The incidence of diseases transmitted by the Aedes aegypti mosquito has been increasing in recent years. Due to climate change, its distribution has also changed. Currently, it is found not only in tropical or subtropical cities, but also in temperate areas at higher altitudes. In the last two years, there have been outbreaks of chikungunya and Zika, which, together with dengue fever, have significantly increased the morbidity of the Mexican population. Although these diseases have a low mortality rate, they generate high costs due to treatment and the functional impairment they can cause. The remarkable adaptability of the Aedes aegypti mosquito has allowed it to survive even in extreme temperatures. It has adapted so well to urban life that it resides comfortably inside houses, feeding and reproducing. In addition, we believe there is a lack of knowledge about the Aedes aegypti mosquito among the general population. Its elimination can be easy, however, the general population seems unaware of this. Therefore, it is necessary to assess the level of knowledge people have about the Aedes aegypti mosquito, in order to subsequently design educational strategies that address this knowledge gap. This would have a positive outcome: reducing cases of diseases transmitted by this mosquito (dengue, chikungunya, Zika, yellow fever). During the 2009-2010 school year, a study was conducted in 19 public schools in Tapachula, Chiapas, with the objective of identifying knowledge, attitudes, and practices regarding dengue fever before and after an educational intervention. The study concluded that, through the implementation of an educational strategy, children's knowledge, attitudes, and practices regarding self-care in their schools increased, and that they can act as promoters of positive attitude change regarding this disease within their homes. In 2010-2011, the Mexican Ministry of Health conducted a perception survey on dengue fever among the general population and schoolchildren in Mexico. Fourteen states of the Mexican Republic were selected, including the 66 priority municipalities with the highest dengue fever incidence. 94% of the general population knows what dengue fever is, and between 80% and 84% know that the vector is found in stagnant water and how to prevent the disease. ²¹

Environmental control strategies are based on the elimination or destruction of breeding sites, such as tires, cans, flowerpots, and other containers. ²⁴ These strategies have been very successful, but are difficult to maintain, mainly because they are labor-intensive and require community participation.

It is important that the population have the necessary knowledge about the Aedes aegypti mosquito to be able to contribute to its elimination. However, the dissemination of this information to the public must be planned appropriately, emphasizing the mosquito's life cycle and the places where it breeds, specifically informing people about what constitutes a breeding site.

Therefore, the first step is to assess the current level of knowledge that people have about the Aedes aegypti mosquito. Subsequently, the results must be analyzed to design educational strategies to disseminate information about the mosquito to the population, emphasizing any knowledge gaps identified in the study.

Currently, the prevention programs for diseases transmitted by the Aedes aegypti mosquito are outdated. The communication methods used by the Ministry of Health are no longer appealing to the public.

Therefore, it is important to understand what information people have about Aedes aegypti, in order to find appropriate strategies to disseminate the necessary knowledge to prevent further spread of the mosquito.

The objective of this study was to determine the level of knowledge and risk perception regarding coexistence with the Aedes aegypti mosquito among the population served by Health Unit No. 1 in Ciudad Obregón, Sonora.

An observational, descriptive, cross-sectional study was conducted at Family Medicine Unit No. 1, belonging to the Mexican Institute of Social Security (IMSS), located in Ciudad Obregón, Sonora, from April 1 to May 30, 2016. Participants included individuals over 12 years of age, of both genders, who were beneficiaries of IMSS and registered with Family Medicine Unit No. 1. Individuals with visual or hearing impairments or those who could not read or write were excluded. Participants who did not complete the entire survey or who decided to withdraw from the study were also excluded. The sociodemographic characteristics of the surveyed population were identified: age, gender, educational level, place of origin, neighborhood of residence, occupation, history of dengue fever, and whether they had a family member with dengue fever. The data collection instrument consisted of six parts. The first part included 14 questions about the respondent's sociodemographic data. The subsequent parts addressed knowledge about dengue, with a total of 49 questions. The second part consisted of 17 multiple-choice questions, some with multiple correct answers. The third part consisted of only 2 fill-in-the-blank questions, where the correct answer was the word "breeding ground" (singular or plural). The fourth part consisted of 10 questions where participants were shown cards with images of animals presented individually; for each card, they wrote the name of the animal shown. The fifth part consisted of 10 questions where participants were shown cards with images of places or objects presented individually; for each card, they indicated whether the image represented a breeding ground for the Aedes aegypti mosquito. Finally, the sixth section consisted of 10 multiple-choice questions. Participants were shown cards with images of different animals, one at a time, and for each image, they had to choose the word they considered most appropriate regarding their perception of the risk of living alongside that animal, that is, the danger it poses to people. Regarding the evaluation of the survey instrument, each correct answer was worth 1 point, except for the third section, which was a fill-in-the-blank question. For this question, the participant had to write either "breeding ground" or "breeding grounds" to receive credit. The sixth section assessed risk perception, evaluating how dangerous participants considered certain animals to be, with the aim of determining whether the Aedes aegypti mosquito, in its various developmental stages, was perceived as a risk. It is important to note that we define mosquitoes as a health hazard. Therefore, the questions that included images of the mosquito's different stages were worth 3 points only if the answer "very dangerous" was selected. After totaling the correct answers, the score was multiplied by 100 and divided by 49 (the maximum possible score), resulting in a weighted score, which was categorized as follows: >80 = High level of knowledge, 60–79 = Some knowledge, < 59 = No knowledge.

The data collection instrument was validated by three experts: a medical epidemiologist, a nurse, and a psychologist. All three reviewed the questions and determined that the survey was appropriate and did not require modifications. Following approval, a pilot test was conducted with 10% of the intended sample size (35 people), using a group of fifth-year medical students from the University of Sonora, Cajeme campus. The survey was administered to this group. The data were then analyzed, and the internal consistency reliability was calculated using SPSS, yielding a Cronbach's Alpha coefficient of 0.785, indicating that the data collection instrument was acceptable. Descriptive analysis of the qualitative variables was performed using frequencies and percentages. Quantitative variables were analyzed using measures of central tendency (mean) and dispersion (standard deviation). A bivariate analysis was conducted, obtaining odds ratios as a measure of association, with 95% confidence intervals. A p-value < 0.05 was considered statistically significant. Data analysis was performed using SPSS Statistics version 22 for Windows. The final results are presented in tables and graphs. After obtaining approval from the Local Health Research Ethics Committee, researchers approached individuals randomly in the waiting areas of Family Medicine Unit No. 1, asking them if they would be willing to participate in a research study by completing a survey. The topic and objective of the study were explained. Upon agreeing to participate, participants were asked to sign an informed consent form, and the survey was then administered to each person in an interview format. Following the multiple-choice and short-answer questions, participants were shown images printed on cards to answer the final three sections. Each of these sections consisted of 10 questions, and participants selected the answer they considered correct for each image. Once the total number of surveys required, based on the sample size, was completed, the data was entered into a data collection form designed in Google Drive using an internet connection. After completion, the database was downloaded to Excel 2016 for Windows. Regarding the survey evaluation, each correct answer received one point; however, the section on perceived risk related to animals was worth 3 points. In total, there were 49 questions, for a maximum possible score of 100. The resulting score was then categorized using a weighted scale (>80 = Good knowledge, 60–79 = Some knowledge, < 59 = No knowledge). Subsequently, a statistical analysis was performed using SPSS version 22 (Spanish version) for Windows. This research protocol complied with ethical principles according to the Regulations of the General Health Law on Health Research, specifically articles 13, 14, 20, 21, and 22 of Title II, Chapter I, regarding Ethical Aspects of Research on Human Subjects. "In any research involving human subjects, the principles of respect for their dignity and the protection of their rights and well-being must prevail." This research, according to Article 17 of the Regulations of the General Health Law on Research, was considered low-risk research: These are studies that use retrospective documentary research techniques and methods, and those in which no intentional intervention or modification of the physiological, psychological, or social variables of the participants is performed. Examples include questionnaires, interviews, and review of medical records, provided that no sensitive aspects of their behavior are identified or addressed.

Data were collected through structured interviews using a 49-item questionnaire, administered by a third-year epidemiology resident to a total of 300 people. Of these, 199 (66.3%) were women and 101 (33.7%) were men. The average age of the study population was 39 years (SD 13.2). Regarding educational level, 7 (2.3%) had incomplete primary education, 33 (11%) had completed primary school, 120 (40%) had completed secondary school, 95 (31.7%) had completed high school, 40 (13.3%) had a university degree, 4 (1.3%) had postgraduate studies, and only 1 (0.3%) had a master's degree. Regarding length of residence in Ciudad Obregón, 7 (2.3%) had lived there for < 1 year, 12 (4%) between 1 and 5 years, 10 (3.3%) between 6 and 10 years, 36 (12%) between 11 and 20 years, 75 (25%) between 21 and 30 years, and 135 (45%) for more than 30 years. 25 (8.3%) lived in locations other than Ciudad Obregón. They were asked if they had dengue fever; 57 (19%) said yes and 243 (81%) said no. Regarding preferred mass media, 51.7% (n=155) chose television, 18% (n=54) the internet, 16.3% (n=49) social media, 10% (n=30) radio, and only 4% (n=12) chose newspapers (Table 1). Respondents were asked what kind of animal Aedes aegypti is. 39% (n=115) knew it was a mosquito, 60% (n=181) did not know, and 1% (n=3) thought it was a flea. Regarding the diseases transmitted by the Aedes aegypti mosquito, 46.7% (n=140) mentioned dengue fever, 11.7% (n=35) mentioned Chikungunya, 5.7% (n=17) mentioned Zika, and only 10.7% (32) mentioned all three diseases (Yellow fever was not an option). They were also asked in what type of water Aedes aegypti mosquitoes breed; only 33% (n=100) knew it was in clean water, while the remaining 67% (n=200) did not know (mentioning mainly dirty water). Regarding the characteristics of the Aedes aegypti vector, only 27.7% (n=83) knew that the female transmits diseases, while 72.3% (n=217) did not know. Regarding the development time, 178 (59.3%) people said 3 days, 85 (28.3%) said 10 days, 22 (7.3%) said 20 days, and 15 (5%) said 30 days. Regarding the life cycle, 39% (n=117) knew only one stage, 25% (n=75) two stages, 9% (n=28) three stages, 1% (n=3) four stages, and 26% (n=77) did not know any stages (Figure 6). Regarding the life cycle stage at which it is easiest to eliminate the mosquito, 41% (n=123) mentioned the egg stage, 26% (n=78) the larval stage, 4.4% (n=13) the adult stage, 3.3% (n=10) mentioned both the larval and egg stages, only 1 (0.3%) person mentioned the pupal stage, and 26% (n=78) did not mention any of the mosquito's life stages. Regarding the distance a mosquito typically flies from its breeding site, 10% (n=29) mentioned 2000 meters, 27% (n=81) 1000 meters, 38% (n=116) 80 meters, and 25% (n=74) 800 meters.

Regarding the time of day when the Aedes aegypti mosquito bites, 1.7% (n=5) mentioned that it is at dawn, 24.3% (n=73) at dusk, 63% (n=189) throughout the day, 9% (n=27) only at night, and only 2% (n=6) mentioned the correct answer, which is both at dawn and dusk. Regarding the most effective measure to eliminate Aedes aegypti, 37 people (12%) mentioned fumigation, 75 people (25%) cleaning the yard, 96 people (32%) eliminating breeding sites, 25 people (9%) chose all options, and 67 people (22%) two or three options. No one chose the option "pruning trees" alone.

Regarding the identification of mosquito breeding sites, 281 people said that buckets with water are breeding sites, while 19 people disagreed; 265 people said that vases are breeding sites, while 35 people disagreed; 288 people said that water tanks are mosquito breeding sites, while 12 people disagreed; 241 people said that the bases of flowerpots are mosquito breeding sites, while 59 disagreed; 226 people said that plants are mosquito breeding sites, while 74 disagreed; and 264 people said that water channels are mosquito breeding sites, while 36 people disagreed. The respondents were shown images of some animals, including three of the four different development stages of the Aedes aegypti mosquito, for visual identification. The results showed that only 1 person (0.3%) correctly identified the pupa (p = 0.001), while 41 (14%) correctly identified the larva and 259 (86%) did not (p = 0.001). Similarly, 285 (95%) correctly identified the adult stage, while 15 (5%) did not (p = 0.001). Regarding visual identification of breeding sites, 275 people said that flower vases are breeding sites, while 25 disagreed; 201 said that containers with water are breeding sites, while 99 disagreed; 275 said that a pond with fish is a mosquito breeding site, while 25 disagreed; all 300 respondents agreed that a puddle of water is a mosquito breeding site; 291 said that tires are breeding sites, while 9 disagreed; 294 said that plants are breeding sites, while 6 disagreed; 190 said that a lake is a breeding site, while 110 disagreed; 262 said that the base of a potted plant is a breeding site, while 38 disagreed; and 274 said that a vacant lot is a breeding site, while 26 disagreed. Regarding the perceived risk of the different developmental stages of the Aedes aegypti mosquito, only one person identified the pupa, classifying it as not dangerous. Of the 41 people who identified the larva, 9 considered it not dangerous, 3 somewhat dangerous, 18 dangerous, and 11 very dangerous. Regarding the adult stage, 5 considered it not dangerous, 12 somewhat dangerous, 116 dangerous, and 152 very dangerous. Regarding the overall score obtained by the respondents, the mean score was 47 (SD 8.4) with a p-value < 0.001. The lowest overall score was 22, while the highest was 75.

91.6% (n=275) of the surveyed population received a score lower than 59, indicating they lacked sufficient knowledge about the Aedes aegypti vector, while only 8.4% (n=25) scored 60 or higher, which is considered a passing grade (Graph 1).

The main objective of the study was to determine the level of knowledge about the Aedes aegypti mosquito. We found that 91.8% of the population affiliated with UMF 1 in Ciudad Obregón scored below 59 (indicating insufficient knowledge), which is considered a failing grade. The remaining 8.4% obtained a passing score (indicating some knowledge), but their scores were below 80. Therefore, according to our classification of knowledge levels, no one had adequate knowledge about mosquitoes. A bivariate analysis showed that having a postgraduate degree was associated with greater knowledge about the Aedes aegypti mosquito (OR 0.27, P < 0.001). As observed in our study, most of the surveyed population had less than a university degree. Regarding the overall score, the mean was 47, and there was an increase in scores with higher levels of education, with those with incomplete primary education having a mean score of 44 (SD 4.9) and those with postgraduate degrees having a mean score of 66 (SD 9.0). There were no significant differences in scores by age group. In a 2010 survey on dengue fever in Mexico, between 88% and 95% knew that the disease was transmitted by mosquito bites, but it did not specify whether respondents knew the name of the mosquito. In our study, we asked what kind of animal Aedes aegypti is; only 39% answered that it is a mosquito, while 60% did not know. Regarding the diseases transmitted by the Aedes aegypti mosquito, only 10.7% knew that it transmits dengue, Zika, and chikungunya, despite information campaigns about these diseases. Almost half of the respondents (46.7%) associated the mosquito only with dengue. It is important to note that yellow fever was not included as an option, although it is also a disease transmitted by this mosquito

Villegas-Trecho et al. conducted a study in the state of Morelos in 2011, in which they sampled water containers, finding that 48.5% of the water tanks contained mosquito larvae, 21.3% of various containers (buckets and tubs) contained larvae, and 12.9% of flowerpots contained larvae. ²³ In our study, we asked about the identification of mosquito breeding sites; 93.6% correctly identified buckets with water, 88.3% identified vases, 96% identified water tanks, and 80% identified the bases of flowerpots. We observed that the surveyed individuals considered all water containers to be mosquito breeding sites, however, not all of them are, such as rivers, where the water has a constant flow, or ponds with fish, which feed on the aquatic stages of the mosquito, such as the pupa or larva. It is important to mention that the mosquito's ability to develop in different breeding sites is due to its adaptability to domestic and peridomestic environments, mainly driven by the blood-feeding habit of the females.²

There are several methods for mosquito control: biological, environmental, and chemical. ²⁴ These strategies are effective, but difficult to maintain, mainly because they require community participation. Currently, there are constant efforts to integrate innovative strategies within the ecological-community context. ²⁰ In our research, we asked which measure is considered the most effective for eliminating the Aedes aegypti mosquito; only 32% of the surveyed population said "eliminating breeding sites," 12% said "fumigation," and 25% said "cleaning the yard." The remaining population chose two or more options.

In the survey, participants were shown images of various animals, with the aim of visually identifying the developmental stages of the Aedes aegypti mosquito. 14% identified the larva, 95% identified the adult stage, and only one person (0.3%) correctly identified the pupa. Regarding the perceived risk of these stages, only 11 people considered the larva to be very dangerous. The adult stage of the mosquito was considered dangerous by 152 people. This shows that, although some people can identify the different stages of the mosquito, they do not consider Aedes aegypti to be a dangerous animal. Compared to other animals whose images were shown, they considered the adult stage of the mosquito almost as dangerous as a scorpion, but less dangerous than a tiger or a viper. However, according to statistics, mosquitoes (various types) cause 725,000 deaths per year (due to the various diseases they transmit), while vipers cause 50,000 deaths per year and lions or tigers cause 100 deaths per year (Gates, 2014). In our study, the preferred communication medium was television (51.7%), followed by the internet (18%) and social media (16.3%). There is a trend among younger people towards preferring the internet and social media, unlike older people who prefer television and radio. In the last two years, in our country, in addition to dengue fever, two other diseases transmitted by Aedes aegypti have appeared: Chikungunya and Zika. The latter has garnered more attention due to the complications it causes in pregnant women (babies with microcephaly). However, there is another disease also transmitted by this mosquito, yellow fever, which has a 50% mortality rate, and to which we could be exposed if we do not control the Aedes aegypti mosquito. Strategies to control this mosquito do not depend solely on the Ministry of Health or public institutions; citizen participation is also necessary. It is important to encourage the population to take effective action against the Aedes aegypti mosquito. We need to promote the idea of "eliminating the mosquito" to prevent diseases.

1. Ríos JF. Aspectos entomológicos del dengue. Infectio [Internet]. 2004 May; 8(3): 231-235. Disponible en: http://revistainfectio.org/site/portals/0/ojs/index.php/infectio/ article/view/252

2. Mora A, Jimenez VF, Trevino AS. Distribución geoespacial y detección del virus del dengue en mosquitos Aedes (Stegomyia) aegypti de Ciudad Juárez, Chihuahua, México. Salud pública Méx [Internet]. 2010; 52 (2): 127-133. Disponible en: http://www.scielo.org.mx/scielo. php?script=sci_arttext&pid=S0036-36342010000200004&lng=es.

3. Enfermedades transmitidas por vector. CENAPRECE (MX) 2014. http://www.cenaprece .salud. gob.mx /programas/interior /vectores/dengue/vector

4. Carrazana TM, Marquetti FM, Vázquez CA, Montes de MJ. Dinámica estacional y temporal de Aedes aegypti (Diptera:Culicidae) en el municipio Cienfuegos. Rev Cubana Med Trop [Internet]. 2010 Ago; 62(2): 98-106. Disponible en: http://scielo.sld.cu/scielo.php?

5. Lars E, Aedes (Stegomyia) aegypti in the Continental United States: A Vector at the Cool Margin of Its Geographic Range. Journal of Medical Entomology 2013; 50(3):467-478.

6. Guzman, M. Scott B.H. et al. Dengue: a continuing global threat. Nature Reviews/Microbiology [Internet]. 2010; pS7-S16. Disponible en: http://www.nature. com/nrmicro/journal/ v8/n12_supp/full/nrmicro2460.html

7. Wang, E. et al. Evolutionary relationships of endemic/epidemic and sylvatic dengue viruses. J. Virol. [Internet] 2000 Apr;74(7):3227-34. Disponible en: http://www.ncbi. nlm.nih.gov/pubmed/10708439

8. Dengue y dengue hemorrágico [Internet]. Organización Mundial de la Salud. (US). Febrero 2015. Nota descriptiva No. 117 Disponible en: http://www.who. int/mediacentre/factsheets/

9. Reuters Health Information. Risk of Dengue Increases Due to Climate Change, City Growth. Medscape. [Internet] 2014, Diciembre. Disponible en: http://www. medscape. com/viewarticle

10. Barrera RA, MacKay AJ. Population Dynamics of Aedes aegypti and Dengue as Influenced by Weather and Human Behavior in San Juan, Puerto Rico. Turell MJ, ed. PLoS Neglected Tropical Diseases. [Internet] 2011;5(12):e1378. Disponible en: http://journals.plos.org/plosntds/ article?id=10.1371/journal.pntd.0001378

11. San Martín JL, Brathwaite O, Zambrano B, et al. The Epidemiology of Dengue in the Americas Over the Last Three Decades: A Worrisome Reality. The American Journal of Tropical Medicine and Hygiene. 2010;82(1):128-135.

12. Chikungunya [Internet]. Organización Mundial de la Salud (US). Mayo 2015. Nota descriptiva No. 327. Disponible en: http://www.who.int/mediacentre /factsheets/fs327/es/

13. Dirección General de Epidemiología (MX). Lineamientos para la Vigilancia Epidemiológica y Diagnóstico por Laboratorio de Fiebre Chikungunya. 2014, México.

14. Dirección General de Epidemiología (MX). Sistema de vigilancia epidemiológica de CHIK. SINAVE [Internet]. México. 2016. Disponible en: http://www.epidemiologia.salud.gob.mx /doctos/avisos/2016/chik/DGE_ CHIK_CASOSYDEF_SEM05_2016.pdf.

15. Dirección General de Epidemiología (MX) .Lineamientos Estandarizados para la Vigilancia Epidemiológica y Diagnóstico por Laboratorio de Infección por Virus del ZIKA. México. 2015.

16. Síndrome neurológico, anomalías congénitas e infección por virus Zika. Actualización Epidemiológica (Internet). Organización Panamericana de la Salud. (US). Febrero, 2016. Disponible en:http://www.paho.org/hq/index.php?option=com_docman&task=doc

17. Dirección General de Epidemiología (MX). Sistema Nacional de Vigilancia Epidemiológica. Panorama Epidemiológico de Fiebre por Dengue y Fiebre Hemorrágica por Dengue. 2014, México.

18. Hospital General Regional No. 1. Unidad de Vigilancia Epidemiológica Diagnostico de Salud. Febrero 2014. p. 45. Localizado en el Departamento de Epidemiología (sótano) Cd. Obregón, Sonora. México.

19. Hoyos RA, Pérez RA. Nivel de conocimientos sobre el dengue en San Mateo, Anzoátegui, Venezuela. Revista Cubana de Salud Pública. 2009; 35(4):161-172.

20. Torres JL, Ordóñez JG, Vázquez-Martínez MG. Conocimientos, actitudes y prácticas sobre el dengue en las escuelas primarias de Tapachula, Chiapas, México. Rev Panam Salud Pública. 2014;35(3):214–8.

21. Olaiz FG, Rivero RL. Et al. Encuesta de percepción sobre dengue en población general y población escolar de México, 2010 – 2011. Subsecretaria de Prevención y Promoción de la Salud. 2011.

22. Undurraga, E, et al. Economic and Disease Burden of Dengue in Mexico. Neglected Tropical Diseases. 2015; p1 – 26.

23. Villegas-Trejo, A, et al. Control enfocado de Aedes aegypti en localidades de alto riesgo de transmisión de dengue en Morelos, México. Salud pública Méx [Internet]. 2011; 53 (2): 141-151. Disponible en: http://www.scielo.org. mx/scielo.php?script=sci_arttext&pid=S0036-36342011000200007&lng=es.

24. Organización Mundial de la Salud y el Programa Especial para la Investigación y Capacitación de Enfermedades Tropicales. [Internet]. Dengue, Guías para el diagnóstico, tratamiento, prevención y control. 2009. Disponible en: http://www2.paho.org/hq/dmdocuments/ 2011/ndeng31570.pdf

Serrano-García EA and Serrano-Trejo MA, Level of knowledge and risk perception of living with the Aedes aegypti mosquito , ERSJ 2025,1(2) 62-75