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Knowledge, attitudes, and practices of Hong Kong population towards human A/H7N9 influenza pandemic preparedness, China, 2014

  • Emily YY Chan1Email author,
  • Calvin KY Cheng1,
  • Greta Tam1,
  • Zhe Huang1 and
  • Poyi Lee1
BMC Public Health201515:943

https://doi.org/10.1186/s12889-015-2245-9

Received: 8 January 2015

Accepted: 7 September 2015

Published: 22 September 2015

Abstract

Background

Since SARS epidemic in 2003, Hong Kong has experienced several major epidemic risks, but how general community might react to the repeated infectious diseases health risks have not been studied. In 2013, imported human H7N9 influenza infected cases from China were reported. Our study aims to assess the knowledge, attitude and practice (KAP) concerning A/H7N9 among Hong Kong general population regarding pandemic preparedness in early 2014.

Methods

A cross-sectional, population-based telephone survey study was conducted among the Cantonese-speaking population aged over 15 years in Hong Kong in February 2014. The study survey was composed of 78 KAP questions. Factors associated with individual and household pandemic preparedness were analyzed.

Results

Final study sample was 1,020 with a response rate of 45.9 %. Among the respondents, most of them believed personal hygiene and avoidance of avian contacts were effective in preventing H7N9 infections. The majority of respondents had satisfactory hand hygiene practices and avoided touching avian species but did not employ other preventive measures. Female, 25 years old or older, white collar workers, people with chronic diseases and people living in the city center tended to report better hygiene practices. The average State-Trait Anxiety Inventory score was 1.85, similar to that of the period during the first wave and at the start of the second wave of the H7N9 epidemic. Self-reported face masks wearing when having influenza-like illness in general population dropped from 92.4 % during H5N1 period in 2007 to 39.0 % in this study.

Conclusion

Hong Kong citizens show a low level of anxiety, misconceptions regarding the novel strains as well as gaps between perceived usefulness and practice of preventive measures towards influenza outbreaks. Educational campaigns and framing the issue to increase public and media awareness are crucial in preventing the current public fatigue towards outbreaks.

Keywords

Knowledge Attitude Practice Influenza A/H7N9 Pandemic preparedness Chinese community Hong Kong

Background

The experience of SARS coronavirus epidemic in 2003 has radically changed the concept and catalyzed actions globally and locally for combating infectious diseases outbreaks at the community level [1, 2]. Different health agencies globally are now striving to increase community resilience in combating this emerging infectious disease challenge. In particular, in the Hong Kong Special Administration Region of China, where a number of infectious diseases epidemic originated, resources were invested for enhancing infrastructure, policies and health education for pandemic preparedness and infection control. Whilst population resilience level in Hong Kong in handling infectious disease challenges are thought to be higher than other global cities, the mild clinical outcome of A/H1N1 influenza pandemic in 2009 and the limited transmissibility of the A/H5N1 avian influenza outbreaks in humans in 2007 may have modified citizens’ attitude and perceived risk towards similar outbreak incidences [35], and may have led them to underestimate the emerging A/H7N9 outbreak at the community level. A study conducted between 2006 and 2010 suggested that prolonged warning of a future pandemic was likely to cause pandemic fatigue in the public [6, 7]. For example, studies showed a decrease in self-reported mask use in case of influenza-like illness symptoms since the SARS in 2003 and post-SARS period [8]. There is currently limited literature to examine how prolonged warning may affect community perception and response to these large scale infectious disease risks.

In March 2013, a human infected H7N9 influenza A virus (A/H7N9) case was first identified in Eastern China and caught global attention [9, 10]. Serious response level of the Preparedness Plan for Influenza Pandemic was activated in Hong Kong in Dec 2013 [11]. As of August 2014, a total of 450 confirmed cases were reported in various provinces in China [12]. A recent study in Hong Kong during the first wave of H7N9 epidemic in April 2013 showed low population anxiety levels [13]. Although current evidence of sustained human-to-human transmission for A/H7N9 is rare, a small cluster of infected cases within the family showed hospitalization might be required [1416]. Confirmed case fatality rate was around 20 %, although the estimated symptomatic case fatality risk was lower [17]. At that time, there were a substantial number of confirmed cases of human infected cases of H7N9 avian influenza during the second wave of the epidemic (Fig. 1). Meanwhile, the infection rate of seasonal influenza was high in Hong Kong, as reflected by the Government Center for Health protection sentinel surveillance system [4].
Fig. 1

Timeline of laboratory-confirmed cases of influenza A(H7N9). Laboratory-confirmed cases of human infection with avian influenza A(H7N9) virus from 31 March 2013 to 23 June 2014, by date of notification to the World Health Organisation. Each asterisk represented an imported case reported in Hong Kong. The grey period on the right indicated the survey period

Some personal behaviors had been suggested to be effective to control pandemics such as SARS and H5N1 in Hong Kong. Previous studies suggested that close contact with live poultry, visiting public places and the places having confirmed cases were risk factors, while frequent mask use, hand washing, disinfection, and avoidance of eating poultry were protective factors [13, 18, 19]. In this study, we conducted a representative, population-based telephone survey in Hong Kong 1) to investigate the current situation regarding the self-reported knowledge, attitude and practice of pandemic responses at individual level on the second wave human infected A/H7N9 avian influenza outbreak; and 2) to investigate factors associated with the self-reported personal hygiene practices.

Methods

Study design and study population

A cross-sectional, population-based telephone survey was conducted from 15–28 February 2014 in Hong Kong. The study population was the population aged 15 years or above residing in Hong Kong, including residents holding valid work or study visas. Exclusion criteria included i) non-Cantonese-speaking respondents; ii) overseas visitors holding tourist visas to Hong Kong; iii) 2-way permit holders from mainland China; and iv) those who were unable to be interviewed due to medical reasons.

Instrument

A structured Chinese questionnaire was constructed and used for data collection. The questionnaire consisted of 78 closed ended questions that aimed to collect the following information from the respondents:
  1. 1.

    Socio-demographic and background information, including age, gender, district of residence, occupation and employment status, educational attainment, type and size of housing, and household income (total 21 questions).

     
  2. 2.

    Knowledge of H7N9 influenza A virus, including the differences between H7N9 and other respiratory diseases, transmission routes and “whether seasonal influenza vaccination could protect people from H7N9 infection” (total 9 questions).

     
  3. 3.

    Attitudes and risk perception towards H7N9 influenza A infections, including attitude towards preventive measures (total 9 questions), perception of H7N9 impact, perceived severity and infectivity, channel preference for information reporting and seeking, and their current anxiety level concerning the outbreak (total 30 questions). The 6 questions short form of the State-Trait Anxiety Inventory (STAI) was used for measuring anxiety [20]. A five point Likert-type scale were used to ascertain level of agreement or disagreement for the questions (from 1 to 5, 1 = strongly disagree, 2 = disagree, 3 = uncertain, 4 = agree, 5 = strongly agree).

     
  4. 4.

    Practices of preventive measures against H7N9 influenza A infections, including personal hygiene practices, avoidance of contact with avian species, household preparedness and vaccination practice (total 18 questions). A four point Likert-type scale were used to ascertain level of the practices (from 1 to 4, 1 = always, 2 = often, 3 = sometimes, 4 = never).

     
  5. 5.

    Active personal hygiene practice was defined by practicing 6 or more of the following 9 personal hygiene measures, including wash more hands, wash hands with soap, do not share utensils, wear mask when sick, bring own utensils during meals, avoid going to public places and avoid using public transport, avoid contacting with live poultry, avoid eating poultry and avoid going to places that had H7N9 confirmed cases. Active personal hygiene attitude was defined by regarding 6 or more of the above 9 personal hygiene measures above as useful for prevention H7N9.

     

Each interview took approximate 15–25 min to complete. The survey questionnaire was pilot tested in January 2014 (n = 50) to ensure practicability, validity, and interpretability of answers. The questionnaire was slightly refined for wording and format before distribution to the study sample based on the results of the pilot study. Results about vaccination practice and channels for disease surveillance have been reported elsewhere and not included in the analysis.

Data collection

Randomly generated telephone numbers from a list of all land-based telephone numbers in Hong Kong was used as the sample frame [3, 8]. The telephone interviews were conducted by trained interviewers. The telephone calls were made in the evening on weekdays (6 pm-10 pm) and during daytime and evening on weekends (10 am-10 pm) to prevent over representation of the unemployed population. The subjects undergoing the interview were chosen based on the “last birthday method” [21, 22], in which the household member who was present in the household during the survey and whose last birthday was closest to the interview date was invited to participate. The subjects were invited on the basis of the proportion of age, gender and living district from the 2011 Hong Kong Population Census data. The sampling would continue until the quotas for each stratum were met. If the selected participant was busy or not there, up to 4 follow-up calls would be made. The numbers were called for a maximum of 5 times before being classified as unanswered.

Statistical analysis

Differences in proportions between demographic characteristics in this survey and the Hong Kong Population Census data in 2011 were examined. Descriptive statistics for knowledge, attitude and practice of H7N9 influenza A prevention in the study population were calculated. Differences in proportions between groups were tested using Pearson’s Chi-square test or Fisher’s exact test. Likert-type scale results were collapsed to binary outcomes for analysis. Cut off point for questions with 5 point scales were defined as >3 and for questions with 4 point scale as >2. Univariate analysis was first conducted to identify apparent associations between individual pandemic preparedness practices with socio-demographic factors, perceived health risk, knowledge and attitudes towards A/H7N9 influenza virus. Backward multivariable logistic regression analyses were then conducted to identify factors associated with actual pandemic preparedness. All variables were retained in the final model if they had P-value < 0.05. All statistical analyses were conducted using R (version 3.0.2, R Development Core Team 2011). Statistical significance was set at α = 0.05.

Research ethics

This study was approved by the Survey and Behavioural Research Ethics Committee of The Chinese University of Hong Kong. Oral consent was obtained from each of the participant at the beginning of the study. All collected data were anonymous.

Results

The final number of respondents who completed the survey was 1020, and the response rate was 45.9 % (1,020/2,221). Figure 2 detailed the data collection algorithm and response rate. Table 1 shows the socio-demographic characteristics of the study population compared with the general population in Hong Kong in 2011 [23].
Fig. 2

Study flow of the telephone survey

Table 1

Socio-demographic characteristics of the respondents and the general population in Hong Kong in 2011

 

Sample population

Hong Kong population 2011

Sample vs. census p-valuea

 

n

%

%

 

Demographics

Age (n = 1,020)

15-24

143

14.0

14.0

0.99

25-44

348

34.1

35.5

 

45-64

363

35.6

35.4

 

65

166

16.3

15.1

 

Gender (n = 1,020)

Male

461

45.2

46.0

1.00

Female

559

54.8

54.0

 

Education (n = 1,019)

Primary education or below

138

13.5

22.7

0.18

Secondary education

517

50.7

50.0

 

Post-secondary education(including diploma and certificate)

364

35.7

27.3

 

Occupation (n = 1,006)

White collar

411

40.9

NA

 

Blue collar

96

9.5

NA

 

Housewife, retired or unemployed

393

39.1

NA

 

Students

106

10.5

NA

 

Area of residence (n = 1,020)

Hong Kong Island

185

18.1

18.0

1.00

Kowloon

308

30.2

29.8

 

New Territories

527

51.7

52.2

 

Marital status (n = 1,018)

Single

355

34.9

42.2

0.36

Married

663

65.1

57.8

 

Household income (n = 969)

<$10,000

135

13.9

23.8

0.30

$10,000-19,999

220

22.7

23.8

 

$20,000-39,999

346

35.7

29.0

 

$40,000

268

27.7

23.5

 

Type of housing (n = 1,017)

Public housing

387

38.1

30.3

0.61b

Subsidized home ownership housing

160

15.7

15.9

 

Private permanent housing

455

44.7

52.3

 

Others

15

1.5

1.4

 

aChi-square test was used to measure the overall difference in proportions between this survey and the 2011 Hong Kong Population Census data. P-value < 0.05 indicates significant difference

bFisher-exact test p-value was used

Knowledge of A/H7N9 avian influenza

Of the respondents, only 25.3 % thought that they had sufficient knowledge to manage the risks that H7N9 avian influenza brings to their health and security. Majority of the respondents (62.5 %) mistook H7N9 influenza A virus as the common seasonal influenza of the current year and many respondents did not demonstrate accurate knowledge of known transmission routes of H7N9. Only 29.0 % of respondents correctly stated H7N9 can be transmitted via animals but not by insects and human feces. More than one fourth (27.5 %) thought insects can be vector for transmission and more than half (53.9 %) thought human feces was a possible transmission route. Meanwhile more than half thought those seasonal influenza transmission routes (human saliva 50.5 %, air 64.2 %, direct hand contact 59.9 %, indirect hand contact 55.0 %) can also transmit H7N9 avian influenza (Table 2).
Table 2

Knowledge assessment questions regarding A/H7N9 avian influenza virus

Characteristics

Yes (%)

No (%)

Do not know (%)

Do you think H7N9 is the seasonal flu of this year? (n = 1,016)

637(62.5)

312(30.6)

67(7.0)

Do you think H7N9 avian influenza can be spread by? (n = 1,009)

Droplets by people

515(50.5)

489(47.9)

15(1.5)

Air borne

655(64.2)

360(35.3)

5(0.5)

Direct hand contact

611(59.9)

400(39.2)

8(0.8)

Indirect hand contact (e.g. via door handle)

561(55.0)

455(44.6)

3(0.3)

Human faeces

550(53.9)

445(43.6)

25(2.5)

Animals

906(88.8)

104(10.2)

10(1.0)

Insects

281(27.5)

711(69.7)

27(2.6)

Do you think seasonal flu vaccination can protect you from H7N9 virus infections? (n = 1,019)

370(36.3)

614(60.2)

35(3.4)

Attitudinal determinants towards the impact of A/H7N9

Around half (51.8 %) of the respondents regarded Hong Kong as susceptible to infectious diseases outbreaks. The majority (86.0 %) believed that H7N9 would not acquire the ability of human-to-human transmission within the current year. Most (72.0 %) of them thought the chances of getting infected by H7N9 within the current year were low or very low. Only a small portion believed the H7N9 outbreak will cause high or very high impact for their health (28.9 %) and economic status (17.0 %). Only 37.8 % believed H7N9 will have high or very high impact affecting society. Respondents believed that H7N9 spread was controllable in general. 26.6 % of respondents did not believe the spread of H7N9 could be prevented at government policy level, and around half (22.6 %) believed that the spread could not be prevented at household and individual level.

The average anxiety level among the respondents towards the current infectious disease outbreak was 1.85 (IQR: 1.33, 2.33) on a scale of 1 (“not anxious at all”) to 4 (“very anxious”), which was similar to the first wave of H7N9 in April 2013 and during the first imported case in Hong Kong in December 2013 [13].

Attitude and practice towards A/H7N9 personal hygiene prevention

Overall, most of the respondents thought that active personal hygiene measures reduced the risk of influenza transmission: Washing hands (87.2 %), using soap for washing hands (88.5 %), not sharing utensils (83.9 %), wearing mask when having respiratory infections (94.4 %), bringing their own utensils during meals (62.0 %), and to a lesser extent, avoiding public places and using public transport (58.4 %). They also had active attitude towards avoiding contact with live poultry (93.1 %), avoiding travel to previous human H7N9 infected areas (80.9 %) and to a lesser extent, avoiding eating avian species (56.0 %) (Table 3).
Table 3

Perceived usefulness and practice of preventive measures against human A/H7N9 influenza infections

Control measures that can protect from A/H7N9 infections

Thought it was useful for prevention

Always or usually practicing currently

Attitude vs. Practice

 

n

%

n

%

p-value

Personal hygiene practices

Wash hands more

888

87.2

990

97.1

0.260*

Use soap to wash hands

900

88.5

740

72.6

0.003

Do not share utensils

852

83.9

466

45.9

<0.001

Wear mask when sick

961

94.4

386

39.0

0.576

Bring own utensils during meals

626

62.0

16

1.6

0.314*

Avoid going to public places and use public transport

592

58.4

71

7.0

<0.001

Avoid source of A/H7N9 virus

Avoid contacting with live poultry

949

93.1

767

75.2

<0.001

Avoid eating poultry

568

56.0

183

17.9

<0.001

Avoid going the places having H7N9 confirmed cases

820

80.9

569

55.8

<0.001

Had taken at least 6 out of all 9 measures above

825

80.9

192

18.8

<0.001

*Fisher’s exact test

Differences between the two groups were tested by Chi-square or Fisher’s exact test. Statistical significant level was set to p < 0.05

While for the actual hygiene practice, most respondents did not practice well the above control measures as shown in Table 3. Not all measures in practice were dependent with the perceived usefulness, such as washing hands, wearing mask when sick and not sharing utensils during meals. Only hand hygiene (97.1 % and 72.6 %) and avoiding contact with live poultry (75.2 %) were widely practiced. More than half (61.0 %) did not wear or just occasionally wore masks when they had respiratory infections. More than half shared utensils (54.1 %), and very few (1.6 %) brought their own utensils during meals when outside home. Over 90 % would not avoid going to public places or using public transport. Around half (55.8 %) would still visit places that had confirmed H7N9 cases.

Factors affecting personal hygiene attitude

Univariate analysis of different socio-demographic factors, attitudinal determinants towards H7N9 and anxiety level that were associated with active personal hygiene attitude (defined as perceiving 6 or more out of 9 measures above useful) was included in the multivariable analysis. Backward multiple logistic regression revealed female gender (OR = 1.51, 95 % CI: 1.08-2.10, P < 0.05), working in office environment (compared to “white collar”, OR for “blue collar” = 0.55, 95 % CI: 0.33-0.92, P < 0.05), and those with high anxiety level towards infectious disease outbreak (compared to “Very low (STAI < 1.5)”, OR for “Medium(STAI 2.00-2.49)” =1.64, 95 % CI: 1.04-2.58, P < 0.05) had active personal hygiene attitude (Table 4).
Table 4

Multiple logistic regression analysis of factors that associate with personal hygiene attitude

Characteristics

aPersonal hygiene attitude

bCOR (95 % CI)

cAOR (95 % CI)

Inactive N (%)

Active N (%)

Gender

Male

105(22.8)

356(77.2)

1

1

Female

90(16.1)

469(83.9)

1.54(1.12, 2.10)

1.51(1.08, 2.10)

Age

15-24

20(14.0)

123(86.0)

1

 

25-49

62(17.8)

286 (82.2)

0.75(0.43, 1.30)

 

50-64

80(22.0)

283(78.0)

0.58(0.34, 0.98)

 

65

33(19.9)

133(80.1)

0.66(0.36, 1.20)

 

Occupation

White collar

74(18.0)

337(82.0)

1

1

Blue collar

28(29.2)

68(70.8)

0.53(0.32, 0.89)

0.55(0.33, 0.92)

Housewife, retired or Unemployed

73(18.6)

320(81.4)

0.96(0.67, 1.38)

0.88(0.61, 1.27)

Student

16(15.1)

90(84.9)

1.24(0.69, 2.22)

1.22(0.67, 2.20)

Anxiety score

Very low (STAI < 1.5)

61(22.0)

216(78.0)

1

1

Low (STAI 1.50-1.99

67(23.5)

218(76.5)

0.92(0.62, 1.36)

0.87(0.58, 1.30)

Medium (STAI 2.00-2.49)

39(14.4)

232(85.6)

1.68(1.08, 2.62)

1.64(1.04, 2.58)

High (STAI >2.49)

26(14.4)

155(85.6)

1.68(1.02, 2.78)

1.63(0.98, 2.72)

Believed Hong Kong is susceptible to infectious diseases outbreaks

No

108(22.0)

383(78.0)

1

 

Yes

87(16.5)

440(83.5)

1.43(1.04, 1.95)

 

Believed that the spread cannot be prevented at household and individual level

Not enough

112(21.9)

399(78.1)

1

 

enough

83(16.4)

424(73.6)

1.43(1.05, 1.97)

 

aActive personal hygiene attitude was defined by practicing 6 or more of the following 9 personal hygiene measures, including wash more hands, wash hands with soap, do not share utensils, wear mask when sick, bring own utensils during meals, avoid going to public places and avoid using public transport, avoid contacting with live poultry, avoid eating poultry and avoid going to places that had H7N9 confirmed cases

bCOR, crude odd ratio in the univariate analysis

cAOR, Adjusted odd ratio in the multivariable analysis

Factors affecting personal hygiene practice

Univariate analysis of different socio-demographic, attitude factors and active attitude towards preventive measures against H7N9 that were associated with active personal hygiene practice (defined as practicing 6 or more out of 9 measures above) was included in the multivariable analysis. Backward multiple logistic regression revealed female gender (OR = 2.17, 95 % CI: 1.48-3.18, P < 0.001), older age (compared to age 15–24, OR for age 25–49 = 4.81, 95 % CI: 1.37-16.89; OR for age 50–64 = 4.46, 95 % CI: 1.25-15.95; OR for age 65 or above = 6.19, 95 % CI: 1.60-23.99. P < 0.05 for all three), working in office environment (compared to “white collar”, OR for “blue collar” = 0.27, 95 % CI: 0.11-0.68, P < 0.01), having chronic diseases (OR = 1.84, 95 % CI: 1.20-2.82, P < 0.01) and living in city center districts (compared to suburb district, OR for densely populated district = 1.59, 95 % CI: 1.06-2.37, P < 0.05; OR for wealthy district = 2.58, 95 % CI: 1.65-4.05, P < 0.001) had better personal hygiene practices.

In terms of attitudinal factors, better personal hygiene practices were associated with those who had active attitude towards personal hygiene practices (OR = 2.83, 95 % CI: 1.60-5.01, P < 0.001), those with higher anxiety level towards infectious disease outbreak (compared to “Very low (STAI < 1.5)”, OR for “High (STAI > 2.49)” = 1.73, 95 % CI: 1.03-2.92, P < 0.05), those who believed H7N9 will obtain human to human transmission in the current year (OR = 1.85, 95 % CI: 1.17-2.93, P < 0.01), those who thought H7N9 will have higher impact to the Hong Kong society (OR = 1.67, 95 % CI: 1.16-2.41, P < 0.01), and those who thought they had sufficient knowledge to manage H7N9 risk (OR = 1.68, 95 % CI: 1.17-2.43, P < 0.01) (Table 5).
Table 5

Multiple logistic regression analysis of factors that associate with personal hygiene practice

Characteristics

aPersonal hygiene practice

cCOR (95 % CI)

dAOR (95 % CI)

Inactive N (%)

Active N (%)

Gender

Male

402(87.2)

59(12.8)

1

1

Female

426(76.2)

133(32.8)

2.13(1.52, 2.98)

2.17(1.48, 3.18)

Age

15-24

131(91.6)

12(8.4)

1

1

25-49

281(80.8)

67(19.3)

2.60(1.36, 4.98)

4.81(1.37, 16.89)

50-64

293(80.7)

70(19.3)

2.61(1.37, 4.98)

4.46(1.25, 15.95)

65

123(74.1)

43(25.9)

3.82(1.92, 7.58)

6.19(1.60, 23.99)

Marital status

Single

305(85.9)

50(14.1)

1

 

Married

521(78.6)

142(21.4)

1.66(1.17, 2.36)

 

Occupation

White collar

332(80.8)

79(19.2)

1

1

Blue collar

90(93.8)

6(6.3)

0.28(0.12, 0.66)

0.27(0.11, 0.68)

Housewife, retired or Unemployed

300(76.3)

93(23.7)

1.30(0.93, 1.83)

0.82(0.52, 1.29)

Student

95(89.6)

11(10.4)

0.49(0.25, 0.95)

1.97(0.53, 7.29)

Religion

No

547(83.6)

107(16.4)

1

 

Yes

280(76.7)

85(23.3)

1.55(1.13, 2.14)

 

Chronic disease

No

679(83.5)

134(16.5)

1

1

Yes

148(71.8)

58(28.2)

1.99(1.39, 2.83)

1.84(1.20, 2.82)

Household type

Public housing

322(83.2)

65(16.8)

1

 

Subsidized home ownership housing

139(86.9)

21(13.1

0.75(0.44, 1.27)

 

Private permanent housing

351(77.1)

104(22.9)

1.47(1.04, 2.07)

 

Vulnerable members

No

330(84.4)

61(15.6)

1

 

Yes

497(79.1)

131(20.9)

1.43(1.02, 1.99)

 

Area of residence

Suburb Districts

448(85.0)

79(15.0)

1

1

Densely Populated Districts

247(80.2)

61(19.8)

1.40(0.97, 2.02)

1.59(1.06, 2.37)

Wealthy Districts

133(71.9)

52(28.1)

2.22(1.49, 3.31)

2.58(1.65, 4.05)

bAttitude towards hygiene practice

Inactive

177(90.8)

18(9.2)

1

1

Active

651(78.9)

174(21.1)

2.63(1.57, 4.39)

2.83(1.60, 5.01)

Anxiety score

Very low (STAI < 1.50)

234(84.5)

43(15.5)

1

1

Low (STAI 1.50-1.99

243(85.3)

42(14.7)

0.94(0.59, 1.49)

0.82(0.49, 1.34)

Medium (STAI 2.00-2.49)

216(80.0)

55(20.0)

1.39(0.89, 2.15)

1.19(0.73, 1.94)

High (STAI >2.49)

131(72.4)

50(27.6)

2.08(1.31, 3.29)

1.73(1.03, 2.92)

Believed Hong Kong is susceptible to infectious diseases outbreaks

No

415(84.5)

76(15.5)

1

 

Yes

412(78.2)

115(21.8)

1.52(1.11, 2.10)

 

Believed H7N9 will be capable of human-to-human transmission this year

Not likely

730(83.3)

146(16.7)

1

1

Likely

96(68.1)

45(31.9)

2.34(1.58, 3.48)

1.85(1.17, 2.93)

Have very high chance to be infected by H7N9

Not likely

777(82.0)

171(18.0)

1

 

Likely

51(71.8)

20(28.2)

1.78(1.04, 3.07)

 

Impact of H7N9 affecting your health

Low impact

620(83.4)

120(16.6)

1

 

High impact

220(75.3)

72(24.7)

1.64(1.18, 2.28)

 

Impact of H7N9 to Hong Kong

Low impact

540(84.9)

96(15.1)

1

1

High impact

287(74.9)

96(25.1)

1.88(1.37, 2.58)

1.67(1.16, 2.41)

Perceived knowledge to combat H7N9 outbreak

Not enough

602(84.0)

115(16.0)

1

1

Enough

225(74.8)

76(25.3)

1.77(1.27, 2.45)

1.68(1.17, 2.43)

aActive personal hygiene practice was defined by practicing 6 or more of the following 9 personal hygiene measures, including wash more hands, wash hands with soap, do not share utensils, wear mask when sick, bring own utensils during meals, avoid going to public places and avoid using public transport, avoid contacting with live poultry, avoid eating poultry and avoid going to places that had H7N9 confirmed cases

bActive personal hygiene attitude was defined by regarding 6 or more of the above 9 personal hygiene measures above as useful for prevention H7N9

cCOR, crude odd ratio in the univariate analysis

dAOR, Adjusted odd ratio in the multivariable analysis

Discussion

We assessed the knowledge, attitude and actual practice of the Hong Kong population for pandemic preparedness during the second wave of human infected H7N9 epidemic in mainland China and when the seasonal influenza activity was high in the community. The result showed respondents still harbored misconceptions of H7N9 influenza, were generally not anxious about the H7N9 outbreak, and were not sufficiently practicing protective measures against infections.

Demographic patterns and knowledge gaps

Our study found several demographic determinants coincided with other studies in previous literature of respiratory epidemics and pandemics [24]. Female, 25 years old or older, having chronic disease, living in city center district and white collar workers were associated with better preventive behaviors.

Similar to other previous influenza studies [25, 26], respondents did not have detailed understanding of H7N9 avian influenza. A lot of them mixed up A/H7N9 with other types of influenza or other respiratory virus. Mixing up the characteristics may lead to inappropriate health behaviors, making the protection suboptimal or even risky. Although some precautionary measures are similar for preventing H7N9 influenza and other respiratory infections, specific precautions against avian types of influenza, in particular those avoiding contacts with live poultries and their feces should be emphasized to increase individual awareness for better informed protective measures.

Population anxiety and risk perception

Our study was conducted during the second wave of H7N9 epidemic, at the time, Hong Kong had 5 imported cases with high case fatality ratio, during the winter peak of seasonal influenza. However we found the population still did not take H7N9 seriously. This was reflected in their attitudinal determinants towards the impact of A/H7N9 and their low anxiety level (STAI of 1.85). The population anxiety level was similar to a recent study in Hong Kong during the first wave of H7N9 epidemic in April 2013, and did not increase comparing to the beginning of the second wave when the first case imported in Hong Kong in December 2013 [13]. The anxiety score was also similar to that during the first wave of H1N1 in 2009. In contrast, the anxiety score was much higher (STAI 2.50) during SARS [5]. 74.8 % of Hong Kong population would avoid going to crowded places, and 74.7 % and 71.8 % would avoid going to mainland China and hospitals respectively during SARS period in 2003 [27]. In current study, only 7 % would avoid going to public places and using public transport, and 55.8 % avoid going to places having H7N9 confirmed cases. The findings may indicate public fatigue in response to prolonged warning of influenza pandemic, with people reporting less adoption of infection control behaviours. Though low anxiety level is expected, the misconceptions, inactive attitudes and lack of preventive practices are not optimal for preparedness of future epidemics.

Gaps between perceived usefulness and practice of preventive measures

There are significant gaps between perceived usefulness and practice of mask wearing and do not share utensils during meals. The population showed high compliance with hand washing. 94 % of the Hong Kong population believed that hand washing was efficacious in preventing human-to-human avian influenza during H5N1 period [19] while 97.8 % perceived washing hands frequently as an effective public health measure during H1N1 period [8]. In the current study, this figure was 87.2 %. This might be due to public health announcements on mass media, emphasizing the importance of washing hands frequently. In contrast, for mask wearing and utensils sharing, the proportion of actual practices was far lower than perceived usefulness. 92.4 % of the Hong Kong residents wore face masks when having influenza-like illness during H5N1 period in 2007 [19] and 88.7 % in 2009 during H1N1 period [8]. In the current study, it dropped to 39.0 %. Barriers for taking action may be partly due to discomfort when wearing mask, traditional Chinese norm of sharing utensils when dining, and the inconvenience. Nevertheless, our study results showed the main reason hindering individual control behaviors were that people did not consider H7N9 outbreak a serious threat. Their attitude could be reflected by their low perceived severity and infectivity of the virus. Targeted interventions may focus on increasing the awareness of the population towards the outbreak according to current situations. And further analysis will be needed to identify other specific barriers and to increase the self- efficacy in overcoming them, thus changing the health behavior for better protection.

Limitations

Limitations in the study included the methodological limitations of telephone survey. Firstly, households with no possession of a land-based telephone service may be missed. Nonetheless, the penetration rate of residential fixed line service in Hong Kong was 102.6 % in November 2013. The residential fixed line penetration is calculated by dividing the number of residential fixed lines by the number of households in Hong Kong [28]. Almost all households have at least one home based telephone service in Hong Kong. Secondly, our sample population had higher household income and education level than the Hong Kong general population. This may overestimate the overall results as these groups are more knowledgeable and have better practices for pandemic preparedness in general. Thirdly, there may be some reporting bias. Data were self-reported and data from non-respondents could not be obtained.

Our results may not be generalizable to other countries or cities that have not experienced previous severe epidemics such as SARS. This study presents as a unique reference for pandemic preparedness behavioral response during a second wave epidemic in an urban setting. External factors may influence the stability of the responses during the survey period. Nevertheless, we managed to finish the field data collection within a short period (two weeks) to produce a stable response.

Conclusion

Similar to previous studies, Hong Kong citizens show a low level of anxiety, misconceptions regarding the novel strains as well as gaps between perceived usefulness and practice of preventive measures towards influenza outbreaks. Educational campaigns and framing the issue to increase public and media awareness is crucial in preventing the current public fatigue towards outbreaks.

Availability of data and materials

Not applicable.

Declarations

Acknowledgements

The authors thank all participants of this study and Prof. William B. Goggins for his help in the supporting of statistical analysis. This work has received financial support from the Research Fund for the Control of Infectious Disease, Food and Health Bureau, Government of the Hong Kong SAR (grant no. CU-13-01-01).

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors’ Affiliations

(1)
Collaborating Centre for Oxford University and CUHK for Disaster and Medical Humanitarian Response, JC School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong

References

  1. Demmler GJ, Ligon BL. Severe acute respiratory syndrome (SARS): a review of the history, epidemiology, prevention, and concerns for the future. Semin Pediatr Infect Dis. 2003;14(3):240–4.View ArticlePubMedGoogle Scholar
  2. Tai DYH. SARS: how to manage future outbreaks? Ann Acad Med Singapore. 2006;35(5):368–73.PubMedGoogle Scholar
  3. Lau JTF, Tsui HY, Kim JH, Chan PKS, Griffiths S. Monitoring of perceptions, anticipated behavioral, and psychological responses related to H5N1 influenza. Infection. 2010;38(4):275–83.View ArticlePubMedGoogle Scholar
  4. Centre for Health Protection. http://www.chp.gov.hk/. Accessed 21 February 2014.
  5. Cowling BJ, Ng DMW, Ip DKM, Liao Q, Lam WWT, Wu JT, et al. Community psychological and behavioral responses through the first wave of the 2009 influenza A(H1N1) pandemic in Hong Kong. J Infect Dis. 2010;202(6):867–76.View ArticlePubMedGoogle Scholar
  6. Liao Q, Cowling BJ, Lam WT, Fielding R. Changing Perception of Avian Influenza Risk, Hong Kong, 2006–2010. Emerg Infect Dis. 2011;17(12):2379–80.View ArticlePubMedPubMed CentralGoogle Scholar
  7. Li T, Feng J, Qing P, Fan X, Liu W, Li M, et al. Attitudes, practices and information needs regarding novel influenza A (H7N9) among employees of food production and operation in Guangzhou, Southern China: a cross-sectional study. BMC Infect Dis. 2014;14(1):4.View ArticlePubMedPubMed CentralGoogle Scholar
  8. Lau JTF, Griffiths S, Choi K-C, Lin C. Prevalence of preventive behaviors and associated factors during early phase of the H1N1 influenza epidemic. Am J Infect Control. 2010;38(5):374–80.View ArticlePubMedGoogle Scholar
  9. Parry J. H7N9 avian flu infects humans for the first time. BMJ. 2013;346:f2151.View ArticlePubMedGoogle Scholar
  10. Uyeki TM, Cox NJ. Global concerns regarding novel influenza A (H7N9) virus infections. N Engl J Med. 2013;368(20):1862–4.View ArticlePubMedGoogle Scholar
  11. Government of Hong Kong. Prevention of avian influenza (press releases). http://www.info.gov.hk/gia/general/201312/03/P201312030566.htm. Accessed 13 August 2014
  12. WHO | Situation updates - Avian influenza. http://www.who.int/influenza/human_animal_interface/avian_influenza/archive/en/. Accessed 13 August 2014.
  13. Wu P, Fang VJ, Liao Q, Ng DMW, Wu JT, Leung GM. Responses to Threat of Influenza A (H7N9) and Support for Live Poultry Markets, Hong Kong, 2013. Emerg Infect Dis. 2014;20(5):3–9.Google Scholar
  14. Gao H-N, Lu H-Z, Cao B, Du B, Shang H, Gan J-H, et al. Clinical findings in 111 cases of influenza A (H7N9) virus infection. N Engl J Med. 2013;368(24):2277–85.View ArticlePubMedGoogle Scholar
  15. Liu T, Bi Z, Wang X, Li Z, Ding S, Bi Z, et al. One family cluster of avian influenza A(H7N9) virus infection in Shandong, China. BMC Infect Dis. 2014;14(1):98.View ArticlePubMedPubMed CentralGoogle Scholar
  16. Qi X, Qian Y-H, Bao C-J, Guo X-L, Cui L-B, Tang F-Y, et al. Probable person to person transmission of novel avian influenza A (H7N9) virus in Eastern China, 2013: epidemiological investigation. BMJ. 2013;347:f4752.View ArticlePubMedPubMed CentralGoogle Scholar
  17. Yu H, Cowling BJ, Feng L, Lau EHY, Liao Q, Tsang TK, et al. Human infection with avian influenza A H7N9 virus: an assessment of clinical severity. Lancet. 2013;382(9887):138–45.View ArticlePubMedPubMed CentralGoogle Scholar
  18. Lau JTF, Tsui H, Lau M, Yang X. SARS transmission, risk factors, and prevention in Hong Kong. Emerg Infect Dis. 2004;10(4):587–92.View ArticlePubMedPubMed CentralGoogle Scholar
  19. Lau JTF, Kim JH, Tsui HY, Griffiths S. Anticipated and current preventive behaviors in response to an anticipated human-to-human H5N1 epidemic in the Hong Kong Chinese general population. BMC Infect Dis. 2007;7:18.View ArticlePubMedPubMed CentralGoogle Scholar
  20. Marteau TM, Bekker H. The development of a six-item short-form of the state scale of the Spielberger State-Trait Anxiety Inventory (STAI). Br J Clin Psychol. 1992;31(Pt 3):301–6.View ArticlePubMedGoogle Scholar
  21. Chan EYY, Kim JH, Ng Q, Griffiths S, Lau JTF. A descriptive study of nonfatal, unintentional home-based injury in urban settings: evidence from Hong Kong. Asia Pac J Public Health. 2008;20(Suppl):39–48.PubMedGoogle Scholar
  22. Chan EYY, Kim JH, Griffiths SM, Lau JTF, Yu I. Does Living Density Matter for Nonfatal Unintentional Home Injury in Asian Urban Settings ? Evidence from Hong Kong. J Urban Heal. 2009;86(6):872–86.View ArticleGoogle Scholar
  23. Census and Statistics Department The Government of the Hong Kong Special Administrative Region. 2011 Population Census. Main Tables. 2012. http://www.census2011.gov.hk/en/main-table.html Accessed 20 Feb 2014.
  24. Bish A, Michie S. Demographic and attitudinal determinants of protective behaviours during a pandemic: a review. Br J Health Psychol. 2010;15(Pt 4):797–824.View ArticlePubMedGoogle Scholar
  25. Di Giuseppe G, Abbate R, Albano L, Marinelli P, Angelillo IF. A survey of knowledge, attitudes and practices towards avian influenza in an adult population of Italy. BMC Infect Dis. 2008;8:36.View ArticlePubMedPubMed CentralGoogle Scholar
  26. Lau JTF, Tsui H, Kim JH, Griffiths S. Perceptions about status and modes of H5N1 transmission and associations with immediate behavioral responses in the Hong Kong general population. Prev Med (Baltim). 2006;43(5):406–10.View ArticleGoogle Scholar
  27. Lau JTF, Yang X, Pang E, Tsui HY, Wong E, Wing YK. SARS-related Perceptions in Hong Kong. Emerg Infect Dis. 2005;11(3):417–24.PubMedPubMed CentralGoogle Scholar
  28. Office of the Communications Authority - Key Communications Statistics. http://www.ofca.gov.hk/mobile/en/media_focus/data_statistics/key_stat/index.html. Accessed 21 Feb 2014.

Copyright

© Chan et al. 2015

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