Zikv on the US-Mexico Border: Analysis of Preventive Actions Taken By Pregnant and Inter-Conception Women

Acquah-Baidoo B, McDonald J, Katherine S, Amatya A, Lynch S and Dankwah Robert OK

Published on: 2021-02-26

Abstract

Introduction

Along the US-Mexico border, women may be at higher risk of adverse pregnancy outcomes due to high unintended pregnancy rates, prevalence of Aedes species mosquitoes, and frequent travel to Zika Virus (ZikV) endemic areas. This research assesses ZikV preventive actions among low-income women across seven border counties, served by five collaborating Healthy Start programs.

Methods

In late 2016, we surveyed 326 pregnant and inter-conception women to assess actions taken to prevent ZikV. Variables used include demographic factors, helpful sources of information, and preventive actions (avoid travel, avoid sex/use condoms, avoid mosquito bites and clinical).  Chi-square tests were used to identify important associations between variables. Log binomial regression analysis was used to estimate adjusted relative risk (ARR) and associated 95%.

Results

Most (63.9%) of 305 women who had heard of ZikV reported ≥ 1 preventive actions. Taking a preventive action was associated with age (31+ years; ARR=1.45, 95% CI:1.17-1.79), and higher education (above high school diploma; ARR=1.25, 95% CI: 1.02-1.54). Women who reported healthcare professionals (HCP) as a helpful information source were more likely to avoid sex/use condoms (ARR=2.38, 95% CI: 1.03-5.53) and take clinical action (ARR = 3.13, 95% CI: 1.30-7.54).

Conclusion

Interventions should focus on improving access to health care services along the border. Also, more emphasis should be put on HCP’s taking a leading role in educating women on ZikV prevention.

Keywords

Zika Virus (ZikV)

Introduction

Growing international exchange have led to increased exposure and ease in the spreading of diseases across borders [1]. According to the CDC, as of March 7, 2018, 95% of the 5,673 symptomatic cases in the US were detected among recent travelers. This number includes 2,418 pregnant women with laboratory evidence of probable Zika Virus (ZikV) infection [2].

Predominantly rural, the US-Mexico border region has more than 7 million residents and includes 44 counties in 4 US states, including California (CA), Arizona (AZ), New Mexico (NM) and Texas (TX). Over 51% of the 55 million US Hispanics reside in these four states [3]. As a region, the border faces unique health challenges and barriers to health care [3]. Women living along the US-Mexico border are at higher risk of ZIKV than women in non-border areas. Seventy-three percent (73%) of counties along the border are designated as Medically Underserved Areas (MUA’s) and 63% designated as Health Professional Shortage Areas (HPSA) [4]. Also, many families with mixed immigration status are forced into isolation and are reluctant to access health care systems due to systemic and political issues surrounding immigration [5]. Along the border, education levels are low [6] and the uninsurance rate (32.2%) compared to the national average (16.3%) is high [7]. Within border states, unintended pregnancy rates are high [8] and women living in border counties are less likely to receive timely prenatal care than women in non-border counties [9]. Tens of thousands of people legally cross the US-Mexico border daily on foot using 16 pedestrian bridges to attend school, work, visit family and in some cases access healthcare services [10,11]. Also, the presence of the Aedes aegypti and albopictus mosquito species which transmit ZikV in the border region and the continuous spread of ZikV in Mexico puts the border population at risk [2]. Led by California and Texas, the four US border states had reported 919 laboratory-confirmed ZikV cases, as of February 21, 2018 [2].

Major CDC Recommended Zikv Preventive Actions

Due to the lack of vaccines or treatment for ZikV infection and the neurological symptoms associated with the disease [2,12], health interventions have focused on disease prevention especially among pregnant women. First, the CDC recommends avoiding travel to areas with active ZikV [2]. Individuals who cannot avoid travel are advised to seek medical attention prior and consider travel destinations above 6,500 feet [2]. Secondly, the CDC recommends avoiding sex or using condoms to prevent ZikV [2]. It also recommends preventing mosquito bites by using insect repellent, wearing protective clothing, and using mosquito nets. Finally, in situations of possible exposure, the CDC recommends that individuals speak to their healthcare providers and get tested [2].

 

Taking preventive actions can reduce the spread of diseases during epidemics [13]. In a 2016 national study among women of reproductive age in US, many (56.8%) reported taking at least one action to prevent ZikV; of these, avoiding travel was the most common [14]. Also, in a 2017 online survey in which 68 participants reported travel plans, 58 cancelled their plans due to ZikV risk [15].

In relation to sexual transmission prevention, following the 2015 ZikV outbreak in Brazil, 56% of women in a nationally representative survey reported avoiding pregnancy [16]. In another study in Aracaju-Brazil, more pregnant women compared to non-pregnant women accessed counseling about family planning, and pregnancy postponement [17]. In the same study, 86.7% of pregnant women chose to use condoms to prevent ZikV [17]. In contrast, in a study among pregnant and inter-conception women in Puerto Rico, only 38.5% of women abstained from sex or used condoms during pregnancy [18].

Women across several studies took measures to prevent mosquito bites. In an online study conducted in the US among pregnant women, 50% of women would use mosquito repellent to prevent ZikV infection [19]. Meanwhile, in Puerto Rico, 98.1% of women who had recently given birth took at least one ZikV action to prevent mosquito bites, e.g. 88.7% removed standing water from around their homes weekly [18].

Women who live along the border are at higher risk of ZikV infection and may be more aware of ZikV than other US women [20]. Despite this, research to date has not examined the preventive action(s) taken by women in US border communities. Also, the factors associated with taking action(s) are unknown. Therefore, the purpose of this study is to (1) determine if women in the US-Mexico border population who are aware of ZikV are taking preventive action(s) to protect themselves and their families against the virus; (2) identify specific ZikV preventive actions women are taking; and (3) explore the relationships between helpful sources of information about ZikV and preventive actions taken.

Method

Study Population and Data Collection

This is a cross-sectional study of pregnant and inter-conception women served by five collaborating Healthy Start programs (Healthy Start Border Alliance -HSBA) in seven US-Mexico border counties, including San Diego (CA), Santa Cruz (AZ), Doña Ana, Sierra, Otero, and Luna (NM); and Webb (TX) [21]. Counties in NM are served by 2 Healthy Start programs named NM-1 and NM-2. We used convenience sampling to recruit participants for the study.

Data was collected through interviews with 326 pregnant and inter-conception women. Trained caseworkers conducted interviews during routine home visits (78%) and Healthy Start clinic appointments (22%) between October 10-November 29, 2016 [20]. There was a 100% participation rate. Surveys were completed using paper or electronic tablets in English or Spanish according to the client’s preference and took 10-15 minutes to complete. A secure internet connection was used to upload and share data among the research team. Only participants who had heard of ZikV (305) were included in this study. The Institutional Review Boards of Project Concern International (PCI) and New Mexico State University approved the project.

Variables

Dependent variables used for analysis included action(s) taken by women. Women who had heard of ZikV were asked: “Have you done anything to reduce your risk for Zika?” Respondents who indicated they had done something to reduce their risk were further asked “What specific actions have you taken to reduce your risk?” Responses were classified into any (at least one) action (yes/no) and four specific action categories based on the four major recommendations made by the CDC; (1) Avoid travel, (2) Avoid sex/use condoms, (3), Avoid mosquito bites and (4) Clinical (e.g. getting ZikV test)

Demographic characteristics for analysis included age, education, currently pregnant, recent travel (participants/their partners who had traveled to Latin America, including Mexico or the Caribbean, within the past 6 months) and study site/residence. Age and education were stratified into three categories each: 15-24 years, 25-30 years, 31+ years, and < high school, high school, > high school, respectively.

We examined which sources of information participants deemed helpful: “Please name any sources of information about Zika virus that have been helpful in informing you about the virus and how to protect yourself from it.” Participants could name more than one helpful source of information. Respondent answers were categorized into five major sources of information: (1) television (TV) and radio; (2) internet (web MD, google, etc.); (3) social media (facebook, twitter etc.); (4) community sources (family, friends); and (5) healthcare professionals (HCP).

Finally, reasons for action or lack thereof were also analyzed. We asked women why they took preventive actions: “What is the single most important reason you made these changes?” Responses were classified based on whether women were pregnant or inter-conceptional. For those who reported they did not take any action, we asked, “Why not?”

Analysis

Demographic variables and helpful sources of information were analyzed in relation to whether women took preventive action(s) or otherwise. Percentages and frequencies were calculated to illustrate the distribution of the demographic variables and taking action. Chi-squared tests were used to study the crude association between each of the actions taken and independent variables, including helpful sources of information and demographic factors. We calculated adjusted relative risks (ARR) and 95% confidence intervals using a log binomial regression of helpful sources of information with taking preventive actions, controlling for demographic variables. Since occurrences of outcome (taking action) was common (>10%), log-binomial regression analysis was used to avoid dramatically overstating the adjusted relative risks [22]. We conducted all analyses using IBM SPSS Statistics for Windows (Version 23.0) and R (Version 3.3.3, package: logbin, Version 2.0.3). P-values of <.05 were considered statistically significant.

Results

Of the 305 pregnant andnter-conception women (mean age 27.65, SD 6.19, range 15-48 years), who had heard about ZikV, 97.40% were of Hispanic ethnicity (data not shown). One hundred and ninety-five (195) took some form of preventive action and 110 did not (Table 1). A third of participants were pregnant and less than a third, 28.5%, had a college degree or above. Also, one-third reported travel in the last 6 months to a country with active ZikV transmission.

Table 1: Distribution of total study population and whether women took preventive actions against ZikV, according to demographic factors and helpful sources of information, HSBAa, US-Mexico border region, October-November 2016.

 

Total Population

Any (At least 1 Action?)

P-value b

 

 

Yes

No

n=305

%

n=195

%

n=110

%

Demographic factors

Age (years)

<0.005

 

15-24

103

33.8

54

52.4

49

47.6

 

25-30

97

31.8

61

62.9

36

37.1

 

31 +

105

34.4

80

76.2

25

23.8

 

Education C

0.1

 

<High School

116

38

 

 

 

 

 

66

56.9

50

43.1

High School

101

33.1

66

65.3

35

34.7

 

>High School

87

28.5

 

 

 

 

 

62

71.3

25

28.7

Currently pregnant

 

 

 

 

 

 

 

0.129

 

Yes

91

29.8

64

70.3

27

29.7

 

No

214

70.2

131

61.2

83

38.8

 

Recent travel d

0.386

 

Yes

96

31.5

58

60.4

38

39.6

 

No

209

68.5

137

65.6

72

34.4

 

Study site/residence

<0.001

 

CA

36

11.8

28

77.8

8

22.2

 

AZ

49

16.1

20

40.8

29

59.2

 

NM-1

52

17

16

30.8

36

69.2

 

NM-2

122

40

97

79.5

25

20.5

 

TX

46

15.1

34

73.9

12

26.1

 

Sources of information perceived as helpful e

TV/Radio

0.852

 

Yes

29

9.5

19

65.5

10

34.5

 

No

276

90.5

176

63.8

100

36.2

 

Internet

<0.005

 

Yes

62

20.3

51

82.3

11

17.7

 

No

243

79.7

144

59.3

99

40.7

 

Social media

0.318

 

Yes

111

36.4

75

67.6

36

32.4

 

 

No

194

63.6

120

61.9

74

38.1

 

Community sources

<0.005

 

Yes

113

37

86

76.1

27

23.9

 

No

192

63

109

56.8

83

43.2

 

Healthcare professionals

<0.001

 

Yes

123

40.3

96

78

27

22

 

No

182

59.7

99

54.4

83

45.6

 

aHSBA = Healthy Start Border Alliance, consisting of the 5 Healthy Start programs in the US-Mexico border region.

bP-Values from chi-square test: assesses relationship between Action Yes and Action No only.

cEducation is missing for 1 of the 305 study participants

dParticipant and/or partner traveled to Mexico, Caribbean or Latin America in the last 6 months

eParticipants could name more than one helpful source of information, so total exceeds 305

Taking At Least One Preventive Action

Most respondents (63.9%) reported taking at least one preventive action (Table 1). Taking at least one was associated with age (p<.005) but not recent travel, or pregnancy status. Over 76% of women above 31 years took at least one action, compared to 52.4% among those aged 15-24 years. The proportion of women who took at least one action across program sites ranged from 30.8% in NM-1 to 79.5% in NM-2. Women who perceived community sources, HCP and/or internet as helpful sources of information were more likely to report taking at least one action to prevent Zika (p<.01).

Specific Preventive Action(S) Taken

Among 195 women who took at least one action, only 41 chose to avoid travel (Table 2). Women who reported the internet, social media and/or community sources as helpful sources of information were more likely to avoid travel than those who did not.

Table 2: Percent distribution of specific preventive actions among women who took action (195) to prevent ZikV, according to demographic factors and helpful sources of information, HSBA a, US-Mexico border region, October-November 2016.

           

 

Avoid travel

Avoid sex/use condoms

Avoid mosquito bites

Clinical action

%b

%b

%b

%b

Demographic factors

Age (years)

 

15-24

22.2

13

33.3

11.1

25-30

26.2

14.8

41

8.2

31 +

16.3

8.8

37.5

16.3

Significance c

NS

NS

NS

NS

Education d

 

 

 

 

 

< High School

25.8

16.7

39.4

9.1

High School

18.2

7.6

40.9

13.6

> High School

19.4

11.3

32.3

14.5

Significance c

NS

NS

NS

NS

Currently pregnant e

 

Pregnant

23.4

15.6

28.1

17.2

Not Pregnant

19.8

9.9

42

9.9

Significance c

NS

NS

NS

NS

Recent travel f

 

Yes

10.3

13.8

39.7

17.2

 

No

25.5

10.9

36.5

10.2

 

Significance c

*

NS

NS

NS

Study site/residence

 

 

 

 

 

CA

21.4

25

21.4

21.4

 

AZ

20

20

40

40

 

NM-1

31.3

0

37.5

18.8

 

NM-2

19.6

10.3

38.1

6.2

 

TX

20.6

5.9

47.1

2.9

 

Significance c

NS

*

NS

***

Sources of information perceived as helpful g

TV/Radio

 

Yes

15.8

21.1

15.8

5.3

 

No

21.6

10.8

39.8

13.1

 

Significance c

NS

NS

*

NS

Internet

 Yes

29.4

12.9

27.4

11.3

 No

18.1

6.2

23.5

7

 Significance c

NS

NS

NS

NS

Social media

 

Yes

26.7

8.1

23.4

9

 

No

17.5

7.2

24.7

7.2

 

Significance c

NS

 NS

 NS

 NS

Community sources

 

Yes

25.6

15.1

37.2

9.3

 

No

17.4

9.2

37.6

14.7

 

Significance c

NS

NS

NS

NS

Healthcare professionals

 

Yes

26

16.7

34.4

18.8

 

No

16.2

7.1

40.4

6.1

 

Significance c

NS

*

NS

**

Total

41

23

73

24

aHSBA = Healthy Start Border Alliance, consisting of the 5 Healthy Start programs in the US-Mexico border region.

bPercentages presented are row % comparing those who took these specific actions to those who did not take these specific actions, although only those who took these specific actions are reported in the table for e.g.; 22.2% of participants aged 15-24 is (12/54), thus 12 out of 54 women aged 15-24 years avoided travel compared to the (42/54) who did not avoid travel.

cLevel of statistical significance: *= p<.05, **= p<.01, ***= p<.001; NS=Non-significant

dEducation is missing 1 of the 195 study participants

e82 pregnant women who were aware of ZIKV are included

fParticipant and/or partner traveled to Mexico, Caribbean or Latin America in last 6 months

gParticipants could name more than one helpful source of information, so total exceeds 195

Only 23/195 of women reported avoiding sex/use condoms. Among this group, there were variations across program sites, ranging from 00.0% in NM-1 to 25.0% in CA. Avoiding sex/using condoms was more common among women who reported HCP as a helpful information source compared to those who did not (16.7% versus 7.1%).

In addition, 73/195 of women reported avoiding mosquito bites. Taking measures to avoid mosquito bites was inversely associated with reporting TV/Radio as a helpful source of information (p < .05). However, there were no significant associations between avoiding mosquito bites and other helpful information sources.

Finally, only 24/195 of women reported taking clinical preventive action. Of these, there were variations across program sites, ranging from 2.9% of women in TX to 40.0% in AZ. Clinical action was more prevalent among women who reported HCP as a helpful source of information compared to those who did not (18.8% versus 6.1%).

Adjusted Analysis

After adjusting for other factors, women aged 31 years and above were more likely to take at least one preventive action compared to those aged 15-24 years (ARR=1.45, 95% CI: 1.17-1.79) (Table 3). Also, women with more than a high school education were more likely to take at least one preventive action compared to those with less than high school education (ARR = 1.25, 95% CI: 1.02-1.54). Women who reported internet (ARR = 1.39, 95% CI: 1.19-1.63), community sources (ARR = 1.34, 95% CI: 1.14-1.57) and HCP (ARR = 1.43, 95% CI: 1.22-1.69) as helpful sources of information were more likely to take at least one preventive action compared to women who did not report these sources as helpful. Also, women who reported HCP were more likely to avoid sex/use condoms (ARR = 2.38, 95% CI: 1.03-5.53), and to take clinical action (ARR = 3.13, 95% CI: 1.30-7.54) compared to those who did not report HCP as helpful information source. However, the association between reporting TV/Radio as a helpful information source and acting to prevent mosquito bites was no longer statistically significant.

Table 3: Adjusted relative risks and 95% confidence intervals a for Any and Specific preventive actions women took to prevent ZIKV, HSBA b, US-Mexico border region, October-November 2016.

 

 

At least 1 Action

Avoid Travel

Avoid Sex/Use Condoms (195) ARR (95% CI)

Avoid Mosquito Bites (195) ARR (95% CI)

Clinical

-305

-195

-195

ARR (95% CI)

 ARR (95% CI)

ARR (95% CI)

Demographic factors

Age (years)

 

15-24

1

1

1

1

1

 

25-30

1.20(0.94-1.52)

1.18(0.61-2.27)

1.14(0.45-2.85)

1.23(0.76-1.99)

0.74(0.24-2.28)

 

31+

1.45(1.17-1.79)c

0.74(0.37-1.50)

0.68(0.25-1.84)

1.13(0.71-1.82)

1.48(0.60-3.65)

Education

Below High School

1

1

1

1

1

High School

1.15(0.93-1.42)

0.71(0.36-1.36)

0.46(0.17-1.24)

1.04(0.68-1.58)

1.50(0.57-3.98)

College & Above

1.25(1.02-1.54)c

0.75(0.39-1.44)

0.68(0.28-1.64)

0.82(0.51-1.31)

1.60(0.60-4.23)

Currently pregnant

 

No

1

1

1

1

1

 

Yes

1.15(0.97-1.37)

1.17(0.67-2.05)

1.56(0.72-3.37)

0.67(0.43-1.04)

1.72(0.82-3.62)

Study site/Residence

 

TX

1

1

1

1

0.37(0.04-3.48)

 

CA

1.05(0.82-1.34)

1.04(0.39-2.74)

4.25(0.96-18.85)

0.46(0.21-1.01)

3.03(0.81-11.36)

 

AZ

0.55(0.38-0.81)c

0.97(0.32-2.91)

3.40(0.68-16.92)

0.85(0.45-1.62)

2.93(0.82-10.44)

 

NM-1

1.08(0.89-1.31)

0.95(0.44-2.06)

NA d

0.81(0.52-1.26)

0.85(0.22-3.27)

 

NM-2

0.42(0.27-0.65) c

1.52(0.57-4.05)

1.75(0.40-7.60)

0.80(0.39-1.65)

1

Recently Traveled

 

No

1

1

1

1

1

 

Yes

0.92(0.76-1.11)

0.41(0.18-0.91)c

1.25(0.56-2.79)

1.09(0.74-1.60)

1.67(0.79-3.55)

Sources of information perceived as helpful

TV/Radio

 

No

1

1

1

1

1

 

Yes

1.03(0.78-1.36)

0.73(0.25-2.15)

1.94(0.74-5.11)

0.40(0.14-1.14)

0.40(0.06-2.82)

Internet

 

No

1

1

1

1

1

 

Yes

1.39(1.19-1.63)c

1.62(0.93-2.80)

1.50(0.67-3.32)

0.79(0.50-1.25)

1.15(0.51-2.62)

Social media

 

No

1

1

1

1

1

 

Yes

1.10(0.92-1.30)

1.51(0.88-2.59)

1.03(0.47-2.26)

0.83(0.57-1.23)

1.13(0.53-2.42)

Community source

 

No

1

1

1

1

1

 

Yes

1.34(1.14-1.57)c

1.48(0.86-2.56)

1.67(0.77-3.62)

.99(0.69-1.43)

0.63(0.29-1.41)

Healthcare professionals

 

No

1

1

1

1

1

 

Yes

1.43(1.22-1.69)c

1.63(0.93-2.85)

2.38(1.03-5.53)c

0.85(0.59-1.23)

3.13(1.30-7.54)c

aUnivariate models include all demographic variables, and all helpful information source variables

bHSBA = Healthy Start Border Alliance, consisting of the 5 Healthy Start programs in the US-Mexico border region

c95% confidence interval does not include 1.0

dNA = Not applicable, NM-1 level of study site/residence was excluded due to the condition of Quasi-complete separation (No one took action to avoid sex/use condom in this site). This reduced the number from 195 to 179 only for this analysis.

Reasons for Taking Preventive Action(S) or Otherwise

Among the 195 women who took at least one preventive action, 190 gave reasons why (Table 4). The major reason (49/64) pregnant women took action was to protect their unborn babies, while (64/131) inter-conception women took action to protect themselves. More than a third (71/190) of all women in our study, took action to protect the health of other family members. Among the 110 women who did not take preventive action, only 54 gave a reason. Of these, 22/54 said they were not planning pregnancy while 19/54 did not know what to do.

Table 4: Distribution of reasons women took preventive actions or otherwise, HSBAa, US-Mexico border region, October-November 2016.

Why did you take any action?

 

My health b

64

 Baby's health c

49

Health of Family

71

Health of others

6

 

Total

190

Why didn't you take any action?

 

I dont plan to get pregnant

22

I dont know what to do

19

I haven’t had time

6

I can't afford it

2

Other

5

Total

54

 

Discussion

This study examined actions pregnant and inter-conception women on the US border took to prevent ZikV. Taking at least one preventive action was positively associated with increasing age of participants. Avoiding sex/using condoms and taking clinical actions were positively associated with helpful information from HCP.

Most (63.9%) women in our study who had heard about ZikV took at least one action to prevent ZikV. This was consistent with the 56.8% in the US national survey [14], but differed from the 98.1% of women in Puerto-Rico [18] who adopted at least one preventive measure. This variation may be attributed to different disease prevalence within each of these study sites. For example, the Puerto-Rico study was conducted at the peak of the disease’s outbreak (August 28 to December 3, 2016) by which time over 5,000 symptomatic cases had been reported on the island [18], compared to one locally transmitted case of ZikV on the border.

Also, in our study, there was a positive association between increasing age of participants and taking at least one action. This association was consistent with findings among pregnant women in Greater Atlanta in 2016 [23]. They found that women over 30 years of age were more likely to take actions to prevent ZikV compared to younger women [23].

In addition, few women (41/195) in our study elected to avoid travel despite the CDC’s recommendations against travel. This was consistent with findings in another survey [19], where a third of participants felt that the recommendation to avoid travel to ZikV endemic areas was very hard to comply with. It was also, consistent with previous studies [14,17], more currently pregnant women in our study avoided travel compared to women who were not currently pregnant, although this was not statistically significant. However, the 21.0% of women in our study who avoided travel to ZikV endemic areas was lower than findings in other surveys [14, 15] among women who avoided travel or cancelled their travel plans due to ZikV although women in all studies were of comparable ages. Not avoiding travel among participants in our study may perhaps be attributed to the high Hispanic population concentration along the border, among whom 35% identify as of Mexican origin. Also, daily commutes and frequent travels to and from Mexico and other ZikV endemic areas may not be an issue of choice for many on the border [11].

In addition, the 15.6% of pregnant women in our study who took action to avoid sex/use condoms, was consistent with the 13.1% found in [14] but lower than the 86.7% of pregnant women in [17]. This variation might be attributed to the differences in disease prevalence in the countries which may have affected people’s perception of risk [20].

The importance of receiving helpful information from HCP is evident across all specific actions taken by respondents and cannot be understated. Women who received information from HCP were more likely to take at least one action than women who did not report HCP as a helpful source of information. That said, relatively few women reported having received helpful information from a HCP as compared to other sources. From our study, 16.7% of women who reported HCP as a helpful source of information reported avoiding sex/using condoms to avoid sexual transmission compared to 7.1% of those who did not report HCPs as helpful. Our findings were relatively higher when compared to the 9.5% of women who used contraceptives to prevent ZikV after receiving helpful information from HCP in another study [17]. Also, 18.8% of women in our study who identified HCPs as a helpful source of information took clinical action. The low percentages of respondents receiving helpful information from a HCP in our sample may reflect relatively low health care access in the surveyed population [3], but the possibility that the information is not being adequately relayed to some patients by providers cannot be ruled out [24].

To add to the above, one third of 54 women in our study who provided information about why they did not act said they did not know what to do. Our study was conducted months after the CDC published its recommendations, which included avoiding travel and mosquito bites and taking clinical action on January 22 and avoiding sex on February 12, 2016. Also, following the travel related cases in Texas, the CDC issued a travel advisory for Mexico [2]. Results from our study revealed a significant gap between the CDC’s prevention guidelines and specific preventive actions women took. For example, despite the CDC’s high emphasis on avoiding travel, very few participants seemed to adhere to this directive. This may perhaps be explained by the high rate of Hispanic residents along the border, as well as the frequent daily crossing which occurs along the border [10]. Also, although HCPs appeared highly influential on women’s decisions to take preventive action, limited access to health care along the border may have hindered the level of influence affecting the overall uptake of specific preventive actions.

Study Limitations

This study had several limitations. First, the study could not identify all important associations which may have existed between specific actions women took and other covariates probably due to the small number of women (195) who took preventive action. Secondly, findings from this study cannot be generalized to all Healthy Start clientele as only women scheduled to be visited by a Healthy Start caseworker were included in the study. Also, the study did not control for the variations in the sample sizes as well as the availability and access to health care services across study sites which hindered site to site comparisons. Finally, although our data is recent, by close of December 2016, after data collection had been completed, there had been five additional cases of local mosquito transmission on the Texas border [2]. If these occurrences resulted in increased preventive actions, our study could not have detected them.

Conclusion

This study revealed that 2/3 of women took actions against ZikV and not knowing what to do was a common reason given for not taking preventive action. Also, compared to other studies [17,18], fewer respondents in our study reported taking specific actions. This may be due to the limited access to healthcare services along the border and the differences in disease prevalence across regions. Public health interventions should focus on increasing access to healthcare among women on the border by focusing on linking women to health care services and available health resources. Also, HCP with access to pregnant and inter-conception women along the border should be motivated to educate and encourage their patients to take actions against ZikV.

Acknowledgement

We are grateful to the staff of the 5 Healthy Start Border Alliance programs for their efforts to collect timely and accurate information and to their clients who participated willingly in this effort.

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