ABSTRACT
Objective This study aimed to understand the knowledge, attitudes and practices (KAP) on seasonal influenza among medical college students in a low-income multiethnic society. Methods A cross-sectional questionnaire survey collected information of KAP related to influenza. A knowledge score was calculated according to the total number of correct points out of 9 questions. Logistic regression was used to identify factors associated with influenza vaccine uptake. Results 856 valid questionnaires were obtained. The average knowledge score was 14.8 ± 3.1 out of 22 correct points. Han Chinese got higher score than minorities (p < 0.001). Knowledge score increased with grade (p < 0.001). Students majoring in pharmacy had lower score than others. Questions on mode of transmission, symptoms, precautions, high risk groups and vaccination schedule had a correct rate lower than 50%. Hand hygiene was practiced by less than 40% of students after touching objects in public areas or sneezing. The proportion of participants received influenza vaccine in the past 3 y was 4.1%, 9.2% and 6.1% respectively. Willingness to receive free vaccine (OR = 2.49, 95% CI 1.31∼4.28), and awareness of the vaccine effectiveness (OR = 1.67, 95% CI 1.08∼2.56) were significantly associated with vaccine uptake, while the general knowledge about influenza, perceived susceptibility and severity, and demographic factors were not. The top 3 reasons for not being vaccinated were poor knowledge of the vaccine (46%), no perceived need due to good health (45%) and worry about adverse reactions (33%). Conclusion Health education is needed to improve the awareness of basic facts about influenza and vaccine, and more attention should be paid to minority groups. The coverage of seasonal influenza vaccine is quite low. Besides individual level behavior change, social and structural factors should be considered to increase the uptake of influenza vaccine.
Introduction
Influenza is a big concern of public health considering that 5–10% of adults and 20–30% of children are infected by influenza virus worldwide every year, resulting in 3–5 million severe cases and 250,000–500,000 deaths.Citation1 Students on campus are at increased risk for infectious diseases including influenza because of the relatively crowded study and living environment. Surveillance data from several provinces in recent years suggested that over 90% of influenza outbreaks occurred on campus.Citation2,3 College students have high mobility between campus and community, and thus their behavior on influenza prevention and control matters to their own health as well as the well-being of the community. Medical students are future health workers, whose behavior will affect the health of their patients. Knowledge, Attitude and Practices (KAP) surveys can reveal misunderstandings and potential barriers to behavior change. Xinjiang province is a typical area with underdeveloped economic status and multiethnic society. In 2014, the per capita consumption expenditure of Xinjiang ranked 25th among 31 provincial administrative units.Citation4 In Urumqi, the provincial capital of Xinjiang, 25% population are minorities (i.e., ethnic groups other than Han), with Uighur being the biggest minority group.Citation5 A previous study in the US revealed variations between ethnic groups in adoption of preventive behaviors of influenza.Citation6 To assess medical college students' KAP toward influenza in a low-income multiethnic setting we conducted this study.
Results
930 students were reached and 856 valid questionnaires were obtained, resulting in a response rate of 92%. The mean age was 21.3 ± 1.4 y. The characteristics of the 856 respondents were listed in . The average knowledge score was 14.8 ± 3.1. The average score was significantly higher in females (15.0 ± 3.0) than in males (14.5 ± 3.2) (P = 0.031). In terms of ethnicity, Han Chinese had an average score of 15.8 ± 2.8, which was significantly higher than that of Uighur (14.0 ± 3.1) and other minority groups (14.7 ± 3.1, P <0.001). Variation of score between grades was also significant (P <0.001). The rank of average score from low to high was preparatory classes, grade 1, grade 2, grade 3 and 4, and the trend was statistically significant (P < 0.001). Pharmacy students had an average score which was about 1.5 points lower than that of students in other majors (P = 0.0032). Some questions had a correct rate (i.e., the fraction of students choosing the correct answer) lower than 50%, including mode of transmission (7%), precautions (17%), influenza symptoms (32%), vaccination schedule (45%), and high risk groups (46%). High awareness existed in the facts that pathogen was virus (75%), and that medical workers had higher risk of infection than ordinary people (67%), and that vaccination was the most effective preventive intervention (58%). Participants reported various sources to get knowledge, of which the most prevalent way was from class lectures (88%).
Table 1. Characteristics of respondents.
When sick, the majority of respondents chose to seek treatment, while the rest 20% of them wouldn't take any medical interventions. 67% of respondents covered their nose when sneezing, and 31% washed hands after sneezing. Hand hygiene was practiced by 36% of students after touching objects in public areas. 88% of students believed it was necessary to wear masks and avoid crowds when being ill. However, the percentage of mask use for self-protection would decrease to 64% if sharing space with flu patients in a dormitory.
760 respondents were able to recall their history of seasonal influenza vaccination in the past 3 y. 17.1% (n = 130) of them received seasonal flu shot at least once, with 7 students (0.9%) vaccinated twice and 5 (0.7%) vaccinated 3 times. The vaccination rates in the year 2009, 2010 and 2011 were 4.1%, 9.2% and 6.1%, respectively. The vaccination rates stratified by gender, ethnicity and grade in each year were presented in . The rate of each subgroup peaked in 2010. Vaccination rates had no significant difference between male and female, or across majors or ethnic groups. Students in grade 3 and 4 had lower rates than their junior counterparts in the past 3 y (P = 0.001). The comparison between vaccinated and unvaccinated people was presented in . After adjusting for other factors, students willing to receive free vaccination were 2.4 times more likely to receive flu shots than those who had reluctant attitude (OR = 2.39, 95% confidence interval 1.31∼4.28). Knowing that flu shot is the most effective precaution of influenza was also a positive predictor of vaccine uptake (OR = 1.67, 95% CI 1.08∼2.56). Other factors including gender, ethnicity, overall knowledge score, perceived susceptibility and severity, attitudes toward using masks had no significant effect on vaccine uptake. The reasons for not being vaccinated were listed in . The top 3 reasons were inadequate knowledge of the vaccine (46%), no perceived need due to their good health (45%), and afraid of the adverse reactions (33%).
Figure 1. Vaccination rate stratified by gender, ethnicity, major and grade in the year 2009, 2010 and 2011.
Table 2. Characteristics of vaccinated and unvaccinated students in the past 3 y.
Figure 2. The reasons for no vaccination in the past 3 y.
Discussion
This study investigated the knowledge, attitude and behaviors related to seasonal influenza among college students in Northwest China. Out of 22 knowledge points, an average student made 15 points right (mean score 14.8 ± 3.1), indicating that the target population were ignorant of 30% of basic facts. The weak points lie in mode of transmission, precautions, symptoms, vaccination schedule, and high risk groups. Health educators should put more emphasis on these issues. Minority groups had bigger knowledge gaps than Han Chinese. There might be language barriers for minorities considering that the official materials are written in Mandarin. In a multi-ethnic area like Xinjiang, health education materials should have multilingual versions to serve the need for different population. We also noticed that the knowledge score increased with grade. It suggests that college education has positive effect on influenza awareness, which is consistent with the fact that the No.1 reported source of knowledge was class lectures. Given that the study was done in a medical school where coursework was related to infectious diseases including influenza, the finding may not be generalized to students from general universities. Major is another factor affecting knowledge level, with students majoring in pharmacy having the lowest score on average. The poor performance of pharmacy students may result from their inadequate sources of knowledge. While 90% of students majoring in western medicine or Chinese medicine get knowledge from coursework, and 80% of students in other majors (i.e., heath service management, biomedical engineering, and medical English) get knowledge from the internet, pharmacy students failed to excel in either way. The findings suggest that specially designed out-of-class education campaigns are needed to increase college students' awareness on influenza.
In terms of lowering the risk of transmission, many students didn't do the right thing. One third of respondents didn't cover their nose when sneezing; nearly 70% didn't practice hand hygiene after sneezing or touching objects in public areas; 36% didn't think it necessary to wear masks if roommates got sick. These beliefs and behaviors need to be altered through communicating transmission routes and measures to avoid contact with potential infectious sources.
The annual vaccination rate of seasonal flu shot among study population was lower than 10% and there was obvious fluctuation between years. The vaccination rate doubled in 2010 (9.2%) compared with that of 2009 (4.1%) and then went down in the next year (6.1%). The increase in 2010 may result from the influence of 2009–2010 H1N1 pandemic on public attention. However, the positive trend didn't continue to the post pandemic period. Variation in vaccination rates across grade was statistically significant, ranging from less than 4% to 13% for subgroups. Senior medical students turned out to have lower vaccine uptake than junior ones, indicating that the vaccine uptake doesn't necessarily increase with more medical knowledge and practice. A telephone survey in 5 cities of China found 9.5% health care workers received influenza vaccine in the past 3 seasons.Citation7 In comparison, a study in Australia reported a 54% vaccine coverage among medical students in 2014,Citation8 and the US has maintained a 40% annual coverage rate among adults since 2009.Citation9 According to the recommendation from China CDC, students receiving influenza vaccine cannot only decrease their own risk of illness but also protect contacts in family and community. Medical students are future health care workers, who are a prioritized group for influenza vaccine.Citation10 Public health workers should take efforts to narrow the coverage gap.
The intention to get free vaccine was a strong predictor of vaccine uptake (OR = 2.39, 95% CI 1.31∼4.28), which was similar to the findings of previous studies among student nurses and the elderly.Citation11,12 However, a free vaccination policy alone is not adequate to improve coverage. For example, Beijing started to offer free influenza vaccine to the elderly from 2007, resulting in a vaccine coverage of 38.7% in 2012,Citation13 which was lower than that of other developing countries with free vaccination policies such as the 74% in Brazil.Citation14 A study in Beijing found that people from low-income families turned out to have higher vaccination rate under the free policy, suggesting that price becomes a weaker incentive as the income increases.Citation13 Other measures should be taken besides elimination of a user fee. General knowledge about influenza didn't have a significant effect on vaccination, while the specific knowledge about vaccine did (OR = 1.67, 95% CI 1.08∼2.56). Other studies also revealed the positive association between awareness of vaccine recommendation and vaccine uptake.Citation8,11,15 Socio-demographic factors and perceived threat turned out to have no significant influence on vaccination, where previous studies had mixed results. Some studies found perceived threats of influenza as a significant predictor,Citation11,15 while others didn't. A study among the elderly in Germany also suggested no determinants of demographic factors.Citation11 The varied conclusion across populations and cultures suggests that the vaccination behavior is determined by not only individual perception, but also social and structural factors such as policy, out-of-pocket payment, and persuasion from health care providers. For example, a study in Korea found that receiving a notice from a public health organization was the most important triggering event for vaccination.Citation16 Another study in the US suggested the existence of a mandatory vaccination policy was the strongest predictor for influenza vaccination among health care workers.Citation17 In China, influenza vaccine is used on a voluntary basis and the majority of local governments don't offer it for free.Citation18 Further research is needed to understand the influence of policy and economic issues on vaccine uptake in low-income regions.
Limitations of the study should be noted. First, this study relies on self-reported information, which may be a threat to internal validity. On one hand, self-reporting can cause recall bias about past behaviors. On the other hand, respondents may intendedly modify their answers on attitude and behaviors to meet the proper norms instead of expressing their actual experience. Take vaccination history as an example, a more accurate way to measure is to check the written record in the immunization reporting system. Second, the study population is medical students in a multi-ethic and underdeveloped setting, which may harm the generalizability of results to students from other parts of China.
To conclude, the study provides important implications of the knowledge, attitudes and practices on influenza among college students in a multi-ethnic and underdeveloped region of China. The misconceptions on influenza and influenza vaccines are barriers toward proper preventive practices. Health education should be adapted according to the weak points and the preference of minority groups. Measures need be taken to increase vaccination rate in this setting. Besides individual level behavior change, economic and policy related interventions may be considered.
Methods
In May 2012, we conducted a cross-sectional survey in Xinjiang Medical University in Urumqi. 6043 students from 19 majors and 98 classes were eligible participants. 85.6% of them are from Xinjiang, and the rest are from other provinces. Multi-stage stratified random sampling technique was used to select participants. Stratification was based on grade, with preparatory classes, grade 1 and 2 being one stratum, and grade 3 and 4 being the other one. The sample size in either stratum was first calculated using the formula for random sampling, which was n = μα2π(1-π)/δ2, with μα = 1.96, π = 0.5 and δ = 6%. The number was then multiplied by 1.5 to account for the clustering feature, and a response rate of 90% was assumed. For either stratum, the sample size was 427. In practice, 20 classes were randomly selected with 22 random students from each class to reach 440 students in either stratum.
Participants were surveyed by a self-administered questionnaire written in Mandarin, which could be read by all participants. The questionnaire collected demographic information (i.e., ethnicity, gender, age); knowledge toward influenza (i.e., the pathogen, transmission, seasonality, high risk population, clinical symptoms, precautions, vaccine effectiveness and schedule), perceived susceptibility (i.e., the risk of infection), perceived severity (i.e., the likelihood of developing severe complications), attitudes and practices on treatment and preventive measures including hand hygiene, wearing masks and vaccination. There were 9 knowledge questions and 22 correct statements. Each correct choice was assigned 1 point, otherwise no score. If a wrong statement was checked, one point was deducted. The minimum total points for each question was 0. We summed the points of the 9 knowledge questions to get an overall score for each person, which could be up to 22.
Data entry was done by Excel. Statistical analysis was performed by STATA 12.0. The differences between means were tested by T-test (2 groups) or ANOVA (more than 2 groups). The differences between rates were analyzed by chi-square test. Wilcoxon rank-sum test was applied for trend across ordered groups such as grade. A logistic regression was used to identify factors associated with seasonal influenza vaccination. The statistical significance was set at p < 0.05.
Disclosure of potential conflicts of interest
No potential conflicts of interest were disclosed.
Funding
This study was supported by the China–US Collaborative Program on Emerging and Re-emerging Infectious Diseases (No. 5U2GGH000018–02).
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