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Assessing the knowledge, attitudes, and practices (KAP) of dengue in Thailand: a systematic review and meta-analysis

Archives of Public Health volume 83, Article number: 38 (2025) Cite this article

Abstract

Aim

Dengue cases are on the rise in Thailand, coinciding with increases in flooding events. Studies pertaining to public knowledge, attitudes, and practices (KAP) of dengue prevention have frequently been used to better understand the public’s needs towards dengue. While these studies were conducted in different settings, it is necessary to initiate a systematic review and meta-analysis of relevant studies.

Subjects and method

We conducted a systematic review and meta-analysis of prior studies in Thailand that assessed the KAP towards dengue. Eligibility criteria were established and independently used by reviewers to select nine studies for the systematic review and three for the meta-analysis. Collectively, the nine studies included 3,058 individuals and 2,519 households.

Results

The overall estimate of the proportion of participants with good knowledge of dengue prevention is 35% (95% CI: 14-59%), suggesting the majority of the population in Thailand had low levels of knowledge towards dengue. The poor levels of practice in Thailand were also observed and confirmed for the majority of the population by meta-analysis, with the pooled estimate of the proportion of participants with good practice of dengue prevention being 25% (95% CI: 22-27%). In contrast, most of the studies included in the systematic review reported positive attitudes towards dengue prevention, and this finding was also affirmed by the meta-analysis, as the pooled estimate of the proportion of positive attitudes towards dengue prevention is 61% (95% CI: 43-77%).

Conclusion

Despite good attitudes towards dengue prevention, poor knowledge and poor practices predominate, highlighting the need for enhanced public health campaigns to educate the public on dengue risks and prevention methods.

Peer Review reports

Text box 1. Contributions to the literature

• The systematic review and meta-analysis of previous studies suggest that the general public in Thailand has a good attitude towards dengue prevention but needs to gain knowledge about dengue, and practices against dengue are poor.

• The study conducted in the urban area reported higher proportions of participants with good KAP towards dengue than those conducted in the rural area.

• Public health campaigns are urgently needed to educate the public on dengue risks and prevention methods, especially in rural areas.

Introduction

Thailand’s tropical location and topography make the Southeast Asian nation vulnerable to flood hazards [1]. Research has examined the relationship between climate change and increases in the frequency and intensity of flooding in Thailand [2,3,4,5,6,7]. Moreover, additional research has examined the impacts of climate change-induced flood increases on several sectors within Thailand, including but not limited to agriculture [5, 8,9,10], housing [10,11,12], and public health [13].

Dengue is recognized as a significant public health problem that is widespread throughout Thailand [14] and exacerbated by the flooding impacts of climate change [15]. Dengue is an infectious disease that is caused by any of the four serotypes of dengue virus [16]. The virus is transmitted to humans through female Aedes mosquitoes and is mainly present in tropical and subtropical environments. Symptoms range from a mild fever to severe dengue hemorrhagic fever and shock syndrome [16]. Increases in dengue cases following flood events in tropical and subtropical environments were detected in previous research [17, 18]. The accumulation of stagnant water from flooding in urban areas is a major breeding ground for Aedes mosquitoes and the subsequent transmission of dengue [19]. Occurrences of dengue in Thailand have increased continuously over the last 60 years [20] with over 45,000 reported cases in the first half of 2023 [21]. The virus is now the leading cause of hospitalizations among children, and precipitation was found to be the most influential weather variable for predicting cases of dengue in Thailand [20]. Furthermore, the high incidents of dengue place substantial economic and societal burdens on Thailand [14]. The average cost per dengue occurrence is estimated to be between 41 USDs and 261 USDs with a total annual cost estimated at 440.3 million USDs [14].

The treatment of dengue consists mainly of alleviating symptoms and avoiding complications that could potentially lead to death [22]. The development of a dengue vaccine has proven to be challenging due to the presence of four antigenically distinct dengue virus serotypes [16]. Each of these serotypes is capable of a cross-reactive and disease-enhancing antibody response against the other three serotypes. A vaccine used in dengue prevention is now available in some countries, but its reported efficacy is low in dengue naïve individuals [16]. In the United States, the dengue vaccine is only approved for use in children aged 9–16 with a previously confirmed dengue infection who are living in areas with high prevalence of the virus [23].

Such challenges in the treatment and vaccination development of dengue have called for the establishment of protocols to prevent the spread of the Aedes mosquito. The Ross-Macdonald model argues that effective interventions for decreasing the transmission of dengue include reducing the adult mosquito population density and the mosquito contact with humans [22]. The Centers for Disease Control and Prevention (CDC) [23] advise individuals to use insect repellent, wear loose-fitting, long-sleeved shirts and pants, and take steps to control mosquitoes inside and outside of the home. Examples of mechanisms that control mosquitoes include the use of screens on windows and doors and the regular emptying of water in items like tires and flowerpots where water can accumulate [23]. Since these measures call for specific actions at the individual and community level, several studies cite the importance of community engagement and public education in reducing the spread of dengue [24,25,26].

Knowledge, attitude, and practice (KAP) surveys are often used to measure individual vulnerability to acquiring dengue. Such surveys aim to measure what is known (knowledge), believed (attitude), and done (practiced) pertaining to the topic of interest [27]. KAP surveys originated in the 1950s and have become widely accepted as a research tool for health-related behaviors and health-seeking practices [27]. Given the health risks of acquiring dengue, sufficient knowledge, positive attitudes, and proper practices are crucial for the prevention and control of the virus [28] and can empower individuals to take part in the necessary disease control and prevention programs [29].

Many studies have used KAP surveys to measure the knowledge, attitudes, and practices pertaining to dengue in different areas of the world. Many of these studies took place in Southeast Asia where the prevalence is high [30]. Research has also provided systematic reviews and meta-analyses for the results of dengue KAP studies in individual countries. Systematic reviews and meta-analyses on dengue KAP studies in the Southeast Asia region have only covered the countries of Malaysia [31, 32] and the Philippines [33]. There is a dearth of research studies that provide systematic reviews and meta-analyses of KAP studies in Thailand. This research is crucial given the increasing cases of dengue [20] and the susceptibility of the country to increased flooding due to the effects of climate change [2,3,4,5,6,7]. This research therefore aims to examine the existing knowledge, attitudes, and practices (KAP) of dengue in Thailand by providing a systematic review and meta-analysis of studies.

Methods

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement [31] was used to guide this systematic review and meta-analysis. The following subsections explain the eligibility criteria, literature review, study selection, data abstraction, study appraisal, and statistical analyses.

Eligibility criteria

Studies were deemed eligible for inclusion in this systematic review and meta-analysis if they were observational, conducted in Thailand, and reported outcomes that included standardized scores for knowledge, attitudes, and practices in addition to specifying the proportion of participants with good knowledge, attitudes, and practices pertaining to dengue. Studies that did not report the results of an observational study, such as comments, case reports, reviews, and letters to the editor were excluded.

Literature search

Two investigators (J.C. and H.J.) conducted separate comprehensive searches of the PubMed and MEDLINE online databases for studies published between January of 1950 and January of 2025 without language restrictions. The following terms were utilized in the search strategy to identify relevant studies: “Thailand”, “KAP”, “Knowledge”, “Attitude”, “Practice”, “Dengue”, “Breakbone Fever”, “Dengue Fever.” J.C. and H.J. also independently examined the references of eligible original studies and relevant meta-analysis articles.

Study selection

At the initial study selection stage, J.C. and H.J. independently screened the titles, and the abstracts of the articles identified with the search strategy. The studies that both reviewers considered to be irrelevant to this systematic review and meta-analysis were excluded, while the remaining studies were prepared for further assessment in the next stage. During the second stage of study selection, J.C. and H.J. independently examined the full texts of articles for eligibility in the meta-analysis and systematic review. Cohen’s Kappa statistic was used to evaluate the level of agreement between the two investigators at both stages of study selection. The disagreements were resolved by two additional investigators (J.C. and B.L.). The details of the study selection are presented in the PRISMA flow diagram in Fig. 1.

Fig. 1
figure 1

PRISMA flow chart

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Data abstraction

The following study characteristics were abstracted: author(s), titles, year of publication, sample size, sampling methods, standardized knowledge scores, standardized attitude scores, standard practice scores, the proportion of study participants with good knowledge, the proportion of study participants with good attitudes, and the proportion of study participants with good practices. With a standardized data extraction form, two reviewers (J.C. and H.J.) independently completed data abstraction and entry. The inconsistencies in data abstraction for the two reviewers were assessed by utilizing Cohen’s Kappa. Disagreements in data abstractions were resolved by two additional reviewers.

Study appraisal

To critically appraise the studies and evaluate the risk of bias, the studies that satisfied the inclusion criteria were examined by J.C. and H.J. based on the Critical Appraisal Skills Programme (CASP) Checklist [32]. The disagreements were resolved by consensus.

Statistical analyses

We conducted meta-analyses to quantitatively summarize the findings from different studies. The DerSimonian and Laird random-effects model was used to pool the effect sizes of included studies [33]. We utilized this model since it accounts for the between-study heterogeneity due to different study populations. For the studies that reported standardized scores of knowledge, attitude, and practice, the pooled mean standardized scores and the corresponding 95% confidence intervals (CIs) are presented. For the studies that reported the proportions of study participants with good knowledge, attitudes, and practices, the pooled proportions and the corresponding 95% CIs are presented. Subgroup analyses were performed with different criteria such as study types and sampling methods. To assess the heterogeneity in the meta-analyses, the Cochran’s Q test was utilized. In addition, the between-study heterogeneity was measured using Higgins I2 statistic [34]. To be consistent with previous literature, we regard I2 < 40% as minimal heterogeneity, 40–60% as moderate heterogeneity, 60–75% as substantial heterogeneity, and > 75% as considerable heterogeneity [35, 36].

To account for potential publication bias, we conducted Begg’s rank correlation test to help assess the presence of publication bias in the funnel plots [37]. All data analyses were conducted using the R statistical software package (Version 4.3.1, Core Team, Vienna, Austria), and a p-value < 0.05 was considered statistically significant. The subsequent results section presents the results of the systematic review and meta-analysis.

Results

The study selection process is displayed in the following PRISMA flow chart of Fig. 1. We identified 265 references initially. After removing duplicates, 193 references were screened. We reviewed the titles and abstracts of all 193 references and identified 10 studies for full-text assessment. 9 studies met the inclusion criteria for systematic review and 3 studies were included in the quantitative meta-analysis.

Knowledge

A total of nine studies on KAP and dengue met the inclusion criteria and were included in the systematic review. Six of the nine included studies observed that participants had overall low knowledge pertaining to dengue [38,39,40,41,42,43] while the remaining three studies reported overall high participant dengue-related knowledge [44,45,46]. Studies commonly used awareness of the Aedes mosquito species as a vector for transmitting dengue to describe participants’ knowledge [40, 44,45,46]. Other frequently cited indictors of dengue-related knowledge include dengue symptom awareness [40, 44,45,46] and recognition of the time of day and season when dengue is most prevalent [40, 44, 45].

More specifically, studies examined associations between dengue-related knowledge and sociodemographic factors. Dengue-related knowledge was associated with participants’ socioeconomic status and 51.4% of urban participants exhibited high knowledge compared to 36.7% of their rural counterparts [41]. Other studies looked at associations between participants’ past experiences and dengue-related knowledge. The overall knowledge of dengue caretakers, caretakers of non-dengue cases, and caretakers of healthy students was almost the same between the three groups [38]. Dengue-related knowledge was also associated with previous dengue experiences [41], but not with the use of insecticide-treated curtains [43]. Table 1 provides details on the nine studies and Table 2 presents the risk of bias assessment.

Table 1 Study characteristics
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Table 2 Risk of bias assessment with the CASP checklist. Questions: (1) Was there a clear statement of the aims of the research? (2) Is qualitative methodology appropriate? (3) Was the research design appropriate to address the aims of the research? (4) Was the recruitment strategy appropriate to the aims of the research? (5) Was the data collected in a way that addressed the research issue? (6) Has the relationship between researcher and participants been adequately considered? (7) Have ethical issues been taken into consideration? (8) Was the data analysis sufficiently rigorous? (9) Is there a clear statement of findings? (10) How valuable is the research?
Full size table

In total, three of the nine studies reported the proportions of study participants with good knowledge of dengue [40,41,42]. The definition of good knowledge of dengue was consistent among the three studies: if a participant received a KAP knowledge score over 80%, then the participant is categorized into the group with good knowledge of dengue. Figure 2A shows the studies that reported the proportions of participants with high knowledge of dengue. One of the studies reported the proportions separately for urban and rural areas [41]. With a random-effect meta-analysis model, the overall estimate of the proportion of participants with high knowledge of dengue is 35% (95% CI: 14-59%). A Higgins I2 of 99% indicates that significant heterogeneity was observed. A funnel plot was constructed to visually inspect the publication bias. Figure 2B indicates a potential issue with publication bias. Publication bias was then numerically examined using Begg’s rank correlation test. The results from rank correlation tests suggested that publication bias was not significant for the proportions of knowledge (p = 0.17).

Fig. 2
figure 2

(A) Forest plot of the proportion of people with good dengue knowledge in Thailand. (B) Funnel plot of the proportions of people with good dengue knowledge in Thailand with 95% confidence limits

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Attitudes

Seven of the nine studies included in the systematic review concluded that the majority of participants demonstrated positive attitudes towards the prevention of dengue through accurate perceptions of the risk of acquiring the disease [38, 39, 41,42,43,44,45]. The remaining two studies displayed negative attitudes towards dengue prevention through inaccurate perceptions of disease acquisition and the perceived effectiveness of preventative actions [40, 46]. Several of the studies measured attitudes by the perceived susceptibility of acquiring dengue [38,39,40, 44,45,46], the severity of the disease [38, 40, 44, 45], a desire to acquire stronger levels of dengue awareness [41, 42], and the validity of strategies to prevent infection [40,41,42,43,44,45,46].

Like with the knowledge component of KAP, studies also examined associations between dengue-related attitudes and sociodemographic factors. Dengue-related attitudes were associated with education levels, but the proportions of positive attitudes were almost the same between participants from rural areas (64.4%) and participants from urban areas (69.8%) [41]. Associations between participants’ past dengue experiences and dengue-related attitudes were also tested. Caretakers of dengue patients had significantly more incorrect perceptions of signs and symptoms of the disease compared to caretakers of non-dengue cases and caretakers of healthy students [38]. Finally, there was an association between the continued use of insecticide-treated curtains and their perceived effectiveness [43].

Of the nine studies included in the systematic review, three reported the proportions of study participants with good attitudes towards dengue prevention [40,41,42]. Three studies used the same definition for good attitudes towards dengue prevention: If a participant received a KAP attitude score over 80%, then the participant is categorized into the group with good attitudes towards dengue prevention.

Figure 3A demonstrates the studies that reported the proportions of participants with good attitudes towards dengue prevention. One study reported the proportions separately for urban and rural areas [41]. The pooled estimate of the proportion of positive attitudes towards dengue prevention is 61% (95% CI: 43-77%). A Higgin’s I2 of 97% suggested that significant heterogeneity was observed. To visually inspect the publication bias, a funnel plot was utilized. The asymmetrical funnel plot suggested potential issues of publication bias (Fig. 3B). However, Begg’s rank correlation test suggested that publication bias was not significant for the proportions of attitude towards dengue prevention (p = 0.17).

Fig. 3
figure 3

(A) Forest plot of the proportion of people with good dengue attitude in Thailand. (B) Funnel plot of the proportions of people with good dengue attitude in Thailand with 95% confidence limits

Full size image

Practice

Of the nine studies included in the systematic review, only two of the studies displayed overall good practices for preventing dengue [45, 46] while the other seven studies displayed overall poor practices [38,39,40,41,42,43,44]. Dengue practices in the studies commonly included the destruction of mosquito breeding sites [38,39,40,41,42, 44, 45], the use of pesticides [38, 41, 42], the use of mosquito nets [39, 41, 42, 45, 46], and wearing long-sleeved shirts and long pants [40,41,42, 46].

In addition to the knowledge and attitude components, studies looked at associations between practices and sociodemographic factors. Dengue-related practices were associated with education levels with proportions of good practices being slightly higher among urban participants (24.0%) compared to rural participants (19.4%) [41]. Past dengue experiences were also applied to practices. Caretakers of dengue patients had significantly better practices than caretakers of non-dengue cases and caretakers of healthy students [38]. Recent or current dengue infections were associated with early care-seeking and good preventive practices [44], and most participants used insecticide-treated curtains [43].

Three studies reported the proportion of participants with good practices for preventing dengue [40,41,42]. An 80% cut-off value for KAP practice scores was chosen for all three studies to determine if the study participants displayed overall good practices for preventing dengue.

Figure 4A presents the studies that reported the proportions of participants with good practices for preventing dengue. The pooled estimate of the proportion of good practices for preventing dengue is 25% (95% CI: 22-27%). Higgin’s I2 of 26% suggested that heterogeneity was not significant. Significant asymmetry was not observed in the funnel plot (Fig. 4B). Begg’s rank correlation test suggested that publication bias was not significant for the proportions of good practices for preventing dengue (p = 1.00). The following section will provide a detailed discussion of the results.

Fig. 4
figure 4

(A) Forest plot of the proportion of people with good dengue practice in Thailand. (B) Funnel plot of the proportions of people with good dengue practice in Thailand with 95% confidence limits

Full size image

Subgroup analysis to assess KAP of dengue in Thailand

We conducted a subgroup analysis to evaluate the differences in KAP related to dengue between children and adults. Table 3 highlights the findings from this subgroup analysis of KAP on dengue in Thailand. Of the three studies included in the quantitative meta-analysis, two focused on adult populations [41, 42], while one examined a sample of children [40]. Significant differences were observed in the proportions of knowledge about dengue (Children: 0.12, 95%CI: 0.11–0.14 vs. Adults: 0.44, 95%CI: (0.35, 0.52); p < 0.01) and attitudes toward dengue (Children: 0.42, 95% CI: 0.39–0.43 vs. Adults: 0.68 95%CI: 0.63–0.72; p < 0.01). However, the difference in practices for dengue prevention was not statistically significant (Children: 0.26, 95% CI: 0.24–0.28, vs. Adults: 0.23, 95%CI: 0.19–0.27; p = 0.23).

Table 3 Subgroup analysis on KAP of dengue in Thailand
Full size table

Of the nine studies in the systematic review, two examined samples of children [39, 40] while the remaining seven focused on adults [38, 41,42,43,44,45,46]. The studies that included children demonstrated that 41.6% [40] and more than half [39] of participants had good attitudes towards dengue prevention. However, both studies displayed considerably lower levels of knowledge and good practices towards dengue prevention compared to good attitudes [39, 40]. In contrast, three of the remaining studies that contained samples of adults reported overall high knowledge of dengue [44,45,46]. Additionally, two of the studies with adult samples displayed overall good practices towards dengue prevention [45, 46]. These findings demonstrate the willingness of children to take the necessary measures to prevent dengue through good attitudes. However, they are lacking in the proper knowledge to implement such preventive practices. It is recommended that Thai schools adopt dengue education programs to increase the knowledge of children towards dengue prevention. This includes the implementation of education programs on effective practices for dengue prevention.

Discussion

The overall low knowledge and poor practice levels pertaining to dengue prevention that were detected in the systematic review and meta-analysis are alarming given the previously cited rates of increasing dengue cases throughout Thailand [20, 47] and the subsequent burdens the virus imposes on the Thai economy [14]. However, the overall positive attitudes towards dengue prevention that were also observed in the systematic review and meta-analysis are reassuring. This finding suggests that there is a high likelihood that participants will be open to dengue education and prevention programs given their overall high-risk perceptions of the virus.

The results of this study displayed both similar and conflicting information when compared to similar studies conducted in other countries in Southeast Asia. For example, the previously cited meta-analysis on dengue KAP in the Philippines presented similar findings pertaining to knowledge with 31.1% of the studies displaying high knowledge [48], which is close to the figure of 35.0% for this study. However, positive attitude levels were lower at 50.1% compared to 61.0% in this study while good practice levels were higher at 35.3% compared to 25.0% in this study [48]. However, greater contrasts were observed for knowledge and practices in the results of the other previously cited meta-analysis on dengue KAP in Malaysia with 51.0% of the studies exhibiting high knowledge and 45.0% displaying good practices [49]. On the other hand, attitude levels were similar with the meta-analysis in Malaysia finding that 56.0% of the studies depicted positive attitudes [49]. Furthermore, the previously cited systematic review of dengue KAP in Malaysia found significant associations between knowledge and dengue experiences [50], which correlates with the scoping review of this study [51].

An additional study provided a scoping review on dengue KAP studies that included geographical representation in Southeast Asia, South Asia, the Caribbean, and South America [51]. In contrast to this study and the meta-analyses in the Philippines [48] and Malaysia [49], they detected that the majority of respondents had high knowledge levels towards dengue [51]. However, the scoping review focused on comparing dengue KAP in dengue epidemic areas to those of controlled dengue areas and did not include a systematic review and/or a meta-analysis [51].

Other systematic reviews and meta-analyses on KAP and different types of mosquito-borne diseases generated comparable results to this study. A systematic review on the global primary literature of risk perceptions, attitudes, and knowledge of chikungunya found overall higher knowledge of the disease in areas that had previous outbreaks of chikungunya [52]. They also concluded that the majority of the populations studied did not understand chikungunya and were therefore less likely to protect themselves from mosquito bites [52]. On a similar note, a systematic review on malaria KAP in South Asia found that a general knowledge of the disease was mostly lacking among the public and healthcare professionals [53].

One limitation of this study is that the survey questions pertaining to knowledge, attitudes, and practices are not standardized across each of the studies that were included in the systematic review and meta-analysis. It is recommended that the Ministry of Public Health of Thailand work with local public health professionals within their agency, the private sector, and academic institutions to develop a standardized guide of the most crucial survey questions that should be included to measure knowledge, attitudes, and practices towards dengue prevention. This would allow for more opportunities to derive meaningful results across studies through systematic reviews and meta-analyses.

The overall positive attitudes towards dengue prevention that were observed by this study suggest that there is a strong willingness for the public to take the necessary steps to mitigate their risks towards exposure to dengue. However, the overall low knowledge levels and poor practices towards dengue prevention indicate that more public health campaigns are needed to educate the public on the risk of dengue and mitigation techniques.

Conclusion

To conclude, the majority of the studies included in the systematic review reported overall low knowledge levels and poor practice levels towards dengue prevention in Thailand. This finding was confirmed by the meta-analysis, which concluded that the overall estimate of the proportion of participants with high knowledge of dengue prevention is only 35% (95% CI: 14-59%). Most of the studies included in the systematic review reported positive attitudes towards dengue prevention, and this finding was also confirmed by the meta-analysis, which concluded that the pooled estimate of the proportion of positive attitudes towards dengue prevention is 61% (95% CI: 43-77%). Lastly, the majority of studies in the systematic review reported overall poor practices towards dengue prevention. Similarly, the meta-analysis found that the pooled estimate of the proportion of good practices for preventing dengue is only 25% (95% CI: 22-27%).

In addition to the previously discussed limitation on the lack of standardization in KAP survey questions across studies, another limitation of this study is that it only examined dengue KAP studies in Thailand. Further research should conduct similar systematic reviews and meta-analyses on dengue KAP in other regions of the world and compare the results to this study.

Data availability

No datasets were generated or analysed during the current study.

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Acknowledgements

The authors wish to acknowledge Abby O’Donnell for assisting with the initial literature search.

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  1. Department of Architecture, Urban Planning and Design, University of Missouri-Kansas City, Kansas City, MO, USA

    Julia Crowley

  2. Division of Computing, Analytics, and Mathematics, School of Science and Engineering, University of Missouri-Kansas City, Kansas City, MO, 64110, USA

    Bowen Liu & Hanan Jan

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JC Conceptualized the study, interpreted the results and prepared the original draft of the manuscript. BL Conceptualized the study and the methodology, performed the statistical analysis, prepared the original draft of the manuscript, interpreted of the results and revised of the manuscript. HJ participated in the data collection and literature review of the study, All authors read and approved the final manuscript.

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Crowley, J., Liu, B. & Jan, H. Assessing the knowledge, attitudes, and practices (KAP) of dengue in Thailand: a systematic review and meta-analysis. Arch Public Health 83, 38 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s13690-025-01522-6

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Keywords

Archives of Public Health

ISSN: 2049-3258