An analysis of influenza prevention measures from air travellers’ perspective P-F. Chou
BA, PhD
Assistant Professor, Department of Business Administration, Far East University, Tainan City, Taiwan
CHOU P-F. (2014) An analysis of influenza prevention measures from air travelers’ perspective. International Nursing Review 61, 371–379 Background: The influenza A virus is easily transmitted through airborne saliva droplets disseminated by unprotected coughing or sneezing, particularly in a crowded, enclosed space. Aim: The purpose of this study was to analyse the knowledge, attitudes and practices of air travellers regarding influenza A preventive measures and to examine any significant differences in perceptions among different types of traveller groups. Methods: This study used a 5-point Likert scale questionnaire and surveyed 1684 passengers at Taoyuan International Airport in Taiwan. The frequencies, mean score and ranking of descriptive analyses were used to evaluate respondents’ demographic profiles. t-Test, one-way analysis of variance and Scheffe post hoc analyses were used to evaluate the relationship among knowledge, attitudes and practices, and respondents’ characteristics. Results: There were significant differences in the knowledge, attitudes and practices measures among groups with different types of trip purposes and among occupation groups. Most passengers expressed common knowledge regarding influenza A; however, their attitudes and their degree of perception were not consistent with their prevention practices. Limitations: This research is limited because it only examined surveyed air travellers in Taiwan. Conclusion: Air travellers could benefit greatly if the government and airlines were to implement a health policy that includes education on the importance of influenza prevention measures, such as frequent hand washing, to citizens. Nurses could be involved in this important health promotion activity. Implications for Nursing and Health Policy: Schools should implement a health education policy to communicate the importance of prevention measures. Nurses can consider how they can be involved in emphasizing the importance of prevention and health promotion regarding this. Airlines should also include basic preventive measures as a component of flight attendant training. Keywords: Air Travellers, Attitudes, Influenza A, Knowledge, Practices, Prevention
Correspondence address: Pin-Fenn Chou, Department of Business Administration, Far East University, No. 49 Zhonghua Road, Xinshi District, Tainan City 74448, Taiwan; Tel: +886-6-5979566 ext. 5213; Fax: +886-6-5977610; E-mail: [email protected].
Source of funding statement: This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. Conflict of interest statement: No conflict of interest has been declared by the author.
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Introduction During 2009, the novel strains of influenza A were aggressive and spread rapidly. Influenza A, also known as H1N1, is a contagious respiratory infection and can be fatal. Influenza A is transmitted through airborne-disseminated saliva particles and through close person-to-person contact (Lin et al. 2011; WHO 2013). The transmission is particularly intensified in crowded, enclosed areas, such as the interior of an
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airplane (Pfeil et al. 2010). Therefore, air travellers with flu-like illnesses play an important role in the spread of novel strains of influenza viruses (Sharangpani et al. 2011). To limit the spread of infection through international travel, the World Health Organization (WHO) advised the postponement of non-essential travel to influenza A-affected areas during the epidemic period. For various reasons, including studying abroad, visiting sick friends or family, and travelling for business, some travellers could not avoid travelling to influenza A-infected countries. To curb the outbreak of influenza A, the Centers for Disease Control and Prevention (CDC) provided guidelines for prevention and response for people in different environmental backgrounds and community settings. The people in environmental backgrounds included patients and pregnant and breastfeeding women. The community settings included child care programs, schools, colleges and universities (CDC 2014). The CDC report indicated that people in different environmental backgrounds exhibit different preventive behaviours. Xiang et al. (2010) reported that a higher percentage of an urban test group used soap for hand washing, whereas a rural test group preferred water only. A knowledge, attitude, and practice (KAP) survey is a representative study of a specific population that is used to collect information on what is known, believed and done in relation to a particular topic (WHO 2008). In the health field, many studies have discussed group perceptions on KAP based on various demographic statistics. Annelies et al. (2007) explored vaccinations for vaccinepreventable respiratory disease among travellers and concluded that women were more likely to receive vaccine boosters than men. Lin et al. (2011) indicated there was no significant difference in knowledge and behaviours regarding influenza A between men and women. However, women were more aware of influenza A risk and exhibited more preventive behaviours than men. Yanni et al. (2010) used the KAP approach to explore avian influenza preventive measures. The results showed there was no significant difference in preventive behaviours between men and women. Many studies also reported no significant difference in knowledge of influenza between genders (Provost & Soto 2001; van Genderen et al. 2012; Yanni et al. 2010). Taglioni et al. (2013) used KAP theory to investigate the influenza A pandemic on Reunion Island and found that over half of the respondents took one or more preventive measures. The study revealed two important preventive measures for infectious disease: frequent hand washing and avoidance of crowded places. The prevention of infectious disease is important; however, some people still do not undertake the necessity of preventive
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measures. Herck et al. (2003) revealed that more than one-third of travellers who were interviewed did not seek pre-travel health advice. Herck et al. (2004) also indicated that the majority of travellers, 73.3%, had sought general information about their destination prior to departure, whereas only 52.1% of the responders had sought travel health advice. Yanni et al. (2010) studied seasonal influenza and H5N1 avian influenza preventive measures based on travellers’ trip purpose and found that those who were visiting friends had significantly different preventive behaviours than other groups. van Genderen et al. (2012) reported that business travellers sought travel health advice for their health less frequently than non-business travellers, even though the business travellers did not have significantly different knowledge or attitudes regarding preventive practices for high-risk destinations compared with other groups. That study also found that business travellers had significantly different KAP for low-risk destinations than other groups. Pistone et al. (2010) showed there were significantly different perceptions of malaria prevention among groups based on different trip purposes, including business, tourism, return to country of origin, humanitarian, and other. Shendre & Tiwari (2005) reported that people with different occupational backgrounds had different perceptions of how diseases are spread. Elias & Shiftan (2012) found that people with different occupational backgrounds had different risk perceptions of and attitudes towards travel behaviour. Kamate et al. (2010) also reported that different occupational groups, such as working and non-working groups, had different KAP of influenza A.
Aim Previous research has focused on KAP, but few empirical studies have examined KAP regarding influenza A among air travellers, which was the aim of the present study. This study developed recommendations for the airline industry regarding how to improve prevention practices for influenza A by involving Taiwan government, schools, nursing professionals and airlines.
Methods Questionnaire design
A questionnaire was used to survey participants. The 16 items in the survey were derived from previous KAP studies, including those by Brug et al. (2004), Herck et al. (2003, 2004) and the CDC (2009). The questionnaire content was separated into two parts: (1) the participants’ perceptions of KAP of influenza A, and (2) participant demographics, including gender, age, trip purpose, education and occupation. In the first part of the survey, items were rated according to a 5-point Likert scale,
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from 1 (totally disagree) to 5 (totally agree). A response greater than 3 indicated that the respondent tended to agree with a given survey item. The instrument’s accuracy and content validity were tested. The content validity of the questionnaire was evaluated based on a literature review, interviews with various aviation and health experts, and a pilot test. The questionnaire items were determined to be relevant, and minor modifications were subsequently made to the wording. Examples were provided for some of the measurement items to improve the validity of the items. Additionally, Cronbach’s alpha was used to determine whether these items were consistent and reliable. In this study, the Cronbach’s alpha values for KAP were 0.807, 0.837 and 0.829, respectively. All values were greater than 0.70 and therefore achieved the threshold of reliability (Nunnally 1978).
Survey and sampling
Convenience sampling was used for this study. This approach is simple, rapid and cost-efficient (Lunsford & Lunsford 1995). In compliance with the ethical approval, a formal request was sent to the Taoyuan International Airport Corporation by the researcher. Permission was granted to conduct interviews related to this study with passengers within the departure hall of Taiwan Taoyuan International Airport. The survey was conducted during 10 days in February 2013 by six interviewers. The interviewers approached the passengers, stated the survey purpose and conducted personal interviews with interested passengers. The sample size needed to be greater than 1067 to obtain a 3% margin of error and a 95% confidence interval (Abraham & Wilbur 2008). A total of 2000 questionnaires were distributed to passengers, but only 1684 were usable for research purposes, representing a response rate of 84.2%.
Statistical analysis
Descriptive statistics, t-test and one-way analysis of variance (ANOVA) were used to analyse the respondents’ demographics. Many health studies also used both of the t-test and ANOVA statistical technique to analyse the differences in the responses groups (Kamate et al. 2010; Lin et al. 2011; Taglioni et al. 2013; Tanaka et al. 2008; van Genderen et al. 2012). Thus, t-test and ANOVA were performed to examine whether there were any significant differences among the respondents’ answers based on gender, trip purpose or occupation. If the ANOVA results showed significant differences, the Scheffe post hoc analysis was used for post-analysis. Appropriate P-values were determined based on the study by Lu et al. (2005), and the significance levels were set at P < 0.05 and P < 0.01.
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Results Demographics
Participant profiles were divided into the following groups: gender, age, trip purpose, education and occupation. Of the 1684 respondents, 820 (48.7%) were male and 864 (51.3%) were female; 650 (38.6%) were 25 years old or younger, 761 (45.2%) were between 26 and 55 years old, and 273 (16.2%) were 56 years old or older. The majority of the respondents, 1063 (63.1%), were leisure travellers, 306 (18.2%) were business travellers, 156 (9.3%) had other travel reasons, 85 (5.0%) were visiting friends, and 74 (4.4%) were returning home. Over half of the respondents, 847 (50.3%), had a university level education, 458 (27.2%) had a high school education, 229 (13.6%) had a secondary education or less, and 150 (8.9%) had a postgraduate education. Approximately one-third of the respondents, 521 (30.9%), worked in the service sector, 382 (22.7%) worked in the manufacturing sector, 236 (14.0%) were students, 221 (13.1%) were government employees, and 324 (19.3%) worked in other sectors. t-Test and one-way ANOVA results Gender
Table 1 shows that all the items had a higher mean score for women than for men, which indicates that women had a higher agreement level for all items describing KAP. In their responses, men and women showed they had almost the same ranking for KAP items. For knowledge, both men and women responded that they had a good understanding of the symptoms of influenza A. Regarding attitudes, both men and women showed the most agreement with the item ‘I care about the influenza A epidemic very much’, whereas the item ‘I think that people who have influenza A are more likely to die’ had the lowest agreement level. Regarding practice, both men and women showed the most agreement on the item ‘I will keep away from those who are suspected of having influenza A’, whereas the item ‘I will wash my hands frequently on the aircraft’ had the lowest agreement level. t-Test analysis results showed that the attitudes and practices significantly differed between genders at the 5% significance level; two knowledge items did not significantly differ, as shown in Table 1. Trip purpose
The passengers’ trip purpose was separated into three subgroups: leisure, business, and other. Their responses are shown in Table 2. Regarding knowledge, all three subgroups answered
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Table 1 The mean, rank and t-test results of the respondents’ agreement level with knowledge, attitudes and practice items by gender Measure items
Male n = 820
Knowledge K2 I understand the symptoms of influenza A K1 I understand how influenza A is transmitted Attitudes A2 I care about the influenza A epidemic very much A4 I am afraid the influenza A epidemics will expand continuously A3 I will avoid travelling by plane during the influenza A epidemic A7 I am scared because I was infected by influenza A viruses before A5 I think it is difficult to control the spread of influenza A viruses A1 I think there is a high probability that I will be infected with influenza A viruses during the epidemic A6 I think that people who have influenza A are more likely to die Practice B7 I will keep away from those who are suspected of having influenza A B5 I will use tissues or use my hands to cover my mouth and nose when I sneeze or cough B6 I am willing to be isolated and checked if I have influenza A B4 I will actively inform the flight crew when I have a fever or a cough B3 I will wash my hands thoroughly before a meal on the aircraft B1 I will wear a mask on the aircraft B2 I will wash my hands frequently on the aircraft
Female n = 864
t-Test
Mean
Rank
Mean
Rank
4.03 4.00
1 2
4.04 4.03
1 2
−0.10 −0.94
4.06 3.80 3.71 3.57 3.44 3.38
1 2 3 4 5 6
4.13 4.03 3.86 3.85 3.55 3.60
1 2 3 4 6 5
−2.07* −5.44** −3.10** −6.55** −2.13* −4.55**
3.14
7
3.27
7
−2.36*
4.29 4.22 4.07 4.05 3.92 3.85 3.81
1 2 3 4 5 6 7
4.37 4.30 4.16 4.16 4.09 3.98 3.96
1 2 3 3 4 5 6
−2.28* −2.23* −2.75** −3.43** −4.91** −3.41** −3.92**
*P < 0.05; **P < 0.01.
that they had a good understanding of the symptoms of influenza A. Regarding attitudes, the three subgroups showed the most agreement on the item ‘I care about the influenza A epidemic very much’, whereas the item ‘I think that people who have influenza A are more likely to die’ had the lowest agreement level. Regarding practice, all three groups showed the most agreement on the item ‘I will keep away from those who are suspected of having influenza A’, whereas the item ‘I will wash my hands frequently on the aircraft’ had the lowest degree of agreement. According to the ANOVA analysis, all items showed significant differences at P < 0.05, except for items A2, A3, A4, B1 and B6. The Scheffe post hoc test showed that the business subgroup had a significantly higher degree of knowledge and a lower perception of attitude items compared with other two groups. Both the leisure and the business subgroups had a higher perception of practice items compared with other groups.
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Occupation
There were five occupational subgroups: student, government, manufacturing, service, and other. To understand whether there were significant differences in the occupational subgroups’ perceptions of KAP, this study chose to exclude those respondents who classified themselves in the ‘other’ group. The results are shown in Table 3. Regarding knowledge, the student, manufacturing and service subgroups agreed the most with the item ‘I understand the symptoms of influenza A’, and the government subgroup agreed the most with the item ‘I understand how influenza A is transmitted’. Regarding attitudes, all four specific subgroups agreed the most with the item ‘I care about the influenza A epidemic very much’, whereas the item ‘I think that people who have influenza A are more likely to die’ had the lowest agreement level. Regarding practice, the government, manufacturing and service subgroups showed the most agreement with the item ‘I will keep away from those who are suspected of having influenza A’, whereas the groups agreed the
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Table 2 The mean, rank, F-value and Scheffe test results of the respondents’ agreement level with knowledge, attitudes and practice items by trip purpose Measure items
Knowledge K1 I understand how influenza A is transmitted K2 I understand the symptoms of influenza A Attitudes A1 I think there is a high probability that I will be infected with influenza A viruses during the epidemic A2 I care about the influenza A epidemic very much A3 I will avoid travelling by plane during the influenza A epidemic A4 I am afraid the influenza A epidemics will expand continuously A5 I think it is difficult to control the spread of influenza A viruses A6 I think that people who have influenza A are more likely to die A7 I am scared because I was infected by influenza A viruses before Practices B1 I will wear a mask on the aircraft B2 I will wash my hands frequently on the aircraft B3 I will wash my hands thoroughly before a meal on the aircraft B4 I will actively inform the flight crew when I have a fever or a cough B5 I will use tissues or use my hands to cover my mouth and nose when I sneeze or cough B6 I am willing to be isolated and checked if I have influenza A B7 I will keep away from those who are suspected of having influenza A
Group 1 Leisure n = 1063
Group 2 Business n = 306
Group 3 Other n = 315
F-value
Scheffe test comparison groups
Mean
Rank
Mean
Rank
Mean
Rank
3.96 3.99
2 1
4.14 4.17
2 1
4.05 4.07
2 1
7.26** 7.46**
2>1 2>1
3.50
5
3.33
5
3.61
6
6.38**
3>1>2
4.10 3.79 3.94 3.49 3.15 3.74
1 3 2 6 7 4
4.12 3.73 3.83 3.29 3.01 3.55
1 3 2 6 7 4
4.08 3.82 3.94 3.73 3.55 3.78
1 3 2 5 7 4
0.26 0.72 1.97 14.13** 19.76** 5.55**
3>1>2 3>1>2 3>1>2
3.93 3.92 4.05 4.14 4.28
6 7 5 3 2
3.90 3.78 3.89 4.09 4.38
5 7 6 4 2
3.87 3.86 3.99 4.01 4.08
6 7 5 4 2
0.83 3.93* 5.75** 4.06* 15.27**
1>2 1>2 1>3 2>1>3
4.12 4.36
4 1
4.16 4.43
3 1
4.05 4.16
3 1
2.24 13.55**
2>1>3
*P < 0.05; **P < 0.01.
least with the item ‘I will wash my hands frequently on the aircraft’. Students had the lowest agreement level for the item ‘I will wear a mask on the aircraft’. The results of the ANOVA showed there were significantly different KAP perceptions among the different occupational groups; however, items A1, A2, A6, A7 and B4 did not show a significant difference. The Scheffe post hoc test results showed that the student subgroup had a significantly higher perception on the K1, K2, A3, A4 and A5 items (P < 0.05) than the other three subgroups (government, manufacturing and service). The government subgroup had a significantly higher perception of the B1, B2, B3, B5, B6 and B7 items than the other three subgroups.
Discussion The best prevention against influenza A is vaccination. This study contributes to the additional everyday measures that can be used to prevent the spread of germs by air travellers.
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Additionally, this study contributes to the extant literature by showing that the instrument used in this study is effective in assessing KAP related to influenza and can therefore be confidently used in future influenza prevention-related studies involving airline passengers. Men and women had similar perceptions of the transmission and symptoms of influenza A; however, there were significant differences in attitude and prevention practice between genders. The significant differences were found to be consistent with those observed in previous health studies (Kamate et al. 2010; Lin et al. 2011; Yanni et al. 2010). Women’s perceptions of the KAP items were found to be higher than those of men. For example, women appeared to consider influenza A epidemics to be more serious than men. Regarding preventive practice, women were more likely than men to avoid travelling during influenza A epidemics and to avoid people suspected of having influenza A; they were also more likely to inform the flight crew when they felt ill and were more willing to be isolated when
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Table 3 The mean, rank, F-value and Scheffe test results of the respondents’ agreement level with knowledge, attitudes and practice items by occupations Measure items
Knowledge K1 I understand how influenza A is transmitted K2 I understand the symptoms of influenza A Attitudes A1 I think there is a high probability that I will be infected with influenza A viruses during the epidemic A2 I care about the influenza A epidemic very much A3 I will avoid travelling by plane during the influenza A epidemic A4 I am afraid the influenza A epidemics will expand continuously A5 I think it is difficult to control the spread of influenza A viruses A6 I think that people who have influenza A are more likely to die A7 I am scared because I was infected by influenza viruses before Practices B1 I will wear a mask on the aircraft B2 I will wash my hands frequently on the aircraft B3 I will wash my hands thoroughly before a meal on the aircraft B4 I will actively inform the flight crew when I have a fever or a cough B5 I will use tissues or use my hands to cover my mouth and nose when I sneeze or cough B6 I am willing to be isolated and checked if I have influenza A B7 I will keep away from those who are suspected of having influenza A
Group 1 Student n = 236
Group 2 Government n = 221
Group 3 Manufacture† n = 382
Group 4 Service‡ n = 521
F-value
Scheffe test comparison of groups
1>2>3 1>3
Mean
Rank
Mean
Rank
Mean
Rank
Mean
Rank
4.10 4.19
2 1
4.09 4.05
1 2
3.90 3.92
2 1
4.01 4.03
2 1
4.73** 6.19**
3.48
6
3.53
5
3.39
5
3.43
6
0.94
4.14 3.95 4.09
1 3 2
4.17 3.61 3.93
1 4 2
4.08 3.71 3.72
1 3 2
4.06 3.75 3.87
1 3 2
1.80 4.92** 9.17**
1>3>2 1>2>4>3
3.64
5
3.35
6
3.39
5
3.45
5
3.73*
1>3>2
3.25 3.74
7 4
3.11 3.63
7 3
3.14 3.63
6 4
3.13 3.66
7 4
0.73 0.70
3.77 3.92 4.04 4.04
6 5 3 3
4.03 3.98 4.11 4.17
6 7 5 4
3.83 3.77 3.84 4.02
6 7 5 4
3.96 3.85 4.01 4.11
6 7 5 4
5.71** 3.65* 8.18** 2.46
2>3>1 2>3 2>1>4>3
4.15
2
4.29
2
4.22
2
4.30
2
2.85*
2>1
4.03 4.18
4 1
4.23 4.44
3 1
4.03 4.28
3 1
4.14 4.37
3 1
4.92** 6.04**
2>1>3 2>4>1
*P < 0.05; **P < 0.01. †Manufacture group: those respondents working in any business that uses machines, tools, and labour to convert raw materials into saleable goods. ‡Service group: those respondents working in any business where no goods are produced.
they had fever. The results revealed that women were more willing than men to wear masks and to wash their hands frequently during their flight. Overall, the study indicated that female air travellers practice more preventive measures than male air travellers to protect their health. Most passengers had knowledge of influenza A, but their attitudes and their preventive behaviours were lacking. Most respondents agreed that they would avoid those individuals who were suspected of having influenza A, which is consistent with the study by Taglioni et al. (2013). However, in the context of the present study, it is physically difficult to avoid individuals who are sick because an airplane is a confined space and people cannot fully distance themselves from sick individuals.
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Therefore, airlines should consider adopting other methods to assist passengers in protecting their health. Taglioni et al. (2013) emphasized that frequent hand washing is a key method for preventing infectious disease. However, the present study found that wearing a mask and washing hands frequently during the flight were the practices with the lowest level of agreement, regardless of gender, trip purpose or occupation. A review of the relevant literature found no research on the direct relationship between hand washing and influenza A prevention. However, according to Bults et al. (2011) and Setbon et al. (2011), hand washing can be effective in preventing the spread of influenza A. Therefore, the present study recommends that airlines implement the following measures to promote
A KAP analysis on influenza prevention measure
passenger health: (1) when travellers enter the boarding gate, the flight crew can distribute masks to passengers; (2) a free mask can be placed in the seat back pocket in front of each passenger seat for passenger use; (3) before airlines serve meals, the flight crew can broadcast hygiene tips such as washing hands before a meal; and (4) before airlines serve meals, the flight crew can distribute sanitizing wipes or offer hand sanitizer to passengers. The significant differences in KAP items among the three subgroups with different trip purposes were similar to the findings reported by Yanni et al. (2010) and van Genderen et al. (2012). The leisure group’s knowledge was lower than that of the business and other subgroups. Leisure travellers do not seek health advice maybe because they do not travel abroad as frequently as the business or other groups. To increase knowledge among leisure travellers, governments could establish a policy requiring travel agencies or airlines to distribute pamphlets on influenza A or infectious diseases to all ticketed passengers to educate them on influenza and its prevention. Chang & Liao (2010) reported that passengers pay attention to cabin safety demonstrations and carefully read the safety briefing card to become familiar with how to react in emergencies. Therefore, passengers would be likely to review influenza A pamphlets. Government agencies could also sponsor and distribute influenza A prevention videos. Travel agencies could be required to show the video to tour clients or leisure travellers during pretour meetings or during the first day of the actual tour. Government could also require the video to be shown during airline safety announcements. The occupation groups had significantly different KAP, which is consistent with the study by Kamate et al. (2010). The student group’s knowledge and attitudes were higher compared with those of the other three subgroups (government, manufacturing and service groups). However, the students’ influenza prevention practices received significantly lower scores than those of the other three subgroups. Fineberg (1988) suggested that education could raise awareness on acquired immunodeficiency syndrome and produce effective preventive behaviour. Therefore, government education policies should raise awareness and emphasize the importance of preventive measures for influenza A and other infectious diseases to students. Such new policies could help curtail the spread of infectious diseases among students.
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capable and knowledgeable healthcare professionals is more important than ever. School nursing and health policy
This study found that most students expressed adequate knowledge regarding influenza A; however, they are indifferent in their attitudes and in practising preventive care. The disconnect between knowledge, on the one hand, and attitudes and preventive care, on the other hand, can be bridged by health care or nursing professionals in schools. This step begins with education in schools at all levels: primary, secondary and college. First, every school should hire a licensed nurse or healthcare professional to be present at the school. The school should require all nurses and healthcare professionals to renew their license, as required by law. These professionals should receive periodic health education training administered by health promotion and welfare government agencies, be kept up to date on the latest health care information, and provide appropriate health care to students and faculty. Second, schools should increase the number of required and elective health education courses in which students can learn about influenza A and other infectious diseases as well as how to prevent them. These courses could be taught by professional nurses or healthcare educators who are permanently stationed at schools. These health education courses could increase student knowledge on the most recent information about influenza A and improve their preventive behaviours. Government
Government plays a large role in public health. In Taiwan, health education policy could be implemented through legislation; however, this method might not be realistic for other countries. If a government’s education agency does not have the power to mandate an expansion of health education classes, then the country must take other steps to achieve this goal. Nurses with medical and health policy knowledge are necessary to implement health policies. Nurses can hold elective offices or work in legislative offices. They can evaluate study findings, develop and implement policies to require health education training, and slow the spread of infectious diseases. Health policy nurses also need to serve as advocates by helping to establish healthcare associations or planning and implementing new policies in the airline industry to help ensure a healthier society.
Implications for nursing and health policy
Airlines
The highly infectious influenza A virus cannot be easily curbed by one person or one organization. This goal requires collaboration among all individuals and all organizations. The need for
Airlines can also help create a healthier society. International infectious diseases have become more prevalent in recent years. Thus, airlines’ training policies should be revised accordingly.
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Flight attendants should be given basic nursing training as part of their required training. During the influenza season, a policy should be established to mandate that a nurse or flight attendants with nursing backgrounds accompany each aircraft to care for sick passengers and maintain the health of all other passengers.
Limitations This study has several limitations. The convenience sampling used in this study might not have produced a representative sample of all air travellers. Because of cost and time constraints, the research was limited to examining air travellers in Taiwan. This study did not examine the KAP regarding influenza A among air travellers in a different environmental setting; future research could consider comparing how they would behave or think while on a plane to another environmental setting. Most studies on pandemic influenza KAP have relied on similar hypothetical scenarios and generally defined terms. Additionally, this study did not survey the ethnicity or country of origin of the passengers; future research could consider adding these demographic items. The results of this study may not reflect current travellers’ KAP towards the influenza A epidemic of 2009, an intense pandemic compared with the hypothetical scenario used in the present study. However, the results may still serve an important planning function and contribute to future research in the public health field.
Summary and conclusion Most passengers had adequate knowledge and understanding of the severity of influenza A; however, many did not undertake preventive practices commensurate with their knowledge and attitudes. Government agencies should establish policies to require all parties in the travel industry to be responsible for raising awareness. Governments should utilize different channels to advise travellers regarding what they can do to prevent the spread of influenza A. Increased awareness, improved attitudes and more consistent preventive actions taken by travellers will help the global community when it is faced with the next infectious disease epidemic. Further studies could extend this research model to explore passengers’ perceptions regarding preventive measures at airports.
Acknowledgement The author would like to thank all participating passengers for their dedicated collaboration.
Author contributions The author used the concept of quantifiable to investigate the air travellers’ influenza prevention behaviour. The author was
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responsible for the study design, collection of questionnaires, statistical calculations, drafting of the manuscript and approval of the final manuscript.
References Abraham, J. & Wilbur, J. (2008) Sampling Strategies for Error Rate Estimation and Quality Control. [Online] Available at: http://www.wpi.edu/ Pubs/E-project/Available/E-project-042308-150804/unrestricted/JPA0703_JHMQP_FINAL.pdf (accessed 25 Feb 2014). Annelies, W.S., et al. (2007) Knowledge, attitude, and practices with regard to adult pertussis vaccine booster in travelers. Journal of Travel Medicine, 14 (3), 145–150. Brug, J., et al. (2004) SARS Risk perception, knowledge, precautions, and information sources, the Netherlands. Emerging Infectious Diseases Journal, 10 (8), 1486–1489. Bults, M., et al. (2011) Perceived risk, anxiety, and behavioural responses of the general public during the early phase of the Influenza A (H1N1) pandemic in the Netherlands: Results of three consecutive online surveys. BMC Public Health, 11 (2), 1–13. Centers for Disease Control and Prevention (CDC) (2009) H1N1 Flu (‘Swine Flu’) and You. [Online] Available at: http://www.cdc.gov/ H1N1flu/qa.htm (accessed 20 Aug 2013). Centers for Disease Control and Prevention (CDC) (2014) H1N1 Flu Clinical and Public Health Guidance. [Online] Available at: http:// www.cdc.gov/h1n1flu/guidance/ (accessed 25 Feb 2014). Chang, Y.H. & Liao, M.Y. (2010) Airline passengers’ awareness of and preferred source of cabin safety information. Asia Pacific Management Review, 15 (4), 533–547. Elias, W. & Shiftan, Y. (2012) The influence of individual’s risk perception and attitudes on travel behavior. Transportation Research Part A: Policy and Practice, 46 (8), 1241–1251. Fineberg, H.V. (1988) Education to prevent AIDS: prospects and obstacles. Science, 239, 592–596. Herck, K.V., et al. (2003) Travelers’ knowledge, attitudes, and practices on prevention of infectious diseases: results from a pilot study. Journal of Travel Medicine, 10 (2), 75–78. Herck, K.V., et al. (2004) Knowledge, attitudes and practices in travelrelated infectious diseases: the European airport survey. Journal of Travel Medicine, 11 (1), 3–8. Kamate, S.K., et al. (2010) Public knowledge, attitude and behavioural changes in an Indian population during the Influenza A (H1N1) outbreak. Emerging Problems in Infectious Diseases, 4 (1), 7–14. Lin, Y., et al. (2011) Knowledge, attitudes and practices (KAP) related to the pandemic (H1N1) 2009 among Chinese general population: a telephone survey. BMC Infectious Diseases, 11 (1), 128–136. Lu, C.S., Lai, K.H. & Cheng, T.C.E. (2005) An evaluation of web site services in liner shipping in Taiwan. Transportation, 32, 293–318. Lunsford, T.R. & Lunsford, B.R. (1995) The research sample, Part I: sampling. Journal of Prosthetics and Orthotics, 7 (3), 105–112. Nunnally, J.C. (1978) Psychometric Theory, 2nd edn. McGraw-Hill, NY. Pfeil, A., Mutsch, M., Christoph, H. & Thomas, D.S. (2010) A crosssectional survey to evaluate knowledge, attitudes and practices (KAP)
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regarding seasonal influenza vaccination among European travellers to resource-limited destinations. BMC Public Health, 7, 402–408. Pistone, T., et al. (2010) Malaria prevention behaviour and risk awareness in French adult travellers. Travel Medicine and Infectious Disease, 8 (1), 13–21. Provost, S. & Soto, J.C. (2001) Predictors of pretravel consultation in tourists from Quebec. Journal of Travel Medicine, 8 (2), 66–75. Setbon, M., et al. (2011) The public’s preventive strategies in response to the pandemic influenza A/H1N1 in France: distribution and determinants. Preventive Medicine, 52 (2), 178–181. Sharangpani, R., Boulton, K., Wells, E. & Kim, C. (2011) Attitudes and behaviors of international air travelers toward pandemic influenza. Journal of Travel Medicine, 18, 203–208. Shendre, M.C. & Tiwari, R.R. (2005) Role of occupation as a risk factor for sexually transmitted disease: a case control study. India Journal of Occupation & Environment Medicine, 9 (1), 35–37. Taglioni, F., et al. (2013) The influenza A (H1N1) pandemic in Reunion Island: knowledge, perceived risk and precautionary behaviour. BMC Infectious Diseases, 13, 34. [Online] Available at:: http:// www.biomedcentral.com/1471-2334/13/34. (accessed 20 Aug 2013).
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Tanaka, Y., Kuniib, O., Hatanoa, T. & Wakai, S. (2008) Knowledge, attitude, and practice (KAP) of HIV prevention and HIV infection risks among Congolese refugees in Tanzania. Health and Place, 14 (3), 434–452. van Genderen, P.J.J., van Thiel, P.P.A.M., Mulder, P.G.H. & Overbosch, D. (2012) Trends in knowledge, attitudes, and practices of travel risk groups toward prevention of hepatitis A: results from the Dutch Schiphol Airport survey 2002 to 2009. Journal of Travel Medicine, 19 (1), 35–43. World Health Organization (WHO) (2008) A guide to developing knowledge, attitude and practice surveys. [Online] Available at: http:// www.stoptb.org/assets/documents/resources/publications/acsm/ ACSM_KAP%20GUIDE.pdf (accessed 20 Aug 2013). World Health Organization (WHO) (2013) Data and Statistics. [Online] Available at: http://www.who.int/research/en/ (accessed 20 Aug 2013). Xiang, N., et al. (2010) Knowledge, attitudes and practices (KAP) relating to avian influenza in urban and rural areas of China. BMC Infectious Diseases, 10 (34), 1–7. Yanni, E.A., et al. (2010) Knowledge, attitudes, and practices of US travelers to Asia regarding seasonal influenza and H5N1 avian influenza prevention measures. Journal of Travel Medicine, 17 (6), 374–381.
BA, PhD
Assistant Professor, Department of Business Administration, Far East University, Tainan City, Taiwan
CHOU P-F. (2014) An analysis of influenza prevention measures from air travelers’ perspective. International Nursing Review 61, 371–379 Background: The influenza A virus is easily transmitted through airborne saliva droplets disseminated by unprotected coughing or sneezing, particularly in a crowded, enclosed space. Aim: The purpose of this study was to analyse the knowledge, attitudes and practices of air travellers regarding influenza A preventive measures and to examine any significant differences in perceptions among different types of traveller groups. Methods: This study used a 5-point Likert scale questionnaire and surveyed 1684 passengers at Taoyuan International Airport in Taiwan. The frequencies, mean score and ranking of descriptive analyses were used to evaluate respondents’ demographic profiles. t-Test, one-way analysis of variance and Scheffe post hoc analyses were used to evaluate the relationship among knowledge, attitudes and practices, and respondents’ characteristics. Results: There were significant differences in the knowledge, attitudes and practices measures among groups with different types of trip purposes and among occupation groups. Most passengers expressed common knowledge regarding influenza A; however, their attitudes and their degree of perception were not consistent with their prevention practices. Limitations: This research is limited because it only examined surveyed air travellers in Taiwan. Conclusion: Air travellers could benefit greatly if the government and airlines were to implement a health policy that includes education on the importance of influenza prevention measures, such as frequent hand washing, to citizens. Nurses could be involved in this important health promotion activity. Implications for Nursing and Health Policy: Schools should implement a health education policy to communicate the importance of prevention measures. Nurses can consider how they can be involved in emphasizing the importance of prevention and health promotion regarding this. Airlines should also include basic preventive measures as a component of flight attendant training. Keywords: Air Travellers, Attitudes, Influenza A, Knowledge, Practices, Prevention
Correspondence address: Pin-Fenn Chou, Department of Business Administration, Far East University, No. 49 Zhonghua Road, Xinshi District, Tainan City 74448, Taiwan; Tel: +886-6-5979566 ext. 5213; Fax: +886-6-5977610; E-mail: [email protected].
Source of funding statement: This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. Conflict of interest statement: No conflict of interest has been declared by the author.
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Introduction During 2009, the novel strains of influenza A were aggressive and spread rapidly. Influenza A, also known as H1N1, is a contagious respiratory infection and can be fatal. Influenza A is transmitted through airborne-disseminated saliva particles and through close person-to-person contact (Lin et al. 2011; WHO 2013). The transmission is particularly intensified in crowded, enclosed areas, such as the interior of an
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airplane (Pfeil et al. 2010). Therefore, air travellers with flu-like illnesses play an important role in the spread of novel strains of influenza viruses (Sharangpani et al. 2011). To limit the spread of infection through international travel, the World Health Organization (WHO) advised the postponement of non-essential travel to influenza A-affected areas during the epidemic period. For various reasons, including studying abroad, visiting sick friends or family, and travelling for business, some travellers could not avoid travelling to influenza A-infected countries. To curb the outbreak of influenza A, the Centers for Disease Control and Prevention (CDC) provided guidelines for prevention and response for people in different environmental backgrounds and community settings. The people in environmental backgrounds included patients and pregnant and breastfeeding women. The community settings included child care programs, schools, colleges and universities (CDC 2014). The CDC report indicated that people in different environmental backgrounds exhibit different preventive behaviours. Xiang et al. (2010) reported that a higher percentage of an urban test group used soap for hand washing, whereas a rural test group preferred water only. A knowledge, attitude, and practice (KAP) survey is a representative study of a specific population that is used to collect information on what is known, believed and done in relation to a particular topic (WHO 2008). In the health field, many studies have discussed group perceptions on KAP based on various demographic statistics. Annelies et al. (2007) explored vaccinations for vaccinepreventable respiratory disease among travellers and concluded that women were more likely to receive vaccine boosters than men. Lin et al. (2011) indicated there was no significant difference in knowledge and behaviours regarding influenza A between men and women. However, women were more aware of influenza A risk and exhibited more preventive behaviours than men. Yanni et al. (2010) used the KAP approach to explore avian influenza preventive measures. The results showed there was no significant difference in preventive behaviours between men and women. Many studies also reported no significant difference in knowledge of influenza between genders (Provost & Soto 2001; van Genderen et al. 2012; Yanni et al. 2010). Taglioni et al. (2013) used KAP theory to investigate the influenza A pandemic on Reunion Island and found that over half of the respondents took one or more preventive measures. The study revealed two important preventive measures for infectious disease: frequent hand washing and avoidance of crowded places. The prevention of infectious disease is important; however, some people still do not undertake the necessity of preventive
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measures. Herck et al. (2003) revealed that more than one-third of travellers who were interviewed did not seek pre-travel health advice. Herck et al. (2004) also indicated that the majority of travellers, 73.3%, had sought general information about their destination prior to departure, whereas only 52.1% of the responders had sought travel health advice. Yanni et al. (2010) studied seasonal influenza and H5N1 avian influenza preventive measures based on travellers’ trip purpose and found that those who were visiting friends had significantly different preventive behaviours than other groups. van Genderen et al. (2012) reported that business travellers sought travel health advice for their health less frequently than non-business travellers, even though the business travellers did not have significantly different knowledge or attitudes regarding preventive practices for high-risk destinations compared with other groups. That study also found that business travellers had significantly different KAP for low-risk destinations than other groups. Pistone et al. (2010) showed there were significantly different perceptions of malaria prevention among groups based on different trip purposes, including business, tourism, return to country of origin, humanitarian, and other. Shendre & Tiwari (2005) reported that people with different occupational backgrounds had different perceptions of how diseases are spread. Elias & Shiftan (2012) found that people with different occupational backgrounds had different risk perceptions of and attitudes towards travel behaviour. Kamate et al. (2010) also reported that different occupational groups, such as working and non-working groups, had different KAP of influenza A.
Aim Previous research has focused on KAP, but few empirical studies have examined KAP regarding influenza A among air travellers, which was the aim of the present study. This study developed recommendations for the airline industry regarding how to improve prevention practices for influenza A by involving Taiwan government, schools, nursing professionals and airlines.
Methods Questionnaire design
A questionnaire was used to survey participants. The 16 items in the survey were derived from previous KAP studies, including those by Brug et al. (2004), Herck et al. (2003, 2004) and the CDC (2009). The questionnaire content was separated into two parts: (1) the participants’ perceptions of KAP of influenza A, and (2) participant demographics, including gender, age, trip purpose, education and occupation. In the first part of the survey, items were rated according to a 5-point Likert scale,
A KAP analysis on influenza prevention measure
from 1 (totally disagree) to 5 (totally agree). A response greater than 3 indicated that the respondent tended to agree with a given survey item. The instrument’s accuracy and content validity were tested. The content validity of the questionnaire was evaluated based on a literature review, interviews with various aviation and health experts, and a pilot test. The questionnaire items were determined to be relevant, and minor modifications were subsequently made to the wording. Examples were provided for some of the measurement items to improve the validity of the items. Additionally, Cronbach’s alpha was used to determine whether these items were consistent and reliable. In this study, the Cronbach’s alpha values for KAP were 0.807, 0.837 and 0.829, respectively. All values were greater than 0.70 and therefore achieved the threshold of reliability (Nunnally 1978).
Survey and sampling
Convenience sampling was used for this study. This approach is simple, rapid and cost-efficient (Lunsford & Lunsford 1995). In compliance with the ethical approval, a formal request was sent to the Taoyuan International Airport Corporation by the researcher. Permission was granted to conduct interviews related to this study with passengers within the departure hall of Taiwan Taoyuan International Airport. The survey was conducted during 10 days in February 2013 by six interviewers. The interviewers approached the passengers, stated the survey purpose and conducted personal interviews with interested passengers. The sample size needed to be greater than 1067 to obtain a 3% margin of error and a 95% confidence interval (Abraham & Wilbur 2008). A total of 2000 questionnaires were distributed to passengers, but only 1684 were usable for research purposes, representing a response rate of 84.2%.
Statistical analysis
Descriptive statistics, t-test and one-way analysis of variance (ANOVA) were used to analyse the respondents’ demographics. Many health studies also used both of the t-test and ANOVA statistical technique to analyse the differences in the responses groups (Kamate et al. 2010; Lin et al. 2011; Taglioni et al. 2013; Tanaka et al. 2008; van Genderen et al. 2012). Thus, t-test and ANOVA were performed to examine whether there were any significant differences among the respondents’ answers based on gender, trip purpose or occupation. If the ANOVA results showed significant differences, the Scheffe post hoc analysis was used for post-analysis. Appropriate P-values were determined based on the study by Lu et al. (2005), and the significance levels were set at P < 0.05 and P < 0.01.
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Results Demographics
Participant profiles were divided into the following groups: gender, age, trip purpose, education and occupation. Of the 1684 respondents, 820 (48.7%) were male and 864 (51.3%) were female; 650 (38.6%) were 25 years old or younger, 761 (45.2%) were between 26 and 55 years old, and 273 (16.2%) were 56 years old or older. The majority of the respondents, 1063 (63.1%), were leisure travellers, 306 (18.2%) were business travellers, 156 (9.3%) had other travel reasons, 85 (5.0%) were visiting friends, and 74 (4.4%) were returning home. Over half of the respondents, 847 (50.3%), had a university level education, 458 (27.2%) had a high school education, 229 (13.6%) had a secondary education or less, and 150 (8.9%) had a postgraduate education. Approximately one-third of the respondents, 521 (30.9%), worked in the service sector, 382 (22.7%) worked in the manufacturing sector, 236 (14.0%) were students, 221 (13.1%) were government employees, and 324 (19.3%) worked in other sectors. t-Test and one-way ANOVA results Gender
Table 1 shows that all the items had a higher mean score for women than for men, which indicates that women had a higher agreement level for all items describing KAP. In their responses, men and women showed they had almost the same ranking for KAP items. For knowledge, both men and women responded that they had a good understanding of the symptoms of influenza A. Regarding attitudes, both men and women showed the most agreement with the item ‘I care about the influenza A epidemic very much’, whereas the item ‘I think that people who have influenza A are more likely to die’ had the lowest agreement level. Regarding practice, both men and women showed the most agreement on the item ‘I will keep away from those who are suspected of having influenza A’, whereas the item ‘I will wash my hands frequently on the aircraft’ had the lowest agreement level. t-Test analysis results showed that the attitudes and practices significantly differed between genders at the 5% significance level; two knowledge items did not significantly differ, as shown in Table 1. Trip purpose
The passengers’ trip purpose was separated into three subgroups: leisure, business, and other. Their responses are shown in Table 2. Regarding knowledge, all three subgroups answered
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Table 1 The mean, rank and t-test results of the respondents’ agreement level with knowledge, attitudes and practice items by gender Measure items
Male n = 820
Knowledge K2 I understand the symptoms of influenza A K1 I understand how influenza A is transmitted Attitudes A2 I care about the influenza A epidemic very much A4 I am afraid the influenza A epidemics will expand continuously A3 I will avoid travelling by plane during the influenza A epidemic A7 I am scared because I was infected by influenza A viruses before A5 I think it is difficult to control the spread of influenza A viruses A1 I think there is a high probability that I will be infected with influenza A viruses during the epidemic A6 I think that people who have influenza A are more likely to die Practice B7 I will keep away from those who are suspected of having influenza A B5 I will use tissues or use my hands to cover my mouth and nose when I sneeze or cough B6 I am willing to be isolated and checked if I have influenza A B4 I will actively inform the flight crew when I have a fever or a cough B3 I will wash my hands thoroughly before a meal on the aircraft B1 I will wear a mask on the aircraft B2 I will wash my hands frequently on the aircraft
Female n = 864
t-Test
Mean
Rank
Mean
Rank
4.03 4.00
1 2
4.04 4.03
1 2
−0.10 −0.94
4.06 3.80 3.71 3.57 3.44 3.38
1 2 3 4 5 6
4.13 4.03 3.86 3.85 3.55 3.60
1 2 3 4 6 5
−2.07* −5.44** −3.10** −6.55** −2.13* −4.55**
3.14
7
3.27
7
−2.36*
4.29 4.22 4.07 4.05 3.92 3.85 3.81
1 2 3 4 5 6 7
4.37 4.30 4.16 4.16 4.09 3.98 3.96
1 2 3 3 4 5 6
−2.28* −2.23* −2.75** −3.43** −4.91** −3.41** −3.92**
*P < 0.05; **P < 0.01.
that they had a good understanding of the symptoms of influenza A. Regarding attitudes, the three subgroups showed the most agreement on the item ‘I care about the influenza A epidemic very much’, whereas the item ‘I think that people who have influenza A are more likely to die’ had the lowest agreement level. Regarding practice, all three groups showed the most agreement on the item ‘I will keep away from those who are suspected of having influenza A’, whereas the item ‘I will wash my hands frequently on the aircraft’ had the lowest degree of agreement. According to the ANOVA analysis, all items showed significant differences at P < 0.05, except for items A2, A3, A4, B1 and B6. The Scheffe post hoc test showed that the business subgroup had a significantly higher degree of knowledge and a lower perception of attitude items compared with other two groups. Both the leisure and the business subgroups had a higher perception of practice items compared with other groups.
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Occupation
There were five occupational subgroups: student, government, manufacturing, service, and other. To understand whether there were significant differences in the occupational subgroups’ perceptions of KAP, this study chose to exclude those respondents who classified themselves in the ‘other’ group. The results are shown in Table 3. Regarding knowledge, the student, manufacturing and service subgroups agreed the most with the item ‘I understand the symptoms of influenza A’, and the government subgroup agreed the most with the item ‘I understand how influenza A is transmitted’. Regarding attitudes, all four specific subgroups agreed the most with the item ‘I care about the influenza A epidemic very much’, whereas the item ‘I think that people who have influenza A are more likely to die’ had the lowest agreement level. Regarding practice, the government, manufacturing and service subgroups showed the most agreement with the item ‘I will keep away from those who are suspected of having influenza A’, whereas the groups agreed the
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Table 2 The mean, rank, F-value and Scheffe test results of the respondents’ agreement level with knowledge, attitudes and practice items by trip purpose Measure items
Knowledge K1 I understand how influenza A is transmitted K2 I understand the symptoms of influenza A Attitudes A1 I think there is a high probability that I will be infected with influenza A viruses during the epidemic A2 I care about the influenza A epidemic very much A3 I will avoid travelling by plane during the influenza A epidemic A4 I am afraid the influenza A epidemics will expand continuously A5 I think it is difficult to control the spread of influenza A viruses A6 I think that people who have influenza A are more likely to die A7 I am scared because I was infected by influenza A viruses before Practices B1 I will wear a mask on the aircraft B2 I will wash my hands frequently on the aircraft B3 I will wash my hands thoroughly before a meal on the aircraft B4 I will actively inform the flight crew when I have a fever or a cough B5 I will use tissues or use my hands to cover my mouth and nose when I sneeze or cough B6 I am willing to be isolated and checked if I have influenza A B7 I will keep away from those who are suspected of having influenza A
Group 1 Leisure n = 1063
Group 2 Business n = 306
Group 3 Other n = 315
F-value
Scheffe test comparison groups
Mean
Rank
Mean
Rank
Mean
Rank
3.96 3.99
2 1
4.14 4.17
2 1
4.05 4.07
2 1
7.26** 7.46**
2>1 2>1
3.50
5
3.33
5
3.61
6
6.38**
3>1>2
4.10 3.79 3.94 3.49 3.15 3.74
1 3 2 6 7 4
4.12 3.73 3.83 3.29 3.01 3.55
1 3 2 6 7 4
4.08 3.82 3.94 3.73 3.55 3.78
1 3 2 5 7 4
0.26 0.72 1.97 14.13** 19.76** 5.55**
3>1>2 3>1>2 3>1>2
3.93 3.92 4.05 4.14 4.28
6 7 5 3 2
3.90 3.78 3.89 4.09 4.38
5 7 6 4 2
3.87 3.86 3.99 4.01 4.08
6 7 5 4 2
0.83 3.93* 5.75** 4.06* 15.27**
1>2 1>2 1>3 2>1>3
4.12 4.36
4 1
4.16 4.43
3 1
4.05 4.16
3 1
2.24 13.55**
2>1>3
*P < 0.05; **P < 0.01.
least with the item ‘I will wash my hands frequently on the aircraft’. Students had the lowest agreement level for the item ‘I will wear a mask on the aircraft’. The results of the ANOVA showed there were significantly different KAP perceptions among the different occupational groups; however, items A1, A2, A6, A7 and B4 did not show a significant difference. The Scheffe post hoc test results showed that the student subgroup had a significantly higher perception on the K1, K2, A3, A4 and A5 items (P < 0.05) than the other three subgroups (government, manufacturing and service). The government subgroup had a significantly higher perception of the B1, B2, B3, B5, B6 and B7 items than the other three subgroups.
Discussion The best prevention against influenza A is vaccination. This study contributes to the additional everyday measures that can be used to prevent the spread of germs by air travellers.
© 2014 International Council of Nurses
Additionally, this study contributes to the extant literature by showing that the instrument used in this study is effective in assessing KAP related to influenza and can therefore be confidently used in future influenza prevention-related studies involving airline passengers. Men and women had similar perceptions of the transmission and symptoms of influenza A; however, there were significant differences in attitude and prevention practice between genders. The significant differences were found to be consistent with those observed in previous health studies (Kamate et al. 2010; Lin et al. 2011; Yanni et al. 2010). Women’s perceptions of the KAP items were found to be higher than those of men. For example, women appeared to consider influenza A epidemics to be more serious than men. Regarding preventive practice, women were more likely than men to avoid travelling during influenza A epidemics and to avoid people suspected of having influenza A; they were also more likely to inform the flight crew when they felt ill and were more willing to be isolated when
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Table 3 The mean, rank, F-value and Scheffe test results of the respondents’ agreement level with knowledge, attitudes and practice items by occupations Measure items
Knowledge K1 I understand how influenza A is transmitted K2 I understand the symptoms of influenza A Attitudes A1 I think there is a high probability that I will be infected with influenza A viruses during the epidemic A2 I care about the influenza A epidemic very much A3 I will avoid travelling by plane during the influenza A epidemic A4 I am afraid the influenza A epidemics will expand continuously A5 I think it is difficult to control the spread of influenza A viruses A6 I think that people who have influenza A are more likely to die A7 I am scared because I was infected by influenza viruses before Practices B1 I will wear a mask on the aircraft B2 I will wash my hands frequently on the aircraft B3 I will wash my hands thoroughly before a meal on the aircraft B4 I will actively inform the flight crew when I have a fever or a cough B5 I will use tissues or use my hands to cover my mouth and nose when I sneeze or cough B6 I am willing to be isolated and checked if I have influenza A B7 I will keep away from those who are suspected of having influenza A
Group 1 Student n = 236
Group 2 Government n = 221
Group 3 Manufacture† n = 382
Group 4 Service‡ n = 521
F-value
Scheffe test comparison of groups
1>2>3 1>3
Mean
Rank
Mean
Rank
Mean
Rank
Mean
Rank
4.10 4.19
2 1
4.09 4.05
1 2
3.90 3.92
2 1
4.01 4.03
2 1
4.73** 6.19**
3.48
6
3.53
5
3.39
5
3.43
6
0.94
4.14 3.95 4.09
1 3 2
4.17 3.61 3.93
1 4 2
4.08 3.71 3.72
1 3 2
4.06 3.75 3.87
1 3 2
1.80 4.92** 9.17**
1>3>2 1>2>4>3
3.64
5
3.35
6
3.39
5
3.45
5
3.73*
1>3>2
3.25 3.74
7 4
3.11 3.63
7 3
3.14 3.63
6 4
3.13 3.66
7 4
0.73 0.70
3.77 3.92 4.04 4.04
6 5 3 3
4.03 3.98 4.11 4.17
6 7 5 4
3.83 3.77 3.84 4.02
6 7 5 4
3.96 3.85 4.01 4.11
6 7 5 4
5.71** 3.65* 8.18** 2.46
2>3>1 2>3 2>1>4>3
4.15
2
4.29
2
4.22
2
4.30
2
2.85*
2>1
4.03 4.18
4 1
4.23 4.44
3 1
4.03 4.28
3 1
4.14 4.37
3 1
4.92** 6.04**
2>1>3 2>4>1
*P < 0.05; **P < 0.01. †Manufacture group: those respondents working in any business that uses machines, tools, and labour to convert raw materials into saleable goods. ‡Service group: those respondents working in any business where no goods are produced.
they had fever. The results revealed that women were more willing than men to wear masks and to wash their hands frequently during their flight. Overall, the study indicated that female air travellers practice more preventive measures than male air travellers to protect their health. Most passengers had knowledge of influenza A, but their attitudes and their preventive behaviours were lacking. Most respondents agreed that they would avoid those individuals who were suspected of having influenza A, which is consistent with the study by Taglioni et al. (2013). However, in the context of the present study, it is physically difficult to avoid individuals who are sick because an airplane is a confined space and people cannot fully distance themselves from sick individuals.
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Therefore, airlines should consider adopting other methods to assist passengers in protecting their health. Taglioni et al. (2013) emphasized that frequent hand washing is a key method for preventing infectious disease. However, the present study found that wearing a mask and washing hands frequently during the flight were the practices with the lowest level of agreement, regardless of gender, trip purpose or occupation. A review of the relevant literature found no research on the direct relationship between hand washing and influenza A prevention. However, according to Bults et al. (2011) and Setbon et al. (2011), hand washing can be effective in preventing the spread of influenza A. Therefore, the present study recommends that airlines implement the following measures to promote
A KAP analysis on influenza prevention measure
passenger health: (1) when travellers enter the boarding gate, the flight crew can distribute masks to passengers; (2) a free mask can be placed in the seat back pocket in front of each passenger seat for passenger use; (3) before airlines serve meals, the flight crew can broadcast hygiene tips such as washing hands before a meal; and (4) before airlines serve meals, the flight crew can distribute sanitizing wipes or offer hand sanitizer to passengers. The significant differences in KAP items among the three subgroups with different trip purposes were similar to the findings reported by Yanni et al. (2010) and van Genderen et al. (2012). The leisure group’s knowledge was lower than that of the business and other subgroups. Leisure travellers do not seek health advice maybe because they do not travel abroad as frequently as the business or other groups. To increase knowledge among leisure travellers, governments could establish a policy requiring travel agencies or airlines to distribute pamphlets on influenza A or infectious diseases to all ticketed passengers to educate them on influenza and its prevention. Chang & Liao (2010) reported that passengers pay attention to cabin safety demonstrations and carefully read the safety briefing card to become familiar with how to react in emergencies. Therefore, passengers would be likely to review influenza A pamphlets. Government agencies could also sponsor and distribute influenza A prevention videos. Travel agencies could be required to show the video to tour clients or leisure travellers during pretour meetings or during the first day of the actual tour. Government could also require the video to be shown during airline safety announcements. The occupation groups had significantly different KAP, which is consistent with the study by Kamate et al. (2010). The student group’s knowledge and attitudes were higher compared with those of the other three subgroups (government, manufacturing and service groups). However, the students’ influenza prevention practices received significantly lower scores than those of the other three subgroups. Fineberg (1988) suggested that education could raise awareness on acquired immunodeficiency syndrome and produce effective preventive behaviour. Therefore, government education policies should raise awareness and emphasize the importance of preventive measures for influenza A and other infectious diseases to students. Such new policies could help curtail the spread of infectious diseases among students.
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capable and knowledgeable healthcare professionals is more important than ever. School nursing and health policy
This study found that most students expressed adequate knowledge regarding influenza A; however, they are indifferent in their attitudes and in practising preventive care. The disconnect between knowledge, on the one hand, and attitudes and preventive care, on the other hand, can be bridged by health care or nursing professionals in schools. This step begins with education in schools at all levels: primary, secondary and college. First, every school should hire a licensed nurse or healthcare professional to be present at the school. The school should require all nurses and healthcare professionals to renew their license, as required by law. These professionals should receive periodic health education training administered by health promotion and welfare government agencies, be kept up to date on the latest health care information, and provide appropriate health care to students and faculty. Second, schools should increase the number of required and elective health education courses in which students can learn about influenza A and other infectious diseases as well as how to prevent them. These courses could be taught by professional nurses or healthcare educators who are permanently stationed at schools. These health education courses could increase student knowledge on the most recent information about influenza A and improve their preventive behaviours. Government
Government plays a large role in public health. In Taiwan, health education policy could be implemented through legislation; however, this method might not be realistic for other countries. If a government’s education agency does not have the power to mandate an expansion of health education classes, then the country must take other steps to achieve this goal. Nurses with medical and health policy knowledge are necessary to implement health policies. Nurses can hold elective offices or work in legislative offices. They can evaluate study findings, develop and implement policies to require health education training, and slow the spread of infectious diseases. Health policy nurses also need to serve as advocates by helping to establish healthcare associations or planning and implementing new policies in the airline industry to help ensure a healthier society.
Implications for nursing and health policy
Airlines
The highly infectious influenza A virus cannot be easily curbed by one person or one organization. This goal requires collaboration among all individuals and all organizations. The need for
Airlines can also help create a healthier society. International infectious diseases have become more prevalent in recent years. Thus, airlines’ training policies should be revised accordingly.
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Flight attendants should be given basic nursing training as part of their required training. During the influenza season, a policy should be established to mandate that a nurse or flight attendants with nursing backgrounds accompany each aircraft to care for sick passengers and maintain the health of all other passengers.
Limitations This study has several limitations. The convenience sampling used in this study might not have produced a representative sample of all air travellers. Because of cost and time constraints, the research was limited to examining air travellers in Taiwan. This study did not examine the KAP regarding influenza A among air travellers in a different environmental setting; future research could consider comparing how they would behave or think while on a plane to another environmental setting. Most studies on pandemic influenza KAP have relied on similar hypothetical scenarios and generally defined terms. Additionally, this study did not survey the ethnicity or country of origin of the passengers; future research could consider adding these demographic items. The results of this study may not reflect current travellers’ KAP towards the influenza A epidemic of 2009, an intense pandemic compared with the hypothetical scenario used in the present study. However, the results may still serve an important planning function and contribute to future research in the public health field.
Summary and conclusion Most passengers had adequate knowledge and understanding of the severity of influenza A; however, many did not undertake preventive practices commensurate with their knowledge and attitudes. Government agencies should establish policies to require all parties in the travel industry to be responsible for raising awareness. Governments should utilize different channels to advise travellers regarding what they can do to prevent the spread of influenza A. Increased awareness, improved attitudes and more consistent preventive actions taken by travellers will help the global community when it is faced with the next infectious disease epidemic. Further studies could extend this research model to explore passengers’ perceptions regarding preventive measures at airports.
Acknowledgement The author would like to thank all participating passengers for their dedicated collaboration.
Author contributions The author used the concept of quantifiable to investigate the air travellers’ influenza prevention behaviour. The author was
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responsible for the study design, collection of questionnaires, statistical calculations, drafting of the manuscript and approval of the final manuscript.
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