International Journal of
Environmental Research and Public Health Article
A Cross-Sectional Study of Heat Wave-Related Knowledge, Attitude, and Practice among the Public in the Licheng District of Jinan City, China Jing Li 1,2,3 , Xin Xu 4 , Guoyong Ding 5 , Yun Zhao 6 , Ruixia Zhao 6 , Fuzhong Xue 7 , Jing Li 2 , Jinghong Gao 2 , Jun Yang 2 , Baofa Jiang 1,3, * and Qiyong Liu 2,3, * 1 2
3 4 5 6 7
*
Department of Epidemiology and Health Statistics, School of Public Health, Shandong University, Jinan 250012, Shandong, China; [email protected] State Key Laboratory of Infectious Disease Prevention and Control, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, National Institute for Communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing 102206, China; [email protected] (J.L.); [email protected] (J.G.); [email protected] (J.Y.) Shandong University Climate Change and Health Center, Jinan 250012, Shandong, China Department of Dentistry, Affiliated Hospital, Weifang Medical University, Weifang 261000, Shandong, China; [email protected] School of Public Health, Taishan Medical College, Taian 271000, Shandong, China; [email protected] Licheng District Center for Disease Control and Prevention, Jinan 250012, Shandong, China; [email protected] (Y.Z.); [email protected] (R.Z.) Department of Biostatistics, School of Public Health, Shandong University, Jinan 250012, Shandong, China; [email protected] Correspondence: [email protected] (B.J.); [email protected] (Q.L.); Tel.: +86-531-88382141 (B.J.); +86-10-5890-0738 (Q.L.); Fax: +86-10-5890-0739 (B.J. & Q.L.)
Academic Editor: Paul B. Tchourwou Received: 4 April 2016; Accepted: 21 June 2016; Published: 29 June 2016
Abstract: Knowledge, attitude, and practice (KAP) are three key components for reducing the adverse health impacts of heat waves. However, research in eastern China regarding this is scarce. The present study aimed to evaluate the heat wave-related KAP of a population in Licheng in northeast China. This cross-sectional study included 2241 participants. Data regarding demographic characteristics, KAP, and heat illnesses were collected using a structured questionnaire. Univariate analysis and unconditional logistic regression models were used to analyze the data. Most residents had high KAP scores, with a mean score of 12.23 (standard deviation = 2.23) on a 17-point scale. Urban women and participants aged 35–44 years had relatively high total scores, and those with high education levels had the highest total score. There was an increased risk of heat-related illness among those with knowledge scores of 3–5 on an 8-point scale with mean score of 5.40 (standard deviation = 1.45). Having a positive attitude toward sunstroke prevention and engaging in more preventive practices to avoid heat exposure had a protective interaction effect on reducing the prevalence of heat-related illnesses. Although the KAP scores were relatively high, knowledge and practice were lacking to some extent. Therefore, governments should further develop risk-awareness strategies that increase awareness and knowledge regarding the adverse health impact of heat and help in planning response strategies to improve the ability of individuals to cope with heat waves. Keywords: knowledge; attitude; practice; heat waves; China; cross-sectional study
1. Introduction The Fifth Report of the Intergovernmental Panel on Climate Change stated that the average global surface temperature increased linearly by 0.85 ˝ C from 1880 to 2012 [1]. Therefore, it is highly possible Int. J. Environ. Res. Public Health 2016, 13, 648; doi:10.3390/ijerph13070648
www.mdpi.com/journal/ijerph
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that the frequency and duration of heat waves will increase in the future. Heat-related diseases may affect the health of billions of people at risk, and will likely affect most populations in the coming decades [2]. The adverse effects of elevated temperature on mortality have been widely reported. For example, in 2012, heat caused more fatalities than any other severe weather event worldwide [3], and a study from USA reported that 8015 deaths were directly caused by heat waves from 1979 to 1999 [4]. Other studies have reported that the 1995 heat wave in Chicago was alone responsible for over 800 deaths [5], and that the heat wave in 2003 across Europe was associated with 22,000 to 35,000 additional deaths [6]. Heat waves have been reported to introduce health risks in some areas in China. The 2003 heat wave in Shanghai was believed to be associated with high respiratory and cardiovascular mortality rates [7]. Furthermore, extremely high temperature in Guangzhou was linked with an increase in the risk of death [8]. Elderly, women, and individuals with pre-existing diseases are considered to be very vulnerable to heat-related illnesses in China [9,10]. Therefore, more attention should be paid to the health effects of heat and heat waves. A “Knowledge, Attitude, and Practice” (KAP) study is performed in a specific population to collect data on what the population knows, believes, and does regarding a certain topic. The public’s attitude to risks, adaptation practices, and knowledge of heat waves are three of the most important factors for reducing the health impact of heat waves [11,12]. KAP studies on heat waves have been mostly performed in developed countries [13–15], and relatively few studies have been performed in developing countries, especially in China. Yet, according to the Global Climate Risk Index 2014, China is vulnerable to extreme weather events [16]. Therefore, it is important to understand the Chinese public’s KAP in order to reduce the negative effects of heat waves. The public’s KAP can be influenced by several aspects, such as climate type, economic level, and public characteristics. Although KAP data are sensitive, the findings can be considered as local indicators that are only representative in a defined and limited area. KAP studies on heat waves have been performed in the south and west regions of China [12,17]. However, KAP studies on heat waves have not been performed in the east region. Heat waves have become increasingly common in Jinan City. From 1951 to 2005, 763 days had high temperatures (ě35 ˝ C) [18]. According to the 2011 Statistical Yearbook of Jinan City, the maximum daily temperature in summer has continuously increased in recent years, and the maximum temperature reached 41.4 ˝ C in the summer of 2009 [19]. Owing to the continuously high temperature in this region, it is necessary to perform a public survey to evaluate the health impact of heat waves so that the number of deaths from heat waves can be reduced. The results could contribute to the understanding of the public‘s KAP with regard to heat waves, which would in turn provide data to local health authorities and communities for future policy-making and implementation in terms of coping with heat waves and the corresponding adverse effects. The present study aimed to obtain data in order to better understand the heat wave-related KAP of a population in Licheng District of Jinan City in the northeast region of China. We selected Licheng District as the study area because its demographic characteristics, climate type, and population lifestyle are representative of Jinan City [19]. The results will be further evaluated so that they can be used to develop policies for coping with heat waves. 2. Methods 2.1. Study Area and Definition of Heat Waves Licheng District is located in the southeast area of Jinan City (geographical coordinates, 36˝ 401 N and 117˝ 031 E, Figure 1). The area of the district is 1298.57 km2 , with a mean elevation of 41 m and a total population of 1.12 million. At the end of 2010, the sex ratio was 99.6:100 (male:female). The climate of the district is characterized as sub-humid and warm, with obvious continental monsoon weather and four distinct seasons. The annual mean temperature, precipitation, and sunshine hours are 13.8 ˝ C, 685 mm, and 5.1 h, respectively. Licheng District has 15 streets, with 47 community resident committees and 655 administrative villages. Individuals living in the communities mainly work in
Int. J. Environ. Res. Public Health 2016, 13, 648 Int. J. Environ. Res. Public Health 2016, 13, 648
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are 13.8 °C, 685 mm, and 5.1 h, respectively. Licheng District has 15 streets, with 47 community resident committees and 655 administrative villages. Individuals living in the communities mainly industries and related and those living inliving the villages mainly grow cash crops. City is work in industries andservices, related services, and those in the villages mainly grow cashJinan crops. Jinan called one of the four “ovens”. According to the Chinese Meteorological Administration, a “heat day” City is called one of the four “ovens”. According to the Chinese Meteorological Administration, a is“heat defined asisa defined day when maximum exceeds 35 ˝ C, and a 35 heat a period day” as the a day when thetemperature maximum temperature exceeds °C,wave and is a heat waveofisata least three consecutive “heat days” [7]. This definition was adopted in the present study. period of at least three consecutive “heat days” [7]. This definition was adopted in the present study.
Figure 1. 1.The sample streets inin Licheng District, China. Figure Thefour four sample streets Licheng District, China.
2.2. 2.2.Study StudyParticipants Participants The method waswas utilized to select a representative sample sample in Licheng Themultistage multistagesampling sampling method utilized to select a representative in District. Licheng First, the district was divided into an urban area and a rural area according to the density of population District. First, the district was divided into an urban area and a rural area according to the density of and vegetation Then,cover. two streets selectedwere non-randomly from each area that hadarea similar population andcover. vegetation Then,were two streets selected non-randomly from each that demographic characteristics and economic status. The four selected streets were Shanda, Quanfu, had similar demographic characteristics and economic status. The four selected streets were Shanda, Baoshan, Wangsheren (Figure 1). Shanda Quanfuand wereQuanfu from the urban area, Baoshan Quanfu, and Baoshan, and Wangsheren (Figure and 1). Shanda were from theand urban area, and and Wangsheren from the rural selected 600 households each street randomly. Baoshan andwere Wangsheren were area. fromWe thefurther rural area. We further selected from 600 households from each Finally, individuals who were over 14who yearswere old and been old living the been selected areas for selected at least street randomly. Finally, individuals overhad 14 years andinhad living in the for at least 6 months eligible were considered eligible forpresent inclusion in the present study. One eligible 6areas months were considered for inclusion in the study. One eligible participant was participant was selected fromusing each household using the Kish grid method. selected from each household the Kish grid method. 2.3. 2.3.Data DataCollection Collection A was drafted draftedafter aftera review a review of the literature on waves heat waves and climate A questionnaire was of the literature on heat and climate change change [13,15,17,20,21]. were consulted during the development of each question and its [13,15,17,20,21]. ExpertsExperts were consulted during the development of each question and its response. response. The following five sections were present the questionnaire: (1) section (questions The following five sections were present in theinquestionnaire: (1) section “A”“A” (questions on on demographic information, as gender, education, and marital status); (2) section “B” demographic information, suchsuch as gender, age, age, education, and marital status); (2) section “B” (eight (eight questions on knowledge about waves); section“C” “C”(one (oneattitude-related attitude-related question, i.e., questions on knowledge about heatheat waves); (3)(3) section i.e., whether were taken to prevent heatstroke if a high warning had been provided); whethermeasures measures were taken to prevent heatstroke if temperature a high temperature warning had been (4) section “D” questions on questions practices for heat waves andheat previous of provided); (4) (four section “D” (four onpreventing practices for preventing wavesexperiences and previous heat-related diseases); and (5) section “E” (questions on economic and social factors, such as dwelling experiences of heat-related diseases); and (5) section “E” (questions on economic and social factors, environment, cooling system, and neighborhood relationships). such as dwelling environment, cooling system, and neighborhood relationships). From 12 toto1818 July 2014, participant was interviewed by a well-trained From 12 July 2014, each each participant was interviewed at home at by ahome well-trained investigator investigator using the structured questionnaire. Various actions were taken to ensure the quality using the structured questionnaire. Various actions were taken to ensure the quality of the of the questionnaire. First, all interviewers received systematic training for several days the before the questionnaire. First, all interviewers received systematic training for several days before survey.
Int. J. Environ. Res. Public Health 2016, 13, 648
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survey. Training provided the interviewers with an opportunity to become familiar with the survey objectives, content, and plan for implementation in the study. The training mainly included the following areas: survey purpose; roles and responsibilities; content and use of the questionnaires; survey forms and materials; appropriate interviewing techniques, including listening skills and probing techniques; and final pre-testing of the questionnaire. A small-scale pilot study was performed to assess the validity and reliability of the questionnaire. Moreover, the questionnaire and the research methods were thoroughly discussed within the research team. Feedback was carefully reviewed, and appropriate modifications were made to the questionnaire. Furthermore, four senior researchers were always present during questionnaire collection to monitor the process and examine the quality of the data collected. 2.4. Statistical Analysis There were eight, one, and four questions regarding knowledge (K), attitude (A), and practice (P), respectively. For the K and P sections, the scores were assessed by assigning 1 point to each response of “Yes” and 0 point to response of “No.” For the A section, a 5-point scale was used as the marking scheme, corresponding to the five options of the questions (the options from “not at all” to “very much” were scored from 1 to 5). The score ranges for the K, A, and P sections were 0–8, 1–5, and 0–4, respectively. The total KAP score was the sum of the scores of the three components, and the score range was 1 to 17. To identify the occurrence of a heat-related illness, which was the dependent variable in our study, every participant was asked if they felt discomfort due to high temperature and visited a doctor; if they showed self-medication behavior to cope with the heat; if they had been diagnosed with heatstroke by a clinical doctor; or if they had any symptoms of heatstroke during the heat wave period in a particular year. Those who responded “yes” to any of the above questions were considered to have experienced heat-related illnesses in this study. Mean and standard deviation (SD) values were calculated for continuous variables, such as age and KAP score. Categorical variables were computed as a percentage of subjects with the perspective attribute. First, univariate analysis of variance was used to test the association of each demographic characteristic with the K, A, and P scores and the total score. Then, Pearson correlation analysis was performed to clarify the correlations among the K, A, and P scores. In the next stage, participants were divided into three groups according to the K score (5), two groups according to the A score (
Environmental Research and Public Health Article
A Cross-Sectional Study of Heat Wave-Related Knowledge, Attitude, and Practice among the Public in the Licheng District of Jinan City, China Jing Li 1,2,3 , Xin Xu 4 , Guoyong Ding 5 , Yun Zhao 6 , Ruixia Zhao 6 , Fuzhong Xue 7 , Jing Li 2 , Jinghong Gao 2 , Jun Yang 2 , Baofa Jiang 1,3, * and Qiyong Liu 2,3, * 1 2
3 4 5 6 7
*
Department of Epidemiology and Health Statistics, School of Public Health, Shandong University, Jinan 250012, Shandong, China; [email protected] State Key Laboratory of Infectious Disease Prevention and Control, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, National Institute for Communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing 102206, China; [email protected] (J.L.); [email protected] (J.G.); [email protected] (J.Y.) Shandong University Climate Change and Health Center, Jinan 250012, Shandong, China Department of Dentistry, Affiliated Hospital, Weifang Medical University, Weifang 261000, Shandong, China; [email protected] School of Public Health, Taishan Medical College, Taian 271000, Shandong, China; [email protected] Licheng District Center for Disease Control and Prevention, Jinan 250012, Shandong, China; [email protected] (Y.Z.); [email protected] (R.Z.) Department of Biostatistics, School of Public Health, Shandong University, Jinan 250012, Shandong, China; [email protected] Correspondence: [email protected] (B.J.); [email protected] (Q.L.); Tel.: +86-531-88382141 (B.J.); +86-10-5890-0738 (Q.L.); Fax: +86-10-5890-0739 (B.J. & Q.L.)
Academic Editor: Paul B. Tchourwou Received: 4 April 2016; Accepted: 21 June 2016; Published: 29 June 2016
Abstract: Knowledge, attitude, and practice (KAP) are three key components for reducing the adverse health impacts of heat waves. However, research in eastern China regarding this is scarce. The present study aimed to evaluate the heat wave-related KAP of a population in Licheng in northeast China. This cross-sectional study included 2241 participants. Data regarding demographic characteristics, KAP, and heat illnesses were collected using a structured questionnaire. Univariate analysis and unconditional logistic regression models were used to analyze the data. Most residents had high KAP scores, with a mean score of 12.23 (standard deviation = 2.23) on a 17-point scale. Urban women and participants aged 35–44 years had relatively high total scores, and those with high education levels had the highest total score. There was an increased risk of heat-related illness among those with knowledge scores of 3–5 on an 8-point scale with mean score of 5.40 (standard deviation = 1.45). Having a positive attitude toward sunstroke prevention and engaging in more preventive practices to avoid heat exposure had a protective interaction effect on reducing the prevalence of heat-related illnesses. Although the KAP scores were relatively high, knowledge and practice were lacking to some extent. Therefore, governments should further develop risk-awareness strategies that increase awareness and knowledge regarding the adverse health impact of heat and help in planning response strategies to improve the ability of individuals to cope with heat waves. Keywords: knowledge; attitude; practice; heat waves; China; cross-sectional study
1. Introduction The Fifth Report of the Intergovernmental Panel on Climate Change stated that the average global surface temperature increased linearly by 0.85 ˝ C from 1880 to 2012 [1]. Therefore, it is highly possible Int. J. Environ. Res. Public Health 2016, 13, 648; doi:10.3390/ijerph13070648
www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2016, 13, 648
2 of 16
that the frequency and duration of heat waves will increase in the future. Heat-related diseases may affect the health of billions of people at risk, and will likely affect most populations in the coming decades [2]. The adverse effects of elevated temperature on mortality have been widely reported. For example, in 2012, heat caused more fatalities than any other severe weather event worldwide [3], and a study from USA reported that 8015 deaths were directly caused by heat waves from 1979 to 1999 [4]. Other studies have reported that the 1995 heat wave in Chicago was alone responsible for over 800 deaths [5], and that the heat wave in 2003 across Europe was associated with 22,000 to 35,000 additional deaths [6]. Heat waves have been reported to introduce health risks in some areas in China. The 2003 heat wave in Shanghai was believed to be associated with high respiratory and cardiovascular mortality rates [7]. Furthermore, extremely high temperature in Guangzhou was linked with an increase in the risk of death [8]. Elderly, women, and individuals with pre-existing diseases are considered to be very vulnerable to heat-related illnesses in China [9,10]. Therefore, more attention should be paid to the health effects of heat and heat waves. A “Knowledge, Attitude, and Practice” (KAP) study is performed in a specific population to collect data on what the population knows, believes, and does regarding a certain topic. The public’s attitude to risks, adaptation practices, and knowledge of heat waves are three of the most important factors for reducing the health impact of heat waves [11,12]. KAP studies on heat waves have been mostly performed in developed countries [13–15], and relatively few studies have been performed in developing countries, especially in China. Yet, according to the Global Climate Risk Index 2014, China is vulnerable to extreme weather events [16]. Therefore, it is important to understand the Chinese public’s KAP in order to reduce the negative effects of heat waves. The public’s KAP can be influenced by several aspects, such as climate type, economic level, and public characteristics. Although KAP data are sensitive, the findings can be considered as local indicators that are only representative in a defined and limited area. KAP studies on heat waves have been performed in the south and west regions of China [12,17]. However, KAP studies on heat waves have not been performed in the east region. Heat waves have become increasingly common in Jinan City. From 1951 to 2005, 763 days had high temperatures (ě35 ˝ C) [18]. According to the 2011 Statistical Yearbook of Jinan City, the maximum daily temperature in summer has continuously increased in recent years, and the maximum temperature reached 41.4 ˝ C in the summer of 2009 [19]. Owing to the continuously high temperature in this region, it is necessary to perform a public survey to evaluate the health impact of heat waves so that the number of deaths from heat waves can be reduced. The results could contribute to the understanding of the public‘s KAP with regard to heat waves, which would in turn provide data to local health authorities and communities for future policy-making and implementation in terms of coping with heat waves and the corresponding adverse effects. The present study aimed to obtain data in order to better understand the heat wave-related KAP of a population in Licheng District of Jinan City in the northeast region of China. We selected Licheng District as the study area because its demographic characteristics, climate type, and population lifestyle are representative of Jinan City [19]. The results will be further evaluated so that they can be used to develop policies for coping with heat waves. 2. Methods 2.1. Study Area and Definition of Heat Waves Licheng District is located in the southeast area of Jinan City (geographical coordinates, 36˝ 401 N and 117˝ 031 E, Figure 1). The area of the district is 1298.57 km2 , with a mean elevation of 41 m and a total population of 1.12 million. At the end of 2010, the sex ratio was 99.6:100 (male:female). The climate of the district is characterized as sub-humid and warm, with obvious continental monsoon weather and four distinct seasons. The annual mean temperature, precipitation, and sunshine hours are 13.8 ˝ C, 685 mm, and 5.1 h, respectively. Licheng District has 15 streets, with 47 community resident committees and 655 administrative villages. Individuals living in the communities mainly work in
Int. J. Environ. Res. Public Health 2016, 13, 648 Int. J. Environ. Res. Public Health 2016, 13, 648
3 of 15 3 of 16
are 13.8 °C, 685 mm, and 5.1 h, respectively. Licheng District has 15 streets, with 47 community resident committees and 655 administrative villages. Individuals living in the communities mainly industries and related and those living inliving the villages mainly grow cash crops. City is work in industries andservices, related services, and those in the villages mainly grow cashJinan crops. Jinan called one of the four “ovens”. According to the Chinese Meteorological Administration, a “heat day” City is called one of the four “ovens”. According to the Chinese Meteorological Administration, a is“heat defined asisa defined day when maximum exceeds 35 ˝ C, and a 35 heat a period day” as the a day when thetemperature maximum temperature exceeds °C,wave and is a heat waveofisata least three consecutive “heat days” [7]. This definition was adopted in the present study. period of at least three consecutive “heat days” [7]. This definition was adopted in the present study.
Figure 1. 1.The sample streets inin Licheng District, China. Figure Thefour four sample streets Licheng District, China.
2.2. 2.2.Study StudyParticipants Participants The method waswas utilized to select a representative sample sample in Licheng Themultistage multistagesampling sampling method utilized to select a representative in District. Licheng First, the district was divided into an urban area and a rural area according to the density of population District. First, the district was divided into an urban area and a rural area according to the density of and vegetation Then,cover. two streets selectedwere non-randomly from each area that hadarea similar population andcover. vegetation Then,were two streets selected non-randomly from each that demographic characteristics and economic status. The four selected streets were Shanda, Quanfu, had similar demographic characteristics and economic status. The four selected streets were Shanda, Baoshan, Wangsheren (Figure 1). Shanda Quanfuand wereQuanfu from the urban area, Baoshan Quanfu, and Baoshan, and Wangsheren (Figure and 1). Shanda were from theand urban area, and and Wangsheren from the rural selected 600 households each street randomly. Baoshan andwere Wangsheren were area. fromWe thefurther rural area. We further selected from 600 households from each Finally, individuals who were over 14who yearswere old and been old living the been selected areas for selected at least street randomly. Finally, individuals overhad 14 years andinhad living in the for at least 6 months eligible were considered eligible forpresent inclusion in the present study. One eligible 6areas months were considered for inclusion in the study. One eligible participant was participant was selected fromusing each household using the Kish grid method. selected from each household the Kish grid method. 2.3. 2.3.Data DataCollection Collection A was drafted draftedafter aftera review a review of the literature on waves heat waves and climate A questionnaire was of the literature on heat and climate change change [13,15,17,20,21]. were consulted during the development of each question and its [13,15,17,20,21]. ExpertsExperts were consulted during the development of each question and its response. response. The following five sections were present the questionnaire: (1) section (questions The following five sections were present in theinquestionnaire: (1) section “A”“A” (questions on on demographic information, as gender, education, and marital status); (2) section “B” demographic information, suchsuch as gender, age, age, education, and marital status); (2) section “B” (eight (eight questions on knowledge about waves); section“C” “C”(one (oneattitude-related attitude-related question, i.e., questions on knowledge about heatheat waves); (3)(3) section i.e., whether were taken to prevent heatstroke if a high warning had been provided); whethermeasures measures were taken to prevent heatstroke if temperature a high temperature warning had been (4) section “D” questions on questions practices for heat waves andheat previous of provided); (4) (four section “D” (four onpreventing practices for preventing wavesexperiences and previous heat-related diseases); and (5) section “E” (questions on economic and social factors, such as dwelling experiences of heat-related diseases); and (5) section “E” (questions on economic and social factors, environment, cooling system, and neighborhood relationships). such as dwelling environment, cooling system, and neighborhood relationships). From 12 toto1818 July 2014, participant was interviewed by a well-trained From 12 July 2014, each each participant was interviewed at home at by ahome well-trained investigator investigator using the structured questionnaire. Various actions were taken to ensure the quality using the structured questionnaire. Various actions were taken to ensure the quality of the of the questionnaire. First, all interviewers received systematic training for several days the before the questionnaire. First, all interviewers received systematic training for several days before survey.
Int. J. Environ. Res. Public Health 2016, 13, 648
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survey. Training provided the interviewers with an opportunity to become familiar with the survey objectives, content, and plan for implementation in the study. The training mainly included the following areas: survey purpose; roles and responsibilities; content and use of the questionnaires; survey forms and materials; appropriate interviewing techniques, including listening skills and probing techniques; and final pre-testing of the questionnaire. A small-scale pilot study was performed to assess the validity and reliability of the questionnaire. Moreover, the questionnaire and the research methods were thoroughly discussed within the research team. Feedback was carefully reviewed, and appropriate modifications were made to the questionnaire. Furthermore, four senior researchers were always present during questionnaire collection to monitor the process and examine the quality of the data collected. 2.4. Statistical Analysis There were eight, one, and four questions regarding knowledge (K), attitude (A), and practice (P), respectively. For the K and P sections, the scores were assessed by assigning 1 point to each response of “Yes” and 0 point to response of “No.” For the A section, a 5-point scale was used as the marking scheme, corresponding to the five options of the questions (the options from “not at all” to “very much” were scored from 1 to 5). The score ranges for the K, A, and P sections were 0–8, 1–5, and 0–4, respectively. The total KAP score was the sum of the scores of the three components, and the score range was 1 to 17. To identify the occurrence of a heat-related illness, which was the dependent variable in our study, every participant was asked if they felt discomfort due to high temperature and visited a doctor; if they showed self-medication behavior to cope with the heat; if they had been diagnosed with heatstroke by a clinical doctor; or if they had any symptoms of heatstroke during the heat wave period in a particular year. Those who responded “yes” to any of the above questions were considered to have experienced heat-related illnesses in this study. Mean and standard deviation (SD) values were calculated for continuous variables, such as age and KAP score. Categorical variables were computed as a percentage of subjects with the perspective attribute. First, univariate analysis of variance was used to test the association of each demographic characteristic with the K, A, and P scores and the total score. Then, Pearson correlation analysis was performed to clarify the correlations among the K, A, and P scores. In the next stage, participants were divided into three groups according to the K score (5), two groups according to the A score (
