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Perceptions, knowledge and guidelines developed by health professionals in the postepidemic context of the Zika virus outbreak

Perceptions, knowledge and guidelines developed by health professionals in the postepidemic context of the Zika virus outbreak

Fernanda Macedo da Silva Lima 1; Jorge Alberto Bernstein Iriart 2; Eduardo Massad 3; John Kinsman 4

1 Institute of Collective Health, Federal University of Bahia, Salvador, Bahia, Brazil.nanda_msl@hotmail.com ORCID - ID: 0000-0001-9108-7831
2 Institute of Public Health, Federal University of Bahia, Salvador, Bahia, Brazil.iriart@ufba.br ORCID - ID: 0000-0002-9518-1240
3 University of São Paulo School of Medicine, São Paulo, São Paulo, Brazil.edmassad@dim.fm.usp.br ORCID - ID: 0000-0002-7200-2916
4 Department of Epidemiology and Global Health, Umeå University 901 87 Umeå, Sweden.johnkinsman@hotmail.com ORCID - ID: 0000-0003-1332-4138

ABSTRACT: Health professionals constitute a fundamental category of personnel who provide individuals with guidance on various health problems and effective prevention measures. Nevertheless, to date, there are no studies describing an analysis of the knowledge and guidance provided on the Zika virus by health professionals in Brazil. The objective of this study was to understand the perceptions, knowledge and guidelines about the Zika virus developed by health professionals in Salvador–Bahia in the postepidemic context. This qualitative study was conducted through thirteen semistructured interviews. The data revealed that health professionals perceived that they were not adequately prepared, even during the postepidemic period, to face the Zika virus. This situation is evidenced by insufficient knowledge about important aspects of this arbovirus. In addition, the guidelines during the epidemic held the population accountable for mitigating the risk of infection, thereby restricting itself to reproducing the guidelines of the health authorities and disregarding socioenvironmental vulnerabilities. In addition to the training of professionals and provision of appropriate health recommendations, it is necessary that the social determinants that result in different levels of susceptibility to illness are effectively addressed.
Keywords: Zika virus; health professional; knowledge.


ABSTRACT: Health professionals constitute a fundamental category of personnel who provide guidance to the population regarding various health problems and effective prevention measures. However, to date, there are no studies describing an analysis of the knowledge and guidance provided on the Zika virus by health professionals in Brazil. The objective was to understand the perceptions, knowledge and guidelines for the Zika virus developed by health professionals in Salvador–Bahia in the postepidemic context. This qualitative study was developed through thirteen semistructured interviews. The data showed that health professionals had the perception of not being adequately prepared to face the Zika virus, even during the postepidemic period. This situation is evidenced by deficiencies in knowledge about important aspects of this arbovirus. Furthermore, guidelines in the course of the epidemic made the population responsible for mitigating the risk of infection, thereby restricting itself to repeating the guidance of health authorities and disregarding socioenvironmental vulnerabilities. In addition to professional training and appropriate health recommendations, it is necessary that the social determinants that result in different levels of susceptibility to illness are effectively transformed.
Keywords: Zika virus; health professionals; knowledge.

INTRODUCTION
Between 2015 and 2016, Brazil experienced an epidemic caused by the Zika virus (ZIKV), and this significantly affected the lives of the population. This virus is transmitted by the bite of the Aedes aegypti mosquito, which tends to reproduce in domestic or peri-urban areas. In addition to this route of contagion, ZIKV can be transmitted sexually and vertically. Infection with this virus can result in a number of consequences for foetal development, such as microcephaly and other congenital abnormalities, a condition known as congenital Zika virus syndrome (CZS), which, at the time, was a national and international public health emergency 1,2,3.
The ZIKV epidemic intensified the sociohistorical vulnerability of minority population groups, as its repercussions affected mainly poorer families living in places with substandard infrastructure and basic sanitation conditions. In addition, barriers to access to health services and information affect the sexual and reproductive rights of these groups, including the difficulty in accessing contraceptive methods and pregnancy planning 4,5,6.
Several documents produced by health authorities during the epidemic contained recommendations regarding the development of care practices at the individual level, such as body protection measures and supervision of the home environment, to reduce exposure to the virus and its main consequences 7,8,9. Rodrigues et al. 10 analysed the recommendations of the Ministry of Health and highlighted the weaknesses inherent in these guidelines, as they did not consider the particularities of the most affected population groups, which impacted the effectiveness of prevention measures.
In turn, when Ribeiro et al. 11 evaluated articles published in mass media outlets between 2015 and 2016, the focus of communication was on measures to eradicate the mosquito vector and control the main disease outcome, namely, microcephaly, thereby attributing the responsibility for prevention mainly to women. In this context, Diniz 5 highlighted how the families most affected by the epidemic were exposed to situations of greater socioenvironmental vulnerability, which reinforces the need for consideration of different levels of susceptibility to the disease when designing control measures.
Health professionals constitute an important category of personnel who provide health-related guidance to members of the population and communicate effective prevention measures. In the current context, the few studies that analysed the knowledge and guidelines provided on ZIKV by health service providers identified important gaps in the understanding of the disease 12,13,14, and to date, there have been no studies of this nature in Brazil. Given the continued exposure of the Brazilian population to mosquito vectors and the uncertainty regarding future ZIKV outbreaks 15, it is essential that health services are prepared to educate the population adequately about the disease.
Therefore, the objective of this study was to understand the perceptions, knowledge and guidelines developed by health professionals in Salvador–BA concerning ZIKV in the postepidemic context. For the preparation of this analysis, the concepts of risk and risk communication in the field of public health will be taken as input from the theoretical contributions of Deborah Lupton 16, which will support the evaluation of health guidelines performed during the ZIKV epidemic. In addition, the concept of vulnerability proposed by Ayres et al. 17 will be examined to understand the structural factors that influence the disease process of the population and that do not depend exclusively on a change in individual behaviour, as these decisions are driven by conditioning socioeconomic, political, environmental and cultural factors.

METHODS
In this qualitative socio-anthropological study, thirteen semistructured interviews were conducted with health professionals from primary care. This study is part of a larger study entitled “Perceptions and knowledge of the Brazilian population about ZIKV: A qualitative comparative study on the dissemination of health information”. The data were produced in Salvador between April and August 2017.
The multiprofessional team of primary care was privileged because it considers the multiplicity of health training courses and the way of approaching the population, as a reference in the community for ZIKV, in an attempt to reflect the plurality of the universe of meanings that represent the field of research. Thus, professionals with secondary education and higher education constituted the corpus of respondents on the basis of a convenience selection strategy, which considered availability, interest and opportunity for participation. The inclusion criterion was exercising a public function in contact with the population at the time of the study.
Respondents worked in two primary care units in the city of Salvador, including three nurses, two physicians, a nutritionist; a social worker; four community health workers; a coordinator of community health workers; and a professional of the Health Surveillance of the Municipal Health Department (Chart 1).
The script used sought to establish a dialogue between the theoretical framework and the empirical reality 18. Its purpose was to guide the interview, in which the dialectic of the participants was explored and deepening a discussion was facilitated to cover all the objectives of the study 19. The script addressed the following themes: perceptions, knowledge and meanings attributed to ZIKV; sources of information about ZIKV; concern about diseases transmitted by mosquitoes; guidelines on ZIKV provided to the population; and community susceptibility to mosquito-borne diseases and their consequences. The interviews were recorded, transcribed and had an average duration of 40 minutes.
Data analysis was performed with reference to the method of interpretation of meanings, anchored in hermeneutic-dialectical principles. According to Minayo 20, the hermeneutic-dialectical approach allows the development of a comprehensive and critical analysis of social reality. In this sense, hermeneutics makes it possible to understand the meaning of communication between human beings, starting from language as a space conducive to the achievement of intersubjectivity and understanding, whereas dialectics considers the social relations that are historically dynamic, antagonistic and contradictory between social relations to be the foundation of communication among classes, groups and cultures.
Coding of the data was performed inductively on the basis of the reading of the interviews and the identification of the nuclei of meaning. The qualitative analysis software QSR NVivo version 8 was used to organize the codes into thematic trees. Thematic maps were the objects of analysis for selecting the most relevant topics. Thus, the data analysis was performed in three steps: 1- Evaluation of the totality of the material collected and apprehension of the particularities of the research data; 2- identification of the perceptions and meanings attributed to ZIKV by the interviewees; and 3- elaboration of the interpretative synthesis, seeking to articulate the objectives of the study, with the theoretical‒methodological frameworks, empirical data and results obtained through other investigations.
The study was approved by the Research Ethics Committee of the Faculdade de Medicina de Jundiaí under protocol number 1,953,782. The study was developed in accordance with Resolution No. 466/2012. Fictitious names were assigned to the interviewees to preserve their anonymity.

RESULTS AND DISCUSSION
Perceptions, knowledge and sources of information about ZIKV among health professionals
Northeast Brazil was the region most affected by the ZIKV epidemic, and the state of Bahia had the highest rates of cases between 2015 and 2016. As of 2017, there was a significant reduction in the occurrence of cases in Bahia 21. Thus, approximately two years after the onset of the epidemic in the country, health professionals were expected to have a high degree of knowledge about the disease caused by ZIKV to guide the population. However, it was observed that health professionals, in general, had little knowledge and doubts about basic aspects of the disease:
“To this day, no one has a concrete answer to the question of microcephaly. Was it true? Really? Is Zika really the cause? I don\'t know... coincidences exist, but the certainties are still lacking”. (Nurse Sabrina).
“Look, I have heard little about this case. I did not hear any case of saying “Look, the man is afraid (...” because it was something that has not yet been proven. I think this subject was vague; there was not much information about it. Therefore, this issue of being transmitted through sexual intercourse was still kind of...dubious. (...) That, for me, was something that even I was still kind of like “Is this true?”, you know?” (Nurse Sabrina).
To date, no studies have been identified in the national scenario that assess the knowledge and guidance provided by health professionals about ZIKV. However, studies conducted with the general population suggest inadequacies in the information provided by health service providers 6,22,23. In this context, a study conducted by Arias et al. 6 with women of reproductive age in Brazil, Puerto Rico and the United States revealed that the lack of medical knowledge to guide them about the disease increased their feelings of insecurity, concern and anxiety, in addition to there being strong criticism of health recommendations aimed mainly at protection against mosquito bites through the continuous application of chemical repellents.
A study conducted by Lima et al.23 with pregnant women in one of the epicentres of the epidemic in Brazil also revealed that although women were linked to health services for prenatal care, this did not affect their knowledge about the disease because the guidelines focused primarily on individual methods of protection. Likewise, other studies have shown the low effect of health services on the orientation of the population 24,25.
In line with these findings, one physician interviewed stressed that learning about ZIKV occurred as the epidemic progressed, given the unprecedented nature of this disease, which could explain the lack of knowledge and difficulty in updating health professionals:
“No, I think the doctors are not so [well informed about the disease], let alone the people! (laughs) It is a new disease, right? Therefore, little is known about it, so I think there is a difficulty even from the point of view of technicians to adapt to the novelty, right?! (...) So everyone adapted, dancing the musical chairs, right?! It was like that and then I think that is what truly stayed, right?! It is a disease that causes itching, can cause pain in the joints and fever and can cause microcephaly. That’s what stuck in people’s minds, and microcephaly was the main thing it could cause, as a complication”. (Doctor Livia).
The health professionals interviewed reported seeking information about ZIKV individually and highlighted the lack of courses and training to prepare them to advise the population. In their reports, there was low expression of the search for academic sources for the update on ZIKV. The official messages produced by health authorities contributed substantially to the learning of health professionals about ZIKV. As evidenced by studies conducted with the general population 24,26, health professionals also highlighted the internet and television as important sources of updates on the disease:
“Where did I learn more?! There were so many places, it was more at the level of what I received from the secretariat itself, which they always send, right, some epidemiological bulletins... We go, consult the internet, you know? However, then, there was not a course, something like that, a specific training”. (Coordinator of Vilma Community Health Agents).
The means used by health professionals to acquire information may explain the lack of knowledge about important aspects of ZIKV infection. After analysing the materials produced by health authorities in Brazil, Clancy et al. 3 reported that the messages emphasized mainly individual and community responsibility for prevention, with guidelines similar to those produced for decades during dengue outbreaks in the country. However, these materials have not been properly updated as knowledge about ZIKV has progressed, and few materials have shown the possibility of sexual and congenital transmission of this virus. The limited attention given to these alternative routes of ZIKV transmission by health campaigns added to the absence of training on the disease may have resulted in a lack of knowledge of health professionals, which represents a missed opportunity for adequate counselling of the population, since these professionals occupy a central space and are coresponsible for transmitting information during outbreaks, which could contribute to reducing the potential risks of the sexual transmission of ZIKV and its congenital repercussions.
These results are particularly relevant because health services, as a component of social support, act as protective factors for mothers and families of children with CZS 27,28. Children with CZS have significant health care demands 29 and are subjected to worse living conditions 30, and their mothers are more likely to have symptoms of depression, stress and anxiety in settings with low social support 31, with negative impacts on activities of daily living. Five years after the birth of children, Oliveira et al. 32 reported significantly high levels of anxiety in mothers, which reflects the maintenance of unfavourable circumstances that require an integrated, intersectoral and multidisciplinary approach within the health care network 33.
Thus, when health professionals are not adequately prepared, care is neglected, and the potential of the service space is compromised 34. In our study, the sensationalist nature of health communication, with its emphasis on the consequences and sequelae caused by the disease, making it responsible for causing fear and panic instead of raising awareness of the population, was evidenced by the health surveillance professional of the Municipal Health Department:
“You observe that sometimes in public health things are very much...sensationalism and the issue of information accompanies this a lot... Information sometimes comes with a certain weight, you know, the weight of fear, it ends by bringing some benefits from the point of view of care, which is not good because this care could go on in a more peaceful way (....). (Professional of Health Surveillance of the Municipal Health Department, Cláudia).
“If you surround yourself more and you hear about the same thing every time, it ends up due to osmosis, right? The population absorbs it, because what we perceive in the information is this, or does it come in a terrorizing form way, right? In the sense of causing fear or panic (... and then you work with a population that is a little scared, they are kind of... motivated by fear. However, the natural information of that incorporated, the everyday information still does not seem to have arrived. Therefore, the information... Several health areas did it, right? The assistance area itself, right?! The Ministry of Health itself, and here we did it, but in the end things start to weaken, right? There is no constancy, it appears along with the problem (....). (Professional of Health Surveillance of the Municipal Health Department, Cláudia).

Thus, it is possible to identify weaknesses in health policies in Brazil, in which health communication actions prioritized during epidemic peaks are not maintained, albeit to a lesser extent, with a focus on educational practices and long-term health promotion to help the population learn to address and prevent these health problems. In this regard, it was found that health guidelines in Brazil were directed towards yellow fever from 2017 onwards as a result of an outbreak that affected the country 35, and in 2020, the new coronavirus (SARS-CoV-2) became the focus of attention in the health guidelines due to the pandemic and high mortality rates 36.
However, it is important to note that the Brazilian population remains exposed to the Aedes aegypti mosquito, and some studies suggest the possibility of new ZIKV outbreaks in future scenarios 37. Given the increase in the incidence of ZIKV in 2022 compared with previous periods, namely, 2019/2021 38, it is necessary to invest in training so that health professionals can ensure health guidelines that are feasible for the population and consider their socioenvironmental contexts and historical and cultural perspectives, which will be further discussed in the next section.

From risk to vulnerability: Renewal of health recommendations and preventive practices
The health guidelines developed by health professionals during the ZIKV epidemic followed the recommendations proposed by health authorities. Women of reproductive age and pregnant women are the main targets of health recommendations and are encouraged to maintain constant vigilance to minimize the possibility of ZIKV infection and the adverse foetal outcomes. This emphasis on individual responsibility appears in the comments of several health professionals interviewed in this study:
“We end up repeating the booklet, right? At the time when it was more evident, when it had all the other associated conditions, right?! (...) It was that advice more about individual protection, personal protective equipment (PPE), you know? Pants, blouse, repellent, right?! (...) Counselling regarding risk situations, right? The person who is pregnant, these things, right?” (Doctor Livia).
In her study, Deborah Lupton 35 highlights the varieties of risk that are responsible for causing apprehension to different population groups within six broad categories. The risk related to lifestyle is especially relevant for this study because it emphasizes self-control or individual responsibility for actions and behaviours that are characterized as threats to health and are considered modifiable. According to this perspective, the individual is primarily responsible for adopting behaviours that minimize the risks to their own health, as well as that of the community in which they live. By choosing to ignore these risks, individuals are exposing themselves to a situation of danger for the development of diseases. In this context, the main function of health professionals is to make the population aware of the potential dangers related to their conduct 20. During the ZIKV epidemic, health professionals developed prescriptive guidelines that emphasized individual responsibility for preventing infection and its complications and thus neglected the structural dimensions that provided the necessary conditions for the outbreak and later maintenance of the epidemic.
The discourse of risk in the field of health allows health professionals to exercise power over the bodies of individuals by stimulating the development of self-control actions and constant surveillance of behaviours that can be characterized as a threat to health. These strategies continue to be reproduced throughout history because of their \'benevolent\' nature in ensuring the control of risks that affect the living and health conditions of the population 16,40. Brazil has extensive experience in developing actions to combat Aedes aegypti. However, measures that prioritize only the eradication of the mosquito and individual care are not sustainable in the long term, and this perspective was evidenced by nurse Sabrina when highlighting the successive failures in the control of vector diseases in the country:
“(...) The feeling I have is that this care is no longer enough. Because the number of sick people increases, the number of mosquitoes increases and I see, I realized that there was this attention with this issue of stagnant water, so I think that... Some other way, I believe, because it is not possible (emphasizing)... for so many mosquitoes to sprout, with so much attention, so much care, you know? (...) No, the feeling that I had that no, for example, first it started with dengue, then chikungunya and then I say, “My God, where will this end? Where is the care? Did it not help?”, it all went down the drain, microcephaly was widespread, affected so many families, so many little babies, so... The feeling I had is that it was not enough, there was more, you know? And that’s where the question remains: could it be that the only aspect of care was the standing water, you know?” (Nurse Sabrina).
From this perspective, environmental hazards represent a second important category of risk to public health. Thus, threats to health are related to external risks over which individuals have little power of intervention 16. During the ZIKV epidemic, this perspective had a marginal role both in management and in the communication of risk by authorities and health professionals. The guidelines do not consider the socioenvironmental vulnerabilities that contributed to the emergence and rapid spread of the disease throughout the country 11.
In this context, the concept of vulnerability proposed by Ayres et al. 17 acquires special relevance because it recognizes the broader determinants that influence the course of an epidemic, in addition to the pathogenic action of a viral agent on the individual dimension. Here, the social vulnerability of the most disadvantaged population, which resides in places with greater infestation of Aedes aegypti and with less access to means of prevention, such as repellents, and quality information about the epidemic and CZS, is evident. Programmatic vulnerability is also observed in the absence of an effective state policy for mosquito control and access to means of prevention. The concept of vulnerability is characterized as both a construct and a builder of a comprehensive and reflexive reality in which epidemics can be considered to be due to individual susceptibilities to the socioeconomic and political organization of society 17. That said, some health professionals interviewed for this study highlighted the influence of structural factors on the social vulnerability of the population to vector-borne diseases, which makes the generic guidelines on individual care somewhat sensitive to the different social realities:
“(...) You go to a neighbourhood that... where there are houses that have swimming pools, which are treated, right? Add chlorine, people take care of the pool. Then, it goes into another one, like, let us see, down there... you see, lakes, you see, totally dirty, you see rivers, these things like that, streams, and that\'s what causes it, the mosquito likes it, that\'s where it places its larva, its egg (...) When it is on television “Look, the neighbourhood I don’t know where it is, where there was the highest incidence of Zika”, and everything, when you will see, it is truly a neighbourhood that is more populous, more humble and with much more precarious basic sanitation than a neighbourhood of a higher class person (...) Have you ever heard of or seen an upper class person have a baby with microcephaly? So far, I have not seen it, I have not seen any! (...) Now you go to the health clinics, wait in line for the vaccine, for the heel prick test, where you will see people who are totally humble and that is where most children have more microcephaly. Why is it?” (Nurse Eliana).
Thus, the notion of risk, although relevant, is no longer sufficient because it focuses primarily on the individual dimension. Ayres et al. 17 noted that holding individuals accountable for the development of preventive behaviours is not fully effective in controlling the spread of diseases, as the adoption of preventive behaviours is not the result of a simple combination of access to information and the possibility of choice. In contrast, this decision is affected by socioeconomic, political and cultural factors unequally distributed among sexes, ethnic groups and social segments. Therefore, it is imperative to invest in actions that affect the structural dimensions, as they operate in the production of social inequalities and inequities in health, providing the necessary conditions for maintaining the occurrence of vector diseases.
On the basis of these gaps, the conception of vulnerability (social, programmatic and individual) has developed and acquired wide application when considering “the chance of exposure of people to illness as the result of a set of not only individual, but also collective, contextual aspects ”, which lead to greater susceptibility to infection and illness and, inseparably, greater or lesser availability of resources of all kinds to protect oneself from both ” 17. This perspective highlights the importance of analysing the impact of different social contexts in determining the varying degrees of susceptibility, which also reinforces the need to develop interventions sensitive to these particularities. In this sense, Dr. Lívia strongly criticizes health campaigns for having a reiterated and repetitive attitude of blaming individuals for minimizing the risk of illness. However, she emphasized that until there are effective interventions on the dimensions of poverty and vulnerability, there will not be adequate or lasting solutions to control the occurrence of these diseases:
“I think the big question is that the campaigns, right?! The focus is that you solve the problem of garbage in your backyard or in your neighbourhood or in your community, right?! The history of microcephaly was the risk that you might have the problem, that you might have had Zika when you were pregnant, and that you will go after it. It is a process like this, reiterated and repetitive of the public policy of accountability of the individual, understand? So I think this is very painful, right? And in the case of the situation of Zika and microcephaly, it generates panic, right?! (...) It is not exactly poverty, but anyway, it is a symptom, right? As long as this type of situation exists, people who live in these conditions, who work in this vulnerable situation, there will be circulation of Aedes, dengue, Zika, chikungunya, so it ends up that this is the great condition, right?” (Doctor Livia).
The ZIKV epidemic exposed the interference of the socioenvironmental context in the health situation of the population. In this regard, Spink’s concept of socioenvironmental vulnerability 41 is essential for analysing how social and environmental risks impact the most vulnerable population groups. They live in places with worse structural conditions and are more susceptible to the effects of environmental changes. Thus, the restriction of essential rights, such as access to treated water, garbage collection and sanitary sewage, has subjected specific groups of the population to successive epidemics throughout history. These aspects are usually neglected by health communications during epidemics such as ZIKV because they are treated only as a vector problem that requires the development of individual protection practices, whereas the structural dimension that has sustained these disparities for generations has received little attention. Intervention is necessary to ensure adequate living and health conditions for individuals 42.
Understanding that exposure to the virus does not occur in the same way among social groups reinforces the perspective that contextual changes do not depend exclusively on individual will. Thus, it is essential to invest in strategies that act in an integrated manner on the behavioural dimensions, social contexts and structural constraints, that is, social inequalities and environmental vulnerabilities that influence the health conditions of the population. Thus, the guarantee of protection of human and social rights, adequate infrastructure conditions, access to health services and information are characterized as inseparable elements of prevention actions and individual health care because they are involved in multiple dimensions of risk at the community level 17,40.

FINAL CONSIDERATIONS
The data produced by this study demonstrated inadequacies in the knowledge of health professionals about important aspects of ZIKV infection one year after the end of the epidemic in Brazil. With respect to health guidelines, the risk communication adopted by health education campaigns and health professionals has shown its limited reach, especially among population groups that are more likely to develop the disease because individual risk control is less sensitive to the specificities existing between the different social contexts.
Thus, health authorities should invest in training programs, incorporating the concept of vulnerability, for health professionals on a permanent basis about vector-borne diseases to provide updated information to the population, encouraging effective prevention and control practices. In addition to undertaking joint actions with managers and policy-makers, ensuring adequate conditions of urban infrastructure with the objective of breaking the cycle of poverty and socioenvironmental vulnerability that affects the population groups most susceptible to the consequences of arboviruses. Finally, more studies are needed in the national context to propose effective, culturally relevant and wide-ranging communication strategies.

ACKNOWLEDGMENTS
We thank CAPES for providing the opportunity for the development of this study through the granting of a postgraduate scholarship.

 
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