Development and validation of the MosquitoWise survey to assess perceptions towards mosquitoes and mosquito-borne viruses in Europe

This publication is part of the project ‘Preparing for vector-borne virus outbreaks in a changing world: a One Health Approach’ (NWA.1160.1S.210) which is (partly) financed by the Dutch Research Council (NWO).

Authors: Ayat Abourashed, Pauline A. de Best, Laura Doornekamp, Reina S. Sikkema, Eric C. M. Van Gorp, Aura Timen, Frederic Bartumeus, John R. B. Palmer, Marion P.G. Koopmans

Abstract

Due to climate change and the expanding geographical ranges of key mosquito species, several mosquito-borne viruses (MBVs) have recently emerged in Europe. Understanding people’s perceptions and behaviours towards these viruses and the mosquitoes capable of transmitting them is crucial for implementing effective prevention measures and targeted communication campaigns. However, there is currently no appropriate validated survey for European populations to assess this. This study developed and validated a standardized survey, based on the Health Belief Model (HBM), to assess perceptions of mosquitoes and MBVs among Europe’s residents. The survey was distributed online to United Kingdom (UK), Dutch and Spanish participants through panel providers. Survey validity and reliability were tested using confirmatory factor analysis (CFA) and Cronbach’s alpha. The optimised survey was completed by 336 UK, 438 Dutch and 475 Spanish residents, respectively, and the HBM items passed our validity and reliability testing in all three countries. The final survey has 57 questions, including 19 validated HBM items, and questions to assess demographic characteristics, knowledge, prevention measures and behavioural determinants. Our MosquitoWise survey bridges researchers’ understandings of European residents’ perceptions and knowledge as a first step to improve preventive behaviour towards mosquitoes and MBVs and guide prevention and communication initiatives.

Introduction

In recent years, several MBVs have emerged in Europe, resulting in autochthonous transmission caused by both invasive and local mosquito species. While most mosquito-borne virus cases (MBVs) occur in Africa and Southeast Asia, increased changes in climate and land use in combination with the expanding geographical ranges of key invasive mosquito species Aedes aegypti and Aedes albopictus drive the potential for more mosquito-borne arboviruses to become endemic in Europe^1,2. International trade and human movement have proven to be crucial drivers of the spread of invasive mosquitoes, with eggs and adult mosquitoes transported in shipping containers, cars and other vehicles³. This phenomenon is well depicted by the introduction of Ae. albopictus in Spain, where the first Ae. albopictus was found in 2004 and believed to have arrived in a shipment of used tires⁴. Since then, this species has been regularly detected along the Mediterranean coast of Spain⁵. While it is known as a nuisance, Ae. albopictus is a primary vector for dengue and chikungunya viruses. These growing Ae. albopictus populations across Europe raises risks for autochthonous viral transmission within human populations¹.

Following the arrival of Ae. albopictus in Europe, local outbreaks of dengue and chikungunya have been reported in Croatia, France, Italy, Portugal, Spain and more^1,2,6. In 2022, 71 cases of locally acquired dengue were reported in mainland Europe (65 in France and 6 in Spain), matching the cumulative count of cases reported from 2010 to 2021⁶. Other emerging mosquito-borne viruses like West Nile virus (WNV) have been spread mainly by Culex pipiens, a native mosquito species found almost everywhere in Europe¹. WNV outbreaks regularly occur in Greece and Italy, and new autochthonous cases in humans have been detected as far north as the Netherlands in 2020^1,6,7. In the EU/EEA, 1133 human WNV cases were reported in 2022. Of these cases, there were 92 deaths and 1112 locally acquired infections, making this a record number of cases since 2018⁶. With this increase in local MBV prevalence, Europe’s residents are facing a new public health threat.

One of the key public health measures to reduce MBV infections is to take effective prevention measures against mosquito bites⁸. Successful implementation of such measures greatly depends on the knowledge and behaviour of the general public. Establishing the basic knowledge and beliefs people have regarding mosquitoes and the viruses they can potentially transmit is an important step in designing effective communication strategies⁹. Questionnaires that assess perceptions, knowledge and behaviour of people towards mosquitoes and MBVs have been widely used but focus on residents of endemic countries in the Americas, South-East Asia and the Western Pacific regions^{10,11,12,13,14,15,16}. The few questionnaires that have been developed for European populations have focused on either invasive mosquitoes or specific MBVs^{17,18,19,20,21}. Currently, there is no appropriate survey validated for European populations that assesses perceptions, knowledge, and behaviour towards prevention measure use for mosquitoes and MBVs in general.

There are many models of human behaviour that can guide survey development in this area. One that is well-established, and particularly relevant, is the Health Belief Model (HBM). The HBM was specifically developed to study people’s perceptions of health risks and influences of these perceptions on their decision to engage in preventive behaviour to promote their health. The model aims to measure certain ideas or concepts, also known as constructs, to assess intent to use preventive behaviours. Since constructs are not directly observable, a group of items can be used to infer what the construct is aiming to measure²². The model includes six constructs (Perceived Susceptibility, Perceived Severity, Perceived Benefits, Perceived Barriers, Cues to Action and Self-Efficacy) which altogether help predict people’s behaviours^23,24. Initially designed to explain the adoption of preventive health behaviours in the United States, the HBM has been adapted for various contexts and topics²⁵.

As MBV risk differs across Europe, a survey that can capture these differences in exposure and their effects on perceptions of health risks is particularly needed but did not yet exist prior to this study. We use the HBM to develop and validate such a survey, suitable for Europe-wide implementation. Furthermore, although the HBM does not account for knowledge as an influence on behaviour, our survey includes items to measure knowledge, along with demographic characteristics, attitudes toward prevention measures and other potential behavioural determinants.

Here, we present the design, validation and translations of the MosquitoWise survey in three European countries.

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