Evaluating livestock farmers knowledge, beliefs, and management of arboviral diseases in Kenya: A multivariate fractional probit approach.

Globally, arthropod-borne virus (arbovirus) infections continue to pose substantial threats to public health and economic development, especially in developing countries. In Kenya, although arboviral diseases (ADs) are largely endemic, little is known about the factors influencing livestock farmers' knowledge, beliefs, and management (KBM) of the three major ADs: Rift Valley fever (RVF), dengue fever and chikungunya fever. This study evaluates the drivers of livestock farmers' KBM of ADs from a sample of 629 respondents selected using a three-stage sampling procedure in Kenya's three hotspot counties of Baringo, Kwale, and Kilifi. A multivariate fractional probit model was used to assess the factors influencing the intensity of KBM. Only a quarter of the farmers had any knowledge of ADs while over four-fifths of them could not manage any of the three diseases. Access to information (experience and awareness), income, education, religion, and distance to a health facility considerably influenced the intensity of farmers' KBM of ADs in Kenya. Thus, initiatives geared towards improving access to information through massive awareness campaigns are necessary to mitigate behavioral barriers in ADs management among rural communities in Kenya.

Introduction

Arthropod-borne viruses (arboviruses), known to be transmitted between vertebrate hosts and arthropod vectors, constitute a great concern for global public health [1]. Historically, arboviruses such as chikungunya virus, dengue virus, Rift Valley fever (RVF) virus, yellow fever virus, and zika virus have caused notable diseases leading to animal and human morbidity and mortality [2]. Infections in humans and animals with clinical manifestations could range from subclinical to life-threatening conditions [3]. For example, approximately 96 million symptomatic dengue cases and an estimated 40,000 deaths due to dengue are reported globally every year [4]. The zoonotic effect of arboviral diseases (ADs) include the decline in household income by reducing livestock stock, product sales and consumption, as well as increasing household vulnerability in cases where livestock is used as a risk-coping mechanism [5].

In Kenya, multiple AD outbreaks have resulted in substantial economic losses and public health distress in the past three decades. These include the yellow fever outbreaks of 1992, 1995, and 2016 [2,6,7]; chikungunya fever in 2004 and 2016 [2,8]; RVF incursions in 1997 and 2006 [8,9], and dengue fever outbreaks of 2011–2014 and 2017 [2]. These outbreaks resulted in widespread abortion and death of livestock, and reduced milk production, wool production, livestock growth, working days in humans, and draft animals [10]. In rural communities where agriculture is the dominant livelihood source, the ADs can cause considerable health and economic losses. For example, the 2007 RVF outbreak in Kenya contributed to economic losses estimated at US$32 million [11].

The incidence of ADs is increasing, not just in East Africa but also in many regions of the world. This is due to several factors, including climate change, increased agricultural activity, and ecosystem changes [12]. Global warming, deforestation, and urbanization have led to a rapid expansion of the vectors’ habitats and have caused an enormous increase in vector-borne diseases worldwide [3]. Besides, the growing movement across regions of people and livestock has contributed to the broader distribution of the vectors that transmit emerging infectious diseases [13].

The effective management of the ADs depends on people’s perceptions of the disease, which in turn, are influenced by the availability of information for decision making as well as the level of knowledge and skills in disease management [14,15]. Previous studies reveal the limited awareness of ADs vectors, signs and symptoms among communities and livestock keepers in East Africa [16-20]. Other studies show poor management regarding ADs [21-23].

Evaluating community knowledge, beliefs, and management practices (KBM) of ADs is relevant for better policy guidance and investment in improving the affected communities’ health and economic status. The study on the KBM of ADs is also useful for setting a research agenda and developing targeted communication messages. Although, KBM studies have been undertaken previously in Eastern Africa on RVF [16-21,24], to the best of our knowledge, no study has examined the KBM of a portfolio of ADs (RVF, Chikungunya fever, and Dengue fever) and their drivers in the region.

The failure to examine the KBM in a portfolio format has important implication in terms of accurate risk assessment with impact on the prevention and control of arbovirus infections [25]. Even where KBM studies were undertaken for RVF, the studies used few respondents in one district. For example, Abdi et al. [21] assessed KBM of RVF among 392 pastoralists living in Ijara district. Similarly, Owange et al. [18] assessed risk factors of RVF among 31 key informants in Ijara district. This study assessed the KBM for three ADs in three hotspot counties in Kenya, namely, Baringo, Kilifi, and Kwale.

Our analysis contributes to the current limited empirical literature on KBM of ADs in the following ways. First, no KBM study has been conducted in the three ADs hotspot counties in the past. Second, our study employs a multivariate probit (MVP) analysis that considers the potential correlation between the KBM across different diseases to assess the socioeconomic and cultural factors that influence household health behavior. Finally, the study used the multivariate fractional probit (MVFP) model that considers the proportion of the correct answers provided by households for each outcome variable to estimate the intensity of KBM. We found low levels of knowledge and poor managerial skills of ADs that were largely driven by access to information and asset ownership.

Methodology

Ethics Statement

The protocol for this study was approved by the Scientific and Ethics Review Unit (SERU) of the Kenya Medical Research Institute (KEMRI) reference number 3312. Before the interviews, the study objectives were clearly explained to all research participants and emphasize on voluntary withdraw from the interview at any given time was provided. With the assurance of confidentiality, oral informed consent was obtained from all study participants before the start of the interviews.

Analytical framework

The Theory of Planned Behaviour (TPB) has been widely used in explaining the relationship between disease management and health-related outcomes [26-28]. The TPB is an extension of the Theory of Reasoned Action (TRA) that explains and predicts human behaviour. The TPB argues that decisions on certain behaviours result from a reasoned process [29]. According to the TPB, three conceptually independent factors determine a person’s intention to manage diseases: attitude (A) towards the behaviour of interest (BI); subjective norms (SN); and perceived behavioural control (PBC). These factors can be presented as:

Where w1, w2 and w3 are the relative weights of attitudes, subjective norms, and PBC [30].

The TPB posits that a person’s attitude (A) towards the behaviour of interest is based on readily accessible beliefs regarding the behaviour’s likely consequences [31]:

Where b is the accessible belief for consequence i and e is the subjective evaluation of the outcome.

On the other hand, subjective norms (SN) refer to the perceived social pressure to perform or not to perform the behaviour of interest [30]. Following Ajzen [31], the SN are a function of an individual’s normative beliefs (n), and the significance (s) to comply with the expectations (Eq 3);

The PBC is a function of the composite score derived by summing the products of control belief strength (c) times perceived power (p) over all accessible control factors such as time, skills, money, and other resources expectations [31]:

We assume that the occurrence of one outcome may be conditional on the occurrence of another outcome, with the correlation between them being either positive or negative [32]. In particular, a knowledgeable household might display positive beliefs or sound management practices towards a disease [33,34]. Knowing the disease signs and symptoms can allow timely recognition of the disease when it occurs. Further, households that are knowledgeable about a particular disease may adopt measures to prevent or quickly seek out either human or animal health services when there is an outbreak.

Empirical model

We employed a MVP model to operationalize Eq 1 and account for the interdependence between the outcome variables [35-38]. Following Young et al. [37], knowledge (K), belief (B) and management (M) of different diseases are a binary function of the decision maker’s characteristics and can be modelled using the MVP regression as follows: where β is the vector of parameters to be estimated, X is a vector of decision maker’s characteristics [24,34,39], and ϵ is a vector of the error term.

In the multivariate model, the error terms jointly follow a multivariate normal distribution (MVN) with zero conditional mean and variance, normalized to unity for identification of the parameters, (ϵ ~ MNV (0, Ω)), where Ω is the symmetric covariance matrix defined as: where ρ is the unobserved correlation of the KBM equations. A significant ρ indicates interdependence between the error terms. A positive value of ρ is considered “promotive” between the measured pair of equations, while a negative value of ρ is “substitutive” [40]. The STATA command “mvprobit” was used to estimate the parameters β and ρ.

The MVP model specification measures the determinants of the binary dependent variables (K, B, and M) with no distinction made between respondents that correctly answered one, two, three, or more knowledge-related questions. In other words, it ignores heterogeneity and/or knowledge intensity differences among the respondents. To correct this anomaly, the MVFP model allows the researcher to assess factors that determine the intensity of KBM. The intensity of each outcome variable is defined as the fraction of the number of correct answers provided by respondents for the sets of questions used in the survey and is estimated by the MVFP by treating those answers as a fractional outcome variable [41]. The MVFP allows the interdependence of the KBM outcome variables.

Because knowledge (K), belief (B), and management (M) are not directly observable, they can be represented by latent variables , and , that underlie the knowledge, belief, and management status of decision-making units in the sample. Following Schwiebert [42], the relationship between the unobservable latent variable (e.g., ) and the outcome of interest (e.g., K) can be specified as follows: where β and X are as previously defined, K, B and M are fractional dependent variables that describe the share of total score obtained by the household, and e, e, and e are disturbance terms assumed to be independent and identical across individual households [41]. The error term, e = (e, e, e) is multivariate normally distributed with a mean vector of zeros and a correlation matrix [42]:

In this study, the unknown parameters β and ρ were estimated using a seemingly unrelated regression with ordered responses [43], under the conditional mixed process estimator with multilevel random effects command “cmp” available in STATA software.

Study area and sampling procedure

This study was carried out in the three ADs hotspot counties of Baringo, Kilifi, and Kwale in Kenya (Fig 1). Baringo is prone to floods leading to outbreaks of arboviral diseases. For instance, the 1997/98 El-Niño rains resulted in an episode of yellow fever, while the 2006/07 heavy rains resulted in an outbreak of RVF [44]. Kwale and Kilifi are areas from where the chikungunya virus started before spreading to other parts of the country, representing one of the critical seeding regions for ADs. Malaria, dengue fever, chikungunya fever, and lymphatic filariasis are common mosquito-borne diseases in the two areas [45]. Initially, focus group discussions were conducted in the study sites to determine the most important ADs and to adjust the survey tool. According to community members living in the three study sites, RVF, Chikungunya fever, and Dengue fever were the most prevalent ADs. Later, a multistage sampling technique was used to select 629 respondents for a survey of their KBM of ADs in their locale. In the first stage, the three ADs hotspot counties (Baringo, Kilifi, and Kwale) were purposively selected. In the second stage, purposive sampling was also used to select the most ADs-prone subcounties (decentralized units within a county) in each of the three counties resulting in three study sites of Marigat in Baringo, Malindi in Kilifi and Msambweni in Kwale. A sampling frame of all households in the three study sites was obtained from the local administration (chiefs and village elders). In the third stage, a simple random sampling technique was used to select 200 households from each study site giving a total sample of 629 households after adjusting for 10 percent of the non-responses following Mutiso [46]. Well-trained enumerators undertook face-to-face interviews through a pre-tested semi-structured questionnaire using CSPro version 7.5 electronic data collection software [47].

Fig 1

Study area and sampled households: Emily Kimathi, GIS unit, icipe; The map was developed using the QGIS 3.16 software, https://qgis.org/en/site/forusers/download.html.

Measurement of variables

Outcome variables

The outcome variables of interest in this study included knowledge, beliefs, and management practices of ADs. These variables were measured as dummy variables. The knowledge score was constructed using 55 binary response questions for RVF and 14 each for chikungunya and dengue fevers. A total of 8 and 7 binary response questions were used to generate the beliefs and management scores for the three ADs. The beliefs section consisted of the perceived threat associated with ADs. The management practices were related to a group of actions taken to prevent the spread of ADs [22]. A respondent was considered knowledgeable, to have positive beliefs, and as having good ADs management practices of the three ADs when they correctly answered 50 percent of the questions posed under each outcome (KBM) variable. Based on this, the outcome variables took a value of one if the respondent answered 50 percent of the questions correctly and zero otherwise (i.e., having either an incorrect response, answering “I don’t know”, or having missing answers). The fractional variable used in the MVFP model was constructed as the sum of correct answers to knowledge, belief, and management practices questions as a ratio of the total number of questions asked per outcome variable. For instance, the intensity of knowledge of RVF was measured as the number of correct answers as a share of the 55 knowledge questions of RVF. The intensity of knowledge of dengue and chikungunya fever were measured as the number of correct answers as a share of 14 questions, Moreover, the intensity of beliefs on each of the three ADs was measured as a ratio of the correct answers to a total 8 questions. Finally, the intensity of management of the three ADs was measured as the number of correct answers as a share of 7 questions.

Explanatory variables

The choice of the explanatory variables used in this study was informed by previous studies [21,24,33,34,39]. These variables included access to health information, social capital and networks, asset endowment and household demographic characteristics. Three variables were used to measure “access to health information”, namely, distance to the nearest health facility, awareness of health impacts of ADs, and household experience with an AD. The distance between the homestead and the nearest health facility measured in the amount of time it takes to walk between the two points was used as proxy for access to health information. The variable awareness of health impacts took a value of one if the respondent understood the health impacts of ADs, and zero otherwise.

Experience with an AD was measured as a dummy variable with a value of one if a family member had suffered from any AD in the 12 months preceding the survey and zero otherwise. Social capital and networking was proxied by group membership measured as a dummy variable with the value of 1 if the respondent was a member of a health promotion group and 0 otherwise. Health promotion group constituted individuals who receive training from health specialists, thus increasing awareness of good health, diet, and exercise in the society. The number of tropical livestock units (TLU) kept by a household was used as a proxy for asset ownership in this study. The heterogeneity of the households was controlled in the regression model by including the household head’s education level, gender, and religion. The level of formal education attained was measured as the number of years of formal schooling completed by the household head. The gender of the household head was measured as a dummy variable, taking a value of one if the household head was male and zero otherwise. In this study, religion was measured as a categorical variable coded 0, 1 and 2 for other religions, Christianity, and Islam, respectively.

Results

Descriptive Results

The socioeconomic characteristics of the 629 households in the three ADs hotspots in Kenya show that 55 percent of the households were aware of the health impacts of ADs while 33 percent of the households had suffered from at least one of them (Table 1). Christianity was the dominant religion, as reported by 63 percent of the respondents, even though almost all respondents (98 percent) in Kwale were Muslims. On the average, Baringo and Kilifi residents took longer (37 and 35 minutes respectively) to reach the nearest health facility as compared to Kwale residents (24 minutes). Eleven percent of Kwale households belonged to a health promotion group as compared to five percent in the other two study sites. The average number of livestock owned in the study area was 3.69.

Table 1

Characteristics of livestock keepers in Kenya’s ADs Hotspots.

Variables		Baringo	Kwale	Kilifi	Overall
		n = 211	n = 218	n = 200	n = 629
Household demographic characteristics
Education	Household head’s years of formal education	7.06a	6.50a	7.09a	6.88
		(4.52)	(4.02)	(4.04)	(4.20)
Gender	Sex of the household head (1 = male 0 = female)	0.85a	0.78a	0.83a	0.82
Religion	Religion of respondent (1 = Yes, 0 = No)
Others		0a	0a	0.05b	0.02
Christianity		0.99c	0.02a	0.92b	0.63
Islam		0a	0.97c	0.04b	0.35
Access to health information
Experience	Household suffered from RVF (1 = Yes, 0 = No)	0.43b	0.00a	0.06a	0.30
	Household suffered from chikungunya fever (1 = Yes, 0 = No)	0.00a	0.50a	0.43a	0.47
	Household suffered from dengue fever (1 = Yes, 0 = No)	-	0.21a	0.25a	0.23
Awareness	Household aware of RVF health impacts (1 = Yes, 0 = No)	0.87c	0.00a	0.25b	0.63
	Household aware of health impacts of chikungunya fever (1 = Yes, 0 = No)	0.00ab	0.71b	0.50a	0.62
	Household aware of health impacts of dengue fever (1 = Yes, 0 = No)	-	0.45a	0.31a	0.40
Distance	Distance to the nearest health facility (Walking minutes)	36.50b	24.32a	34.61b	31.67
		(35.91)	(25.84)	25.84	30.05
Social capital and networking
Group membership	Whether a member of the household belongs to a health promotion group (1 = Yes 0 = No)	0.05a	0.11b	0.05a	0.07
Asset endowment
Livestock	Livestock ownership in Tropical livestock unit (TLU)	8.36b	1.36a	1.29a	3.69
		(13.28)	(6.16)	(1.87)	(9.18)
Income	Total income from all enterprises (KES/Year) 000	112.62a	169.50a	145.23a	142.70
		(142.93)	(443.67)	(264.76)	(312.44)

Notes: Standard deviation in parenthesis; 1US$ = KES 102 at the survey time; Means in the same row, followed by the same letters, are not significantly different at 5%.

The summary statistics of the 629 farmers KBM of ADs in Kenya showed that 16, 29, and 18 percent of respondents had good knowledge of RVF, chikungunya fever, and dengue fever infections, respectively (Table 2). The highest knowledge of RVF was recorded in Baringo (20 percent), while Kwale (36 percent) and Kilifi (23 percent) residents had the highest knowledge of chikungunya fever and dengue fever, respectively. Despite the low knowledge, most respondents had positive beliefs about the three ADs. In Kwale County, 75 and 55 percent of respondents believed that chikungunya and dengue fever, respectively, were dangerous diseases as compared to 44 and 38 percent of the respondents in Kilifi County. The low level of knowledge in the study areas translated into poor management of ADs that ranges between 6 percent of RVF and 27 percent of chikungunya fever.

Table 2

Farmers knowledge, beliefs and management of ADs in Kenya.

Variable	Description	Baringo	Kwale	Kilifi	Overall
Outcome variables	Dummy (1 = yes if half of the number of questions were correctly answered)
RVF		n = 207	n = 23	n = 89	n = 319
Knowledge	Knowledgeable of RVF	0.20b	0.00a	0.09a	0.16
Beliefs	Positive beliefs towards RVF	0.88c	0.00a	0.33b	0.66
Management	Have good management practices to prevent RVF	0.04a	0.09a	0.09a	0.06
Chikungunya fever		n = 1	n = 191	n = 145	n = 337
Knowledge	Knowledgeable of Chikungunya fever	0.00ab	0.36b	0.19a	0.29
Beliefs	Positive beliefs towards Chikungunya fever	0.00ab	0.75b	0.55a	0.66
Management	Have good management practices to prevent Chikungunya fever	0.00ab	0.35b	0.17a	0.27
Dengue fever		n = 0	n = 84	n = 52	n = 136
Knowledge	Knowledgeable of Dengue fever	-	0.15a	0.23a	0.18
Beliefs	Positive beliefs towards Dengue fever	-	0.44a	0.38a	0.42
Management	Have good management practices to prevent Dengue fever	-	0.23a	0.17a	0.21

Notes: Standard deviation in parenthesis; Means in the same row, followed by the same letters, are not significantly different at 5%.

The study of farmer’s specific knowledge of signs, symptoms, transmission methods, beliefs and management practices of the three ADs in Kenya showed that the main signs of the three ADs in human were fever, abdominal pains and headache as reported by 82, 29 and 19 percent of the respondents, respectively (Table 3). In animals, the major signs of RVF were bloody diarrhea, bloody discharge and death among young ones as reported by 58, 57 and 56 percent of the respondents. Over 80 percent of respondents correctly identified mosquitoes as the vectors of the three diseases. Direct contact with blood and other body tissues of infected animals/humans were reported as common methods of transmission of RVF and dengue fever by 48 and 13 percent of the respondents, respectively. When asked about the Aedes mosquito’s breeding grounds, less than 40 percent of the respondents indicated that mosquitoes breed in water containers. Most respondents (70 percent) did not know when the Aedes mosquito bites and incorrectly identified nighttime as the biting time. In comparison, less than two percent of the respondents correctly indicated that chikungunya and dengue vectors bite during the day.

Table 3

Farmers knowledge of signs, symptoms, transmission methods, beliefs and management of ADs in Kenya.

Characteristics	RVF		Chikungunya fever		Dengue fever		Overall
	Number of observations (N)	%	N	%	N	%	%
Have you heard about this disease?	629	51	629	54	629	22	42
Main signs and symptoms in humans
Fever	250	72	273	85	71	89	82
Generalized weakness	250	43					43
Bleeding from nose and gums	250	11					11
Skin rashes					71	10	10
Back pain	250	25					25
Nausea/vomiting	250	8			71	44	26
Joint pain			273	32			32
Abdominal pain	207	28	272	25	71	34	29
Pain behind the eyes	250	2	272	12	71	8	7
Abortion in pregnant women	250	10					10
Inflammation of brain-headaches, coma, seizures	250	20	272	13	71	24	19
Fatigue			272	34			34
Main signs and symptoms in animals
Abortion	249	33					33
Bloody Discharge	249	57					57
High fever	249	54					54
Bloody Diarrhea	249	58					58
Death Among young animals	249	56					56
Is mosquito responsible for ADs transmission?	165	82	200	96	54	94	91
Direct contact with blood and other body tissues from an infected person/animal	249	48			71	13	31
Do mosquitoes breed in water containers	319	29	337	35	136	29	31
When are the Aedes mosquitoes most likely to feed/bite?
Nighttime	319	59	337	77	136	75	70
Day time	319	1	337	0	136	1	1
Both day and night	319	39	337	23	136	24
Awareness of the methods to prevent mosquito breeding
Clearing bushes around the house	319	58	336	62	136	60	60
Creating proper drainage of water around the home	319	31	336	40	136	46	39
Covering water holding containers tightly	319	20	336	28	136	32	27
Proper disposal of discarded containers	319	16	336	25	136	23	21
Methods used to control mosquito bites
Mosquito bed nets	319	96	336	98	136	99	98
Mosquito repellants	319	38	336	53	136	58	50
Indoor residual insecticides spraying	319	35	336	52	136	65	51
Screening/fencing windows and doors	319	15	336	37	136	43	32
Close doors and windows by 6.00PM	319	44	336	38	136	35	39
Plants to repel Mosquitoes	319	6	336	10	136	8	8
Player of a major role in the control of this disease
Veterinary Authority	249	80	272	4	71	1	28
Health Authority	249	64	272	90	71	97	84
Environmental Authority	249	7	272	16	71	17	13
Community	249	29	272	24	71	32	28
What would your household do if you suspect that you or your family member has been infected with this disease?
Local herb (e.g. pawpaw leaves to treat Chikungunya)	250	6	273	24	71	1	10
Chemist medicine	250	5	273	7	71	6	6
Seek traditional treatment	250	8	273	8	71	4	7
Seek treatment in hospital	250	85	273	88	71	92	88

Mosquito nets were the most widely used method of preventing mosquito bites as reported by over 90 percent of the respondents. Over half of the respondents reported bush clearing of overgrown vegetation across the homestead as the most prevalent method used in the control of mosquito breeding whereas covering water-holding containers and/or their proper disposal was reported by only a quarter of the respondents. Eighty and 64 percent of respondents respectively, reported that the management of RVF was the responsibility of the Veterinary Department and the Ministry of Health. Treatment in hospitals was the most dominant management practice followed by purchasing drugs in pharmaceutical outlets, using traditional treatment, and using local herbs.

Econometric results

The correlation coefficients of the error terms of the multivariate probit MLE estimates of the drivers of KBM of ADs in Kenya were analyzed (Table 4). The likelihood ratio rejects the null hypothesis of no correlation between the three equations’ error terms. This confirms the use of the MVP model instead of binary choice models. Some of the pair-wise correlation coefficients between the error terms in the KBM equations were significant, which further supports the MVP model. Knowledge complements beliefs in all three diseases. We estimated MVP and MVFP specifications and find the statistically significant variables in both models to be the same. For brevity, we only presented the results of the MVFP model.

Table 4

Correlation coefficients of the error terms of the MVP estimates.

Disease	ρK	ρB	ρM
RVF
ρK	1
ρB	0.640 (0.136)**	1
ρM	-0.371 (0.216)	-0.171 (0.190)	1
Likelihood ratio test of ρKB = ρKM = ρBM = 0: χ2 (3) = 8.500, Prob > χ2 = 0.037
Chikungunya fever
ρK	1
ρB	0.364 (0.114)**	1
ρM	0.538 (0.084)***	0.233 (0.111)**	1
Likelihood ratio test of ρKB = ρKM = ρBM = 0: χ2 (3) = 42.558, Prob > χ2 = 0.000
Dengue fever
ρK	1
ρB	0.650 (0.165)**	1
ρM	0.253(0.173)	0.216 (0.173)	1
Likelihood ratio test of ρKB = ρKM = ρBM = 0: χ2 (3) = 7.002, Prob > χ2 = 0.072

Notes: Standard errors in parenthesis; K = Knowledge, B = Beliefs, M = Management;

* = significant at p < 0.1;

** = significant at p < 0.05;

*** = significant at p < 0.00

The Multivariate Fractional Probit (MVFP) maximum likelihood estimates (MLE) of the intensity of livestock farmers KBM of ADs in Kenya was estimated (Table 5). Access to information (experience and awareness), income, and some household characteristics (education, and religion) positively and significantly influence the intensity of livestock farmers KBMs on ADs at least at the 5 percent level (P<0.05). In conformity with the expectations, awareness of the health impacts of ADs positively influenced the intensity of livestock farmers KBM of all three ADs in Kenya and was significant at least at the 5 percent level except for the management of RVF. Income had positive significant influences on the intensity of livestock farmers KMB of the three ADs in Kenya at least at the 5 percent level except for the case of the beliefs on RVF.

Table 5

Multivariate fractional probit maximum likelihood estimates of the intensity of farmers KBM of ADs in Kenya.

Variables	RVF			Chikungunya fever			Dengue fever
	Knowledge	Beliefs	Management	Knowledge	Beliefs	Management	Knowledge	Beliefs	Management
Household demographic characteristics
Education	0.010*	0.006	0.024***	0.006	-0.015	0.024***	0.004	-0.005	0.031**
	(0.006)	(0.009)	(0.006)	(0.005)	(0.010)	(0.007)	(0.010)	(0.023)	(0.012)
Gender	-0.097*	-0.045	-0.112	-0.054	-0.030	-0.080	-0.007	-0.190	-0.077
	(0.054)	(0.115)	(0.070)	(0.043)	(0.091)	(0.060)	(0.084)	(0.204)	(0.090)
Christianity	-0.165	0.325	-0.207	-0.086	-0.060	0.054	-0.045	-0.768*	-0.015
	(0.209)	(0.309)	(0.170)	(0.184)	(0.207)	(0.122)	(0.378)	(0.417)	(0.198)
Islam	0.138	5.156***	-0.130	-0.112	-0.390	-0.066	-0.619	-0.279	-0.089
	(0.215)	(0.370)	(0.181)	(0.217)	(0.265)	(0.138)	(0.379)	(0.442)	(0.232)
Access to health information
Experience	0.230***	0.240**	0.079	0.080**	0.547***	-0.069	0.092	0.513**	0.036
	(0.044)	(0.082)	(0.066)	(0.038)	(0.077)	(0.052)	(0.099)	(0.161)	(0.099)
Awareness	0.314***	0.762***	0.110	0.365***	0.739***	0.339**	0.482***	1.544***	0.414***
	(0.073)	(0.103)	(0.098)	(0.041)	(0.090)	(0.058)	(0.080)	(0.180)	(0.087)
Distance	0.012	-0.050	-0.061**	-0.015	-0.018	-0.034	0.066*	0.110	0.021
	(0.021)	(0.035)	(0.031)	(0.019)	(0.043)	(0.028)	(0.036)	(0.083)	(0.045)
Social capital and networks
Group membership	-0.003	0.060	0.078	-0.011	0.150	-0.051	-0.083	-0.472**	-0.011
	(0.102)	(0.162)	(0.126)	(0.066)	(0.154)	(0.100)	(0.080)	(0.208)	(0.112)
Asset endowment
Livestock units	0.022	-0.005	-0.011
	(0.018)	(0.030)	(0.022)
Income	0.046**	0.058	0.126***	0.048***	0.123***	0.041**	0.067**	0.213**	0.084**
	(0.020)	(0.038)	(0.026)	(0.012)	(0.034)	(0.017)	(0.029)	(0.071)	(0.034)
Location fixed effects
Kwale	-0.988***	-6.859***	0.000	-0.284**	6.324***	0.199
	(0.126)	(0.434)	(0.229)	(0.140)	(0.527)	(0.155)
Kilifi	-0.276**	-0.631***	0.048	-0.454***	5.840***	-0.122	-0.153	0.404**	-0.154
	(0.083)	(0.138)	(0.111)	(0.090)	(0.504)	(0.124)	(0.102)	(0.176)	(0.147)
Constant	-1.050***	-1.070**	-2.036***	-0.613**		-0.929**	-1.063**	-3.624***	-1.626***
	(0.299)	(0.512)	(0.340)	(0.256)		(0.279)	(0.506)	(0.989)	(0.451)
Wald statistics	χ2 (36) = 1834.52, Prob > χ2 = 0.000			χ2 (33) = 62028.06, Prob > χ2 = 0.000			χ2 (30) = 294.08, Prob > χ2 = 0.000
Observations	276			334			136

Notes: Other religion used as the base in the religion category; Baringo used as the base in the location fixed effects category (RVF and chikungunya) while Kwale is used as the base in the case of dengue fever in the location fixed effects category; Confidence intervals (95%) in parenthesis;

* = significant at p < 0.1;

** = significant at p < 0.05;

*** = significant at p < 0.00.

Education positively influenced the intensity of livestock farmer’s knowledge and management practices of the three ADs with the exception of dengue fever and was significant at least at the 5 percent level. Belonging to the Muslim faith positively influenced the intensity of livestock farmers’ beliefs on RVF and was significant at the 1 percent level. While being a Christian reduced the intensity of livestock farmer’s beliefs regarding dengue fever, being a Muslim increased the intensity of livestock farmers’ beliefs towards RVF. However, belonging to a health group and the distance to the nearest health facility negatively influenced the intensity of livestock farmers’ beliefs and management practices of dengue and RVF, respectively, and were both significant at the 5 percent level.

Discussion

Slightly above half of the households in the study were aware of the three ADs while a third of them had experienced at least one of the ADs (a family member had suffered from at least one of the ADs). Most households in Baringo were aware of RVF but none of them was aware of the health impacts of chikungunya and dengue fever. On the other hand, majority of the households in Kwale and Kilifi Counties were aware of the health impacts of chikungunya and dengue fever. More residents in Baringo County experienced RVF infections among family members as compared to their counterparts in Kilifi and Kwale counties. Similarly, more households in Kwale and Kilifi counties had family members who had suffered from chikungunya and dengue fever as compared to households in Baringo County. These findings support Atoni et al. [2] who have reported RVF to be endemic in Baringo County while Kwale and Kilifi counties are hotspots of both chikungunya and dengue fever.

With regards to the KBM, we found that most respondents had poor knowledge of the three ADs. However, many households believed that the three ADs were dangerous diseases. This could be explained by the fact that most people in the society perceive diseases as a real threat despite having little knowledge about them. Good management skills of the three ADs were reported only by a few of the respondents in Kenya. Fever was the most prevalent sign and symptom of ADs among humans. This was consistent with earlier studies that have reported fever as the most frequently stated symptom of RVF [21], chikungunya fever [48], and dengue fever [33]. Other disease signs and symptoms mentioned by a few respondents included abdominal pains and headaches among humans and bloody diarrhea, bloody discharge, and death of young animals. These findings suggest that most of the respondents had limited knowledge of these AD signs, symptoms, and methods used to control their spread.

The most widely used methods of mosquito control reported by respondents in declining order of importance included use of nets, bush clearing, covering water-holding containers and/or their proper disposal. However, mosquito nets may offer little protection in reducing the risk of ADs. This is because most ADs mosquitoes feed during the day when households are not using the nets [49,50]. Similar findings have been reported in Kenya [21] and Pakistan [39]. Lack of such knowledge, especially in areas with a high density of Aedes aegypti, poses a challenge in ADs prevention. Almost all respondents reported that management of ADs was the responsibility of the Veterinary Department and the Ministry of Health. Expecting that government departments would control ADs might hinder community-based efforts towards controlling their spread leading to increased risk of infection. Bartumeus et al. [51] highlighted the importance of local communities in vector control. Most respondents indicated they will visit hospital when they suspect of ADs infection. These findings are consistent with other studies such as Kumaran et al. [52] and Nguyen et al. [23] that have reported hospital health-seeking behaviour in managing ADs.

We found positive significant influences of access to information (experience and awareness), income, education, distance to a health facility and religion on the intensity of livestock farmers’ KBM of ADs in Kenya. In conformity with the expectations, information access (experience and awareness) increased livestock farmer’s intensities of KBM of ADs in Kenya. Awareness of the health impact of the three ADs increased the intensity of livestock farmers KBM by between 31 and 154 percent (Table 5). Individuals who were aware of AD health impacts were more likely to undertake disease mitigation strategies or seek medical intervention [53]. Overall, farmers who were aware of the attributes of any intervention were more likely to have favourable management practices than their counterparts who were not aware [54].

The study identified that a household head’s education level increased the intensity of knowledge, beliefs, and management of ADs, which was consistent with previous studies [22,23,52,55]. An extra year spent in school increased a livestock farmer’s intensity of management practices of RVF and chikungunya fever by two percent while that of dengue fever increased by three percent. Education improves access to information and provides individuals with the ability to interpret and implement different disease management strategies [34]. Education provides good knowledge of disease signs and symptoms as illustrated by Khun and Manderson [56] which is important for timely disease prevention. The relationship between education and management of ADs has been documented in other studies [23,33,34,57].

Experience of the health impacts of a disease is important in influencing the management of ADs. Households that had experienced RVF and chikungunya fever had a higher intensity of knowledge and beliefs of both diseases by between 8 and 54 percent as compared to their counterparts who did not have at least a family member who had suffered from any of the three ADs (Table 5). This finding was consistent with the findings of Abdi et al. [21] and Harapan et al. [34] that demonstrated a positive and significant relationship between household’s experience and knowledge and beliefs of ADs. Income was associated with increased livestock farmer intensities of KBM on ADs in Kenya. A one percent increase in household income increased livestock farmers intensities of KBM of the three ADs by between 4 and 13 percent. The possible reason for a positive association between the intensity of KBM and income is that people with higher economic status might have better information access on ADs and resources to manage the diseases [58,59]. A direct relationship between income and good knowledge of dengue has been documented [59-61]. Similarly, Alhoot et al. [62], Ghani et al. [63], and Lugova and Wallis [61] have reported a significant association between income and positive beliefs regarding dengue fever.

Farmers who were located further away from health facilities had poor management skills of ADs as compared to their counterparts who had better access to medical facilities. An extra minute spent walking to the health facility to seek treatment reduced the intensity of a livestock farmer’s management skills of RVF by six percent. This suggested that as distance increased, the likelihood of the household members visiting health facilities declined and thus they were less likely to manage the diseases. Health facilities are the principal point for sourcing health information in many rural settings through the distribution of education materials on signs and symptoms and prevention methods of a diseases [64]. Feikin et al. [65] has documented a negative relationship between distance of residence from a health facility and utilisation of health services in Kenya.

Being a Muslim increased the intensity of a livestock farmers’ beliefs that RVF is a dangerous disease by a huge margin of 516 percent (Table 5). Religion positively or negatively influences people’s beliefs regarding their willingness to receiving a certain treatment [66]. Similar finding has been documented by Chandren et al. [67] and Harapan et al. [34] which indicated that religion influenced people’s beliefs regarding dengue fever in Malaysia and Indonesia.

Though our study generates important information, the study has the following caveats. First, our results must be interpreted with caution since the relationships are based on one point and do not account for the relationship dynamics of the factors analyzed. Therefore, we cannot construe the relationships between knowledge, beliefs, management, and associated factors. Secondly, our study conducted interviews using a semi-structured questionnaire; thus, some questions, especially on beliefs, might have been influenced by the respondent’s social desires. Finally, despite its wide-spread use, the TBP does not account for other factors that might influence intention and motivation of individuals [68]. Nevertheless, this study provides an insight into the knowledge, beliefs, and management of people regarding RVF, chikungunya fever, and dengue fever in Kenya.

Conclusions and policy implications

This study evaluated the intensity of livestock farmer’s knowledge, beliefs, and management of RVF, chikungunya, and dengue fever in Kenya using a MVFP model that employs a sample of 629 households. Slightly above half of the respondents were aware of the three ADs, while a third of the respondents had experienced (suffered) the ADs. While only a small share of the respondents have basic knowledge about the three diseases, a vast majority of them considered ADs as serious diseases affecting both animals and humans. Despite the low knowledge, more than half of the respondent expressed positive beliefs towards ADs. There was a low translation of knowledge about disease transmission and prevention into good management practices.

We demonstrated the importance of access to information (experience, awareness, and distance to a health facility), income, education, and religion in influencing the KBM of ADs. These findings demonstrate the importance of access to information in influencing the intensity of livestock farmers KBM of ADs. Thus, policy initiatives should focus on increasing livestock farmers’ awareness of the three ADs in Kenya to mitigate their negative health impacts. Moreover, the awareness programs on these three ADs should also target different religions separately. Most importantly, ADs prevention and control should be promoted among individuals who have experienced the diseases, their families, and visiting neighbors by hospitals to raise awareness among community members and use them as outreach program. This will increase the knowledge of ADs’ and improve the management of these diseases in the society.

5 Jul 2021

Dear Nyangau,

Thank you very much for submitting your manuscript "Evaluating Knowledge, Beliefs, and Management of Arboviral Diseases in Kenya: A Multivariate Fractional Probit Approach" for consideration at PLOS Neglected Tropical Diseases. As with all papers reviewed by the journal, your manuscript was reviewed by members of the editorial board and by several independent reviewers. In light of the reviews (below this email), we would like to invite the resubmission of a significantly-revised version that takes into account the reviewers' comments.

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Associate Editor

PLOS Neglected Tropical Diseases

Victor S. Santos

Deputy Editor

PLOS Neglected Tropical Diseases

***********************

Reviewer's Responses to Questions

Summary and General Comments

Use this section to provide overall comments, discuss strengths/weaknesses of the study, novelty, significance, general execution and scholarship. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. If requesting major revision, please articulate the new experiments that are needed.

Reviewer #1: The authors did a very good job with this study at a time when the required information was lacking. This study will serve as guide to future similar studies due to the detailed explanations of the steps and equations used.

Reviewer #2: Overall, this is a very well written manuscript with a very precise explanation of the methods used and the results found. Further, the discussion has put the the studies finding in the context of the current literature and has discussed public health relevance.

Some mentioning of ethical procedure should be added, such as ethical study approval of the institution.

Further, minor changes are attached in the attached document.

Reviewer #3: Given that the condition for positive changes resulting from research is to establish a relationship with the community and positive involvement of the community, the present study has positive dimensions in identifying weaknesses related to knowledge, important beliefs of the community and the management of arbovirus diseases in Kenya (perhaps extendable to some other places), and has provided valuable information to address these issues.

--------------------

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

--------------------

Key Review Criteria Required for Acceptance?

As you describe the new analyses required for acceptance, please consider the following:

Methods

-Are the objectives of the study clearly articulated with a clear testable hypothesis stated?

-Is the study design appropriate to address the stated objectives?

-Is the population clearly described and appropriate for the hypothesis being tested?

-Is the sample size sufficient to ensure adequate power to address the hypothesis being tested?

-Were correct statistical analysis used to support conclusions?

-Are there concerns about ethical or regulatory requirements being met?

Reviewer #1: • Sections 2.1 and 2.2: The authors should separate an equation with its supporting sentences from that of the next equation. This will make it easier to follow where one equation ends and the next one starts.

• Page 9: It will be better to replace “sub-counts” with “towns”. If the authors want to retain “sub-counts”, then they should add further details about what they mean.

• On section ‘2.3.Study Area and Sampling Procedure’, the authors should include an Ethics statement. The ethics statement should describe if there was informed consent from the study participants, and how the participants of the study consented to it or how the consent was obtained. It should also explain if there was ethical approval for the study, state the approving organisation(s) and approval number (where applicable).

Reviewer #2: The methodology was very well and in detail described. Potentially it could be made a little more concise as the manuscript overall is quite long, and about 1900 words of 5400 words in total are the methodology.

Some mentioning of ethical procedure should be added, such as ethical study approval of the institution.

Detailed comments are in the attached document.

--------------------

Results

-Does the analysis presented match the analysis plan?

-Are the results clearly and completely presented?

-Are the figures (Tables, Images) of sufficient quality for clarity?

Reviewer #1: The authors presented the results starting with each Table. The approach is good and easy to follow. However, it seemed as if the table titles were repeated with each table number number. To avoid this repetition and to make the Results sections easier to grasp, it will be better if the authors summarise the main findings of each table at the beginning of the paragraph instead. Then, they can put the Table number being referred to in brackets. Alternatively, the authors can maintain their format but replace the table headings with the summary of the findings of that table.

Reviewer #2: The analysis presented matches the analysis plan.

A very well described and clearly presented result section.

Tables are very clear.

In Figure 1, do the red spots on the three countys depict the sampled sites or sampled households? As if it were households these seem quite few on the county map, if they were 200 per county? It would additionally make sense to make the county maps bigger, for the sites to be more visible.

--------------------

Conclusions

-Are the conclusions supported by the data presented?

-Are the limitations of analysis clearly described?

-Do the authors discuss how these data can be helpful to advance our understanding of the topic under study?

-Is public health relevance addressed?

Reviewer #1: Discussion

The authors were not generous with the interpretation of their Results. They mostly repeated the Results and sometimes, compared it to previous studies. Few suggestions on how to improve the Discussion section include:

• It will be nicer if the authors started the Discussion with a summary of their results in the study in relation to the aim of their study.

• The Discussion can be broken down into sub-sections that correspond with those in the Results, so that the particular Result being discussed can be easily identified in the article. Alternatively, since the focus of the study is intertwined amongst knowledge, belief and management of arboviral diseases, the authors can separate the Discussion into three groups to tackle the three areas well.

• Summarise a particular finding, discuss what it implies, and then compare if it is consistent or in contrast with the results of other studies. See instances in the comments on page 17.

Conclusion

The authors should indicate the limitation of their study before or after the recommendations.

Reviewer #2: The conclusions is supported by the data presented.

A more extensive section on limitations of analysis should be added to the discussion.

The authors discussed very well the studies public health relevance add how the data can be helpful to advance our understanding of the topic under study.

--------------------

Editorial and Data Presentation Modifications?

Use this section for editorial suggestions as well as relatively minor modifications of existing data that would enhance clarity. If the only modifications needed are minor and/or editorial, you may wish to recommend “Minor Revision” or “Accept”.

Reviewer #1: Summary of the research

The study described the current status of farmers’ (people’s) knowledge, beliefs and management of arboviral diseases. This is mostly a neglected section of disease control, which is very important, especially in decision making. The authors used good techniques for the study and ensured that they wrote for diverse audience, which is commendable. However, the authors need to correct some minor aspects of their manuscript:

• For future purposes, the authors should include line numbers in the manuscript to make it easier to review.

• Kindly alternate the word “majority” with “many” or “most” to avoid redundancy.

• The word “significant” is often linked to the intensity of the results in the Results section. Outside the Results section, it will be better to replace it with similar words like “considerably”, “greatly”.

Authors’ names and affiliations

• The authors should provide full address of their affiliated institutions. For instance, in which town and country is icipe located?

• The email address of the corresponding author shows that he is affiliated to “icipe” but he did not include it as one of his affiliations. Correct accordingly.

Abstract

• The study was on livestock farmers according to the Conclusion section but this was not captured in the aim of the study. So, please rephrase the aim of the study to, “This study evaluated the drivers of livestock farmers’ KBM of ADs from a sample of 629 respondents selected using a three-stage sampling procedure in Kenya’s three hotspot counties of Baringo, Kwale, and Kilifi”.

Keywords

• All the listed keywords are already contained in the title. Kindly replace them with words that are not in the title but are within the abstract to make the manuscript more discoverable. Few suggestions include: public health, livestock farmers, awareness, Rift Valley fever, Chikungunya fever, Dengue fever.

Introduction

• Page 4: The word, “present” in the last paragraph portrayed the preceding words as humans. Since the authors were trying to describe the content of the remaining sections of the manuscript, “contain” is a better word to use. (Please see the corrections in the MS Word version).

Tables

• Table 3: The authors should insert question mark (?) where necessary under the “characteristics” column.

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Submitted filename: Nyangau et al - 2021 - PLOSNTD.docx

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Submitted filename: PNTD-D-21-00736_Review.docx

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26 Jul 2021

Submitted filename: Response to Reviewer Comments - PNTD - 21-00736.docx

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2 Sep 2021

Dear Mr. Nyangau,

We are pleased to inform you that your manuscript 'Evaluating Livestock Farmers Knowledge, Beliefs, and Management of Arboviral Diseases in Kenya: A Multivariate Fractional Probit Approach' has been provisionally accepted for publication in PLOS Neglected Tropical Diseases.

Before your manuscript can be formally accepted you will need to complete some formatting changes, which you will receive in a follow up email. A member of our team will be in touch with a set of requests.

Please note that your manuscript will not be scheduled for publication until you have made the required changes, so a swift response is appreciated.

IMPORTANT: The editorial review process is now complete. PLOS will only permit corrections to spelling, formatting or significant scientific errors from this point onwards. Requests for major changes, or any which affect the scientific understanding of your work, will cause delays to the publication date of your manuscript.

Should you, your institution's press office or the journal office choose to press release your paper, you will automatically be opted out of early publication. We ask that you notify us now if you or your institution is planning to press release the article. All press must be co-ordinated with PLOS.

Thank you again for supporting Open Access publishing; we are looking forward to publishing your work in PLOS Neglected Tropical Diseases.

Best regards,

Alberto Novaes Ramos Jr

Associate Editor

PLOS Neglected Tropical Diseases

Victor Santana Santos

Deputy Editor

PLOS Neglected Tropical Diseases

***********************************************************

Please consider the minor observations indicated by the reviewers 1 and 2.

Reviewer's Responses to Questions

Key Review Criteria Required for Acceptance?

As you describe the new analyses required for acceptance, please consider the following:

Methods

-Are the objectives of the study clearly articulated with a clear testable hypothesis stated?

-Is the study design appropriate to address the stated objectives?

-Is the population clearly described and appropriate for the hypothesis being tested?

-Is the sample size sufficient to ensure adequate power to address the hypothesis being tested?

-Were correct statistical analysis used to support conclusions?

-Are there concerns about ethical or regulatory requirements being met?

Reviewer #1: The authors did a good a good job in their description of the study in such a way that non-experts in the field can understand the message being communicated. There was ethical approval for the study and all participants gave informed consent, which is important for this kind of study.

Reviewer #2: NA

Reviewer #3: (No Response)

**********

Results

-Does the analysis presented match the analysis plan?

-Are the results clearly and completely presented?

-Are the figures (Tables, Images) of sufficient quality for clarity?

Reviewer #1: The results were clearly presented.

Reviewer #2: NA

Reviewer #3: (No Response)

**********

Conclusions

-Are the conclusions supported by the data presented?

-Are the limitations of analysis clearly described?

-Do the authors discuss how these data can be helpful to advance our understanding of the topic under study?

-Is public health relevance addressed?

Reviewer #1: The conclusion was directly linked to the aim of the study and its implication was elaborated.

Reviewer #2: For line 498 : "However, mosquito nets may offer little protection in reducing the risk of ADs [49,50]. " add a sentence why nets only offer limited protection. Spell out what you are trying to tell the reader, so that reader does not have to guess.

Reviewer #3: (No Response)

**********

Editorial and Data Presentation Modifications?

Use this section for editorial suggestions as well as relatively minor modifications of existing data that would enhance clarity. If the only modifications needed are minor and/or editorial, you may wish to recommend “Minor Revision” or “Accept”.

Reviewer #1: On line 37, kindly include "African" to read ...Sub-Saharan African countries.

The authors should consistently use the past tense in the Discussion section. For instance, they should rephrase lines 402-403 to "Individuals who were aware of AD health impacts were more likely to

403 undertake disease mitigation strategies or seek medical intervention".

Reviewer #2: For all citations mentioned in the text, such as in line 469, 504, 564,565 (this is an unexhaustive list) after each citation a dot is needed, when "et al" is mentioned in the text, it should be spelled out as following "et al.".

In line 487, 526 there is double dot after the sentence, which should be reduced to a single dot.

Rephrase Line 493 "young ones among animals" to "young animals".

In line 534: "A household head’s education level increased the intensity of knowledge, beliefs, and management of ADs. ", mention that this is a finding from this study, e.g. "The study identified that a household head’s education level increased the intensity of knowledge, beliefs, and management of ADs.

In line 698 : "Conclusion’s and policy implications" should be rephrased as "Conclusions and policy implications" .

Reviewer #3: (No Response)

**********

Summary and General Comments

Use this section to provide overall comments, discuss strengths/weaknesses of the study, novelty, significance, general execution and scholarship. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. If requesting major revision, please articulate the new experiments that are needed.

Reviewer #1: People's knowledge of a disease is very important in the management of that disease. The authors did well to undertake this study and expound on an often understudied area of disease control.

Reviewer #2: The authors addressed the reviewers' comments in a very thorough way and thus have strongly improved the manuscript.

The reviewer had a few very minor points to be addressed by the authors.

Reviewer #3: (No Response)

**********

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

9 Sep 2021

Dear Mr. Nyangau,

We are delighted to inform you that your manuscript, "Evaluating Livestock Farmers Knowledge, Beliefs, and Management of Arboviral Diseases in Kenya: A Multivariate Fractional Probit Approach," has been formally accepted for publication in PLOS Neglected Tropical Diseases.

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Thank you again for supporting open-access publishing; we are looking forward to publishing your work in PLOS Neglected Tropical Diseases.

Best regards,

Shaden Kamhawi

co-Editor-in-Chief

PLOS Neglected Tropical Diseases

Paul Brindley

co-Editor-in-Chief

PLOS Neglected Tropical Diseases