Uneven mosquito control knowledge, attitudes, and practices in Malaysia shape sustainable dengue prevention across urban and rural settings.

Dengue remains a persistent public health challenge in Malaysia, where rapid urbanization, ecological transformation, and behavioral gaps sustain Aedes mosquito proliferation despite decades of control programs. Understanding geographic and urban-rural disparities in community knowledge and preventive practices is essential for developing sustainable, evidence-based strategies. This cross-sectional study, conducted from February to May 2024, involved 866 respondents from 12 states in Peninsular Malaysia representing diverse urban and rural populations. Using a validated Knowledge, Attitudes and Practices (KAP) questionnaire, composite Knowledge, Practice, and Overall KAP indices were computed on a 0-100% scale. State-level differences were examined using one-way ANOVA with post-hoc tests, and urban-rural disparities were evaluated using Welch's t-tests and Mann-Whitney U tests. Significant heterogeneity was found across states for all indices. Knowledge scores varied widely (F(11,854) = 8.42, p < 0.001, η²=0.10), with Selangor and Perak scoring highest (≥ 80%) and Kedah and Pulau Pinang lowest (< 60%). Practices lagged behind knowledge (F(11,854) = 6.17, p < 0.001, η²=0.07), with Johor showing the strongest knowledge-behavior alignment. Urban respondents exhibited higher knowledge in Johor (+ 0.34, 95% CI: 0.21-0.47) and Pahang (+ 0.29, 95% CI: 0.14-0.44), whereas rural communities in Selangor scored slightly higher (-0.13, 95% CI: - 0.24 to - 0.01). The findings reveal persistent state-level and urban-rural inequalities in mosquito control literacy and behavior. These results highlight the broader relevance of localized, participatory strategies for strengthening dengue prevention across diverse socio-ecological settings, with potential applicability to other endemic regions globally.