Dengue virus infections, transmitted by Aedes aegypti mosquito, is endemic in more than 100 countries from Africa and America to Asia, with Asia representing around 70% of the global disease burden. Most dengue infection is mild in nature, but it can potentially be severe and fatal. With an estimated 100–400 million infections annually, dengue is now a threat to about half of the world population. The dengue incidence has risen significantly over the past few decades from 0.5 million cases in 2,000 to 5.2 million in 2019, while the real number of cases is likely underreported (1). In 2020, Singapore recorded a total of 35,315 dengue infections, almost double the number from 2019 with an IR (incidence rate) of 621 per 100,000 population (2). Dengue infection will continue to rise dramatically worldwide due to climate change and global warming, which will escalate the spread of dengue in endemic areas, with extension to new areas such as Europe (3, 4).

With no specific treatment available, prevention becomes the most effective strategy to curb the spread of the disease. Vector control is crucial due to the unique characteristics of the Aedes mosquitoes and the complex nature of dengue transmission. Vector control strategies encompass a range of approaches that aim to disrupt the mosquito lifecycle, reducing their population and consequently the risk of dengue transmission.

The National Environment Agency (NEA) of Singapore is a government agency overseeing Singapore’s public health standard and ensuring a clean and sustainable environment by working with local community partners and the public. For dengue control, the agency provides updates on the current reported dengue infection rate and areas of dengue clusters under its website and myENV digital app (5). NEA also has launched various vector control measures like “Mozzie Wipeout” campaign, Gravitrap and the project Wolbachia (6). The “Mozzie Wipeout” campaign was launched in 2016 to promote source reduction through implementing the 5-step Mozzie Wipeout technique (7). The 5 step Mozzie Wipeout technique consists of Breaking up hardened soil, Lifting and emptying flowerpot plates, Overturning pails and wiping their rims, Changing water in vases and Keeping roof gutters clear and placing BTI (Bacillus Thuringiensis Israelensis) insecticide (B-L-O-C-K).

Since 2017, NEA has deployed in-house–developed Gravitraps at various locations throughout Singapore with the intention to trap gravid female Aedes on the sticky lining. The traps are monitored every 2 weeks, and Gravitrap indices are mapped on a geographical information system (GIS) to identify areas to intensify source-reduction programs. High Gravitrap index areas are also listed on the NEA website to encourage the local community to undertake appropriate measures to prevent the spread of dengue (6).

Another method using Wolbachia, a maternally inherited endosymbiotic intracellular bacterium, suppresses mosquito population when artificially introduced into male Aedes aegypti. Male Wolbachia-Aedes mosquitoes are let to mate with female mosquitoes, yet their resultant eggs do not hatch, and no offspring is produced (6). Despite continued effort in implementing these vector control measures in Singapore, dengue infections were estimated to have reached their second highest peak (32,173) in 2022 (8).

Digital games have been widely used as a medium for learning especially in recent years. “Serious games” are digital games that are built for the purpose of learning and education beyond just entertainment. Through these serious games, participants will be able to learn about the disease and its prevention, treatment and vaccination in an interactive and engaging way which will lead to the intended behavior change. As a significant proportion of the local youths own personal smart phone, there is potential for the use of phone-based games in disseminating important health and disease preventive information to the public.

Community engagement plays an integral role in successful vector control, in which youths (aged 15–24) play a crucial role because of their ability to adopt new behaviors (9). By involving the youths, communities can tap into a subset of the population to complement national efforts in dengue prevention. With IR of 344.9 and 140.9 per 100,000 population (DENV-1 and DENV-2 respectively), dengue incidence among youths was also the second highest after that of adults (25–44 years) among Singapore residents (10). Youths can play a significant role in dengue vector control as they are not only at increased risk of infection but also capable of implementing preventive measures. However, little is known about their level of awareness on dengue disease and its prevention. Hence, this cross-sectional study aims to evaluate the knowledge on dengue disease, level of awareness of its prevention, and the perceived effectiveness of the current measures in vector control among local multi-ethnic Asia youths.

Majority of the youths in this study population possess good knowledge of dengue infection. 84.1% of participants are aware that dengue infection can be fatal and 91.9% of them agree that a person can be infected with dengue more than once. This is consistent with another study by Mustafa et al. on knowledge, attitude and preventive behavior regarding dengue fever among youth in neighboring Malaysia (18). Such finding is attributed to the high literacy rate among the youths in these dengue endemic countries in which reports of its outbreaks frequently appear in various media (19).

However, only 33.5% of the participants are aware of the availability of dengue vaccine in Singapore, and a similar percentage are aware of the age eligibility criteria for such vaccination. The comparatively low awareness of dengue vaccine can be attributed to the lack of publicity by the authorities because of its limited use in only previously infected individuals who are aged 12 to 45 years old. Currently the transmission of information is mainly channeled from general practitioners (GPs) or clinicians to patients. A comprehensive program to educate and increase public awareness of dengue vaccine and its use is necessary to motivate individuals who meet the eligibility criteria to proactively get vaccinated. Such a proactive approach will help to reduce the risk of future dengue infection within the community. Other ways to enhance uptake of dengue vaccine among suitable individuals can be more extensively addressed in a more detailed questionnaire designed to explore the reasons for poor uptake of dengue vaccine among the local youths.

Teenagers (15–19 years old) tend to have higher knowledge scores in dengue disease and its vaccine. The higher knowledge scores may be related to close collaboration between different government agencies and schools in Singapore in promoting awareness of dengue in recent years. NEA works with schools to organize anti-dengue outreach programs (20). The importance of such educational programs is further emphasized by the ongoing global warming projected to lead to a record number of dengue infection and schools being potential dengue clusters (3, 21). Similar findings on increased awareness of students are observed in a few Asia-Pacific countries after an intervention program (22–24). Raising the dengue literacy of youths through schools can potentially spread their knowledge and practice to other family and household members.

In this study, dengue infection status is not a significant factor to predict knowledge level, with dengue knowledge scores of previously infected participants (14.2 ± 3.45), which are similar to those who are naïve to the infectious disease (14.1 ± 2.78). Studies in Aceh in Indonesia and Kachanadit district in Southern Thailand also reported that participant’s previous dengue infection status was not associated with their dengue knowledge (25, 26). Interestingly, the result identifies a missed opportunity to vaccinate those who were infected, which will reduce their risks of future dengue infection. GPs or clinicians can also share vector control measures with these infected youths during their consultation, leveraging on the well-established primary care network in Singapore. Local primary healthcare clinics are easily accessible to residents, maximizing efforts by healthcare professionals to raise the awareness of the public, including the youth on dengue prevention measures.

Most study participants were aware of the dengue prevention initiatives by NEA in controlling the spread of dengue. Approximately 90 and 69% of participants were aware of the Mozzie Wipeout campaign and the use of Wolbachia mosquitoes, respectively. Participant’s knowledge of such initiatives is likely due to the guides and toolkits distributed to each household on such measures. Nevertheless, high level of awareness of these measures may not necessarily translated to the relevant actions to curb mosquito breeding. An article by Ong et al. reported knowledge-practice gap in Singapore where motivation plays a role in translating knowledge into practice of preventive measures (27). Similar inertia was observed among the local population in Malaysia and Northern Thailand (28, 29). The motivation to initiate preventive measures was largely dependent on the health beliefs of a person. In Malaysia, a focus group discussion on health beliefs relating to dengue prevention identified low self-efficacy, low perceived susceptibility, and perceived lack of benefit as barriers to the uptake of dengue preventive measures (30). Further research to develop and test multi-dimensional interventions which can effectively address these barriers is needed to improve dengue prevention measures. In addition, practice of dengue prevention is dependent on community efforts. Other members of the community besides the youths also play a part in dengue prevention. The study starts by looking at the youths, the group that has the second highest incidence of dengue in the community as they can be engaged to further improve dengue prevention because of their receptivity and ability to adopt new behaviors. There was no preceding studies on this area among youths in Asia thus the findings of this study will be useful to enhance vector control and make a difference in reducing incidence of dengue in the local area.

Approximately 40% of participants in this study agreed that phone-based games would be effective in raising awareness of dengue infection and its vaccine although only 7.1% of participants were aware of it being used as a vector control measure. The positive perception of phone-based serious games as an effective educational tool raises its potential for application among the younger gamers and complement current modality such as talks in school to improve their dengue literacy. Usage of games for educational purposes on dengue and its prevention has gained traction in the past decade, progressing from computer games to serious games (31). A recent study conducted by Tan et al. reported that the serious game “Sam’s Mozzie Adventure” improved public awareness of dengue preventive measures (32). The local setting is conducive to implement serious games, especially almost all of youths in Singapore are equipped with a smartphone and 82% of them engage in online games using their phones (33, 34). Hence, serious games could potentially play a crucial role in activating them to take on dengue preventive measures.

Information on dengue infection rate and the effectiveness of specific preventive measures are the two main important factors to increase the youth’s uptake of dengue preventive measures. Comparison across age groups revealed significant difference between teenagers (69.1%) and young adults (42.3%) in undertaking dengue preventive measures. Educational efforts on dengue prevention should be sustained among the youths as they mature via regular and targeted community health publicity and engagement programs.

The surveyed population especially the teenagers aged 15–19 years old has good knowledge of dengue, but awareness of its vaccine is low. While encouraging vaccination among the at-risk population, vector control measures are essential in controlling the spread of the endemic disease. It can be a springboard for further studies to identify the essential steps to translate knowledge to appropriate mitigating actions. More efforts may need to be made to engage the young adults (20–24 years old) to take proactive steps to prevent dengue. Social and digital media can be used to reach out to the youths as many have access to these portals and are savvy in the use of technology. They can assist to disseminate information on dengue disease, neighborhood infection rates, vaccination, and preventive measures, in tandem with the involvement of schools and GPs as a proactive, multifaceted community preparedness program to strengthen vector control measures against dengue and other mosquito-borne diseases.

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.

WS: Writing – review & editing, Writing – original draft. KG: Writing – review & editing, Writing – original draft. DN: Writing – review & editing, Writing – original draft. KK: Writing – review & editing, Writing – original draft. NT: Writing – review & editing.