1. Community Participation

Community participation (CP) has been defined "as a process whereby individuals, families and communities are involved in the planning and conduct of local vector control activities so as to ensure that the programme meets the local needs and priorities of the people who live in the community, and promotes community's self-reliance in respect to development." In short, CP entails the creation of opportunities that enable all members of the community and extended society to actively contribute to, influence the development of, and share equitably in the fruits of accrued benefits. Objectives of community participation in dengue prevention and control:

• To extend the coverage of the programme to the whole community by creating community awareness. This however often requires intensive inputs.
• To make the programme more efficient and cost-effective, with greater coordination of resources, activities and efforts pooled by the community.
• To make the programme more effective through joint community efforts to set goals, objectives and strategies for action.
• To promote equity through sharing of responsibility, and through solidarity in serving those in greatest need and at greatest risk.
• To promote self-reliance among community members and increase their sense of control over their own health and destiny.

How to invoke community participation

• By showing concern: Community and government organizers should reflect the true concern for human suffering, i.e. morbidity and mortality due to dengue in the country, economic losses to the families and the country, and how the benefits of the programme fit into the people's needs and expectations.
• Initiating dialogue: Community organizers and opinion leaders or other key personnel in the power structure of the community, namely women's groups, youth groups and civic organizations, should be identified. Dialogue should be undertaken through personal contacts, group discussions and film shows. Interaction should generate mutual understanding, trust and confidence, enthusiasm and motivation. The interaction should not be a one-time affair, but should be a continuing dialogue to achieve sustainability.
• Creating community ownership: Organizers should use community ideas and participation to initiate the programme, community leaders to assist the programme, and community resources to fund the programme. Mosquito control, abatement agency and community partnerships should be strong, but limited to providing technical guidance and expertise.
• Health education (HE): Health education should not be based on telling people the do's and don'ts through a vertical, top-down communication process. Instead, health education should be based on formative research to identify what is important to the community and should be implemented at three levels, i.e. the community level, systems level and political level.

Community level: People should not only be provided with knowledge and skills on vector control, but education materials should empower them with the knowledge that allows them to make positive health choices and gives them the ability to act individually and collectively.

Systems level: To enable people to mobilize local actions and societal forces beyond a single community, i.e. health, development and social services.

Political level: Mechanisms must be made available to allow people to articulate their health priorities to political authorities. This will facilitate placing vector control high on the priority agenda and effectively lobby for policies and actions.

Defining community actions: For sustaining DF/DHF prevention and control programmes, the following community actions are essential:

• At the individual level, encourage each household to adopt routine health measures that will help in the control of DF and DHF, including source reduction and implementa-tion of proper personal protection measures.
• At the community level, organize "clean-up" campaigns two or more times a year to control the larval habitats of the vectors in public and private areas of the community. Some key factors for the success of such campaigns include extensive publicity via mass media, posters and pamphlets, proper planning, pre-campaign evaluation of foci, execution in the community as promised, and follow-up evaluations. Participation by municipal sanitation services should be promoted.
• Where community-wide participation is difficult to arrange for geographical, occupational or demographic reasons, participation can be arranged through voluntary associations and organizations. The people in these organizations may interact daily in work or institutional settings, or come together for special purposes, i.e. religious activities, civic clubs, women's groups and schools.
• Emphasize school-based programmes targeting children and parents to eliminate vector breeding at home and at school.
• Challenge and encourage the private sector to participate in the beautification and sanitary improvement of the community as sponsors, emphasizing source reduction of dengue vectors.
• Combine community participation in DHF prevention and control with other priorities of community development. Where municipal services (such as refuse collection, wastewater disposal, provision of potable water, etc.) are either lacking or inadequate, the community and their partners can be mobilized to improve such services, and at the same time reduce the larval habitats of Aedes vectors as part of an overall effort at community development.
• Combine dengue vector control with the control of all species of disease-bearing and nuisance mosquitoes as well as other vermin, to ensure greater benefits for the community and consequently greater participation in neighborhood campaigns.
• Arrange novel incentives for those who participate in community programmes for dengue control. For example, a nationwide competition can be promoted to identify the cleanest communities or those with the lowest larval indices within an urban area.
  
2. Intersectoral Coordination

Developing economies in countries of the South-East Asia Region have recognized many social, economic and environmental problems which promote mosquito breeding. The dengue problem thus exceeds the capabilities of ministries of health. The prevention and control of dengue requires close collaboration and partnerships between the health and non-health sectors (both government and private), nongovernmental organizations (NGOs) and local communities. During epidemics such cooperation becomes even more critical, since it requires pooling of resources from all groups to check the spread of the disease. Intersectoral cooperation involves at least two components:

• Resource-sharing
• Policy adjustments among the various ministries and nongovernmental sectors.

Resource sharing

Resource sharing should be sought wherever the dengue control coordinator can make use of underutilized human resources, e.g. for local manufacture of needed tools, seasonal government labourers for water supply improvement activities, or community and youth groups to clean up discarded tyres and containers in neighbourhoods. The dengue control programme should seek the accommodation or adjustment of existing policies and practices of other ministries, sectors, and municipal governments to include public health as a central focus for their goals. For instance, the public works sector could be encouraged to adjust its policies to give first priority to water supply improvements for communities at highest risk of dengue. In return, the Ministry of Health could authorize the use of some of its field staff to assist the ministry responsible for public works to repair water supply and sewerage systems in other urban areas. The following examples show how several government ministries may contribute to dengue vector control efforts.

Role of the ministry responsible for public works: The ministry responsible for public works and its municipal counterparts should play a key role in dengue control. They can contribute to source reduction by providing a safe, dependable water supply, adequate sanitation, and effective solid waste management. In addition, through the adoption and enforcement of housing and building codes, a municipality may mandate the provision of utilities such as individual household piped water supplies or sewerage connections, and rainwater (storm water) run-off control for new housing developments, or forbid open surface wells.

Role of the Ministry of Education: The Ministry of Health should work closely with the Ministry of Education to develop a health education (health communication) component targeted at school children, and devise and communicate appropriate health messages. Health education models can be jointly developed, tested, implemented and evaluated for various age groups. Research programmes in universities and colleges can be encouraged to include components that produce information of direct importance (e.g. vector biology and control, case management) or indirect importance (e.g. improved water supply, educational inter-ventions to promote community sanitation, waste characterization studies) to dengue control programmes.

Role of the ministry responsible for the environment: The Ministry of Environment can help the Ministry of Health collect data and information on ecosystems and habitats in or around cities at high risk of dengue. Data and information on local geology and climate, land usages, forest cover, surface waters, and human populations are useful in planning control measures for specific ecosystems and habitats. The Ministry of Environment may also be helpful in determining the beneficial and adverse impacts of various Ae. aegypti control tactics (chemical, environmental and biological).

Role of the ministry responsible for information, communication and the mass media: Information directed at the community at large is best achieved through the mass media, such as television, radio and newspapers. Therefore, the ministry responsible for information, communication and the mass media should be approached to coordinate the release of messages on the prevention and control of dengue developed by public health specialists.

Role of Nongovernmental organization (NGOs): NGOs can play an important role in promoting community participation and implementing environmental management for dengue vector control. This will most often involve health education, source reduction, and housing improvement related to vector control. Community NGOs may be informal neighbourhood groups or formal private voluntary organizations, service clubs, churches or other religious groups, or environmental and social action groups. 

After proper training by the Ministry of Health staff in source reduction methods, NGOs can collect discarded containers (tyres, bottles, tins, etc.), clean drains and culverts, fill depressions, remove abandoned cars and roadside junk, and distribute sand or cement to fill tree holes. NGOs may also play a key role in the development of recycling activities to remove discarded containers from yards and streets. Such activities must be coordinated with the environmental sanitation service. 

NGOs may also be able to play a specific, but as yet unexplored, role in environmental management during epidemic control. Under guidance from the Ministry of Health, NGOs could concentrate on the physical control of locally identified, key breeding sites such as water drums, waste tyre piles, and cemetery flower vases.

Service clubs such as Rotary International have supported DF/DHF prevention and control programmes in the American Region for over 15 years. In Asia and the Pacific, programmes have been initiated in Sri Lanka, Philippines, Indonesia and Australia to provide economic and political support for successful community-based campaigns. A new grant from the Rotary Foundation of Rotary International \as been awarded to study the possibility of up scaling this project to a global programme. Women's clubs have contributed to Ae. aegypti control by conducting household inspections for foci and carrying out source reduction. There are many opportunities, mostly untapped, for environmental organizations and religious service groups to play similar roles in each Ae. aegypti-infested community.

3. Model Development: Model development for dengue control through a community participation approach should be initiated in order to define potential prime movers in the communities and to study ways to persuade them to participate in vector control activities. Social, economic and cultural factors that promote or discourage the participation of these groups should be intensively studied in order to gain more participation from the community. Model development focusing on school children has been studied in several countries and this strategy should be modified and introduced into each country.
   
4. Social Mobilization: Advocacy meetings should be conducted for policy makers to attain political commitment for mass clean-up campaigns and environmental sanitation. Intersectoral coordination meetings should be conducted to explore possible donors for m\ass antilarval control campaigns and measures and to help finance the programme. Reorientation training of health workers should be conducted to improve their technical capability and ability to supervise prevention and control activities. A "DHF month" should be identified twice a year, during the pre-transmission season and during the peak transmission period.
   
5. Health Education: Health education is very important in achieving community participation. It is a long-term process to achieve human behavioural change, and thus should be carried out on a continuous basis. Even though countries may have limited resources, health education should be given priority in endemic areas and in areas at high risk for DHF. Health education is conducted through the different channels of personal communication, group educational activities, and mass media. Health education can be implemented by women's groups, school teachers, formal and informal community leaders, and health workers. Health education efforts should be intensified before the period of dengue transmission as one of the components of social mobilization. Th\e main target groups are school children and women.
   
6. Legislative support: Legislative support is essential for the success of dengue control programmes. All countries of the Region have legislation addressing control of epidemic diseases which authorize health officers to take necessary action within the community for the control of epidemics. On a continuous and sustainable basis, various municipalities have adapted legislation for the prevention of "nuisance mosquitoes", however they lack specific provision related to dengue and/or Ae. aegypti control. At the national level, all countries are signatories to the International Health Regulations which have a specific provision for the control of Ae. aegypti and other disease vectors around international sea/airports.

The formulation of legislate/on on dengue/Ae.aegypti control should, therefore, take into consideration the following points:

• Legislation should be a necessary component of all dengue/Ae.aegypti prevention and control programmes.
• All existing decrees and resolutions on dengue/Ae.aegypti prevention and control must be reviewed, and their effectiveness evaluated in terms of structural, institutional and administrative changes. It is also important to add dengue to the list of diseases that require mandatory notification in each country.
• Regulations should be formulated on the basis of existing sanitary codes, a strategy that is most needed in those countries which lack legislation on the subject. In countries where sanitary regulations are primarily the responsibility of agencies other than the Ministry of Health (e.g. municipal governments), a coordinated and cooperative line of action with the ministry should be developed.
• Legislation should incorporate municipal authorities from affected regions as the central element for implementation and enforcement. Where national legislation is weak or absent, municipal governments may consider the adoption of local ordinances for Ae. aegypti control.
• Legislation should contemplate intersectoral coordination among the ministries involved in national development in order to prevent isolated implementation of individual programmes and harmful environmental changes that could create potentially hazardous public health conditions. Ministries should be advised on the best ways to encourage disease prevention.
• Legislation should cover all aspects of environmental sanitation in order to effectively contribute to the prevention of all transmissible diseases.aimed at developing human resources within the institutional framework.
• In developing legislation, the social component must be considered. Legislation should seek support based on justice and justification: individuals and the community must be persuaded that the law is good and that it is intended to protect them and their families, and that compliance with it is one of the most important components for dengue control.
• Laws should contemplate the existing judicial administrative framework in the context of national public administration. Importance should also be placed on norms.