A model of community capacity building for sustainable dengue problem solution in Southern Thailand

doi:10.4236/health.2011.39100

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Vol.3, No.9, 584-601 (2011)

doi:10.4236/health.2011.39100

Health

A model of community capacity building for sustainable

dengue problem solution in Southern Thailand

Charuai Suwanbamrung1*, Anan Dumpan2, Suw ich Thammapalo3, Ratana Sumrongtong4,

Pitaya Phedkeang5

1School of Nursing, Walailak University, Thasala District, Nakhorn Si Thammarat Province, Thailand;

*Corresponding Author: Scharuai@wu.ac.th

2The Office of Prevention and Control Disease, 11 Nakhorn Si Thammarat Province, Thailand;

3The Office of Prevention and Control Disease, 12 Songkhla Province, Thailand;

4College of Public Health Sciences, Chulalongkron University, Bangkok, Thailand;

5Nakhorn Si Thammarat Provincial Public Health Office, Nakhorn Si Thammarat Province, Thailand

Received June 18th, 2011; revised August 2nd, 2011; accepted August 10th, 2011.

ABSTRACT

Dengue community capacity (DCC) is important

for developing a sustainable approach to over-

coming the problem of dengue. The objectives

were 1) to develop and 2) evaluate a dengue

community capacity building model for the

leader and non-leader group in three communi-

ties selected by purposive technique. A mixed

method research design was used employing

both qualitative and quantitative methods with

qualitative studies conducted for community

capacity building model: assessment, planning,

implementation, and evaluation. DCC level was

assessed by the Dengue Community Capacity

Assessment Tool (DCCAT) including larval in-

dices, and morbidity and mortality rate. To ana-

lyze the differences of the leader and non-

leader’s DCC levels both pre and post-inter-

ventions in each model, the Mann-Whitney and

Independent T-te st were used and to anal yze the

difference of the DCC level among the three

models (Ban Mon, Ban Nangpraya and Ban

Kang), the Kruskal-Wallis Test, ANOVA, and

ANCOVA were used. The findings showed that

there were some differences among the three

models in dengue community capacity building

in terms model. The participants consisted of

leader (n = 26, 24 and 2 8) and no n-lea der grou ps

(n = 200, 215 and 176 respectively). The DCC

levels of both leader and non-leader groups in-

creased post-intervention in each model (p <

0.001) and in all three models, show ing a statis-

tically significant difference between pre and

post-intervention (p < 0.001). Ban Kang model

demonstrated the highest DCC levels of leader

and non-leader groups, the lowest larval indices

(HI, BI, and CI), and no dengue morbidity. In

contrast, Ban Mon and Ban Nangpraya model

showed low DCC level in both leader and

non-leader groups, a high rate of larval indices

and high dengue morbidity rate. How ever, there

was no mortality rate in three areas. The con-

clusion indicates that the model with a high

DCC level show ed low risk on the dengue index

both entomological and epidemiology index.

The model of dengue community capacity

building for dengue solution was sustainability

not only needs to be maintained DCC le vels but

also increased dependent upon the contexts of

each community.

Keywords: Dengue Proble m Solution; Model;

Community Capacity Building; Sustainable;

Thailand

1. INTRODUCTION

In Thailand, dengue has been a significant public

health problem for the past fifty years. The effectiveness

of dengue treatment has improved but the morbidity rate

is still higher than the Thai Ministry of Public Health’s

disease standard. The Thai Ministry of Public Health’s

most recent plan calls for a morbidity rate that does not

exceed twenty cases per 100,000 people and a mortality

rate which does not exceed 0.2%. This was the Ministry

of Public Health’s “Plan 9” in line with the 9th National

Social and Economic Development Plan for 2002 - 2006.

Due to the changing nature of dengue in Thailand, the

disease is difficult to manage only by case management.

Although the mortality rate has decreased in hospitals,

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the morbidity rate has unfortunately increased in all ar-

eas. The southern area, especially, has seen higher den-

gue incidence than other areas, possibly due to factors

such as a greater number of rainy days, the amount of

rainfall, the relative humidity, and a warmer temperature

[1].

One of the challenges of dealing with the problem of

dengue is to change from a centralized controlled health

program to a newer epidemiological paradigm involving

a community-based program [2,3] but which may lack

sustainability [2-4]. Sustainability is defined and meas-

ured differently depending upon the specific situation

[5,6]. The sustainability of community-based dengue

prevention and control is defined as the successful out-

come of community capacity building for dengue pre-

vention and control, and is measured by: 1) community

capacity domains; 2) the housing environment; 3) larval

indices, consisting of the Breteau Index (BI), House In-

dex (HI), and Container Index (CI); and 4) the epidemi-

ology index for the morbidity rate and mortality rate of

dengue [7-10].

Community capacity building is a strategy to achieve

sustainable dengue prevention and control [5]. It is a

necessary intervention process to achieve sustainability

which increases a community’s competence to define,

analyze, evaluate, and act on the health concerns of its

members [11-13]. Community capacity building is not

only concerned with the large-scale prevention and con-

trol of communicable diseases, but also focuses on indi-

vidual protection within communities [14]. This study of

dengue community capacity building presents a model

consisting of identifying community capacity domains,

assessing community capacity levels, planning and im-

plementing, and re-assessment [15,16]. The community

capacity domain assesses the ability of a community to

conduct anti-dengue efforts, and is based on specific

conditions within community [5,6,11,17-19]. These

dengue capacity domains were identified and then de-

veloped into an instrument to measure and assess the

dengue community capacity (Dengue Community Ca-

pacity Assessment Tool: DCCAT) [16]. The domains of

dengue community capacity were defined as a set of

characteristics relating to dengue prevention and control

undertaken by leaders (14-domain) and non-leaders

(11-domain) in the community [16]. There is no clear

‘appropriated model’ for sustainable dengue problem

solution because community capacity building is based

on the context of the community and different communi-

ties would have different community capacity models

[15,20]. As to which model would be most appropriate

in providing a sustainable solution to the problem of

dengue, the objectives of this study were to develop and

evaluate a community capacity model which is based on

the community context.

2. THE CONCEPTUAL FRAMEWORK

A model of community capacity for a sustainable so-

lution to the problem of dengue in this study consists of

three dimensions: community-based dengue prevention

and control (leaders and non-leaders), a community ca-

pacity building process, and sustainable community-based

dengue prevention and control. These dimensions can be

seen as Figure 1.

2.1. Community-Based Dengue Prevention

and Control

A community-based dengue prevention and control

Sustaina ble community -ba se

dengue prevention and control

- Dengue community capacity level

of leader (14 domains) and

non-leader (11 domains)

- Dengue entomology index;

Larval Indices (Breteau Index

(BI), House Index (HI) and

Container Index (CI)

- Dengue epidemiology index;

morbidity rate and mortality rate

Community-based

dengue prevention

and control

Non-Leader

Group: Capacity

for sustainable

group

Leader Group:

Capacity for

delivery and

building group

Community capac ity buildi ng for sustainable community-based

dengue prevention and control process

Assessment

Plan and

implement

Re-assessment

Preparation of

community

igure 1. Conceptual framework of community capacity for sustainable dengue problem solution.

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586

process enables key stakeholders in the community to

actively prevent and control their dengue problem. The

strategies of dengue prevention and control at the sub-

district level focuses on vector control and transmission

of infections to humans, based on the community as the

setting, target, agent and resources for dengue activities

[8,21].

In this study, community-based dengue prevention and

control was analyzed in three communities with dengue

focusing on two groups for dengue prevention and con-

trol: the first group was the leader group who assumed

the role as the “capacity building activities group” and

consisted of representatives of dengue health promoters,

local authority/organization networks, schools, temples,

and village health volunteers. The second group was the

non-leader group whose role was as the “sustainable

prevention and control activities group” and consisted of

community members (see Figure 2 for participants on

community-based).

2.2. Community Capacity Building Process

Community capacity building is a process which dem-

onstrates an increase in the various domains of commu-

nity capacity in a community-based dengue prevention

and control program. The processes of community ca-

pacity building involves the following steps: 1) prepara-

tion (Develop the operational domain and prepare to

assess the community capacity); 2) assessment of com-

munity capacity 3) development of a strategic plan and

implementation and 4) follow-up or reassessment [12,13,

21-23]. In this study, dengue community capacity build-

ing is defined as a process of building community capac-

ity for dengue prevention and control in community in-

volving 4 steps such as 1) community preparation, 2)

assessment, 3) plan and implement and 4) re-assessment.

In the process of the dengue community capacity

building (DCCB) were the community capacity domains

of the leader group (14 domains) and non-leader group

(11domains) [15,24]. There were three domains of the

leader group more than the non-leader group—Leaders

group networking domain, Leaders group and commu-

nity networking domain, and Community participation

domain as following:

2.2.1. Critical Situation Management Domain

The critical situation management is a distinctive ca-

pacity domain because it is the first domain of both

groups. The critical situation management domain of the

leader group includes nine capacities whereas this do-

main of the non-leader group consists of 13 sub-capaci-

ties. There are five capacities which overlap in both

groups. The relevant capacities of critical management

domain focused on key dengue stakeholders and their

activities in quickly prevention and control dengue

problem.

2.2.2. Personal Leadership Domain

The personal leadership is the second domain of both

groups. The domain in the leader group includes 12

sub-capacities and the non-leader group consists of eight

- Capacity to build sustainability program

- Capacity building relationship

Local government and

authority representative

Members

- Capacity for program delivery

- Capacity for capacity-building relationship

- Capacity for dengue prevention and control

- Capacity to sustain the program

1. Leader gr ou p;

Capacity building

2. Non-lea d er group; Sustai nable preventio n

and control

Figure 2. Community-based relationships for building community capacity to overcome the dengue problem.

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sub-capacities. An examination of content related to this

domain focuses on individual perception of their activi-

ties to prevent and control dengue disease. For the

leader’ group, there are five activities focusing on ca-

pacities to enhance other dengue stakeholders for dengue

prevention and control.

2.2.3. Health Care Provider Capacity Domain

This was the third domain of the leader group (8

sub-capacities) and the fifth domain of the non-leader

group (6 sub-capacities). An examination of the activi-

ties content reveals that these sub-capacities focused on

dengue prevention and control activities of health care

workers and village health volunteers. Five sub-capaci-

ties overlapped in both groups. These capacities indi-

cated the important capacity of village health volunteers

for dengue prevention and control because village health

volunteers are key stakeholders of the health care service

in the community in Thailand.

2.2.4. Needs Assessment Domain

This domain is the fourth domain of the leader group

(8 sub-capacities) and the eleventh of the non-leader

group (5 sub-capacities). There were four sub-capacities

which overlapped in both groups. An examination of the

sub-capacities showed that these sub-capacities focused

on community members’ needs related to the dengue

problem and its solution. These sub-capacities indicated

the importance of the local administrative organization

as a centre of the dengue solution provider.

2.2.5. Senses of Community Domain

This domain is the fifth domain of the leader group (11

sub-capacities) and the sixth domain for the non-leader

group (8 sub-capacities). There are seven sub-capacities

which overlapped both groups. An examination of ca-

pacities content indicated that these capacities focused

on perception of the dengue problem and the solution in

the community.

2.2.6. Leaders Group Networking Domain

This domain is the sixth domain for only leader group

included 11 sub-capacities An examination of the capac-

ity content of these sub-capacities indicated a focus on

the individual dengue network of the leader group

members with representatives of other stakeholders.

2.2.7. Communication of Dengue Information

Domain

This domain is the seventh capacity domain of leader

group (10 sub-capacities) and the seventh domain of the

non-leader group (7 sub-capacities). An examination of

the sub-capacities content indicated that these sub-ca-

pacities focused on channels and resources of receiving

dengue information. Four sub-capacities overlapped in

both groups focusing on familiar channels in sub-dis-

tricts of Southern Thailand.

2.2.8. Community Leadership Domain

This domain is the eighth capacity domain of the

leader group (8 sub-capacities) and the fourth domain of

the non-leader group (8 sub-capacities). Almost all ac-

tivities (7 of 8 sub-capacities) in the non-leader and

leader overlapped in both groups. An examination of the

capacities content related to these sub-capacities focused

on the community members’ perception of dengue pre-

vention and control as their responsibility. The overall

group perception in the community of community lead-

ership is a person who shows strength, consults, man-

ages, accepts clear responsibility, listens, and focuses

attention on dengue prevention and control.

2.2.9. Religious Capacity Domain

This domain is the ninth capacity domain of the leader

group (9 sub-capacities) and the third capacity domain of

the non-leader group (10 sub-capacities). There are nine

sub-capacities which overlap in both groups. An exami-

nation of activities content related to these sub-capacities

focused on the capacity of imams and monks to under-

take activities of dengue prevention and control.

2.2.10. Leaders Group and Communi ty

networking domain

The tenth domain of only the leader group contained

of seven sub-capacities. An examination of the capacity

content focused on dengue prevention and control by

networking between community members and leaders.

Leader and non-leader groups both participate for den-

gue prevention and control activities.

2.2.11. Resource Mobilization Domain

This is the eleventh capacity domain of the leader (4

sub-capacities) and the tenth domain of the non-leader (5

sub-capacities). Four sub-capacities overlapped in both

sub-tools. An examination of the sub-capacities content

revealed that these focused on the ability of the commu-

nity’s members to mobilize resources for dengue pre-

vention and control.

2.2.12. Dengue Working Group Domain

This domain is the twelfth capacity domain of leader

(6 sub-capacities) and the ninth capacity domain of the

non-leader (7 sub-capacities). There were five sub-ca-

pacities which overlapped both groups. An examination

of the sub-capacities content indicated that these capaci-

ties focused on the community member group and rep-

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588

resentatives of organizations in the community as the

leader group to prevent and control dengue disease. The

core leader means the community group which takes the

lead in capacity building for dengue prevention and con-

trol.

2.2.13. Community Participation Domain

The thirteenth capacity domain of only the leader

group is community participation. This domain consisted

of six sub-capacities. An examination of the sub-capaci-

ties content suggested that these focused on community

leader’s participation in dengue prevention and control.

Community participation (CP) is the most important

strategy in dengue management.

2.2.14. Continuing Activities Domain

This domain is the fourteenth capacity domain of

leader (6 sub-capacities) and the eighth capacity domain

of non-leader (6 sub-capacities). An examination of the

capacities content indicated these capacities focused on

community guidelines and policies of dengue prevention

and control. Four sub-capacities overlapped in both

groups.

2.3. Sustainable Community-Base Dengue

Prevention and Control

Community-based dengue prevention and control

comprise activities through which people to control and

eliminate larval breeding sources, control adult mosqui-

toes, apply personal protection, introduce dengue symp-

tom detection and outbreak prevention [8]. They were

measured by assessing the effective performance in spe-

cific community capacity domains, exhibiting dengue

prevention and control behaviors as continuing evidence

of implementing dengue strategies or activities, and the

results of such 1) dengue community capacity level of

the leader group (14 domains) and the non-leader group

(11 domains), 2) dengue entomology index; Larval In-

dices such as Breteau Index (BI), House Index (HI), and

Container Index (CI), and 3) dengue epidemiology index;

morbidity rate and mortality rate [7-10].

3. MATERIAL MATHODS

The study design was revised and forwarded to the

International Review Board (IRB), the Ethical Review

Committee for Research Involving Human Research

Subjects, the Health Science Group, Walailak University,

Thailand. A mixed method research design using both

qualitative and quantitative was employed. The qualita-

tive aspect centred on collecting data based on the par-

ticipation of the community in the community capac-

ity-building process conducted in 4 stages of community

participation―community preparation, assessment, plan

and implementation, and re-assessment. Moreover, the

quantitative collecting data for the assessment and re-

assessment steps used the Dengue Community Capacity

Assessment Tool (DCCAT) and surveyed the larval in-

dices and morbidity and mortality rates.

3.1. Community Preparation Step

Three communities were prepared based on the com-

munity participation approach. This consisted of study

areas selection, identification of dengue leader group

(DLG) and Dengue supporting team.

3.1.1. Study Areas

The study took place between October, 2009 and Oc-

tober, 2010, in Southern Thailand. The researchers dis-

cussed with the sub-district’s council and other stake-

holders at a meeting about their dengue problems and

solutions. Three villages as communities were then se-

lected using purposive criteria: high dengue incidence

and a volunteer and community approach to solving the

problem of dengue. The villages were Ban Mon com-

munity of Tharou sub-district, Ban Nangpraya commu-

nity of Paknakhorn sub-district, and Ban Kang of Kum-

pansou sub-district in the Meung district, Nakhon Sri

Thammarat province, Southern Thailand. The three

communities from three sub-districts had a high DHF

morbidity rate as high larval indices indicated a high risk

of dengue transmission based on WHO guidelines [25].

These communities were amenable to attempting to im-

plement a community based approach to sustainable

dengue prevention and control. Leaders and non-leaders

in the community were empowered and encouraged by

the research team at the beginning process.

3.1.2. Leader Group

The leader group was involved with the prevention

and control of dengue activities and participated actively

in conducting and collecting data. The leader group con-

sisted of village health volunteers (VHVs) and other

volunteers. VHVs were mostly community members

who took responsibility for implementing dengue control

activities in a community, covering about fifteen to

twenty households. The members of the leader group

were well trained by the research team for data collec-

tion and were knowledgeable in the study process.

3.1.3. Dengue Support Team

The dengue support team consisted of a health worker

representative from a primary health care station who

was involved with providing dengue solutions in the

communities, local administrative officers, and the re-

searcher. The team supported and facilitated the activi-

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ties for building community capacity, such as meeting

with and training the leader group to increase their

knowledge of dengue.

3.2. Assessment Step

The assessment step consisted of situation assessment

and assessment of the community capacity level. The

situation assessment used qualitative methods by the

researcher such as interviews, the leader group discus-

sions, community consensus and environmental obser-

vation. This specific mixture of methods was selected in

order to better understand the diversity of community

dynamics within the overall qualitative approach [26].

The community capacity level was assessed by the

leader group which was trained in collection method of

DCCAT form.

3.2.1. Interviews

The interview method focused on obtaining key in-

formation about the community’s leaders of dengue ac-

tivity. This study elicited detailed information about

people’s perceptions of the dengue problem, possible

solutions, and methods for sustainable dengue prevention

and control in the community. The interview involved

participants and researchers talking about dengue issues.

The conversations generally lasted from forty-five to

sixty minutes, depending on the content. The researchers

prepared question guidelines and an audio recorder, and

set a time and place where participants felt comfortable

and where transportation was available. The researcher

in the study started each interview by introducing and

obtaining permission from the participants to allow re-

cording of the conversation.

3.2.2. Dengue Working Group Discus sions

From community participation in the community ca-

pacity building process, DLG obtained information

about the feelings, opinions, perceptions, attitudes, and

plans of the group. All participants in each community

met to discuss at least twice per month to assess, plan,

implement and reassess. The researcher provided the

objectives of the study, obtained informed consent, dis-

cussed the focus group process, and obtained permission

to audio record the session. To foster a flexible climate

for discussion, the conversations were held in the local

language, and lasted between ninety to 120 minutes.

3.2.3. Community Consensus

Community consensus was achieved by all represen-

tatives of all stakeholders in each community. Leaders

and non-leaders met to discuss community capacity

building process: preparation, assessment, plan and im-

plement, and reassessment.

3.2.4. Dengue Community Capacity Level of the

Leader and Non -Leader Groups

The output and outcome of community capacity

building were measured by quantitative collecting data

methods such as the self-reporting DCCAT, larval indi-

ces survey and monitoring morbidity and mortality.

3.2.4.1. Dengue Community-Capacity Assessment

Tool (DCCAT)

The Dengue Community-Capacity Assessment Tool

(DCCAT) was developed and tested by both qualitative

and quantitative methods [27-29]. The format consisted

of four parts: Part I: General characteristics, Part II:

Dengue community capacity, Part III: Household envi-

ronment observation form with open ended questions,

and Part IV: Larval indices survey form. The form in

part four was actually the old entomological vector sur-

veillance form, consisting of the following indices: the

House Index (HI), the Breteau Index (BI), and the Con-

tainer Index (CI), which were calculated to indicate the

density of dengue occurrence. The DCCAT contained

separate questionnaires for community leaders and non-

leaders. The dengue community capacity questionnaire

for leaders comprised 115 items over fourteen domains

producing the best fit regarding content validity (CVI =

0.90), construct validity (commutative percent of vari-

ance = 57.58), and Cronbach’s alpha coefficient (0.98).

The dengue community capacity of non-leaders ques-

tionnaire covered eleven domains totaling eighty-three

items. Factor analysis produced the best fit for content

validity (CVI = 0.91), construct validity (com % of vari-

ance = 57.11), and Cronbach’s alpha coefficient (0.97).

3.2.4.2. Partic ipant s and S ampl e si ze of C omm unity

Capacity Level

The responsible parties for dengue prevention and

control intervention included two groups in the commu-

nities: non-leaders and leaders [5,8,19]. The leaders

group consisted of representatives holding both formal

and informal leadership positions, i.e., local administra-

tive organization officers (LAO), health care workers,

school health teachers, community political leaders, reli-

gious leaders, village health volunteers, students, and

community club members. They were selected by health

workers based on their positions and responsibilities

concerning community dengue activities. The non-lead-

ers group was considered the group with the ability to

achieve sustainable dengue prevention and control ac-

tivities. They were representatives of households in the

communities selected by the dengue leader group.

Members of both groups were required to have resided

in their respective communities for more than one year,

to be eighteen years of age or older, to be fluent in the

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590

language used, and to be available for the study.

3.2.4.3. Data Collection

The researcher and the leader group, the members of

which were well trained in data collection, introduced

themselves and presented the objectives of the study to

community council representatives. They then met a

health worker for assistance in collecting data and mak-

ing the objectives of the study clear to participants. Next,

they obtained consent from participants at the first ses-

sion and began collecting data.

3.2.5. Entomological Survey

Standard larval index surveys [30] as epidemiological

indicators of dengue transmission should be viewed with

caution. The three traditional larval indices were: the

House Index (HI)—the percentage of houses infested

with larvae and/or pupae; the Container Index (CI)—the

percentage of water-holding containers infested with

larvae and/or pupae; and the Breteau Index (BI)—the

number of positive containers per 100 houses inspected.

Additionally, these were compared before and after

building community capacity for dengue problem solu-

tion [8,31]. Sample size, in an entomological survey

involving a large community of more than 300 house-

holds, a sample size of approximately 10%, or 100

households, should be taken [8]. In this study, the three

communities contained more than 100 households, re-

spectively. The leader group collected data for the larval

indices survey. Each VHV surveyed 10 - 15 households

after collecting the DCCAT report. The research team

then analyzed and reported this to the community for

planning and discussion.

3.2.6. Epidemiological Surveillance Monitoring

Dengue is a complex problem because it involves en-

tomology, epidemiology, and socio-ecological compo-

nents. Therefore, secondary data collection for commu-

nities involved rates of dengue incidence. Dengue statis-

tics for the current and previous three years, and the re-

sults of dengue programs were all collected from health

centers and local administrative organizations.

3.3. Planning and Implementation Step

This step followed the preparation and assessment

steps. The researcher and the leader group discussed

techniques and methods of analysis of the problem of

dengue to find solutions in each community over a six

month period. The leader group from three communities

planned the interventions for each community and par-

tial interventions for all three communities. The concep-

tual framework of community capacity building for sus-

tainable dengue prevention and control suggests a com-

munity-based model, a community capacity building

process, and assessment of outcomes [15,24]. The com-

munity capacity domains of leader consisted of 14 do-

mains: Critical situation management, Personal leader-

ship, Health care provider capacity, Needs assessment,

Sense of community, Leader group networking, Com-

munication of dengue information, Community leader-

ship, Religious leader capacity, Leader group and com-

munity networking, Resources mobilization, Dengue

working group, Community leader participation, and

Continuing activities domain. The other group of com-

munity stakeholders were represented by the non-leader

group and whose capabilities in community-building

capacities were assessed in 11 domains such as Critical

situation management, Personal leadership, Religious

leader capacity, Community leadership, Health care pro-

vider capacity, Sense of community, Communication of

dengue information, Continuing activities, Dengue

working group, Resources mobilization, and Needs as-

sessment.

The basic strategies for dengue prevention and control

of both leaders and non-leaders were for them to engage

together in activities within these three communities.

The study built abilities through training, operational

meetings, group discussions and consensus, promotional

campaigns, and local innovations of each community.

The large meeting of all the leaders from all three com-

munities was participatory and created several plans for

dengue solutions from the beginning and until the end of

intervention.

3.4. Re-Assessment Step

The main activities in the re-assessment step centred

on assessing the outcomes of community building ca-

pacity as a sustainable solution to the dengue problem—

the same steps as the assessment, evaluation and com-

parison before and after capacity building. The meetings

were structured as a series of workshops attended by

researcher, the leader group and the dengue support team

who were involved in dengue prevention and control in

these communities with the central focus being an ap-

propriate model for solving the problem of dengue.

4. DATA ANALYSIS

4.1. Qualitative Data

Dengue situation, community capacity building proc-

ess, in-depth interviews, focus group discussions, and

community consensus were used for content analysis.

4.2. Community Capacity Level

1) Information of participants, leaders and non-leaders,

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were collated by descriptive statistics, percentage, mean,

and standard deviation.

2) Dengue community capacity was analyzed with

descriptive statistics and was divided into different do-

mains for each group of participants. The dengue com-

munity capacity questionnaire for leaders consisted

of115 items covering fourteen domains. The range of

mean scores was divided into five levels for ranking

purposes: very low, low, moderate, high, and very high.

The questionnaire for non-leaders consisted of eighty-

three items divided among eleven domains. The mean

score categories were divided into five levels such as

very low, low, moderate, high, and very high.

3) The differences of the leader and non-leader group’s

capacity levels used the Mann-Whitney and Independent

T-test to compare these groups pre and post-intervention

for building community capacity. The difference be-

tween community capacities among three models used

the Kruskal-Wallis Test, ANOVA, and ANCOVA.

4.3. Dengue Entomological Index and Data

of Main Breeding Sites

This study only used larval indices which were ana-

lyzed as the House Index (HI)—the percentage of houses

infested with larvae and/or pupae; the Container Index

(CI)—the percentage of water-holding containers in-

fested with larvae and/or pupae; and the Breteau Index

(BI)—the number of positive containers per 100 houses

inspected.

4.4. Dengue Epidemiological Index

Morbidity and mortality rates of dengue were ana-

lyzed based on information from health care centers in

communities.

5. RESULTS

The results of study showed 4 sections: 1) the model

of community capacity building in three communities,

and 2) Sustainable outcome of dengue problem solution

model were consisted of dengue community capacity

level (leader and non-leader group), 3) dengue entomol-

ogy index, and 4) dengue epidemiology index.

5.1. The Model of Community Capacity

Building in Three Communities

Leader and non-leader group, Ban Mon, Ban Nanghraya,

and Ban Kang model were the leader group (26, 24, and

28) and the non-leader group (200, 215, and 176). The

research team, support team, and the leader group used

discussion techniques and carried out analysis of the

dengue problem in each model over a 13 months period

(October, 2009-October, 2010). The leader group in the

three models planned the interventions and partial inter-

ventions for each model as well as joint interventions for

all three models. Both groups volunteered to participate

in the dengue capacity building process.

The three models followed the concept of the dengue

community capacity building process with its four steps:

preparation, assessment, planning and implementation,

and re-assessment. Meetings of the leader and non-

leader groups for all four steps of activities were held at

least once monthly throughout the study. Planning and

implement activities were achieved through consensus of

the community based on their particular context and the

resources in their community. Each community devel-

oped a complete action plan and implemented activities

appropriate to the context of their communities.

1) Ban Mon model, it was a village at a crossroads

community selected by representatives of the local ad-

ministrative organization, health center, community

leader, religion leader, and village health volunteers. The

community consisted of 320 households, a health center,

a utility building, a temple, and a community school.

Most households were situated near a large road which

was the crossroads of a semi-urban community and had

4 to 6 months with rainy day in a year in an area that was

low with still water in several areas. The model imple-

mented four activities based on the specific problems

and available community resources such as conducting a

dengue prevention and control campaign, communica-

tion from their community leaders, obtaining community

consensus for dengue prevention and control from local

administrative organizations, and meeting of the dengue

leaders group once mouth.

The Ban Mon model had eight issues that showed up

in the pre-test: 1) poor environment, 2) community needs

more of everything, 3) lack of capacity of health center

officer, 4) misconceptions in the of use of chemical in-

secticides, 5) deficit of dengue knowledge, 6) commu-

nity resources management, 7) low community partici-

pation, and 8) lack of continuity. For example, some

participants said that chemical fogging teams showed a

lack of knowledge in using chemicals which were used

in fogging by such statements as if there were an out-

break of dengue illness, there “needs to be chemical

fogging 2 - 3 times per month” and “needs fogging fre-

quency”. After intervention, leaders and non-leaders’

suggestions in Ban Mon were fewer than pre and post-

intervention: 1) poor environment, 2) capacity of health

center official, 3) misconception in using chemical, 4)

deficit of dengue knowledge, 5) community participation.

For example, some participants said: “no clear dengue

information provided” “should give information for

every household in community and take real survey”.

C. Suwanbamrung et al. / Health 3 (2011) 58 4-601

592

2) Ban Nangpraya model, it was a seaside community

in Pak Na Khorn sub-district selected by representatives

of all stakeholders in the community. The community

was semi-urban; with households situated closely and

with more than 10 houses per group. It consisted of total

of 344 households, an all-purpose building, a temple, a

community school, a health center, a local district or-

ganization, community leaders, and village health vol-

unteers. Fishing and unskilled labor was the occupation

of most of the community.

The model was three special activities—community

communication of dengue knowledge, employing red

lime for use in water containers as in the community.

There were many water containers per house, meeting of

DLG once a month to monitor and evaluate the program.

In Ban Nangpraya community, leader and non-leader

groups pointed out six issues: 1) poor environment be-

cause of low land and more water containers, 2) com-

munity needs all stakeholders to solve the dengue prob-

lem, 3) dengue information communication, 4) deficit of

capacity of health center officials, 5) dengue knowledge

of community, and 6) low community participation. For

example, some participant said: “there should be meet-

ing of dengue management among people, VHVs and

health center official…”, “most people in community

had little knowledge of dengue”, “breeding sites were

many…”, “no clear dengue campaigns whereby people

receive true information” “…no government officials

who were really responsibility so people in community

are not attentive for prevention and disease control” “No

promotion of dengue campaign and dengue information

transfer…needs VHVs help to inform about dengue

prevention and control”. The intervention finished the

post-intervention showed decreased suggestions of only

four issues: 1) poor environment, 2) lack of knowledge

of dengue prevention and control, 3) lack of capacity of

health center officials, and 4) low community participa-

tion. For example, some participant said: “community

has more forests and canals...cannot cover the entire

area…villagers help only their own households to cover

water containers and cultivate citronella” “needs to

broadcast dengue information...increased broadcasts are

beneficial”.

3) Ban Kang model, it was a small village in a sub-

district near Meung district consisting of 239 households,

an all-purpose building, a temple, a mosque, a commu-

nity school, a health center, a local district organization,

community leaders, and village health volunteers. There

were two religions; Buddhism (70%) and Muslim (30%).

Most people in the community were rubber tappers and

fruit farmers with the gardens of risk as mosquito breed-

ing place.

Ban Kang was the garden model carried out three ac-

tivities—a mobile meeting of the DLG conducted in

each area of the community, mass communication from

leaders of religion and the community leaders, and door

to door survey of larval index once a month by DLG.

Moreover, there were the strongest of leader and non-

leader participation in all activities such as environment

in and out houses for elimination dengue sources.

The initially identified issues of Ban Kang model

were six such as 1) not clear who are the VHVs and

health center official, 2) community participation needs

to be strengthened, 3) lack of continuity of activities, 4)

unclear dengue information, 5) misconceptions concern-

ing chemical fogging, and 6) unclear community con-

sensus. At the completion of the intervention process,

the community had fewer suggestions from the leader

and non-leader groups. The major issues were a partially

poor environment, lack of community participation, and

inadequate dengue information communication.

Summary, the dengue community capacity building

process of these three models carried out different ac-

tivities based on the same four steps. The basic strategies

and resulting activities for the prevention and control of

dengue in these three communities evolved into the

dengue community network. The dengue network car-

ried out seven activities—meeting to prepare plan for

intervention, chemical fogging training for control after

dengue morbidity in community, herbal training to de-

velop a citronellas bank, developing a Gambia fish bank,

establishing community radio to share dengue knowl-

edge, carrying out a larval index survey every month,

developing leadership training, and evaluation meeting.

Overall, the issues and suggestions of all three models

decreased at the end of intervention process. Community

consensus contributed towards the building of commu-

nity capacity, activities for prevention and control were

undertaken appropriate for the context of community,

and there was commitment to continue activities as the

model for overcoming the problem of dengue. For ex-

ample, some participants said: “the community (all peo-

ple in the community) needs to continue all activities to

solve the problem of dengue solution...thank you for the

project ” “...as the past one year of conducting the den-

gue program...our community was attentive to dengue

prevention and control...however, we will be continuing

the program”

5.2. Sustainable Outcome of Dengue

Problem Solution

Sustainable outcome of dengue problem solution was

the results of the study consisted of dengue community

capacity level, dengue entomology index, and dengue

epidemiology index.

C. Suwanbamrung et al. / Health 3 (2011) 58 4-601

593593

5.2.1. Dengue Community Capacity Level of the

Leader Group

5.2.1.1. Charact eristics of the Leader Group

The characteristics of the leader group pre and post

building dengue community capacity in three models in

Ban Mon, Ban Nangpraya, and Ban Kang models were

28, 24, and 26 respectively. The majority percentage (%)

of participants in Ban Mon, Ban Nangpraya, and Ban

Kang model were female (Pre- 75%, 83%, and 46%;

Post- 86%, 83% and 58%), Buddhist (Pre- 100%, 100%

and 69%: Post- 100%, 100% and 65%), married (Pre-

72%, 84% and 82%; Post- 72%, 84% and 82%), basic

elementary (Pre- 39%, 38% and 23%; Post- 55%, 38%

and 15%), most common occupation; Ban Mon (Un-

skilled laborer; Pre- 27% and post- 25%), Ban Nang-

praya (Homemaker; 59% and 49%), and Ban Kang

(Farming; Pre 65% and post 62%). Highest positions in

community were the village health volunteers (Pre- 72%,

79% and 62%: 72%, 67% and 85%). Receiving dengue

knowledge in the past 12 months showed an increase in

the post-intervention (61%, 79% and 89%) from pre-

intervention (50%, 14%, and 89%). Having experienced

dengue on the pre-intervention was lower than on post-

intervention (50%, 14% and 89%: 61%, 79% and 89%)

(no present table).

The characteristics of the leader group of pre and

post-intervention in each model were not significantly

different. The mean age, the length of time residing in

the community, and dengue education time in the past 12

months were not significantly different in their mean

scores in the pre-post tests and among three different

communities. However, the mean of family monthly

income was significantly different (p < 0.05); Ban Kang

was higher than the other model (no present table). The

characteristics of the variables of the leaders in the three

model were compared in the pre and post-intervention

showing significantly different variables such as sex (p <

0.01 and p < 0.05), religion (p < 0.00, p < 0.00), occupa-

tion (p < 0.00, p < 0.00), and community status as com-

munity committee (p < 0.05 and p < 0.05) (no present

table).

5.2.1.2. Dengue Community Capacity Level of the

Leader Group in Three Models

Table 1 shows various levels of dengue community

capacity of leaders in Ban Mon (n:24), Ban Nangpraya

(n:24), and Ban Kang communities (n:28) focusing on

pre and post-intervention results which were signifi-

cantly different (p < 0.05). In the pre-intervention, the

total community capacity level of Ban Mon, Ban Nang-

praya, and Ban Kang communities were high (

, SD:

351, 15), moderate (

, SD: 297,16), and high (

, SD:

352,15) respectively. The post-intervention results show

that Ban Mon, Ban Nangpraya, and Ban Kang model

were high (

, SD: 389, 11), high (

, SD: 357,10), and

high (

, SD: 406,12) as follows.

For the Ban Mon model, the dengue community ca-

pacity level of 14 domains of leader the group were at

the high level (5-domains), at the moderate level (8-

domains), and low level (1-domain as Religious leader

capacity domain) in the pre-intervention. Pos-interven-

tion’s results showed increase scores of all domains with

a high level (10-domains), and moderate level (4-do-

mains). There were significant differences of increased

scores in two domains, namely, in the Community lead-

ership domain (p < 0.05) and in Dengue working group

domain (p < 0.05).

Most domains of Ban Nangpraya model in the

pre-intervention were at moderate levels (9-domains),

high level (3-domains), low level (1-domain—Dengue

working group domain), and very low (1-domain—Re-

ligious leader capacity domain). The increased scores on

the post-intervention showed high level (8-domains),

moderate level (5-domains), low level (1-domain—Reli-

gious leader capacity domain). There were significant

differences with increased scores in nine domains (p <

0.05) and continuing activities (p < 0.01).

In the last community, Ban Kang model’s scored at

mostly at moderate levels (10-domains), high level

(4-domains) in the pre-test, but on the post-test, most

domains were at the high level (13-domians) which

showed significantly increased scores in seven domains

(p < 0.01), and a moderate level in only one domain—

Resource mobilization domain (p < 0.05). Among the

three models, pre-intervention’s scores were signifi-

cantly different in total (p < 0.01) and in five domains

such as Critical situation management domain (p < 0.01),

Needs assessment domain (p < 0.01), Communication of

dengue information domain (p < 0.01), Community lead-

ership domain (p < 0.05), and Religious leader capacity

domain (p < 0.001). In the post-intervention, the Critical

situation management domain and Religious leader ca-

pacity domain were significantly different among the

communities (p < 0.01), and three domains were sig-

nificantly different (p < 0.05) such as Leader group net-

working domain, Communication of dengue information

domain, and Leader group and community network. See

Table 1 for community capacity level of leaders in be-

fore and after intervention.

5.2.1.3. Multiple Comparison of Dengue Commu nity

Capacity of the Leader Group Pre and Post

Intervention a mong Three Models

The community capacity levels of the leaders in Ban

Mon, Ban Nangpraya, and Ban Kang model were found

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594

Table 1. Comparison dengue community capacity levels of leaders between pre and post intervention in Ban Mon, Ban Nangphaya,

and Ban Kang model.

Dengue community capacity level

Ban Mon (n:26) Ban Nangpraya (n:24) Ban Kang (n:26)

(Kruskal-Wallis

Test, p)

Dengue community capacity domains

of the leaders group

Pre Post

(

SD))

Pre

(

(SD))

Post Pre

(

(SD))

Post

(

(SD)) Pre

(SD))(SD))(

(Post

29(1)4 L1: Critical situation management 32(1)4 24(1)3 28(1)4* 28(1)4 34(1)4** 0.004** 0.009**

L2: Personal leadership 39(1)4 43(1)4 38(1)4 40(1)4 40(1)4 44.624 0.496 0.111

L3: Health care provider capacity 28(1)4 30 (1)4 25(1)4 29(1)4 27(1)4 30(1)4* 0.279 0.201

L4: Needs assessment 24(1)3 26(1)4 17(2)3 24(0.9)323(1)3 27(1)4 0.009** 0.084

L5: Sense of community 42(1)4 41(1)4 39(2)4 43(1)4 38(1)4 43(0.9)4** 0.150 0.823

L6: Leader group networking 31(2)3 35(1)3 27(2)3 32(1)3* 33(2)3 37(1)4 0.051 0.049*

L7: Communication of dengue information 28(1)3 32(1)3 21(1)3 26(1)3* 27(1)3 31(1)4 0.004** 0.019*

L8: Community leadership 25(1)4 27(0.8)4* 21(1)3 26(1)4* 24(1)3 28(0.9)4** 0.038* 0.290

L9: Religious leader capacity 17(2)2 24(2)3 8(2)1 15(2)2* 24(1)3 28(1)4* 0.000***0.002**

L10: Leader group and Community networking 20(1)3 23(1)4 18(1)3 22(0.9)421(1)3 25(1)4** 0.237 0.049*

L11: Resource mobilization 10(0.7)311( 0 .6)310(0.7)312(0.5)3* 10(0.7)312(0.7)3* 0.910 0.816

L12: Dengue working group 15(1)3 20(0.7)4* 12(1)2 17(0.8)3* 15(0.9)319(0.8)4** 0.163 0.078

L13: Community leader participation 18(1)3 20(0.8)416(1)3 20(0.6)4* 18(1)3 19(0.7)4 0.481 0.825

L14: Continuing activities 18(1)3 20(0.7)416(0.9)319(0.6)4** 18(1)3 21(0.8)4** 0.066 0.129

Total 351(15)4389(11)4** 297(16)3357(10)4**352(15)4406(12)4** 0.005** 0.018*

Remake: Level of community capacity as 1very low; 2low; 3moderate; 4 high; *p < 0.05; **p < 0.01; ***p < 0.001.

to be significantly different. The total of dengue com-

munity capacity levels in the pre-intervention showed a

significant difference between Ban Mon and Ban Nang-

praya (p < 0.05) and Ban Nangpraya and Ban Kang (p <

0.01), and in the post-test there was a significant differ-

ence between Ban Nangpraya, and Ban Kang (p < 0.05).

In the multiple comparison test, Ban Mon and Ban

Nangpraya showed significant differences in the com-

munity capacity domain before the intervention in five

domains—Critical situation management (p < 0.01),

Needs assessment (p < 0.01), Communication of dengue

information (p < 0.01), Community leadership (p < 0.01),

and Religious leader capacity (p < 0.05), but after the

post-test, the only significant difference was in Critical

situation management domain (p < 0.01). Ban Mon and

Ban Kang models showed significant difference in the

community capacity domain during the pre-test only in

Religious leader capacity domain (p < 0.05). Multiple

comparisons between Ban Nangpraya and Ban Kang

models showed significant differences in the community

capacity domain in the pre-intervention in three domains,

namely, Critical situation management domain (p < 0.01),

Needs assessment domain (p < 0.01), Religious leader

capacity domain (p < 0.01), but the post-intervention

showed five domains with significant differences—Criti-

cal situation management domain (p < 0.01), Leader

group networking domain (p < 0.05), Communication of

dengue information (p < 0.05), Religious leader capacity

domain (p < 0.01), Leader group and community net-

working domain (p < 0.05) (see Table 2).

5.2.2. Dengue Community Capacity Level of the

Non-Leader Grou p

5.2.2.1. Characteristics of the Non-Leader Group

Table 4 describes the characteristics of the non-leader

group in the pre and post-intervention in the three com-

munities, Ban Mon, Ban Nangpraya, and Ban Kang

models were 200, 215, and 176 respectively. A large

majority of participants in the Ban Mon, Ban Nangpraya,

and Ban Kang model in the pre and post-intervention

were female, (pre- 69%, 64%, and 50%: post- 73%, 64%

and 58%), Buddhist (pre- 99%, 99% and 71%; post-

100%, 99% and 72%), married (pre- 76%, 66% and 70%;

Openly accessible at

C. Suwanbamrung et al. / Health 3 (2011) 58 4-601

595595

Tab le 2 . Multiple comparison of differences of dengue community capacity of the leader group in pre and post-intervention among

three models.

Multiple comparison of differences of models (Mann-Whitney Test)

Ban Mon (n:28) and Ban

Nangpraya (n:24)

Ban Mon (n:28) and Ban

Kang (n:26)

Ban Nangpraya (n:24) and

Ban Kang (n:26)

Dengue community capacity of the

leader group

Pre Post Pre Post Pre Post

L1: Critical situation Management 0.002** 0.033* 0.013* 0.003**

L4: Needs assessment 0.005** 0.012*

L6: Leader group networking 0.013*

L7: Communication of dengue information 0.004** 0.022*

L8: Community leadership 0.018*

L9: Religious leader capacity 0.004** 0.018* 0.000** 0.001**

L10: Leader group and community networking 0.022*

Total 0.016* 0.001** 0.005**

Remake: *p < 0.05; **p < 0.01.

post- 72%, 65% and 71%), basic elementary education

(pre- 55%, 44% and 49%; post- 49%, 42% and 56%).

The most common occupation in Ban Mon and Ban

Nangpraya model were unskilled labor (pre- 41% and

49%; post- 32% and 41%), Ban Kang model was farm-

ing (pre- 46%; post- 52%). Receiving dengue knowledge

in past 12 months showed an increase in the post-inter-

vention (16%, 14% and 17%) from pre-intervention

(50%, 14%, and 89%). Having experienced dengue, the

pre-intervention was lower than post-intervention (pre-

14%, 23% and 34%; post- 61%, 79% and 89%). The

characteristics of the non-leader group of pre and

post-intervention in each community were not signifi-

cantly different. The mean of age, length of time resid-

ing in the community, and dengue education in the past

12 months were not significantly different between the

mean scores in pre-post intervention and among the

three models. However, the mean of family monthly

income was significantly different (p < 0.05): Ban Kang

was higher than others model. The characteristics of the

variables of the non-leader group in three models were

compared in the pre and post-intervention showing sig-

nificant difference in some variables such as sex (p <

0.01 and p < 0.05), religion (p < 0.001, p < 0.001), oc-

cupation (p < 0.001, p < 0.001), and community status as

community committee members (p < 0.05 and p < 0.05)

(no present table).

5.2.2.2. Dengue Community Capacity Level of the

Non-Leade r Group in Models

Table 3 shows various levels of community capacity

of leaders in Ban Mon (n: 200), Ban Nangpraya (n: 215),

and Ban Kang communities (n: 176) focusing on pre-test

and post-test results which were significantly different

(p < 0.05). In the pre-test, the total community capacity

level of non-leaders in Ban Mon, Ban Nangpraya, and

Ban Kang communities were at a moderate level (

, SD:

247, 72; 196, 70, and 242, 35).

On the post-test, Ban Mon and Ban Kang communi-

ties were at a high level (

, SD: 263, 52; 290, 54), and

Ban Nangpraya community was at a moderate level (

SD: 218, 62) as follows. On the pre and post-interven-

tion, all three models were significantly different at

various community capacity levels (p < 0.001). For Ban

Mon model, the dengue community capacity levels of 11

domains for the non-leader group were at a high level

(6-domains), at a moderate level (4-domains), and at a

low level (1-domain—Religious leader capacity domain)

in the pre-intervention. The post-intervention showed

increased scores in all domains—a high level (7-domains),

a moderate level (4-domains). There was a significant

difference of increased scores in six domains—five do-

mains were different (p < 0.05) and one other domain

was different (p < 0.01). The Ban Nangpraya model

showed moderate levels in 7-domains, a high level in

1-domain, and low levels in 3-domains (Religious leader

capacity, Communication of dengue Information, Den-

gue working group). Most domains increased their

scores in the post-test showing high levels in 3-domains,

moderate levels in 6-domains, low levels in 2-domains

in (Religious leader capacity domain and Communica-

tion of dengue information). There were a significant

difference of increased scores in nine domains; four do-

mains (p < 0.01) and five domains (p < 0.05).

In the last model, the Ban Kang, most domains were

at a moderate level (8-domains), and at a high level in

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596

Table 3. Comparison pre and post-intervention of community capacity levels of non-leader in Ban Mon, Ban Nangphaya, and Ban

Kang.

Model

Ban Mon (n:200) Ban Nangpraya (n:215)Ban Kang (n:176)

ANOVA

Dengue community capacity domain

of the non-leader group

Pre

(

(SD))

Post

(

(SD))

Pre

(

(SD))

Post

(

(SD))

Pre

(

(SD))

Post

(

(SD))

Pre

(p)

Post

(p)

NL1: Critical situation management 38(13)3 42(8)4*** 32(12)3 35(11)3** 39(6)3 45(9)4*** 0.000*** 0.000***

NL2: Personal leadership 25(7)4 27(6)4* 19(8)3 22(6)3** 23(4)3 28(5)4*** 0.000*** 0.000***

NL3: Religious leader capacity 19(13)2 22(11)3* 11(12)2 14(13)2* 22(8)3 31(9)4*** 0.000*** 0.000***

NL4: Community leadership 25(8)4 26(5)4* 19(8)3 21(7)3 24(5)3 28(5)4*** 0.000*** 0.000***

NL5: Health care provider capacity 21(6)4 22(4)4* 18(6)3 19(5)5 21(4)4 23(4)4*** 0.000*** 0.000***

NL6: Sense of community 30(6)4 30(5)4 29(5)4 29(6)4* 27(5)4 31(4)4*** 0.000*** 0.000***

NL7: Communication of dengue Information 19(8)3 20(6)3 12(9)2 14(8)2* 16(5)3 21(7)3*** 0.000*** 0.000***

NL8: Continuing activities 18(6)3 19(4)4 15(6)3 17(5)3* 18(3)3 21(4)4*** 0.000*** 0.000***

NL9: Dengue working group 20(8)3 21(6)3 14(8)2 17(7)3** 19(4)3 24(6)4*** 0.000*** 0.000***

NL10: Resources mobilization 19(5)4 15(3)3* 13(4)3 14(4)3* 15(3)3 16(4)4** 0.000*** 0.000***

NL11: Needs assessment 14(6)4 15(4)4 11(6)3 13(5)4** 14(3)4 17(5)4*** 0.000*** 0.000***

Total 247(72)3 263(52)4** 196(70)3218(62)** 242(35)3290(54)4*** 0.000*** 0.000***

Remake: Level of community capacity as 1very low; 2low; 3moderate; 4high; *p < 0.05; **p < 0.01; ***p < 0.001.

3-domains in pre-test, but almost all domains achieved a

high level (10-domian) and 1 a moderate level (Resource

mobilization domain) in the post-test. Between the pre-

test and post-test, there were significant differences in all

11 domains with 10 domains showing significant differ-

ences in increased scores in seven domains (p < 0.001)

and a slight increase in only one domain (Resources mo-

bilization domain) (p < 0.01). Among these three models,

the pre-intervention’s scores were significantly different

in total (p < 0.001) and all 11 domains as same as post-

intervention (p < 0.001).

5.2.2.3. Multiple Comparisons for Significant

Differences of the Dengue Community

Capacity Level of the Non-Leader Grou p

Multiple comparisons for significant differences of

community capacity scores were testing the difference

scores among three models when protested and post-

tested for building community capacity. Ban Mon (n:200)

and Ban Nangpraya (n:215) showed significantly differ-

ent capacities in the various domains. In the pre- inter-

vention, there were 8 domains (p < 0.001) and in the

post-intervention, 10 domains (9 domains, p < 0.001;

Resources mobilization domains, (p < 0.01). Ban Mon

(n:200) and Ban Kang Model (n:176) also were signifi-

cantly different in their stronger domains. In the pre-

intervention, there were five domains (Religious leader

capacity domain and Resources mobilization domain, p <

0.05; Personal leadership and Communication of dengue

information domains, p < 0.01; Religious leader capacity

domain, p < 0.001) and in the post-intervention, eight

domains varied—(four domains, p < 0.01; four domains,

p < 0.05). Ban Nangpraya (n:215) and Ban Kang (n:176)

were not significantly different with scores only in the

Personal leadership domain in the pre-test, but all do-

mains in post-test were significantly different (p <

0.001).

In summary, the community capacity of non-leader

domains in the three model were significantly different

when contrasting Ban Mon (n:200) and Ban Nangpraya

(n:215), Ban Mon (n:200) and Ban Kang (n:176), and

Ban Nangpraya (n:215) and Ban Kang (n:176) (see Ta-

ble 4).

5.3. Dengue Entomological Index

5.3.1. Larval Index

Larval surveys were conducted to determine types of

containers and larval indices. The total households in

pre-test (October, 2009) and post-test (October, 2010) of

C. Suwanbamrung et al. / Health 3 (2011) 58 4-601

597597

Ban Mon, Ban Nangpraya, and Ban Kang communities

involved 230, 145, and 139 households as follows.

Total number of water containers inspected in pre and

post-intervention of Ban Mon model were 2597 and

1173, then BI, HI, and CI of post-intervention decreased

from 303, 51, and 24 to 130, 45, and 22 respectively.

Ban Nangpraya total number of water containers num-

bered 2800 pieces in the pre-intervention and 1720

pieces in the post-intervention. The BI, HI, and CI in the

pre-intervention were 350, 55, and 31 and decreased to

140, 44, and 12 in the post-intervention. The results (BI,

HI, CI) in Ban Kang model showed 358, 63, and 25 in

the pre-intervention and 65, 31, and 5 in the post-inter-

vention. Of special interest, HI of the three models was

an important index which aimed to reach less than 10%.

The comparison between the pre and post intervention of

Ban Mon model showed a decrease of HI 12%, at Ban

Nangpraya model 17% and at Ban Kang model 51% (see

Table 5).

5.3.2. Type of Water Container Inspected

Total larval survey of seven types of water containers

observed during the pre-test (October, 2009) and post-

test (October, 2010) in Ban Mon, Ban Nangpraya, and

Ban Kang were 2014, 2800, and 2014 pieces, and 1173,

1720, and 1822 pieces respectively.

These three communities showed a very high percent-

age of positive containers being discarded surrounding

the houses in both the pre-test and post-test—37% ,82%;

and 62% in the pre-test and 21%; and 48% and 14%. In

the post-test However, the number of water containers

inspected in the post-test decreased from the pre-test in

each community: Ban Mon 12%, Ban Nangpraya 17%,

and Ban Kang 80% (see Table 6).

Table 4. Multiple comparisons among three models showing the dengue community capacity level of the non-leader group in pre and

post-intervention.

Multiple comparisons among communities

Ban Mon (n:200) and

Ban Nangpraya (n:215)

Ban Mon (n:200) and

Ban Kang (n:176)

Ban Nangpraya (n:215)

Ban Kang (n:176)

Community capacity of non-leaders

Pre Post Pre Post Pre Post

NL1: Critical situation management 0.000*** 0.000*** 0.001** 0.000*** 0.000***

NL2: Personal leadership 0.000*** 0.000*** 0.008** 0.000***

NL3: Religious leader capacity 0.000*** 0.000*** 0.042* 0.000*** 0.000*** 0.000***

NL4: Community leadership 0.000*** 0.000*** 0.007** 0.000*** 0.000***

NL5: Health care provider Capacity 0.000*** 0.000*** 0.000*** 0.000***

NL6: Sense of community 0.000*** 0.002** 0.002** 0.000***

NL7: Communication of dengue Information 0.000*** 0.000*** 0.004** 0.000*** 0.000***

NL8: Continuing activities 0.000*** 0.000*** 0.001** 0.000*** 0.000***

NL9: Dengue working group 0.000*** 0.000*** 0.000*** 0.000*** 0.000***

NL10: Resources mobilization 0.006** 0.012* 0.000*** 0.000*** 0.000***

NL11: Needs assessment 0.000*** 0.000*** 0.000*** 0.000*** 0.000***

Total 0.000*** 0.000*** 0.000*** 0.000*** 0.000***

Remake: *p < 0.05; **p < 0.01; ***p < 0.001.

Table 5. Comparison of larval index (BI, HI, CI) pre and post-intervention at Ban Mon, Ban Nongpraya, and Ban Kang model.

Ban Mon model

(Number of households: 230)

Ban Nangpraya

Model (Number of households: 145)

Ban Kang Model

(Number of households: 139)

Larval Indices

Pre Post Pre Post Pre Post

BI (<50) 303 130 350 140 358 65

HI (<10) 51 45 55 44 63 31

CI (<1) 24 22 31 12 25 5

Percentage of decrease HI 12% 17% 51%

C. Suwanbamrung et al. / Health 3 (2011) 58 4-601

598

Table 6. Type of containers inspected, positive containers with larval and percentage.

Ban Mon model

Number of containers inspected:

Positive larval (Percentage) (n:n,(%))

Ban Nangpraya model

Number of containers inspected:

Positive larval (Percentage) (n:n,(%))

Ban Kang model

Number of containers inspected:

Positive larval (Percentage) (n:n,(%))

Types of water containers

Before (n:n,(%)) Before (n:n,(%))Before (n:n,(%))Before (n:n,(%))Before (n:n,(%)) Before (n:n,(%))

1) Drinking water 513:103(19) 253:33(12) 860:192(22) 608:92(15) 282:13(5) 242:1(0)

2) Water containers in

bathroom and toilet 378:94(25) 213:57(27) 241:74(31) 187:14(7) 239:5(2) 270:8(3)

3) Potable water containers 416:96(23) 199:41(21) 409:100(24) 323:24(7) 247:18(7) 313:10(3)

4) Vases 362:112(31) 264:56(21) 246:79(32) 142:9(6) 297:48(16) 321:12(4)

5) Cupboard saucers 147:23(16) 69:5(7) 145:64(44) 78:10(12) 110:30(27) 103:3(3)

6) Plants-related containers 318:57(18) 120:34(28) 475:95(20) 152:8(5) 338:142(42) 243:10(4)

7) Discarded containers

surrounding household 345:129(37) 45:37(82) 424:264(62) 219:46(21) 501:241(48) 330:47(14)

Total 2497:614(25) 1173:263(22) 2800:868(31) 1720:203(11) 2014:497(24) 1822:91(5)

Percentage of containers

inspected decreased 12% 17% 80%

5.4. Dengue Epidemiological Index

The epidemiological index in this study consisted of

the morbidity and mortality rates. The morbidity rate of

dengue from 2007, 2008, 2009, and October, 2009 to

October, 2010 in Ban Mon, Ban Nangpraya, and Ban

Kang models showed alternative change from the stan-

dard level (<50 cases/100,000 populations).

For Ban Mon, the population in the middle of the year

was 1485; one year before conducting intervention mor-

bidity rate was 67 cases/100,000 populations. When the

dengue program (November, 2010) was just concluded,

the morbidity rate was 202 case/100,000 populations. In

total, there were three cases of dengue illness; one stayed

in the community and 2 cases of dengue illness stayed

outside the community.

Ban Nangpraya community, with a population of 1695

persons in middle year showed a morbidity rate of the

community every year of one or two cases. When the

program finished, the community showed 2 cases of

dengue illness resulting in a morbidity rate of 118 case/

100,000 populations.

Ban Kang community’s population was 1650 persons

in the middle of the year. In the past three years, the

community had a high morbidity rate; 61, 182, 61 cases/

100,000 population. At the time of conducting and fin-

ishing the program, there was no morbidity rate.

None of the models showed an increased mortality

rate after conducting the program. Moreover, Ban Kang

model had no incidence of dengue whereas other vil-

lages in the sub-district had incidences of dengue illness

(see Table 7).

6. DISCUSSION

Efforts of control dengue prevention and control have

been redirected from central Thai Ministry of Public

Health (MoPH) to local administrative organization

(LAO) using all the leader and non-leader group because

the problem of dengue is a community problem needing

to be solved by the community [15,20]. The community

capacity building process was a different strategy ap-

plied in these three communities. A principle researcher,

the leader group, and the support team were discussion

appropriate techniques and methods of analysis of the

dengue problem and how to resolve it in each commu-

nity for 13 months (October, 2009-October, 2010).

However, the sustainability needs the long-term com-

munity-based maintenance of the health program [32].

This study demonstrates positive results because it de-

fined the sustainability of community-based dengue so-

lution as the successful outcome of community capacity

building for dengue prevention and control, and is

measured by: 1) the increasing level of community ca-

pacity domains; 2) the decreasing of entomology index

as larval indices; the Breteau Index (BI), House Index

(HI), and Container Index (CI); and 3) the decreasing

epidemiological index for the morbidity rate and mortal-

ity rate of dengue [7-10].

After one year of applying the dengue community ca-

pacity building model in these three models, the com-

munity capacity building process for a sustainable solu-

tion to dengue has shown varying differences according

to the context of that community. Results show an in-

crease in the community capacity level, a decrease in the

C. Suwanbamrung et al. / Health 3 (2011) 58 4-601

599599

Table 7. Morbidity and mortality rate of dengue in three models among 3 years in pre and post-intervention of community capacity

building.

Number (case): Morbidity rate (case)/100,000 population): Morbidity rate (percentage)

Pre-intervention of building community capacity Post-intervention building community capacity

Model

Year; 2007 Year; 2008 Year; 2009 Year; 2010

Ban Mon (n:1485) 0:0:0 0:0:0 1:67:0 3:202:0

Ban Nangpraya (n:1695) 2:118:0 1:59:0 0:0:0 2:118:0

Ban Kang (n:1650) 1:61:0 3:182:0 1:61:0 0:0:0

Resources: The primary health center in each model.

entomological index, and a low morbidity rate has dem-

onstrated to varying degrees, together with other sugges-

tions from the communities that building capacity can

influence community health, the sustainability of com-

munity initiatives and community abilities to respond to

emerging health issues [18,33].

The basic strategies for prevention and control of

dengue of these three models have given rise to carrying

out activities as a dengue community network. The den-

gue network held seven activities, namely, 1) meeting to

prepare plans of intervention, 2) chemical fogging train-

ing to control dengue morbidity in community, 3) herb

training to create a citronellas bank, 4) development of a

Gambia fish bank, 5) communication through commu-

nity radio disseminating dengue knowledge, 6) larval

indices survey every month, and 7) leadership training

and holding an evaluation meeting. Local or specific

strategies of each model were planned in detail and im-

plemented through activities according to the context of

community. Ban Mon model showed the highlight of

activity as Gambia fish bank at the temple in their com-

munity because the religious leadership capacity level in

the pre-intervention was low so the intervention of the

community focused on built religious leadership capac-

ity. Ban Nangpraya model, as seaside community, the

highlight activities were red lime to use in water con-

tainers because the community hade many water con-

tainers per household. Ban Kang model, as a rubber and

fruits garden community, strengthened mobile meeting

of leader group in each area of the community, mass

communication from religious leaders and community

leaders, and door to door surveys of larval index once a

month.

The results of the study show activities following the

concept of sustainable dengue solutions as a commu-

nity-based process creates a new paradigm of dengue

epidemiology, and vector-control services. This commu-

nity-based approach underlines the need for operational

standards for measurement, delivery of a combination of

interventions as central and local strategies, and con-

tinuing monitoring and evaluation process and outcome

[34]. The outcomes of searching for a sustainable solu-

tion to the problem of dengue generated increased the

dengue community capacity levels of community leader

group (14-domains) and non-leader group (11-domains),

constant monitoring of larval indices, and improved

morbidity and mortality rates.

In each model, pre and post-interventions of dengue

community building increased the dengue community’s

capacity level of the leader group a seen in all domains

and the total level likewise increased in the post-inter-

vention evaluations of all three models. Nevertheless,

significant differences showed in the increases in almost

all domains in the Ban Nangpraya and the Ban Kang

model. The relation of the comparisons when analyzed

in the pre-intervention evaluations of the dengue com-

munity capacity levels of the leaders group among the

three models showed significantly different increases in

five domains: Critical situation management, Needs as-

sessment, Communication of dengue information, Com-

munity leadership, and Religious leadership. Post the

intervention, the leader group networking domain, and

the leader group and community networking domain

showed increases significantly different from the pre-

intervention (p < 0.05), but Critical situation manage-

ment, and Religious leader capacity were significantly

different (p < 0.01). The community capacity levels of

the non-leader groups in all domains and in total in the

post intervention showed increased scores from pre-

intervention. All domains of Ban Kang community and

almost all domains of Ban Nangpraya community

showed a significant difference in their increase, but the

other community in only half of all domains. Among

these three communities, all domains and totals indicated

significantly different capacities. The difference of do-

mains showed commitment of the leader group for

building capacity within the leaders and supporting team

in two strengthened communities, whereas the other

community conducted activities only by their VHVs

group. The results were indicated in a previous study

C. Suwanbamrung et al. / Health 3 (2011) 58 4-601

600

which focused on the important roles of the leader group

in the community [5,35,36].

Entomology and epidemiology outcomes of these

three models showed different scores all indicating de-

creases of both larval indices and morbidity rate. Ban

Kang model exhibited excellent model of dengue com-

munity capacity through their process—preparation, plan-

ning, implement and continual monitoring. The leader

group in the model was involved in intersectoral coordi-

nation between the representatives from local adminis-

trative organization, primary health care center, commu-

nity leaders, religious leaders, committee leaders, and

VHVs. Then, it was clearly seen that the results of the

dengue community capacity of leader and non-leader

group in the community supported the premise and ap-

proach of the dengue capacity of community to decrease

dengue risk. Moreover, the larval indices (HI, BI, and CI)

and morbidity rates were shown to be the lowest level of

three models [37-40].

The model with highest the dengue community capac-

ity level showed the lowest risk of dengue utilizing the

index of both larval indices and morbidity rate. Thus, the

model of community capacity building for sustainable

dengue problem solutions needs to be maintained and

increased the level of the dengue community capacity

within the context of each community.

7. LIMITATION

One limitation of the study is that it was conducted

over one year. Longer term periods are needed to assess

sustainability [32]. Nevertheless, the study assessed the

outputs and outcomes of intervention at an early stage in

achieving sustainability of a solution to dengue [5,41].

Another limitation was the adoption of the HI, BI, and

CI as they were easier to collect and to interpret than

other entomological measures, and that the leader group

perceived ownership of own community and provided

available participation. The advantage of a community

capacity building approach is that it demonstrated a high

degree in the ability of community capacity levels of

both leaders and non-leaders to change since after one

year of intervention, the reduction in all larval indices,

and type of water containers could be found.

8. CONFLICT OF INTEREST

The author(s) declare that they have no competing in-

terests.

9. ACKNOWLEDGEMENTS

Grateful acknowledgements are to people (leaders and non-leaders)

of three communities and all representatives from government officers

who were involved in the project. The author(s) would like to thank

Walailak University, Thailand for funding the project and the School

of Nursing for the support by providing available time. Special thanks

to Victor Greenspoon who has edited the manuscript.

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