interventions included education and outreach, distribution of Zika prevention kits† to pregnant women in the USVI, and provision of free Zika virus laboratory testing and vector control services. In November 2016, USVI DOH staff members conducted interviews with convenience samples of community members and pregnant women to gather feedback about current and proposed interventions.[2] Pregnant women reported taking a median of two actions to protect themselves from Zika, with repellent use being the most commonly reported action. Community members reported taking a median of one action and were supportive of several proposed vector control approaches. Whereas multiple pregnant women and community members reported hearing messages about the cause and consequences of Zika virus infections, few recalled messages about specific actions they could take to protect themselves. Integrating evaluation into response measures permits ongoing assessment of intervention effectiveness and supports improvement to serve the population's needs.
During November 15–December 9, 2016, interviews were conducted with 269 pregnant women and community members living in the USVI to assess awareness, beliefs, and actions related to Zika virus and local prevention and control measures. USVI DOH interviewers identified commercial and clinic (public and private) locations to conduct interviews; these locations represented different locales and demographic groups of each island.[3] Interviews were conducted in English and included open- and closed-ended questions. Pregnant women were asked about receipt, use, and usefulness of interventions including Zika prevention kits, laboratory testing, and vector control services. Community members were asked about their level of support for backpack spraying, spraying from trucks, spraying from airplanes, and placement of mosquito traps in yards. Interviewers received training on obtaining consent for participation and use of the interview instruments and Epi Info for Mobile Devices,§ which permitted audio recording of questions and responses. This project was determined by CDC as not subject to Institutional Review Board review. An Atlanta-based analytics team reviewed audio files and provided feedback to field staff members to improve fidelity to protocols, analyzed closed-ended and multiple-choice responses, and transcribed, coded, and analyzed responses to open-ended questions.
A systematic process for tallying the number of interview requests and refusals was not used; however, refusals were rare. The final sample included 269 completed interviews with 104 (38.7%) pregnant women and 165 (61.3%) nonpregnant community members, including 120 (44.6%) participants on St. Croix, 116 (41.3%) on St. Thomas, and 33 (12.3%) on St. John ( Table 1 ). The median age of pregnant women respondents was 27 years (range = 18–43 years). Among 95 pregnant respondents for whom information on race/ethnicity and education was available, 58 (61.1%) were non-Hispanic black, 28 (29.5%) were Hispanic, and eight (8.4%) were non-Hispanic white. Thirty-six (37.9%) pregnant respondents were high school graduates, 25 (26.3%) attended some college, 17 (17.9%) were college graduates, and six (6.3%) had postgraduate education. Most pregnant women were in their third (48.1%) or second (37.5%) trimester of pregnancy.
Among 165 community members who were interviewed, 74 (45.7%) were male; the median age was 45 years (range = 18–81 years); 113 (70.2%) were non-Hispanic black, 21 (13.0%) were Hispanic, and 17 (10.6%) were non-Hispanic white. Fifty-one (31.5%) had less than a high school education, 43 (26.5%) were high school graduates, 45 (27.8%) had attended some college, 11 (6.8%) were college graduates, and 12 (7.7%) had postgraduate education.
Pregnant women provided a median of two responses (range = 1–5) to the question, "What have you heard about Zika?" and the most common responses were that Zika causes microcephaly or brain defects in babies (67.3%) and is transmitted by mosquitoes (34.6%) ( Table 2 ). Community members provided a median of one response (range = 0–5); the most common response was that Zika is transmitted by mosquitoes (48.5%). Only 11.5% of pregnant women and 9.1% of community members reported hearing that Zika virus can be sexually transmitted. Less than 3% of pregnant women or community members mentioned hearing about individual actions that could be taken to prevent Zika virus infection. Only 3.8% of pregnant women and 6.1% of community members stated that Zika virus transmission was occurring in the USVI.
Among 103 pregnant women, 56 (54.4%) reported being moderately or extremely concerned about becoming infected with Zika virus. Whereas 14 (13.9%) of 101 pregnant women stated it was likely or extremely likely that they would become infected, 86 (83.5%) of 103 said they were confident or very confident in their ability to protect themselves and their baby from infection during their pregnancy. Zika virus was reported as a serious or very serious health concern to the community by 124 (75.6%) community members, and to them personally by 82 (49.7%), with 69 (41.8%) stating that it was likely or very likely that they would become infected ( Table 2 ). A majority of pregnant women and community members reported having either no conversations or only one or two conversations with family members or friends about Zika in the past month ( Table 2 ).
When asked, "What actions have you taken to protect yourself from getting infected with Zika virus since you found out you were pregnant?" women reported taking a median of two actions (range = 0–6) with use of mosquito repellent (74.0%) and wearing clothing that covers arms and legs (26.9%) as the most frequently reported actions ( Table 2 ). When community members were asked what actions they had taken to protect themselves, they reported taking a median of one action (range = 0–9) with use of mosquito repellent (42.4%) the most commonly reported action ( Table 2 ).
Pregnant women were asked questions about their receipt of specific interventions and performance of specific behaviors. Among 97 pregnant women, 69 (71.1%) reported having received a Zika prevention kit ( Table 3 ) with 67.2% stating that the repellent was the most important item in the kit and the one most frequently depleted. Among 95 pregnant women for whom information on Zika testing was available, 74 (77.9%) reported having been tested; 67.6% reported receiving their test results within 2 weeks; 22 (22.4%) reported that their partner had also been tested. Among 97 pregnant women, 48 (49.5%) said they heard about the availability of vector control services. Among the 31 pregnant women who reported hearing about and being offered vector control services, 25 wanted the service and 21 had been contacted by the USVI DOH to schedule the appointment for service delivery. Twenty (80%) of the 25 pregnant women who wanted vector control services reported receiving them.
Among 102 pregnant women, 44 (43.1%) reported using insect repellent in the last 24 hours, 13 (12.7%) reported having slept under a bed net in the last 24 hours, and 27 (28.4%) reported removing standing water from their property in the past week ( Table 3 ). Among 81 pregnant women who reported having sexual intercourse since becoming pregnant, only 15 (18.8%) reported using a condom every time they had sex, whereas 46 (57.5%) reported they never used a condom. At the time of the interview, 45.5% of pregnant women were observed to be wearing long pants and 22.2% were wearing long sleeves.
Community members were asked about their level of support for vector control methods to reduce mosquito populations in their community. Among those who responded, most supported or strongly supported putting mosquito traps in their yard (91.2%) and backpack spraying (75%); 66.5% and 23.9% supported spraying from trucks and airplanes, respectively.
Morbidity and Mortality Weekly Report. 2017;66(34):909-913. © 2017 Centers for Disease Control and Prevention (CDC)
