Factors affecting early identification of pregnant women by community health workers in Morogoro, Tanzania.

BACKGROUND: It is recommended that Antenatal Care (ANC) be initiated within the first trimester of pregnancy for essential interventions, such folic acid supplementation, to be effective. In Tanzania, only 24% of mothers attend their first ANC appointment during their first trimester. Studies have shown that women who have had contact with a health worker are more likely to attend their first antenatal care appointment earlier in pregnancy. Community health workers (CHWs) are in an opportune position to be this contact. This study explored CHW experiences with identifying women early in gestation to refer them to facility-based antenatal care services in Morogoro, Tanzania. METHODS: This qualitative study employed 10 semi-structured focus group discussions, 5 with 34 CHWs and 5 with 34 recently delivered women in three districts in Morogoro, Tanzania. A thematic analytical approach was used to identify emerging themes among the CHW and RDW responses. RESULTS: Study findings show CHWs play a major role in identifying pregnant women in their communities and linking them with health facilities. Lack of trust and other factors, however, affect early pregnancy identification by the CHWs. They utilize several methods to identify pregnant women, including: asking direct questions to households when collecting information on the national census, conducting frequent household visits and getting information about pregnant women from health facilities. CONCLUSIONS: We present a framework for the interaction of factors that affect CHWs' ability to identify pregnant women early in gestation. Further studies need to be conducted investigating optimal workload for CHWs, as well as reasons pregnant women might conceal their pregnancies.

Caregiver mental health and HIV-infected child wellness: perspectives from Ugandan caregivers.

Prior studies indicate a substantial link between maternal depression and early child health but give limited consideration to the direction of this relationship or the context in which it occurs. We sought to create a contextually informed conceptual framework of this relationship through semi-structured interviews with women that had lived experience of caring for an HIV-infected child while coping with depression and anxiety symptoms. Caregivers explained their role in raising healthy children as complex and complicated by poverty, stigma, and isolation. Caregivers discussed the effects of their own mental health on child well-being as primarily emotional and behavioral, and explained how looking after a child could bring distress, particularly when unable to provide desired care for sick children. Our findings suggest the need for investigation of the reciprocal effects of child sickness on caregiver wellness and for integrated programs that holistically address the needs of HIV-affected families.

The development and evaluation of a community-based clinical diagnosis tool and treatment regimen for postpartum sepsis in Bangladesh and Pakistan.

BACKGROUND: Postpartum sepsis accounts for most maternal deaths between three and seven days postpartum, when most mothers, even those who deliver in facilities, are at home. Case fatality rates for untreated women are very high. Newborns of ill women have substantially higher infection risk. METHODS/DESIGN: The objectives of this study are to: (1) create, field-test and validate a tool for community health workers to improve diagnostic accuracy of suspected puerperal sepsis; (2) measure incidence and identify associated risk factors and; (3) describe etiologic agents responsible and antibacterial susceptibility patterns. This prospective cohort study builds on the Aetiology of Neonatal Infection in South Asia study in three sites: Sylhet, Bangladesh and Karachi and Matiari, Pakistan. Formative research determined local knowledge of symptoms and signs of postpartum sepsis, and a systematic literature review was conducted to design a diagnostic tool for community health workers to use during ten postpartum home visits. Suspected postpartum sepsis cases were referred to study physicians for independent assessment, which permitted validation of the tool. Clinical specimens, including urine, blood, and endometrial material, were collected for etiologic assessment and antibiotic sensitivity. All women with puerperal sepsis were given appropriate antibiotics. DISCUSSION: This is the first large population-based study to expand community-based surveillance for diagnoses, referral and treatment of newborn sepsis to include maternal postpartum sepsis. Study activities will lead to development and validation of a diagnostic tool for use by community health workers in resource-poor countries. Understanding the epidemiology and microbiology of postpartum sepsis will inform prevention and treatment strategies and improve understanding of linkages between maternal and neonatal infections.

Household Animal and Human Medicine Use and Animal Husbandry Practices in Rural Bangladesh: Risk Factors for Emerging Zoonotic Disease and Antibiotic Resistance.

Animal antimicrobial use and husbandry practices increase risk of emerging zoonotic disease and antibiotic resistance. We surveyed 700 households to elicit information on human and animal medicine use and husbandry practices. Households that owned livestock (n = 265/459, 57.7%) reported using animal treatments 630 times during the previous 6 months; 57.6% obtained medicines, including antibiotics, from drug sellers. Government animal healthcare providers were rarely visited (9.7%), and respondents more often sought animal health care from pharmacies and village doctors (70.6% and 11.9%, respectively), citing the latter two as less costly and more successful based on past performance. Animal husbandry practices that could promote the transmission of microbes from animals to humans included the following: the proximity of chickens to humans (50.1% of households reported that the chickens slept in the bedroom); the shared use of natural bodies of water for human and animal bathing (78.3%); the use of livestock waste as fertilizer (60.9%); and gender roles that dictate that females are the primary caretakers of poultry and children (62.8%). In the absence of an effective animal healthcare system, villagers must depend on informal healthcare providers for treatment of their animals. Suboptimal use of antimicrobials coupled with unhygienic animal husbandry practices is an important risk factor for emerging zoonotic disease and resistant pathogens.

Prevalent high-risk respiratory hygiene practices in urban and rural Bangladesh.

OBJECTIVES: To identify existing respiratory hygiene risk practices, and guide the development of interventions for improving respiratory hygiene. METHODS: We selected a convenience sample of 80 households and 20 schools in two densely populated communities in Bangladesh, one urban and one rural. We observed and recorded respiratory hygiene events with potential to spread viruses such as coughing, sneezing, spitting and nasal cleaning using a standardized assessment tool. RESULTS: In 907 (81%) of 1122 observed events, households' participants coughed or sneezed into the air (i.e. uncovered), 119 (11%) into their hands and 83 (7%) into their clothing. Twenty-two per cent of women covered their coughs and sneezes compared to 13% of men (OR 2.6, 95% CI 1.6-4.3). Twenty-seven per cent of persons living in households with a reported monthly income of >72.6 US$ covered their coughs or sneezes compared to 13% of persons living in households with lower income (OR 3.2, 95% CI 1.6-6.2). In 956 (85%) of 1126 events, school participants coughed or sneezed into the air and 142 (13%) into their hands. Twenty-seven per cent of coughs/sneezes in rural schools were covered compared to 10% of coughs/sneezes in urban schools (OR 2.3, 95% CI 1.5-3.6). Hand washing was never observed after participants coughed or sneezed into their hands. CONCLUSION: There is an urgent need to develop culturally appropriate, cost-effective and scalable interventions to improve respiratory hygiene practices and to assess their effectiveness in reducing respiratory pathogen transmission.

Impact of clean delivery kit use on clean delivery practices in Beni Suef Governorate, Egypt.

OBJECTIVE: A major factor contributing to neonatal and maternal infections is unhygienic delivery practices. This study explores the impact of clean delivery kit (CDK) use on clean delivery practices during home and facility deliveries. DESIGN: Kits were distributed from primary care facilities and mothers and birth attendants received training on kit importance and use. The study was designed as a cross-sectional cohort study. Raedat (community health workers) visited 349 women during the postpartum period to administer a structured questionnaire. SETTING: The study was conducted from mid-March through mid-July 2001 in two rural areas of Ihnasia district in Beni Suef Governorate (Upper Egypt). RESULT: In bivariate analysis, CDK users in the home were more likely to report that the birth attendant had clean hands (P<0.001), washed/wiped the mother's perineum (P<0.001), used a sterile cord tie (P=0.001), applied antiseptic to the cord after cutting (P<0.001), and used a sterile cord cover (P<0.001) as compared with non-CDK users. CDK users at the facility were more likely to report that the birth attendant washed/wiped the mothers perineum (P=0.049) and used a sterile cord cover (P=0.030) as compared with non-CDK users. CONCLUSION: In settings in which unhygienic practices during home as well as facility deliveries are prevalent, use of inexpensive CDKs can promote clean delivery practices.

Community perceptions of birth weight in rural Uttar Pradesh, India: implications for care of low-birth-weight infants.

Effective implementation of interventions targeting low birth weight (LBW) and preterm infants, who contribute 60 to 80% of all neonatal deaths, requires an understanding of local people's perceptions of birth weight. This study was conducted to understand how birth weight is perceived in a low-resource setting, including the etiology, signs and care given to infants of various weights. In this qualitative research study, in-depth interviews and focus group discussions were conducted with recently delivered women (RDW) and their families, as well as local health stakeholders in a rural North Indian community. Birth weight per se is not considered a determinant of newborn health. Instead, newborns are classified into types, and care is provided based on these types. Classification is based on observable criteria, including feeding, vigor and alertness, and interviewees did not always consider low weight a criterion for weak type. In communities that do not perceive birth weight to be an important determinant of health, public health programmes and practitioners must reframe messages regarding additional care for LBW infants at home and care seeking outside the home in locally relevant ways.

Newborn umbilical cord and skin care in Sylhet District, Bangladesh: implications for the promotion of umbilical cord cleansing with topical chlorhexidine.

Newborn cord care practices may directly contribute to infections, which account for a large proportion of the four million annual global neonatal deaths. This formative research study assessed current umbilical and skin care knowledge and practices for neonates in Sylhet District, Bangladesh, in preparation for a cluster-randomized trial of the impact of topical chlorhexidine cord cleansing on neonatal mortality and omphalitis. Unstructured interviews (n=60), structured observations (n=20), rating and ranking exercises (n=40) and household surveys (n=400) were conducted to elicit specific behaviors regarding newborn cord and skin care practices. These included hand-washing, skin and cord care at the time of birth, persons engaged in cord care, cord cutting practices, topical applications to the cord at the time of birth, wrapping/dressing of the cord stump and use of skin-to-skin care. Overall 90% of deliveries occurred at home. The umbilical cord was almost always (98%) cut after delivery of the placenta, and cut by mothers in more than half the cases (57%). Substances were commonly (52%) applied to the stump after cord cutting; turmeric was the most common application (83%). Umbilical stump care revolved around bathing, skin massage with mustard oil and heat massage on the umbilical stump. Overall 40% of newborns were bathed on the day of birth. Mothers were the principal provider for skin and cord care during the neonatal period and 9% of them reported umbilical infections in their infants. Unhygienic cord care practices are prevalent in the study area. Efforts to promote hand-washing, cord cutting with clean instruments and avoiding unclean home applications to the cord may reduce exposure and improve neonatal outcomes. Such efforts should broadly target a range of caregivers, including mothers and other female household members.

Can early postpartum home visits by trained community health workers improve breastfeeding of newborns?

OBJECTIVE: Whether postpartum visits by trained community health workers (CHWs), reduce newborn breastfeeding problems. METHOD: Community health workers made antenatal and postpartum home visits promoting newborn care practices including breastfeeding. CHWs assessed neonates for adequacy of breastfeeding and provided hands-on support to mothers to establish breastfeeding. History and observation data of 3495 neonates were analyzed to assess effects of CHW visitation on feeding problems. RESULT: Inappropriate breastfeeding position and attachment were the predominant problems (12 to 15%). Only 6% of newborns who received home visit by CHWs within 3 days had feeding difficulties, compared to 34% of those who did not (odds ratio: 7.66, 95% confidence interval (CI): 6.03 to 9.71, P=0.00). Latter group was 11.4 times (95% CI: 6.7 to 19.3, P=0.00) more likely to have feeding problems as late as days 6 to 7, than the former. CONCLUSION: Counseling and hands-on support on breastfeeding techniques by trained workers within first 3 days of birth, should be part of community-based postpartum interventions.

Impact of IMCI training and language used by provider on quality of counseling provided to parents of sick children in Bougouni District, Mali.

This study evaluates the impact of the Integrated Management Of Childhood Illness (IMCI) training on quality of counseling provided to caregivers about administration of antimalarials to their children. Ten community health centers in southern Mali were randomized to either training or comparison arms of the study, and health providers' consultations with caregivers were observed. Out of a 10-point counseling scale (Cronbach's alpha=0.77), IMCI-trained providers completed an average of 1.47 (95% CI, -0.25, 3.2) more tasks than did providers who had not received IMCI training in a linear regression analysis that accounted for intra-provider correlations. Drug consultations done in both French and the local language, Bambara, had higher scores than those conducted exclusively in Bambara. The effect of providers receiving IMCI training was more pronounced in bilingual consultations, with an average increase of 2.49 (95% CI, 0.76, 4.22) in IMCI, bilingual consultations, and average increase of 0.87 (95% CI, -0.95, 2.69) in IMCI monolingual (Bambara) consultations as compared to non-IMCI-trained providers in monolingual consultations. IMCI training showed a non-significant trend overall in improving drug counseling provided to caregivers, with significant improvements in bilingual consultations. The IMCI program in Mali should consider strategies such as role-playing of counseling in Bambara or other local languages during training to improve patient-provider communication. Similar problems related to counseling by health workers in local languages are likely to be present throughout Africa, and warrant further study.

Increases in correct administration of chloroquine in the home and referral of sick children to health facilities through a community-based intervention in Bougouni District, Mali.

Save the Children/USA in collaboration with the Ministry of Health of Mali has established over 300 village drug kits in southern Mali since 1996. A cluster-randomized trial was conducted between November 2001 and February 2002 in 10 health zones of Bougouni District to evaluate an intervention to (i) improve the skills of the village drug kit managers to counsel parents on correct home administration of chloroquine (CQ), and (ii) increase the referral of sick children to community health centres (CHC). Children's carers were interviewed 5 d after the sale of CQ about knowledge of danger signs requiring referral, quality of counselling, administration of CQ, and referral. The intervention was associated with significant increases in knowledge of danger signs requiring referral, reported quality of counselling by the manger of the drug kit, and correct administration of CQ in the home. Parents reported that 42.1% of children in the intervention group were referred to the CHC by the drug kit manager compared with 11.2% in the comparison group (odds ratio = 7.12, 95% CI 2.62-19.38). CHC registers indicated that 87.0% of referrals recorded in drug kit referral notebooks arrived at the health centre. Further research is needed to increase the effectiveness of the counselling and the community referral mechanism tested in this study.

Trial of a community-based intervention to decrease infestation of Aedes aegypti mosquitoes in cement washbasins in El Progreso, Honduras.

Washbasins and metal drums are important sources of Aedes aegypti mosquitoes in much of Latin America. When manual cleaning was found to be ineffective in eliminating mosquito larvae in a community-based control programme in El Progreso, Honduras, it was decided to develop and evaluate an improved method of removing mosquito eggs based on commonly-available materials. The method, named La Untadita ('The Little Dab', in English), consists of five steps: mixing chlorine bleach and detergent to make a paste, applying the mixture to the walls of the container, waiting 10 min, scrubbing with a brush, and finally rinsing with water. A field trial of the Untadita was conducted in 13 peri-urban neighbourhoods. At the first post-intervention survey, in spite of high levels of exposure to the community-based intervention, high levels of knowledge regarding the Untadita and high levels of its reported use, little or no impact was discernable on mosquito larvae and pupae. The method was then modified by increasing the recommended quantities of bleach and detergent and simplifying the instructions. In the second post-intervention survey, knowledge of the steps and their order increased further; the intervention neighbourhoods had significantly fewer algae on washbasin walls, an indicator of more effective cleaning; and numbers of pupae and 3rd and 4th instar larvae were significantly lower than in untreated neighbourhoods. Effective promotion of the Untadita should be able to control mosquito infestation in many washbasins, especially those in frequent use, thus reducing the need for chemical and biological larvicides that may be either more costly or less acceptable to householders.

Development of an indicator to evaluate the impact, on a community-based Aedes aegypti control intervention, of improved cleaning of water-storage containers by householders.

Householders in a community-based programme to control dengue in El Progreso, Honduras, are being encouraged to improve the cleaning of the water-storage containers in which many of the vectors thrive. The objective of the present study was to develop an indicator of the change occurring in human behaviour. Traditional Aedes aegypti larval indices do not differentiate between containers in which all the immature stages are present and those which hold only first- and second-instar larvae. However, it is not essential to prevent all larval development to limit transmission of pathogens by the adults; if the Ae. aegypti in the containers only manage to develop to young larvae before the containers are cleaned, then control of the vector in these containers will be effective. In field trials, sampling of third- and fourth-instar larvae in washbasins by taking five dips (quick immersions to a standard depth) with a hand-held net was found to be sufficient for estimating the true population size of that same cohort. This sampling method was then included in a large-scale survey of households, conducted for programme monitoring. An index was then developed as a summary measure of the degree of infestation of a washbasin by Ae. aegypti. This index was the sum of four variables assessed in the survey: presence of any immature stages (larvae and/or pupae); presence of pupae; detection of third-fourth-instar larvae in a five-dip sample; and a log-transformation of the number of larvae recovered. Based on this new index, the 884 washbasins encountered in the survey were classified as infestation-free (76.2%), or with low-(6.7%), medium-(14.9%) or high-level (2.2%) infestation. Application of the same procedure to 240 drums encountered in the survey showed that 66.3% were infestation-free and 9.2%, 17.1% and 7.4% had low-, medium- and high-level infestations, respectively. Compared with the traditional indices, this new index should be more sensitive to changes in human behaviour resulting from a control programme exposure than a simple, dichotomous variable (i.e. positive/negative for presence of immature stages). The use of such an index could make the control programme more efficient, allowing the greatest efforts to be targeted at households that have medium-high levels of infestation.

La Untadita: a procedure for maintaining washbasins and drums free of Aedes aegypti based on modification of existing practices.

Chlorine bleach and detergent are routinely used by householders in El Progreso, Honduras in the process of cleaning washbasins and drums, the two most important larval habitats of Aedes aegypti in the city. The efficacy of these materials in eliminating eggs, larvae, and pupae of Ae. aegypti was assessed under controlled conditions. The promising results obtained led to trials using a combination of chlorine bleach and detergent to apply to the walls of washbasins and drums as a method for eliminating eggs. The bleach maintained its ovicidal properties when mixed with detergent, and the detergent gave the mixture consistency so that it could be applied as a thin film to the walls. This new procedure was named the little dab (Untadita in Spanish) and allows households to direct their efforts against a stage of the mosquito life cycle that has been ignored in the past: the egg.

Rate of reinfection with S. mansoni following treatment in two newly reclaimed areas of Egypt.

This paper reports an on-going study in two newly reclaimed areas in Ismailia Governorate, El-Manayef, 10 km south-west of the city of Ismailia (area 1) and the other in Siani Peninsula, just east of the Bitter Lakes (area 2). In he baseline survey, the prevalence of infection of 49.9% and 40.1% and high intensity infection of 21.8% and 15.7% were found for S. mansoni in areas 1 and 2 respectively. Geometric mean egg counts for those found positive were 101.2 and 75.9. In a subsequent survey, a year after treatment of positives, the overall prevalence was 30.2% and 30.5% and the prevalence of high intensity infection was 8.6% and 10.5% in the two areas. The prevalence among those found positive and then treated during the first round (reinfection rate) was 31.7% and 19.2%. Geometric mean egg counts had declined from 141.3 to 63.1 and from 133.6 to 59 among those who were reinfected. The occurrence of reinfection was strongly associated with younger age in both areas. Rates of reinfection showed a strong but not significant association with male sex in area 2 (p = 0.087), but no association in area 1. These high rates of reinfection demonstrate the importance of promotion of hygiene behaviors as well as ensuring access to chemotherapy.

The prevalence of hepatitis B and C infections among immigrants to a newly reclaimed area endemic for Schistosoma mansoni in Sinai, Egypt.

Serology for hepatitis B and C markers was performed on a community-based random sample of 506 residents of an area recently reclaimed from the desert and endemic for Schistosoma mansoni. The mean age of the study subjects was (20 +/- 14), and 52% were males. The overall seroprevalence of hepatitis B (Anti-HBc and/or HBsAg) was 19.6%, hepatitis C (Anti-HCV) was 10.3%, while 5% were positive for both hepatitis B and C. A strong association was present with increasing age for both hepatitis B and C markers. However, there was no association with either sex, S. mansoni infection or schistosomal periportal fibrosis. Also HBV seropositivity was not associated with increased risk of HCV seropositivity. Anti-HCV seropositivity was significantly associated with previous parenteral treatment for schistosomiasis (OR = 7.9), and with history of previous surgery (OR = 3). Hepatitis B and C are major public health problems in this population. It is recommended to consolidate the Egyptian programme of infant hepatitis B vaccination, and to extend it to older children and high risk adult groups. There is also an urgent need to study more closely the epidemiology, natural history, risk factors and modes of transmission of hepatitis C.

PIP: In Egypt, infection with hepatitis B (HBV) and C (HCV), together with schistosomiasis are major causes of chronic liver disease. Findings are presented from a study conducted in January 1994 to determine the prevalence of HBV and HCV infections in a Schistosoma mansoni-endemic area east of the Bitter Lakes recently reclaimed from the desert for agriculture. Serology for hepatitis B and C markers was performed on a community-based random sample of 506 area residents of mean age 20 years, and 52% male. The seroprevalences of hepatitis infection were 19.6% for HBV, 10.3% for HCV, and 5% both HBV and HCV. The prevalence of HBV and HCV markers generally increased with age. No association, however, was found with either sex, S. mansoni infection, or schistosomal periportal fibrosis. HBV seropositivity was not associated with increased risk of HCV seropositivity. Anti-HCV seropositivity was significantly associated with previous parenteral treatment for schistosomiasis and history of previous surgery. HBV and HCV infection is a major problem in this population. The Egyptian program of infant hepatitis B vaccination should be consolidated and extended to older children and high-risk adult groups. There is also an urgent need to study more closely the epidemiology, natural history, risk factors, and modes of hepatitis C transmission.

Factors affecting knowledge of the symptoms of schistosomiasis in two rural areas near Ismailia, Egypt.

The primary method of control of schistosomiasis in Egypt is through passive chemotherapy, in which people who suspect they have the disease are encouraged to go to their local health unit to be tested and treated. If people are unable to recognize the symptoms of schistosomiasis, this strategy may fail. This paper presents data on local knowledge of the symptoms of schistosomiasis from two areas recently reclaimed from the desert near Ismailia. Using data from free-listing and triadic comparisons, it is shown that schistosomiasis is primarily seen as a urinary disease. Factor analysis performed on a series of 12 questions on the symptoms of schistosomiasis included in a survey demonstrated that responses group into three patterns, the first stressing constitutional symptoms such as weakness, the second stressing abdominal symptoms and the third blood in the urine, burning on urination and blood in the stool. The paper discusses the implications of these findings for efforts to promote regular treatment with praziquantel of people living in or near the Nile Delta who are at risk for intestinal schistosomiasis.

Social and cultural factors affecting rates of regular retreatment of mosquito nets with insecticide in Bagamoyo District, Tanzania.

Insecticide-treated mosquito nets have an impact on mortality and morbidity in young children under controlled conditions. When integrated into larger control programs, there is the danger that rates of regular retreatment of the nets with insecticide will drop, greatly limiting their effectiveness as a public health intervention. In Bagamoyo District, Tanzania, rates of retreatment dropped significantly when payment for the insecticide was introduced. A series of neighbourhood (hamlet) meetings were held in all study villages to discuss people's concerns about the insecticide and ways to increase rates of retreatment. Although changes were made in the procedure for retreatment, rates of retreatment remained lower than expected and showed marked variation within as well as between villages. We then conducted unstructured key informant interviews as well as informal discussions in a village with strong variation between different sectors of the villages in rates of retreatment. While logistical problems were most frequently cited as reasons not to bring nets for retreatment, political and social divisions within the community provided a better explanation. This is borne out by the low response to rearrangements in logistics which made retreating the nets significantly easier for households, and the higher response when changes were made in the channels of communication as well as the logistic features. It is clearly more difficult for villagers to appreciate the benefits of the insecticide than those of the nets. Great emphasis needs to be placed on the insecticide and its beneficial effects from the outset for any large-scale programme to be sustainable.

Factors favoring houseplant container infestation with Aedes aegypti larvae in Marília, São Paulo, Brazil.

Since reinvasion of São Paulo State by the Aedes aegypti (L.) mosquito in 1985, flower pots and vases have been important larval habitats despite educational messages focusing on their control. The objectives of this study were to characterize flower pots and vases as larval habitats with respect to the quantities present and infested, the types of plants involved, and the specific locations of the mosquito larvae; to explore local names for houseplants; and to examine factors affecting acceptance of control measures. The results showed an average of more than four potential plant-related larval habitats per premises, of which only 0.4% were occupied by the vector. Plant-related containers represented 31% of all the containers with Aedes aegypti larvae. Although a sample of 126 respondents was able to list 105 different houseplant names, 49% of the positive plants were of two types: ferns and the ornamental plant Dieffenbachia avoena. The public's apparent unwillingness to accept recommended anti-aegypti control measures involving houseplants seems related to the relative rarity of aegypti larvae in the very common houseplant containers, the control program's poor credibility as a source of information about plants, and a perception that the recommended control measures are harmful to plants. An intervention currently being planned for dengue control will use educational material that refers specifically to those plants whose containers are most commonly found to harbor aegypti larvae; it will also utilize information sources such as botanists with greater credibility regarding plants; and it will set out alternative plant care recommendations that are more likely to appeal as beneficial to the plants and that will stand a better chance of being accepted.