Abstract

Author summary

Citation: Kittayapong P, Ninphanomchai S, Jalichandra N, Sringernyuang L, Sherer P, Meemon N (2025) Knowledge, attitude, and practice (KAP), and acceptance and willingness to pay (WTP) for mosquito-borne diseases control through sterile mosquito release in Bangkok, Thailand. PLoS Negl Trop Dis 19(7): e0011935. https://doi.org/10.1371/journal.pntd.0011935

Editor: Audrey Lenhart, Centers for Disease Control and Prevention, UNITED STATES OF AMERICA

Received: January 19, 2024; Accepted: June 12, 2025; Published: July 28, 2025

Copyright: © 2025 Kittayapong et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the paper and its Supporting Information files.

Funding: This investigation received financial support from the following grants awarded to PK: The UNICEF/UNDP/World Bank/WHO/Special Programme for Research and Training in Tropical Diseases (TDR) (B70012); The International Development Research Centre (IDRC) (106556); and Mahidol University (Program-Based Research and Innovation). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: I have read the journal's policy and the authors of this manuscript have the following competing interests: PK and SN are also affiliated with Go Green Co., Ltd., formerly a spin-off company of Mahidol University, which gives advice and service on mosquito control using environmental friendly approaches.

Introduction

Arthropod-borne or arbovirus diseases are public-health concerns in many regions of the world, including Thailand. Important mosquito-borne diseases affecting humans in Thailand include dengue, chikungunya and Zika [1]. However, there are currently no safe and highly effective vaccines available for preventing these diseases [2,3]. Aedes mosquitoes are the most important arbovirus vectors, and Ae. aegypti is the major vector of dengue and Zika virus transmission, while Ae. albopictus is the major vector of chikungunya virus in Thailand [4–6]. Vector control has been the principal method of preventing vector-borne diseases. In Thailand, the control of vector-borne diseases, like elsewhere, largely has depended on vector management [7]. However, due to physiological resistance and behavioral avoidance to insecticides of the primary mosquito vectors of human diseases, persistent threats remain and continue to impose a public health burden to vulnerable populations [8].

Two environmental friendly insect control strategies, namely the radiation-based Sterile Insect Technique (SIT) and the Wolbachia-induced Incompatible Insect Technique (IIT), are based on a male release that aims to introduce sterility or lethality in the target population [9–11]. SIT relies on mass-rearing production, sterilization, and the recurrent release of sterile males of the target species, which are typically attained by radiation in a way that does not impair male mating and insemination capabilities. Radiation causes germ-cell chromosome fragmentation which then results in the ultimate death of the embryo [12]; hence, when wild females mate with sterile males, the eggs do not hatch [10] resulting in population suppression over the generations. An alternative is IIT, a method involving the release of Wolbachia-harboring insects in a natural habitat where they can mate with wild females [13,14]. IIT relies on reducing female fertility by utilizing endosymbiotic bacteria from the genus Wolbachia, instead of radiation, to induce a form of reproductive incompatibility known as cytoplasmic incompatibility (CI) in wild females [14]. Wolbachia induces a form of embryonic death [15], resulting from the sperm-egg incompatibility that occurs when Wolbachia-infected males mated with uninfected females or females infected with an incompatible Wolbachia strain. Successful implementation of SIT and IIT in field trials for mosquito control have been reported in many countries [16–19]. However, in the absence of an efficient and robust method of sex separation for Aedes species, it was recently suggested that irradiation (SIT) and Wolbachia (IIT) could be combined, which may eliminate the risks associated with the presence of a few females in sterile male batches being released in the field to suppress a target population [10,20–22].

The success of SIT or IIT programs depend largely on effective engagement and education of the community where the intervention will take place [23]. Community engagement has been the priority in SIT or IIT programs; and such programs can rapidly fail without community involvement, because community opinion and perception can positively or negatively shape the outcome of the program [24]. In our previous work, we had successfully shown proof of concept of a significant reduction of natural populations of Ae. aegypti mosquitoes in semi-rural settings in Plaeng Yao District, Chachoengsao Province, eastern Thailand by an application of a combined Sterile Insect Technique (SIT) and Incompatible Insect Technique (IIT) approach which relied on open field release of sterile males [21]. Currently, this combined SIT/IIT approach is in the preparation phase for a scale-up application in the capital city of Bangkok, Thailand and its implementation is estimated to launch in the middle of the year 2025.

Vector control involves collaboration with the non-health sector because it increases the sustainability of vector control programs against vector-borne diseases [25]. Knowledge, attitudes, and practices (KAP) of the populations have played a major role in the implementation of vector-borne disease control measures [26]. Understanding and enhancing households’ KAP is crucial for effective community disease control and prevention initiatives [27]. As such, KAP surveys have been conducted in many parts of the world in order to understand local contexts which can be useful for the implementation of vector control programs for dengue, chikungunya, Zika and malaria [26–33]. Some KAP surveys have used to study dengue vaccine acceptance [34], while some vector control implementers have applied KAP surveys before implementation of the new vector control technology [28].

From an economic perspective, a few studies have been done to assess the willingness to pay (WTP) for the SIT or IIT approach [35]. The WTP method has usually applied in a cost-benefit analysis and health technology assessment [36]. These are relevant methodological approaches to estimate the minimum and maximum amount (i.e., how much they are willing to pay) that an individual is willing to allocate to programs, services and health technologies [36,37]. Although many studies used the WTP approach for dengue vaccine, insecticide treated mosquito nets, and mosquito control programs [38–41], to date only one study was focused on the WTP for the SIT and it was specific only for fruit fly control [35]. Thus, the need for WTP studies with SIT/IIT mosquito control is great, especially for countries where SIT or IIT technology is planning to be implemented.

Therefore, in this study we aimed to conduct a KAP survey in order to collect information regarding community knowledge, attitudes, and perceptions about the risk of mosquito exposure and the acceptance of the new SIT/IIT technology from local residents before releasing sterile mosquitoes in a larger scale application in Bangkok, Thailand. In addition, we assessed the WTP that residents were willing to pay for sterile mosquitoes as an alternative method for mosquito control in the Thai context. Results from this study should be useful for policy makers who are considering integrating this new technology together with the routine methods for vector control in Thailand, especially in the capital city of Bangkok.

Materials and methods

Results

Discussion

This study revealed that participants living in Bangkok were more familiar with dengue (85.25%) and at a much higher level than those familiar with chikungunya (39.75%) or Zika (33.75%). Level of knowledge on dengue was the highest amongst the studied diseases. This finding is supported by Saminpanya and Jarujit who reported high levels of knowledge among respondents towards dengue (71%) when compared to those of chikungunya (23%) [47]. Dengue has been endemic for more than 60 years in Thailand [48], and it has been recognized as a major public health problem [49] since the first major outbreak of dengue in Thailand in 1958 [50,51]. Moreover, dengue virus infections usually occur with common severe presentation of hemorrhagic manifestations and occasional deaths from shock [51], thus it has remained a significant threat to the welfare of the Thai population [52]. Although a chikungunya outbreak was also reported in 1958 [53,54], little was known, so the disease received little attention as it had generally been regarded as self-limiting with few severe complications [55].

The first report of the possible occurrence of Zika virus in Thailand was published in 1963 [56] and Zika virus has been circulating in Thailand since 2012 [57]. However, Zika virus infections represent a small proportion of ongoing flaviviral infections in Thailand [52], with the exception of rare cases of more severe disease [58]. In addition, Zika was a relatively mild and self-limiting disease, which was often resolved without medical attention [59], thus little was known for Zika, especially to the general public.

In this study, participants had a generally high knowledge of mosquito vectors and vector-borne diseases, i.e., they could identify at least one mosquito breeding site, they could correctly identify biting time of Aedes mosquitoes, and they considered dengue, chikungunya, and Zika as severe diseases, even though they did not experience virus infections themselves. When we focused on socio-demographics, we found that females had a higher knowledge on dengue than males, but this was not the case for chikungunya and Zika. Age, education, family status, marital status, monthly income, and number of family members were not associated with the level of knowledge on dengue, chikungunya and Zika. Our study was supported by Elson et al. who found a greater knowledge of dengue in females when compared to males in Peru [60]. So et al. supported that there was no correlation between education, age, marital status, family income and knowledge levels [61]. However, our findings together with So et al. contradicted other studies that showed good correlation between knowledge and socio-demographic information, i.e., age, education, marital status, employment and monthly income [62–65]. In this study, we found that most people had good knowledge on dengue, and this might be the reason why we found no association between knowledge on dengue and socio-demographic characteristics.

In terms of prevention and control measures for vector control, covering water storage containers was the most common preventive measure cited by participants, followed by disposal of mosquito breeding sites such as discarded water containers or garbage, and weekly change of water in water storage containers. These results are supported by the study of Swaddiwudhipong et al. [66]. High number of Aedes mosquitoes was present in water storage containers, and large water storage containers represented 80% of Aedes breeding sites [67]. This could explain why participants might be aware of treating these water storage containers [68].

When we focused on attitude, although the majority of participants had good attitude in many aspects, such as regularly changing water in water storage containers, sleeping under a bed net, and preventing themselves from mosquito bites, many still believed that elimination of mosquito breeding sites was the sole responsibility of the health officials. Similarly, Kamaran et al. showed that people were less likely to apply vector control measures despite its benefits since the government had performed vector control measures for a long time and people believed that it was the government’s responsibility [68].

Other studies observed good knowledge and poor practice [60,62,68]. Although we found that good knowledge on dengue was positively associated with good attitude, and good attitude was associated with good practice, when we focused on a specific activity, such as covering water storage containers to get rid of mosquito breeding sites, many participants had never practiced it (47.75%). The reason why participants rarely covered water storage containers might be the fact that they lived in urban or suburban areas in Bangkok where they could easily access a water supply without storing water, hence, less water storage containers are found. However, we generally found that participants with a good attitude practiced more frequent activities in vector control. These findings are supported by Al-Dubai et al., who found an association between knowledge and practice in dengue control [69].

High level of knowledge has been related to the diffusion of information [33]; and the media has played a major role in the dissemination of public health knowledge [32,70,71]. In this study, we found that television was one of the major sources of information on dengue, chikungunya and Zika, followed by health officers or community health volunteers. Our findings are supported by Al-Dubai et al., who also showed that TV was the main source of information on vector-borne diseases in Malaysia [69]; and Swaddiwudhipong et al. who revealed the important role of health personnel in disseminating information and prevention methods of dengue in Thailand [66]. Village health volunteers or community health volunteers have played an important role in facilitating effective health activities that increase awareness, motivation, involvement and monitoring health status within a community [72–74]; and together with primary health care units, they have been the public’s first point of contact with primary health care and the broader health system in Thailand [48].

Regarding knowledge on sterile mosquitoes and relevant information, many participants knew nothing about sterile mosquitoes while a few had some knowledge, such as how to sterilize mosquitoes, benefits of sterile mosquitoes, difference between sterile and wild mosquitoes, etc. Our study highlighted the importance of communication channels through municipal officials and community health volunteers in Bangkok, Thailand. Municipal officials were the major source of information about sterile mosquitoes, followed by leaflets or flyers, and community broadcast towers. More efforts have to be done in order to deliver more information and knowledge on sterile mosquitoes through the previously mentioned channels of communication in order to reach more people in the community prior to the release or implementation of sterile mosquitoes in the fields. Moreover, various media channels, i.e., TV and online media, are needed in order to reach more people and the general public. Good communication strategies to inform target communities in order to solicit their acceptance and support are essential for successful implementation of a mosquito control program that includes an SIT component [28,75,76].

When we focused on knowledge of sterile mosquitoes and socio-demographic characteristics, we found no association amongst them. These findings could be explained by the fact that the majority of participants had poor knowledge on sterile mosquitoes; and since this technology is still new in Thailand (together with limited or less channels of communication to deliver key messages on the technology), no correlation was found in this study. Also, when we focused on attitudes toward sterile mosquitoes or the application of sterile mosquitoes to reduce mosquito vectors of dengue, chikungunya and Zika, we found no association between attitude and level of knowledge on sterile mosquitoes. A poor knowledge on sterile mosquitoes, as previously described, could be explained by the same reason. Although many participants showed a positive attitude towards sterile mosquitoes, i.e., they were interested in having sterile mosquitoes released in their homes or communities, and they believed that it could reduce chemical use and reduce the Aedes mosquito populations in their homes or communities, a non-negligible percentage of participants was still uncertain about sterile mosquitoes. In comparison, the majority of respondents from the questionnaire survey in Greece agreed that SIT has many advantages over chemical control methods; however, their attitudes toward SIT still ranged from indecisive to fully supportive [28].

In this study, there were some limitations attributed to the methodology and the questionnaire surveys. As all information was acquired via self-reporting questionnaire (S1 File), respondents might have provided answers that were not reflective of their actual attitudes and practices but to satisfy social expectations, which might contribute to reporting bias. In addition, we had limitations in the result interpretation in some sections because of a high non-response rate of more than 50%. To improve this study, face-to-face interviews by trained interviewers in order to prove and clarify the responses of respondents should be conducted, which in turn could help increase knowledge and basic information on SIT/IIT technology. Basically, we first aimed to conduct face-to-face interviews, but it was not possible since this study was done during the period when the COVID-19 pandemic occurred and access to the communities was restricted or almost impossible. In Greece, the presence of key persons, i.e., scientific experts and municipality members, was shown to raise community awareness and might prove important in granting permission to enter their private properties for entomological surveillance [28]. Another limitation in our study was that the periods when respondents answered the questionnaire were different in each community, and it took a year to complete, while it should take 1–3 months for face-to-face interviews. This might have affected the opinions or perceptions of respondents. In addition, since this study used a non-probability sampling method for data collection, it might introduce potential selection bias that could lead to over or under representation of certain groups of participants; as a result, our findings might not be generalized to a broader community.

Besides, the level of education might be another limitation of this study since some questions required a higher level of education to be comprehensive and responsive. Although most respondents in this study were educated to the secondary or high school level, others received an education only through primary school. Higher education leads to better and easier access to information, and has an indirect effect on knowledge, reflected by the ability to understand and comprehend complex information [77]. In this study, we found that answers ranged from non-negligible to high percentages of non-response in each section of the questionnaires, and this could be due to the fact that respondents had low education or had difficulty understanding and answering the questionnaire. Less knowledge on chikungunya, Zika, sterile mosquitoes and poor practices on vector control were also observed in those who showed no response in this study. Moreover, as this study was carried out only in Chatuchak and Bang Khae Districts, and most respondents had their education in the primary or secondary schools, the results might only represent information about these studied groups of people, and it might not represent those with higher education or those living in other parts of Bangkok. Lastly, before the questionnaire survey, we conducted community engagement and knowledge about sterile mosquitoes was partly delivered through community health volunteers. Therefore, people in the studied communities might have higher or more knowledge about sterile mosquitoes than the general public.

Overall, this study was the first survey examining community knowledge and acceptance of the SIT/IIT technology alongside traditional control methods in Thailand. Results from this study showed that most people in Bangkok were more familiar and had better knowledge on dengue than those of chikungunya and Zika. However, there was no association between socio-demographic factors and knowledge on dengue, chikungunya, and Zika. A strong association between good knowledge on dengue, good attitude, and good practice were observed, but this was not the case for chikungunya and Zika. Generally, the majority of people had poor knowledge on sterile mosquitoes, and no association between socio-demographic factors and knowledge on sterile mosquitoes was found. Also, there was no association between knowledge and attitude on sterile mosquitoes. More information on vector-borne diseases, mosquito vectors, and their prevention and control should be provided to the general public by health authorities in order to increase the level of knowledge. In addition, more efforts in communication and community engagement are required in order to educate people about sterile mosquitoes and SIT/IIT technology before implementing it at a larger scale in Bangkok.

Our study was the first willingness to pay (WTP) analysis of SIT/IIT deployment for mosquito control. Prior to this, WTP analysis was conducted only for fruit fly control using the SIT approach. Moreover, this study provides unique insights into about how local residents in the capital city of Bangkok viewed SIT/IIT technology. Although many residents still lack of knowledge on the technology, they were willing to accept or would like to have this new technology implemented in their communities. This was because they considered that the available conventional mosquito control methods were not effective enough and this technology could be an alternative mosquito control method. Many residents were willing to receive the sterile mosquitoes if they were public supported by government authorities. However, many of them were less likely to purchase the sterile mosquitoes if the costs were on their own expenses. For those few of them who were willing to pay, only 9.0-9.5% of them could afford to purchase sterile mosquitoes at a price of 1–2 THB (~US$ 0.03-006) per sterile mosquito. These findings highlighted the funding challenges for SIT/IIT mosquito control programs, as it emphasized the need for government subsidization of the costs and the need to explore alternative funding strategies to ensure the program sustainability, which is a very big challenge for developing countries. Collaboration or continued support from the government is vital for strengthening a successful long-term SIT/IIT large-scale vector control program; as was the case in Singapore [78].

Supporting information

Acknowledgments

The authors would like to thank the staff of the Department of Health, Bangkok Metropolitan Administration (BMA) for their field accompany and their assistance with the questionnaire management; and David A. Blyler for editing this manuscript.

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