Knowledge, attitude, and practice regarding dengue among non-health undergraduate students of Nepal (2024)

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PLoS Negl Trop Dis
v.18(5); 2024 May
PMC11161042

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PLoS Negl Trop Dis. 2024 May; 18(5): e0012222.

Published online 2024 May 28. doi:10.1371/journal.pntd.0012222

PMCID: PMC11161042

PMID: 38805553

Sheetal Bhandari, Conceptualization, Formal analysis, Investigation, Methodology, Resources, Writing – original draft,¹ Manish Rajbanshi, Formal analysis, Methodology, Writing – review & editing,^1,^* Nabin Adhikari, Writing – review & editing,¹ Richa Aryal, Methodology, Writing – review & editing,² Ksh*tij Kunwar, Methodology, Writing – review & editing,¹ and Rajan Paudel, Supervision, Writing – review & editing^1,³

Amy C. Morrison, Editor

Author information Article notes Copyright and License information PMC Disclaimer

Associated Data

Supplementary Materials

Data Availability Statement

Abstract

Dengue poses a significant public health concern worldwide. It is identified as a recent emerging infectious disease in Nepal. Understanding the situation and dynamics between knowledge, attitudes, and practices (KAP) related to dengue among students is crucial for effective prevention and control strategies. This study aimed to assess the KAP and their associated factors of dengue among non-health undergraduate students of Nepal to identify gaps and suggest appropriate interventions. A web-based cross-sectional study was conducted among 429 non-health undergraduate students at eleven Nepalese Universities, with 80% of participants from the four most prominent ones in the country. Self-administered online forms were administered via Google Forms platform predominantly through social media for data collection. Data was cleaned and then exported to IBM SPSS Statistics 20.0 for analysis. Demographic characteristics of respondents were described using descriptive statistics. Multivariate logistic regression was conducted to determine the association between individual characteristics and KAP. Pearson’s correlation coefficient was used to determine the association between knowledge-attitude, attitude-practice, and knowledge-practice. Statistical significance was determined at the P-value < 0.05. Around half of the participants were female (50.3%). The majority of participants were between 22 to 37 years, unmarried, and belonged to the Brahmin/Chhetri ethnic group. This study demonstrated a significant gap in KAP. Only 15.2% of participants had good knowledge while 25.9% and 68.3% of participants exhibited good attitudes and practices respectively. Marital status (AOR = 3.32, CI: 1.32–8.34), third-year educational level (AOR = 3.59, CI:1.34–9.57), and fourth-year educational level (AOR = 4.93, CI:1.88–12.94) were significantly associated with knowledge regarding dengue. Age (AOR = 1.73, CI: 1.10–3.01) was significantly associated with preventive practice regarding dengue. None of the demographic or socio-economic characteristics of respondents was associated with attitude on dengue. The knowledge-attitude (r_ka = 0.01), knowledge-practice (r_kp = 0.22), and attitude-practice (r_ap = 0.01) were positively correlated in this study.

Author summary

Dengue has been identified as one of Nepal’s youngest emerging infectious diseases. Nepal had its first dengue outbreak in 2006 followed by major cyclic outbreaks in 2010, 2013, 2016, 2019, and 2022.
This study particularly tried to capture the situation of the knowledge, attitude, and practice of non-health undergraduate students and to possibly help identify the gaps and to support interventions planning to improving the endemic condition of dengue.
This study found that 15.2% of participants had good knowledge, 25.9% and 68.3% of the participants had good attitudes and preventive practices regarding dengue respectively.
To bridge the gap between knowledge and practice on dengue and promote KAP on dengue, television, and social media can be effective tools as these are major sources of information about dengue.
Tailored interventions addressing demographic-specific factors are imperative for enhancing KAP on dengue prevention and control.

Introduction

Dengue is considered one of the predominant arboviral infections caused by serotypes (DENV 1–4) and is transmitted through bites of infected Aedes aegypti [1]. In the last 50 years, the incidence of dengue has increased 30 times with increasing geographic expansion and has become a major public health concern globally [2]. Around 70% of dengue cases were reported in the Asian Region [3]. Dengue is endemic in more than 100 countries, mostly among the tropical and subtropical populated areas. It is being reported predominantly in the South-East Asia Region (SEAR), the Americas and the Western Pacific region [4].

Dengue has been identified as a recent emerging infectious disease in Nepal. A substantial increase in dengue incidence has been challenging to the health system of Nepal for the prevention and control of dengue [5]. Nepal had its first dengue outbreak in 2006 followed by the major outbreak in 2010, 2013, and 2016 [6]. Tracking cyclic outbreaks, 18,000 cases were reported in 68 districts in 2019 [7]. In 2022, there had been 54,784 reported dengue cases and 88 deaths which were almost three times higher compared to 2019 marking the largest number ever recorded in the country. As of July 15, 2023, 2,930 dengue cases and 8 deaths had been identified from 68 districts [8]. The ongoing response of the Government of Nepal (GoN) towards dengue including vector control needs to be improved [9,10].

Previous studies among non-health students showed that their knowledge of dengue was poor [11]. University students represent an engaged demographic group to gauge knowledge, perceptions, and practices against vector-borne diseases like dengue. Additionally, University students can be a good source for community preparedness that will help to share knowledge with families and establish sound dengue fever preventive and control practices for the community as a whole. We view undergraduate non-health students as a potential target population to tackle the growing dengue crisis, environmental control, and community engagement and for improving prevention and control.

Previous studies have focused on community members or health-related students, the latter likely to have more knowledge than the general public. This study particularly tried to capture the situation of the knowledge, attitude, and practice of non-health undergraduate students and to possibly help identify the gaps and to support interventions planning to improving the endemic condition of dengue. The findings of the study may be the point of reference to bridge the gap to design interventional strategies in collaboration with educational institutions, communities, local health authorities, and policymakers to establish effective vector control programs and to prepare for dengue outbreaks in the future.

Methods

Ethics statement

The approval for the study was obtained from the Institutional Review Committee (IRC) of the Institute of Medicine (IOM), Tribhuvan University, Nepal (Reference no; 216 [6–11] E2 077/078). Study objectives were clearly explained on the online form to the study participants before data collection. Informed consent was obtained from participants on the first page of the online questionnaire.

Study design and setting

A web-based cross-sectional study was employed across all the provinces of Nepal. Data collection was carried out between January to April 2020.

Study population

The study population was non-health undergraduates, older than 18 years of age. Undergraduates from engineering, agriculture, management, forestry, veterinary, arts, and information technology backgrounds were classified as non-health students. It included participants from 11 national Universities in Nepal, and more than 80% of the undergraduate and postgraduate students are concentrated in the following four top Universities: Tribhuvan University (75.94%), Purbanchal University (6.23%), Pokhara University (6.91%) and Kathmandu University (4.15%).

Sample size calculation

Convenience sampling was adopted to recruit participants for data collection. Sample size was calculated using the formula N = Z²pq/d² [12]. Assuming 50.0% prevalence (p) from a previous study [13], 5% margin of error (d), 95% confidence interval (CI), and 10% non-response rate, the total number of participants for this study was determined as 424 in this study.

Data collection

A self-administered online questionnaire in English was distributed via Facebook, Gmail, WhatsApp, and Viber for data collection. No personally identifiable information was collected from study participants or included in the study analysis. Each participant was allowed to complete the form only once, maintained by setting the ’limit to one response’ feature.

Tools and measures

The study tool was obtained from a similar study conducted by Dhimal et.al in Nepal [14]. The pretesting was done among around 10% of the sample size of the study (n = 45) via online form. Cronbach’s Alpha was used to assess the reliability coefficient which is a measure of the internal consistency of the questionnaire. The result showed that Cronbach’s Alpha coefficients of KAP domains were 0.80, 0.72 and 0.74 respectively.

The KAP questionnaire (S1 Questionnaire) consists of two sections, the first section is related to the socio-economic and demographic characteristics of participants which includes: age (in completed years), sex (male/female), marital status (married/unmarried), ethnicity (Brahmin/Chhetri, Janajati, Madhesi, Dalit, Muslims, and others), education level (firstyear, second-year, third-year, and fourth-year), family monthly income (<NRs.40,000 and ≥NRs.40,000) and Province (Koshi Province, Madhesh Province, Bagmati Province, Gandaki Province, Lumbini Province, Karnali Province and Sudurpaschim Province).

The second section consisted of questions related to the knowledge, attitude and practice of dengue. Altogether there were a total of 48 questions in this section. It included 24 questions on knowledge regarding signs/symptoms, mode of transmission and preventive practices on dengue.

In the attitude section, 6 questions were on serious illness, risk and prevention of dengue, strategies to prevent dengue, the breeding place of mosquitoes, and active participation of the community in the prevention of dengue. A total of19 questions were asked on the preventive practices towards dengue among participants.

Participant’s KAP on dengue was categorized as “good” if they scored 80% or higher and “poor” otherwise, respectively. Evaluation of knowledge was done by assigning score 1 for correct response and score 0 for incorrect response. Participants were categorized into having good knowledge if they scored 19 or above and poor knowledge score below 19 in this study [14].

Participants were asked to rate their attitude on dengue using a five-point Likert scale. The scale ranged from “Strongly disagree” to “Strongly agree”. For each question, participants were assigned scores of 1, 2, 3, 4, and 5 corresponding to the following responses: Strongly Disagree, Disagree, Not Sure, Agree, Strongly Agree. Based on the total score, participants were categorized as having poor (score <24) and good attitudes (score ≥ 24).

There were a total of 19 questions related to practice. Each participant was assigned a score of 1 for positive practice and 0 for negative practice. Based on the total score, participants were categorized as having poor practice (score < 16) and good practice (score ≥ 16).

Data management and analysis

Data collected online was downloaded as a spreadsheet. All the collected information was systematically compiled, coded, checked, and edited before exporting to IBM SPSS Statistics 20.0 IBM for analysis. The respondents’ socio-economic and demographic characteristics were described using frequencies, percentages, median and interquartile ranges. We employed multivariate logistic regression analysis to investigate the association between individual characteristics and participants’ KAP on dengue. The model was constructed with individual characteristics as independent variables and KAP served as the dependent variable, dichotomized into ’good’ and ’poor’ categories. The significance of associations was determined using P-values. Adjusted Odds Ratios (AOR) with 95% Confidence Interval (CI) were calculated to quantify the strength and direction of these associations. Pearson’s correlation coefficient was used to determine the relationship between knowledge-attitude, attitude-practice, and knowledge-practice. The statistical significance was set at P-value <0.05.

Results

Individual characteristics of the participants

Out of 590 participants invited to participate in our study, 429 responded, yielding a response rate of 72.2%. The study included a nearly equal distribution of females (50.3%) and males (49.7%). Over half of the participants (54.1%) were between the age of 22 and 37 years. The majority of participants (71.8%) belonged to Brahmin/Chhetri ethnic group followed by Janajati (15.6%). Nearly all of the participants (94.2%) were unmarried. This study represented all four years of undergraduates with the highest participation from fourth-year students (38.2%), followed by first-year (28.9%), third-year (19.6%) and second-year students (13.3%) respectively.

In this study, the majority of the participants (63.2%) belonged to families having a monthly income of below 303.03 USD. Most participants were from Lumbini Province (41.5%) and Bagmati Province (24.7%) as these provinces have the greatest number of colleges compared to other. (Table 1)

Table 1

Individual characteristics of the participants.

Characteristics	Numbers (n)	Percentage (%)
Sex
Female	216	50.3
Male	213	49.7
Age group (in years) Median ± IQR = (22.0±3.0)
18–21	197	45.9
22–37	232	54.1
Ethnicity
Brahmin/Chhetri	308	71.8
Janajati	67	15.6
Madhesi	24	5.6
Dalit	12	2.8
Others (Marwari, Bangali)	18	4.2
Marital status
Unmarried	404	94.2
Married	25	5.8
Educational level
First-year	124	28.9
Second-year	57	13.3
Third-year	84	19.6
Fourth-year	164	38.2
Monthly income of the family (in NRs)
Below or equal to NRs. 40000 (≤USD 303.03)	267	63.2
Above NRs. 40000 (>USD 303.03)	162	37.8
Province
Koshi Province	61	14.2
Madhesh Province	33	7.7
Bagmati Province	106	24.7
Gandaki Province	20	4.7
Lumbini Province	178	41.5
Karnali Province	18	4.2
Sudurpaschim Province	13	3.0

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Demographics of participants in a knowledge, attitude, and practices (KAP) study on Dengue. This table summarizes the demographic characteristics of the participants who participated in the study (Table 1).Sources of information on dengue

The most common sources of information on dengue among participants were television (16.2%) followed by social media (15.6%).

Knowledge on dengue among the participants

The majority of the participants recognized fever (90.0%), headache (67.1%) and rash (59.7%) as major signs/symptoms of dengue. However, only 13.5% incorrectly stated that all mosquitoes could transmit dengue. Around (67.0%) were aware that Aedes mosquitoes transmit dengue. This study found that 43.6% and 34.5% of the participants believed dengue could be transmitted by flies/ticks and from the infected person with dengue, respectively. Most participants (71.3%) correctly observed that dengue could be transmitted by blood transfusion but 46.6% incorrectly thought transmission could occur through contaminated water and food. The majority (80.7%) of the participants were aware of the way of reducing mosquito bites by using mosquito screens, bed nets and while 81.4% were aware of being able to do so using insecticide sprays. (Table 2)

Table 2

Knowledge on dengue among participants.

Statements	Correct response n (%)
Knowledge on signs/symptoms
Fever	386 (90.0)
Headache	288 (67.1)
Rash	256 (59.7)
Nausea/vomiting	219 (51.0)
Joint pain	213 (49.7)
Muscle pain	190 (44.3)
Pain behind eyes	172 (40.1)
Back pain	90 (21.0)
Diarrhea	86 (20.0)
Stomach pain	61 (14.2)
Knowledge on transmission
All mosquito transmits dengue fever	58 (13.5)
Aedes mosquito transmit dengue fever	286 (66.7)
Flies and ticks transmit dengue fever	187 (43.6)
Ordinary person-to-person contact transmits dengue fever	148 (34.5)
Transmitted through food and water	200 (46.6)
Transmitted by blood transfusion	306 (71.3)
Mosquito breed in stagnant water	365 (85.1)
Mosquito screens and bet nets reduce mosquito	346 (80.7)
Insecticide sprays reduce mosquito and prevent dengue	349 (81.4)
Tightly covering water containers reduce mosquitoes	334 (77.9)
Removal of standing water can prevent mosquito breeding	378 (88.1)
Mosquito repellants prevent mosquito bite	313 (73.0)
*Can you identify Aedes* mosquito**	167 (38.9)
Dengue mosquito feeding time
Day time	192 (44.8)
Night time	237 (55.2)

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Knowledge on dengue among participants. This table summarizes participants’ understanding of dengue signs/symptoms, transmission methods, and preventive measures (Table 2).

Factors associated with knowledge on dengue among participants

Table 3 presents the results of multivariate logistic regression analysis investigating the factors associated with knowledge on dengue among the study participants. Only 15.2% of the participants had good knowledge on dengue. Married participants exhibited higher knowledge levels compared to the unmarried participants, indicating a significant association (AOR: 3.32, 95% CI: 1.32–8.34). Participants in their third and fourth University year demonstrated significantly higher knowledge levels compared to those in their first year (AOR: 3.59, 95% CI: 1.34–9.57; AOR: 4.93, 95% CI: 1.88–12.94, respectively).

Table 3

Factors associated with knowledge on dengue among the participants.

Characteristics	Knowledge			Multivariate logistic regression
				Good knowledge
	Good n (%)	Poor n (%)	P-value	AOR	95% CI	P-value
Level of knowledge	65 (15.2)	364 (84.8)
Age
18–21	21 (10.7)	176 (89.3)	0.01	1.0 (ref.)		0.49
22–37	44 (19.0)	188 (81.0)		0.77	0.37–1.61
Sex
Male	34 (16.0)	179 (84.0)	0.6	1.0 (ref.)		0.50
Female	31 (14.4)	185 (85.6)		0.82	0.47–1.44
Marital status
Unmarried	56 (13.9)	348 (86.1)	0.005	1.0 (ref.)		0.01
Married	9 (36.0)	16 (64.0)		3.32	1.32–8.34
Education level
First-year	8 (6.5)	116 (93.5)	0.00	1.0 (ref.)		0.008
Second-year	5 (8.8)	52 (91.2)	0.5	1.53	0.47–4.96	0.47
Third-year	14 (16.7)	70 (83.3)	0.02	3.59	1.34–9.57	0.01
Fourth-year	38 (23.2)	126 (76.8)	0.00	4.93	1.88–12.94	0.001
Monthly income
Below or equal to NRs. 40000 (≤USD 303.03)	36 (13.5)	231 (86.5)	0.2	1.0 (ref.)		0.29
Above NRs. 40000 (>USD 303.03)	29 (17.9)	133 (82.1)		1.35	0.77–2.36

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A summary of factors associated with knowledge on dengue among participants (Table 3). Good knowledge refers to a higher understanding of dengue compared to poor knowledge.

Additionally, no significant associations were found between sex, age, and monthly income level with knowledge of dengue among the participants.

Attitude on dengue among the participants

In this study, more than half of the participants (55.5%) agreed that dengue is a serious disease. Furthermore, one-third (32.4%) agreed that they were at risk of contracting dengue. More than half of the participants (54.1%) believed that dengue could be prevented. Half of the participants (47.8%) strongly agreed that controlling the breeding place is a good strategy to prevent dengue. While 45% of the participants strongly agreed that dengue breeds in stagnant water of pots and bottles. (Table 4)

Table 4

Attitude on dengue among the participants.

Statements	Strongly agree	Agree	Disagree	Strong disagree	Not sure
	n (%)	n (%)	n (%)	n (%)	n (%)
Dengue fever is a serious disease	160 (37.3)	238 (55.5)	17 (4.0)	2 (0.5)	12 (2.8)
Risk of getting dengue	33 (7.7)	139 (32.4)	82 (19.0)	25 (5.8)	150 (35.0)
Dengue fever can be prevented	165 (38.5)	232 (54.1)	5 (1.2)	0 (0)	27 (63.0)
Good strategy to prevent dengue is controlling the breeding place	205 (47.8)	186 (43.4)	13 (3.0)	4 (0.9)	21 (4.9)
Stagnant water in pots/bottles are breeding places for Aedes	193 (45.0)	186 (43.4)	9 (2.1)	3 (0.7)	38 (8.9)
Communities are responsible for controlling the vector of dengue	269 (62.7)	136 (31.7)	6 (1.4)	2 (0.5)	16 (3.7)

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A summary of participants’ attitudes on dengue (Table 4). This table explores how participants view the seriousness of dengue, their perceived risk of getting it, and their beliefs about prevention strategies.

Factors associated with attitude on dengue among the participants

In this study, almost three-fourths of the participants (74.1%) had a poor attitude on dengue. However, the attitude was not found to be associated with any individual characteristics of the study participants.

Practice on dengue among the participants

Table 5 shows the frequency of use of common dengue prevention practices including preventing human/mosquito contact (73.2%), use of insecticide spray (77.9%), use of window screens (84.4%), eliminating standing water around the house (85.8%), cutting down the bushes in the yard (83.9%), using mosquito coils/repellent cream (82.1%), garbage removal (92.1%), disposal of water containing containers (90.2%), and covering body with clothes (88.6%). Additionally, 14.0% believed that even doing nothing could reduce mosquitoes.

Table 5

Practice on dengue among the participants.

Statements	Correct response n (%)
Use insecticide spray	334 (77.9)
Prevent mosquito man contact	314 (73.2)
Use professional pest control	294 (68.5)
Use window screens	362 (84.4)
Eliminate standing water around the house	368 (85.8)
Cut down bushes in the yard	360 (83.9)
Using mosquito eating fish	216 (50.3)
Using mosquito’s coils/mosquito repellent cream	352 (82.1)
Removal of garbage/trash	395 (92.1)
Disposing water holding containers such as tires, parts of automobiles, plastic bottles, crack pots etc.	387 (90.2)
Use of fan to drive repelling mosquitoes	269 (62.7)
Use of smoke to drive away mosquitoes	206 (48.0)
Covering body with clothes	380 (88.6)
Do nothing to reduce mosquitoes	60 (14.0)
Eliminating mosquito breeding sites	373 (86.9)
Covering water containers in house	391 (91.1)
Government spray insecticide for controlling mosquitoes	270 (62.9)
Turning containers upside down to avoid water collection	309 (72.0)
Frequently cleaning water-filled containers and ditches around the house
Always	44 (10.3)
Often	86 (20.0)
Sometimes	290 (67.6)
Never	9 (2.1)

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Practices on dengue prevention among participants (Table 5). This table summarizes the different methods participants use to prevent dengue mosquito breeding and bites.

Factors associated with practice on dengue among the participants

Table 6 displays the results of multivariate logistic regression analysis examining the factors associated with the practice of dengue prevention and control among the study participants. More than two-thirds of the participants (68.3%) had good dengue prevention and control practices in this study. Participants aged 22–37 years demonstrated a significantly higher likelihood of practicing good dengue prevention and control measures compared to those aged 18-21(AOR: 1.73, 95% CI: 1.10–3.01). Additionally, no significant associations were observed between sex, marital status, and different educational levels with dengue prevention and control practices among the participants.

Table 6

Factors associated with practice on dengue among the participants.

Characteristics	Practice			Multivariate logistic regression
				Good practice
	Good n (%)	Poor n (%)	P-value	AOR	(95% CI)	P-value
Level of practice	293 (68.3)	136 (31.7)
Age
18–21	123 (62.4)	74 (37.6)	0.01	1.0 (ref.)		0.04
22–37	170 (73.3)	62 (26.7)		1.73	1.10–3.01
Sex
Male	149 (70)	64 (30)	0.46	1.0 (ref.)		0.77
Female	144 (66.7)	72 (33.3)		0.94	0.61–1.43
Marital Status
Married	15 (60)	10 (40)	0.35	1.0 (ref.)		0.20
Unmarried	278 (68.8)	126 (31.2)		0.57	0.24–1.34
Educational level
First-year	80 (64.5)	44 (35.5)	0.27	1.0 (ref.)		0.92
Second-year	36 (63.2)	21 (36.8)		0.86	0.44–1.67	0.66
Third-year	61 (72.6)	23 (27.4)		1.08	0.56–2.09	0.80
Fourth-year	116 (70.7)	48 (29.3)		0.92	0.48–1.76	0.82
Monthly income
Below or equal to NRs. 40000 (≤USD 303.03)	187 (70.0)	80 (30.0)	0.3	1.0 (ref.)		0.33
Above NRs. 40000 (>USD 303.03)	106 (65.4)	56 (51.4)		0.80	0.52–1.24

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Factors associated with practices on dengue prevention among participants (Table 6). This table summarizes the association between participant characteristics and their dengue prevention practices. ’Good practice’ refers to participants who adopted more preventative measures.

Correlation between knowledge, attitude and practice on dengue of the study participants

This study found a positive correlation coefficient between knowledge, attitude and practice on dengue (r_ka = 0.01, r_kp = 0.22, r_ap = 0.01). (Table 7)

Table 7

Correlation between knowledge, attitude and practice on dengue.

	Knowledge	Attitude	Practice
Knowledge	1	0.010	0.221
Attitude	0.010	1	0.013
Practice	0.221	0.013	1

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Correlation between knowledge, attitude and practice on dengue (Table 7). This table shows the strength of the correlation between participants’ knowledge of dengue, their attitude about dengue prevention, and the practices they take to prevent dengue.

Discussion

Undergraduate students represent a significant segment of the young population and can serve as key agents in spreading accurate information about dengue, thereby contributing to raising awareness and fostering behavioral changes within their communities [15].

This study showed that 15.2% of the students exhibited good knowledge which is quite comparable to a similar study in Nepal [14] but contrasts with the studies conducted in some other countries (Jamaica, Bangladesh and Malaysia) [11,16,17]. Although lower, students in Nepal had higher levels of knowledge compared to the general population which could be due to the students being the major group particularly involved within the internet and social media to explore health-related issues. Another reason could be that students are also connected to different groups and sectors where they can access and exchange health-related information from various sources. However, our study has different outcomes than reported with similar studies conducted in Indonesia, India, Nepal, and Malaysia [13,18–20]. Thus, comparatively good knowledge among the students reflects that they have an adequate awareness level that can be used to aware communities. Our findings also demonstrated that there is a significant gap in the KAP on dengue among undergraduate students, demonstrating an urgent need for improved public education and outreach about these issues in Nepal, a country which is experiencing a surge in cases and deaths due to dengue since 2022.

Most of the respondents were able to correctly identify typical symptoms of dengue. Among them, fever (90%) and headache (67.1%) were the most frequently mentioned symptoms and that is similar to the studies conducted in Jamaica, Bangladesh, Sri Lanka, India, and Nepal [11,16,18,19,21].

Half of the participants failed to mention other recognized symptoms of dengue such as pain behind the eyes and back pain. It could be because most participants were not experienced with the disease or had not witnessed a case from a close relative or a friend previously. Additionally, almost one-third (34.5%) of respondents also believed that ordinary person-to-person contact could also transmit dengue, possibly due to confusion with other communicable diseases such as COVID-19 and influenza.

Our study reported that most people were unaware of the transmission of dengue. Only 38% could correctly identify the vector (Aedes mosquito) responsible for causing dengue. This finding was supported by similar studies conducted in Sri Lanka [21] and Nepal [15].

This study demonstrated a positive correlation between knowledge, attitude, and practice. This finding is consistent with similar studies conducted in Nepal, Thailand and Jamaica [16,19,22]. This suggests an opportunity for proportionately improving all domains of KAP by working on one or more domain improvements. Another reason could be that the higher the health literacy, the more positive the attitude, and preventive practices.

Most of the participants reported that television, social media and teachers were predominant sources on accessing information regarding dengue which is similar to the findings reported by Jamaica, India and Malaysia [16,18,20].

This study found that knowledge was significantly associated with marital status and educational level, consistent with the findings from studies conducted in Malaysia, Nepal and Indonesia [13,17,19]. It might be due to the high health literacy level among adults. This is supported by a study done in Malaysia which revealed that educational intervention was effective in creating positive awareness about dengue [20] and was associated with preventive practices regarding dengue. This implies that younger participants were more likely to engage in dengue preventive practices.

This study demonstrated that married participants had a better level of knowledge than unmarried. It could be that married couples often share their daily experiences including health information, and if one partner has access to health-related information or works in the health sector, they may share their knowledge with family members.

This study highlighted that the current level of KAP on dengue demands effectively designed community-based interventions to improve prevention and control strategies regarding dengue.

Limitations

Due to the COVID-19 pandemic, this study was conducted online, this limited to participate the students without internet access. This study relies on self-report measures; therefore, it is possible that some participants may not have responded accurately. This study was limited with respect to environmental factors like climatic conditions, temperature, precipitation, and rainfall which could influence the prevalence of dengue.

Conclusion

Around 15.2% of non-health undergraduates in Nepal have good knowledge on dengue while 25.9% and 68.3% of them have good attitudes and good practices respectively. This suggests the gap in the knowledge, attitude, and practices (KAP) on dengue among undergraduate students. There were significant gaps in understanding certain aspects of the disease transmission and symptoms among non-health undergraduates. To control this recently emerging disease, community-based interventions, and school health education can be the medium to help spread awareness on dengue.

To bridge the gap between knowledge and practice on dengue and promote KAP on dengue, television and social media can be effective tools as these are major sources of information about dengue. Tailored interventions for different demographic groups such as the young and old, married and unmarried are necessary to improve knowledge and encourage dengue prevention practices across the entire population. There was a positive correlation between knowledge, attitude, and practice, indicating that enhancing knowledge could lead to more favorable attitudes and practices toward dengue prevention.

Recommendation

The federal government should support schools and Universities in implementing health programs by providing guiding documents while also expanding its national dengue awareness campaign, targeting high-risk communities and planning tailored demographic interventions in collaboration with local governments.

Local governments can help promote KAP on dengue by implementing targeted educational and awareness campaigns, practical training on dengue prevention practices, tailoring interventions to specific demographic groups, supporting school-based preventive programs, and engaging in community-led actions for dengue prevention and improving preventive behaviors. These measures can significantly reduce dengue morbidity and mortality, promoting public health and well-being.

Supporting information

S1 Questionnaire

Knowledge, Attitude and Practices regarding Dengue among non-health undergraduate students of Nepal.

(DOCX)

Click here to view.^{(2.7M, docx)}

Acknowledgments

We would like to acknowledge all the faculty of the Central Department of Public Health, Institute of Medicine, Tribhuvan University, Nepal for their guidance during the research project. Our appreciation goes to all individuals responding to the questionnaire for their participation.

Funding Statement

The author(s) received no specific funding for this work.

Data Availability

The data is publicly available on data repository. URL: https://doi.org/10.6084/m9.figshare.25796230.v1.

References

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PLoS Negl Trop Dis. 2024 May; 18(5): e0012222.

Decision Letter 0

2024 May; 18(5): e0012222.

Published online 2024 May 28. doi:10.1371/journal.pntd.0012222.r001

Audrey Lenhart, Section Editor and Mei L. Trueba, Guest Editor

30 Oct 2023

Dear Mr. Rajbanshi,

Thank you very much for submitting your manuscript "Knowledge, attitude and practice regarding dengue among non-health undergraduate students of Nepal" for consideration at PLOS Neglected Tropical Diseases. As with all papers reviewed by the journal, your manuscript was reviewed by members of the editorial board and by several independent reviewers. In light of the reviews (below this email), we would like to invite the resubmission of a significantly-revised version that takes into account the reviewers' comments.

This is an important subject, but the manuscript requires susbstantial revisions.

We cannot make any decision about publication until we have seen the revised manuscript and your response to the reviewers' comments.

We cannot make any decision about publication until we have seen the revised manuscript and your response to the reviewers' comments. Your revised manuscript is also likely to be sent to reviewers for further evaluation.

When you are ready to resubmit, please upload the following:

[1] A letter containing a detailed list of your responses to the review comments and a description of the changes you have made in the manuscript.Please note while forming your response, if your article is accepted, you may have the opportunity to make the peer review history publicly available. The record will include editor decision letters (with reviews) and your responses to reviewer comments. If eligible, we will contact you to opt in or out.

[2] Two versions of the revised manuscript: one with either highlights or tracked changes denoting where the text has been changed; the other a clean version (uploaded as the manuscript file).

Important additional instructions are given below your reviewer comments.

Please prepare and submit your revised manuscript within 60 days. If you anticipate any delay, please let us know the expected resubmission date by replying to this email. Please note that revised manuscripts received after the 60-day due date may require evaluation and peer review similar to newly submitted manuscripts.

Thank you again for your submission. We hope that our editorial process has been constructive so far, and we welcome your feedback at any time. Please don't hesitate to contact us if you have any questions or comments.

Sincerely,

Mei L. Trueba, PhD

Guest Editor

PLOS Neglected Tropical Diseases

Audrey Lenhart

Section Editor

PLOS Neglected Tropical Diseases

***********************

This is an important subject, but the manuscript requires susbstantial revisions.

We cannot make any decision about publication until we have seen the revised manuscript and your response to the reviewers' comments.

Reviewer's Responses to Questions

Key Review Criteria Required for Acceptance?

As you describe the new analyses required for acceptance, please consider the following:

Methods

-Are the objectives of the study clearly articulated with a clear testable hypothesis stated?

-Is the study design appropriate to address the stated objectives?

-Is the population clearly described and appropriate for the hypothesis being tested?

-Is the sample size sufficient to ensure adequate power to address the hypothesis being tested?

-Were correct statistical analysis used to support conclusions?

-Are there concerns about ethical or regulatory requirements being met?

Reviewer #1: Sample size calculation: How the authors confirm the equal participation from the provinces or considered other factors for the selection of the samples to generalized the results.

Discuss in briefly about the sample size calculation using the formula with non-response rate

Study population age group: is it 18-22 or up to 25?

Ethical clearance: Is the clearance from Institute of Medicine (IOM), Tribhuvan university is applicable for all University? What about NHRC clearance for this study.

Reviewer #2: -Are the objectives of the study clearly articulated with a clear testable hypothesis stated? Yes

-Is the study design appropriate to address the stated objectives? Yes

-Is the population clearly described and appropriate for the hypothesis being tested? Yes

-Is the sample size sufficient to ensure adequate power to address the hypothesis being tested? Yes

-Were correct statistical analysis used to support conclusions? I am not a statistician but in my understanding, analysis need to be conducted multivariate analyses

-Are there concerns about ethical or regulatory requirements being met? Yes

--------------------

Results

-Does the analysis presented match the analysis plan?

-Are the results clearly and completely presented?

-Are the figures (Tables, Images) of sufficient quality for clarity?

Reviewer #1: Results: I suggest to highlights the important result findings of table rather than explaining too much below the particular table

- - P<00.5 significant value indicates by asterisk rather than bold in table

- Please construct the 2x2 table throughout the manuscript as far as possible. including table 5

There are too many irreverent tables. It is suggested to remove tables if there are no significant results including table 5.

Fig: 1 It is suggested for further formatting

It is some how difficult to understand the knowledge in relation to marital status? Could you explain?

Discussion needs rewriting to discuss finding in relation to previous publications and high lighting the major issues to be focused since the disease is first reported 2004.

It is also suggested to have clear recommendation for the local and national government based on the finding.

Reviewer #2: -Does the analysis presented match the analysis plan? As mentioned, instead of univariate, multivariate analysis would be better

-Are the results clearly and completely presented? These will change according to the analysis

-Are the figures (Tables, Images) of sufficient quality for clarity? Yes

--------------------

Conclusions

-Are the conclusions supported by the data presented?

-Are the limitations of analysis clearly described?

-Do the authors discuss how these data can be helpful to advance our understanding of the topic under study?

-Is public health relevance addressed?

Reviewer #1: The conclusion was given, but not much was supported by the findings. There are some descriptions mentioned on the limitation that need further clarification. It has discussed the usefulness of the data. However, further recommendations for the system should be mentioned in more detail.

Reviewer #2: -Are the conclusions supported by the data presented? This may change after the multivariate analysis

-Are the limitations of analysis clearly described? Please see my comments

-Do the authors discuss how these data can be helpful to advance our understanding of the topic under study? Yes

-Is public health relevance addressed? Yes

--------------------

Editorial and Data Presentation Modifications?

Use this section for editorial suggestions as well as relatively minor modifications of existing data that would enhance clarity. If the only modifications needed are minor and/or editorial, you may wish to recommend “Minor Revision” or “Accept”.

Reviewer #1: (No Response)

Reviewer #2: (No Response)

--------------------

Summary and General Comments

Use this section to provide overall comments, discuss strengths/weaknesses of the study, novelty, significance, general execution and scholarship. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. If requesting major revision, please articulate the new experiments that are needed.

Reviewer #1: Major comments: This MS was prepared based on a web-based interview with a non-health undergraduate student from four universities in Nepal. I wonder why the four universities selected the undergraduate non-health group was selected in this study. The other point is the language of the questioners: is it in English or Nepali? I could find if the author performed preformed pretesting and validation the questioners. The questions are so specific that they can only be understood by health workers, and these seem to be leading questions that have different outcomes. How have you defined non-health and health groups? Justification for adding value to this paper in relation to previous publications, including Dhimal et al. and others? There are lots of redundancies and duplications in the MS and the tables. The other important and pertinent issue is that there is not much emphasis on climatic factors, including temperature, precipitation, or rainfall.

Minor comments

• Write complete form of KAP in the initially in the abstract.

• Page 4, line 68 mentioned focused based awareness including street families. I am not aware of the such families in Nepal! Can author clarify.

• Typographical error on page line 121 term strongly used twice? Needs appropriate correction.

• Line 149-150 error 94.2% married does not correlate with the Table 1.

• The meaning is not understandable on Page 20 lane 216. It is suggested to rewrite.

• It seems appropriate attention was not given preparing MS since several there are careless mistakes.

• Grammatical errors should be addressed properly.

Reviewer #2: The study is important as Dengue is considered endemic in Nepal and is associated with significant socioeconomic burden for the country. The study is well conducted but few issues needs to be considered before publication.

As the sampling was convenience, how many students were approached for the survey? What was the response rate?

The analysis consists of several univariate analyses using chi squared test and correlation. Multivariate analysis using logistic regression would be more appropriate to identify independent predictors of knowledge, attitude and practice.

In the discussion section, it would be good to discuss the stigma associated with the disease regarding common misconception that the disease can spread directly from person to person.

The limitation of convenience sampling should be discussed in the limitation section.

The questionnaire needed to be provided in the supplementary file.

--------------------

PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

Attachment

Submitted filename: Reviewer Response.docx

Click here to view.^{(30K, docx)}

PLoS Negl Trop Dis. 2024 May; 18(5): e0012222.

Decision Letter 1

2024 May; 18(5): e0012222.

Published online 2024 May 28. doi:10.1371/journal.pntd.0012222.r003

Amy C. Morrison, Section Editor

1 Apr 2024

Dear Mr. Rajbanshi,

Thank you very much for submitting your manuscript "Knowledge, attitude, and practice regarding dengue among non-health undergraduate students of Nepal" for consideration at PLOS Neglected Tropical Diseases. As with all papers reviewed by the journal, your manuscript was reviewed by members of the editorial board and by several independent reviewers. In light of the reviews (below this email), we would like to invite the resubmission of a significantly-revised version that takes into account the reviewers' comments.

Section Editor Comments

I have taken over for Dr. Lenhart and taken the opportunity to provide another review of the revised manuscript. Below I try to provide a roadmap that will get this manuscript accepted for publication as all reviewer’s saw relevance and value in the publication. I have also taken the opportunity to edit the manuscript using the word version provided by the authors. All my suggestions are optional, and my assumption is that most grammatical errors were removed but some additional editing will improve understanding and the flow of the manuscript. Additionally, I include some comments to the review responses, and argue for inclusion of more of those responses in the body of the manuscript.

Previous Review Responses:

Reviewer #1 had a few questions associated with sample size and study design. (Sample size calculation: How did the authors confirm equal participation from the provinces or consider other factors for the selection of samples to generalize the results?, Study population age group: is it 18-22 or up to 25?) and Reviewer #2 asked how many students were approached.

Editor: To better address these concerns more details are needed in the study design and setting section. Principally, how did you approach students and who did you choose? I’m guessing you were able to email students inviting them to go to a link taking you to the online form. Alternatively, some kind of advertisem*nt asking students to participate was distributed. It looks like students were recruited from the top four universities in Nepal. It would be easier to justify your approach, by simply stating that our aim was to understand Knowledge, Attitudes, and Practices of non-health oriented students and we selected these Universities because the had students from the widest cross section of provinces across Nepal and had access to the internet, etc. (not trying to put words in your mouth, but give us the reason you selected this population). This may represent the best and brightest and that would be something you would point out but seems like a reasonable starting point. Getting a perfectly representative sample is always very difficult so don’t claim that was your aim.

• You need to better describe how you made contact with students and incorporate your response to Reviewer #2 about the response rate to the questionnaire.

• Report the range of age, from your response one still asks if the range is from 19-22 or 19-25. For example, in Table 1 instead of Less than 22 and 22 or above include the ranges, i.e. 19-21 versus 22-25.

• For provinces, perhaps you can included Bagmati and Lumbini (assuming they are closest to the named universities) and Other (you can list the as a footnote).

• When updating this sections, please give the reasons why you selected these 4 universities and what segment of the Nepalese population they are likely to represent.

• State in the methods that the form was administered in English.

• Add your response to Major comment from Reviewer #1. That is add a section to the methods on validation and pretesting of the study instrument.

• Include the definition of non-health students (also in the response to Major comments Reviewer #1) in this section.

• Ethical clearance: I am not as concerned about this, but all individuals who worked with identifiable information (PII) should have approval from each person’s institution or have those institutions defer to Tribhuvan University. Usually this is done through what is called a relying agreement or a letter indicating this was okay with each of the other institutions.

• In the Data management and analysis section, you should state that you carried out a multivariate analysis, but no significant differences were found and will not be discussed more, however this suggests that some of your univariate findings are due to confounding and should be interpreted with caution.

• In addition, to the inclusion of the questionnaire, you should indicate what you scored as a “correct” answer. In regard to this in Table 2, perhaps you could highlight statements that are incorrect in another color to distinguish with statements that are true. I will put the incorrect statements in red.

Other comments and observations:

• “youngest” emerging infection. Note sure what you mean by that. Do you a “recent”?

• Abstract – see some of my edits in yellow highlight or by comment. I have some concerns about Lines 40-42 and Lines 43-49.

• Introduction: see edits in yellow highlight.

• Methods: While you clearly describe how knowledge was scored (80%), it is not clear how you scored Attitudes or Practices. Because of the Likert scale it would be different for Attitudes. You do not describe how “Not sure’s” are handled. You should clearly state for each section the maximum number of points awarded.

• Methods: We need a bit information, based on the previous question on the correlation analysis. Were all percentages or was the correlation analysis done with absolute scores. I would like to see a regression of these data. It is difficult to believe the negative correlation of attitudes with practices, we need to understand that. There is often a gap between knowledge and practice, but I think you might consider a knowledge-Attitude combined score.

• Methods: Need to mention you tried a multi-variate model. My strong suggestion would be to ask for some statistical help on this. Additionally, you should look into logistic regression for your univariate analysis as well. Chi squares to test for independence of two variables but not an association.

• Results: Is a bed net viewed as a preventative measure for dengue? Aedes aegypti is a daybiter so bed nets really are not protective.

• Results: Age and education level look confounded here. You could try a stratified analysis looking to find if you where you look at young people with more education, older people with less education, young people with less education and older people with more education.

• Results: You can’t do anything about it now, but I don’t like your questions associated with breeding sites (larval habitats). No questions about mosquito larvae and if people get they become adult mosquitoes. Also don’t like reference to “broken” containers. Aedes is very happy in intact containers.

• Results: LINES 195-199. WHAT IS A POOR ATTITUDE ON DENGUE AND HOW WAS THAT CALCULATED? IF you add strongly agree with agree, seems like most respondents have an appropriate attitude about dengue, although some of these questions are more about knowledge.

CRITICAL ISSUES.

• How were attitude and practice scores calculated.

• Correlation analysis seems wrong – I can not access the data set which should be saved in csv or txt format.

When you are ready to resubmit, please upload the following:

[2] Two versions of the revised manuscript: one with either highlights or tracked changes denoting where the text has been changed; the other a clean version (uploaded as the manuscript file).

Important additional instructions are given below your reviewer comments.

Sincerely,

Amy C. Morrison, PhD

Section Editor

PLOS Neglected Tropical Diseases

Amy Morrison

Section Editor

PLOS Neglected Tropical Diseases

***********************

Section Editor Comments

Previous Review Responses:

• You need to better describe how you made contact with students and incorporate your response to Reviewer #2 about the response rate to the questionnaire.

• For provinces, perhaps you can included Bagmati and Lumbini (assuming they are closest to the named universities) and Other (you can list the as a footnote).

• When updating this sections, please give the reasons why you selected these 4 universities and what segment of the Nepalese population they are likely to represent.

• State in the methods that the form was administered in English.

• Add your response to Major comment from Reviewer #1. That is add a section to the methods on validation and pretesting of the study instrument.

• Include the definition of non-health students (also in the response to Major comments Reviewer #1) in this section.

Other comments and observations:

• “youngest” emerging infection. Note sure what you mean by that. Do you a “recent”?

• Abstract – see some of my edits in yellow highlight or by comment. I have some concerns about Lines 40-42 and Lines 43-49.

• Introduction: see edits in yellow highlight.

• Results: Is a bed net viewed as a preventative measure for dengue? Aedes aegypti is a daybiter so bed nets really are not protective.

CRITICAL ISSUES.

• How were attitude and practice scores calculated.

• Correlation analysis seems wrong – I can not access the data set which should be saved in csv or txt format.

Reviewer's Responses to Questions

Key Review Criteria Required for Acceptance?

As you describe the new analyses required for acceptance, please consider the following:

Methods

-Are the objectives of the study clearly articulated with a clear testable hypothesis stated?

-Is the study design appropriate to address the stated objectives?

-Is the population clearly described and appropriate for

Attachment

Submitted filename: Review to PlOS NTD.docx

Click here to view.^{(16K, docx)}

Attachment

Submitted filename: Tracked version_KAP_Nepal.docx

Click here to view.^{(426K, docx)}

PLoS Negl Trop Dis. 2024 May; 18(5): e0012222.

Author response to Decision Letter 1

2024 May; 18(5): e0012222.

Published online 2024 May 28. doi:10.1371/journal.pntd.0012222.r004

5 Apr 2024

Attachment

Submitted filename: Reviewer Response (R2).docx

Click here to view.^{(24K, docx)}

PLoS Negl Trop Dis. 2024 May; 18(5): e0012222.

Decision Letter 2

2024 May; 18(5): e0012222.

Published online 2024 May 28. doi:10.1371/journal.pntd.0012222.r005

Amy C. Morrison, Section Editor

11 Apr 2024

Dear Mr. Rajbanshi,

Please see my responses in red to your response document.

Overall the manuscript is much improved, but I must insist that you redo your statistical analysis. At a minimum you need to present Univariate logistic regression instead of Chisquare analysis. Conclusions will probably be very similar. You need to provide some evidence that you tried to build an appropriate multivariate model, using some model building strategy (Forward selection / backward selection or some alternative). At some point you should have a model if only a few variable stay in.

You need to explore the relationships between Age and Education, you have the data to do so, as suggest in my review graph it and look to see if anything jumps out, but it is in no way beyond the scope of your analysis.

See my suggestion on the correlation analysis. I can live with it but you should not talk about statistically insignificant results like they are significant. No significant correlation and stop there.

Please address my remaining queries in red.

I've also included a word version with edits. There was some very wierd formating issues so I just had to rescue the text. Just compare this version to your next version and I think most of my changes are appropriate.

All the best,

Amy

When you are ready to resubmit, please upload the following:

[2] Two versions of the revised manuscript: one with either highlights or tracked changes denoting where the text has been changed; the other a clean version (uploaded as the manuscript file).

Important additional instructions are given below your reviewer comments.

Sincerely,

Amy C. Morrison, PhD

Section Editor

PLOS Neglected Tropical Diseases

Amy Morrison

Section Editor

PLOS Neglected Tropical Diseases

***********************

Please see my responses in red to your response document.

Please address my remaining queries in red.

All the best,

Amy

Figure Files:

Data Requirements:

Reproducibility:

Attachment

Submitted filename: Reviewer Response (R2) -editor response.docx

Click here to view.^{(27K, docx)}

Attachment

Submitted filename: R2_trackclean_editor_Nepal_KAP.doc

Click here to view.^{(221K, doc)}

PLoS Negl Trop Dis. 2024 May; 18(5): e0012222.

Author response to Decision Letter 2

2024 May; 18(5): e0012222.

Published online 2024 May 28. doi:10.1371/journal.pntd.0012222.r006

14 May 2024

Attachment

Submitted filename: Reviewer Response.docx

Click here to view.^{(23K, docx)}

PLoS Negl Trop Dis. 2024 May; 18(5): e0012222.

Decision Letter 3

2024 May; 18(5): e0012222.

Published online 2024 May 28. doi:10.1371/journal.pntd.0012222.r007

Amy C. Morrison, Section Editor

16 May 2024

Dear Mr. Rajbanshi,

We are pleased to inform you that your manuscript 'Knowledge, attitude, and practice regarding dengue among non-health undergraduate students of Nepal' has been provisionally accepted for publication in PLOS Neglected Tropical Diseases.

Before your manuscript can be formally accepted you will need to complete some formatting changes, which you will receive in a follow up email. A member of our team will be in touch with a set of requests.

Please note that your manuscript will not be scheduled for publication until you have made the required changes, so a swift response is appreciated.

IMPORTANT: The editorial review process is now complete. PLOS will only permit corrections to spelling, formatting or significant scientific errors from this point onwards. Requests for major changes, or any which affect the scientific understanding of your work, will cause delays to the publication date of your manuscript.

Should you, your institution's press office or the journal office choose to press release your paper, you will automatically be opted out of early publication. We ask that you notify us now if you or your institution is planning to press release the article. All press must be co-ordinated with PLOS.

Thank you again for supporting Open Access publishing; we are looking forward to publishing your work in PLOS Neglected Tropical Diseases.

Best regards,

Amy C. Morrison, PhD

Section Editor

PLOS Neglected Tropical Diseases

Amy Morrison

Section Editor

PLOS Neglected Tropical Diseases

***********************************************************

Congratulations.

I appreciate you taking most of my suggestions. There is still a few places with awkward grammar, also you do not refer to your supplementary material in the text and should. Because I know the people in production will ask for this I will pass them on to you. I hope you agree that it was worth doing the multivariate analysis, providing a lot of clarity. Thanks for putting up with my meddling but the "knowledge gap" is so great throughout the world despite many efforts and that is only step 1 as you show no association between knowledge/attitudes and knowledge/practices. I wish you luck using this information to better inform your national dengue control program.

All the best,

Amy

PLoS Negl Trop Dis. 2024 May; 18(5): e0012222.

Acceptance letter

2024 May; 18(5): e0012222.

Published online 2024 May 28. doi:10.1371/journal.pntd.0012222.r008

Amy C. Morrison, Section Editor

22 May 2024

Dear Mr. Rajbanshi,

We are delighted to inform you that your manuscript, "Knowledge, attitude, and practice regarding dengue among non-health undergraduate students of Nepal," has been formally accepted for publication in PLOS Neglected Tropical Diseases.

We have now passed your article onto the PLOS Production Department who will complete the rest of the publication process. All authors will receive a confirmation email upon publication.

The corresponding author will soon be receiving a typeset proof for review, to ensure errors have not been introduced during production. Please review the PDF proof of your manuscript carefully, as this is the last chance to correct any scientific or type-setting errors. Please note that major changes, or those which affect the scientific understanding of the work, will likely cause delays to the publication date of your manuscript. Note: Proofs for Front Matter articles (Editorial, Viewpoint, Symposium, Review, etc...) are generated on a different schedule and may not be made available as quickly.

Soon after your final files are uploaded, the early version of your manuscript will be published online unless you opted out of this process. The date of the early version will be your article's publication date. The final article will be published to the same URL, and all versions of the paper will be accessible to readers.

Thank you again for supporting open-access publishing; we are looking forward to publishing your work in PLOS Neglected Tropical Diseases.

Best regards,

Shaden Kamhawi

co-Editor-in-Chief

PLOS Neglected Tropical Diseases

Paul Brindley

co-Editor-in-Chief

PLOS Neglected Tropical Diseases

Articles from PLOS Neglected Tropical Diseases are provided here courtesy of PLOS