Saeed S, Chaudhry A, Baig Z, Akram K, Hussain Z, Khan M, Malik M, Ikram
A. Factors associated with noncompliance of COVID-19 guidelines
recommended by Government of Pakistan for international travelers
arriving at Islamabad International Airport, 1st June to 30th July 2021.
Global Biosecurity, 2022; 4(1).
RESEARCH ARTICLES
Factors associated with noncompliance of COVID-19 guidelines
recommended by Government of Pakistan for international travelers
arriving at Islamabad International Airport, 1st June to 30th July 2021
Sara Saeed1, Ambreen Chaudhry1, Zeeshan Baig1, Khurram Akram1, Zakir Hussain1, Mumtaz Ali Khan1, Muhammad
Wasif Malik2, Aamer Ikram3
1
Field Epidemiology & Laboratory Training Program (FELTP), Pakistan
Field Epidemiology & Disease Surveillance Division, National Institute of Health, Islamabad, Pakistan
3
Executive director, National Institute of Health, Islamabad, Pakistan
2
Abstract
Introduction: Since the start of pandemic new variants have been evolving and moving from one country to another
either by air travel or ground crossings.
Objective: To find out factors associated with noncompliance of recommended guidelines by international passengers
so that we can improve the arrangements at airports where required, improve future preparedness, and give
recommendations to concerned authorities for improvement in enforcing guidelines.
Methodology: A cross-sectional study was carried out at Islamabad International Airport during the months of June
and July 2021. The study population included international arriving passengers aged 12 years and above. Questions
were asked about following guidelines before boarding, on board, and after disembarkation. Twenty questions were
asked to assess compliance level. A median cut off value was set for assessment of noncompliance.
Results: The male to female ratio was 1:1. The age range was 12 – 75 years. The odds of noncompliance to guidelines
were higher in females compared to males. The results revealed a significant association between region of arrival of
respondents and noncompliance. Passengers arriving from Afghanistan, the UK and the USA were more likely to be
noncompliant to guidelines (p-value = 0.00). There was a significant association between occupation of participants
and noncompliance. Housewives and retired were more likely to be noncompliant (p-value = 0.00). A significant
association was observed between vaccinated people and noncompliance.
Conclusion: Travelers arriving from some specific countries were noncompliant to guidelines. Vaccinated were most
noncompliant which indicates still we need to work on awareness and need legislations, fines, or travel restrictions
for noncompliant travellers.
Keywords: Noncompliance, COVID-19, travel health, biosecurity, pandemic
Introduction
The COVID-19 pandemic is a global public health
challenge, causing acute respiratory illness leading to
pneumonia and even death in severe cases.
Irrespective of location, there is always a threat of
cross border disease transmission due to increasing
trend of air travel. Islamic Republic of Pakistan is
bordered by India to the east, Afghanistan to the
west, Iran to the southwest, and China to the
northeast
(1).
It
also
shares
a maritime
border with Oman. During this pandemic all these
areas were affected by COVID-19. The first case of
COVID-19 was detected in Pakistan during February
2020 with a travel history from Iran (2). Since the start
of the pandemic, new variants have been evolving and
moving from one country to another either by air
travel or ground crossings. It is important to take
vigorous measures to limit the spread of the virus in
early phases of new outbreaks. This has prompted the
demand for the detection, isolation, and quarantine of
suspected cases at points of entries including airports,
seaports and ground crossings (3) (4). In view of the
above, a protocol was prepared and implemented by
Ministry of National Health Services, Regulations and
Coordination at all point of entries in early 2020 to
contain COVID-19 (5). These protocols are equally
applicable to arriving passengers as well as the crew.
However, with the appearance of new variants and
speed of spread, the on-the-ground situation has been
changing continuously (6). Keeping pace with the
evolving epidemiological situation across the world,
these guidelines are reviewed and updated
Saeed S, Chaudhry A, Baig Z, Akram K, Hussain Z, Khan M, Malik M, Ikram
A. Factors associated with noncompliance of COVID-19 guidelines
recommended by Government of Pakistan for international travelers
arriving at Islamabad International Airport, 1st June to 30th July 2021.
Global Biosecurity, 2022; 4(1).
periodically by Ministry of National Health Services,
Regulations and Coordination (3).
During the coronavirus (SARS-CoV-2) pandemic in
2020, citizens from the United States of America,
United Kingdom, Netherlands, and Germany
experienced relatively high levels of mis- and
disinformation about COVID-19 that lowered their
compliance towards following guidelines (7). Many
countries are conducting entry screening for arriving
passengers as per International Health Regulations
(2005) screening guidelines. Pakistan, being a
signatory of IHR (2005), was mandated to conduct
entry screening at airports, seaports and ground
crossings.
In general, successful control of the spread of
COVID-19 through entry screening is possible only
with sufficient resources in terms of human resource
and logistics. For efficient and effective screening,
updated equipment such as thermal scanners and
thermal guns are required along with trained human
resource to operate and interpret such equipment.
Refresher courses for the training of staff are also
required on regular basis (8).
In Pakistan, testing on arrival began for arriving
passengers in December 2020 and has continued to
date. Rapid antigen tests are being conducted for all
arriving passengers. Those passengers who turned out
positive are quarantined at designated quarantine
facilities set up by government of Pakistan. From the
first variant to every new variant, all have been
imported to
Pakistan from other countries. At
present we are experiencing a surge in cases for the
fourth time since start of pandemic despite standard
operating procedures for arriving international
travelers, so it is important to probe the factors
associated with non-compliance of guidelines by
travelers as well as to know if any other stake holder is
responsible for non-compliance (9). The objective of
this study was to find out factors associated with noncompliance of Ministry of National Health Services
Regulation and Co-ordination, Government of
Pakistan
recommended
guidelines
by
the
international arriving passengers so that we can
improve the arrangements at airports wherever
required, improve future preparedness, and give
recommendations to concerned authorities for
improvement in enforcing guidelines.
Methods
A cross sectional study was carried out at
Islamabad International Airport during the months of
June and July 2021. The study population included
international arriving passengers aged 12 and above
arriving to Islamabad from different countries during
the study period. The lower age limit of 12 was selected
because many of the standard operating procedures
does not apply to passengers less than 12 years old.
The sample size was calculated using Open Epi
calculator. The population was taken as the total
number of arriving passengers from different
countries in one month. The sample size for the study
was calculated with 95% confidence interval,
anticipated frequency as 50 % and 10% non-response
rate as 421. The total number of international arriving
passengers at Islamabad International Airport was
approximately 6,000 per day (information collected
from civil aviation authority arrival desk), so the
number of arrivals over 30 days was approximately
180,000. Simple random sampling was done. Out of
450 travelers asked to participate in the study 426
participated voluntarily giving a response rate of 95%.
Inclusion criterion
International passengers of 12 years and above
arriving from different countries at Islamabad
International Airport during study duration.
Exclusion criterion
Passengers with any mental disability who were
unable to respond properly.
Data Collection
The data collection tool was a semi-structured
questionnaire as well as observation. The travelers
were observed for wearing masks and maintaining
social distance at time of arrival and during interview.
The questionnaire consisted of 3 main sections: a
consent form and questions about sociodemographic
characteristics, travel preparedness and their level of
compliance to follow guidelines recommended by
Government of Pakistan, Ministry of National Health
Services, Regulations and Co-ordination, before
boarding, on board and after disembarkation (3).
Passengers were also asked about reasons for
noncompliance of specific guidelines. Travelers were
interviewed and questionnaires were filled by
principal investigator after taking informed verbal
consent from the respondents. Twenty questions were
asked about compliance of recommended guidelines.
All questions were designed to be responded as YES or
NO, as for following the recommended guidelines
there was no mid-way, either they are following or not.
A median cut off value was set for evaluation of
noncompliance in travelers. Those following less than
50 % of the recommended precautionary measures
were considered noncompliant whereas those
following more than 50 % were considered compliant.
Data was collected both during the day and at night
to include as many travelers as possible arriving from
different regions of the world. A pilot study was carried
out on 10 % of sample size to check the validity and
reliability of the questionnaire, to check the
understanding of the questions by respondents and to
check time to complete one questionnaire. Data
cleaning was carried out and analysis was done using
Epi info version 7. Independent variables included
sociodemographic characteristics of the respondents
whereas the dependent variable was noncompliance of
guidelines. Frequencies and percentages for
categorical variables were calculated. Chi square test
Saeed S, Chaudhry A, Baig Z, Akram K, Hussain Z, Khan M, Malik M, Ikram
A. Factors associated with noncompliance of COVID-19 guidelines
recommended by Government of Pakistan for international travelers
arriving at Islamabad International Airport, 1st June to 30th July 2021.
Global Biosecurity, 2022; 4(1).
was applied to find out any significant association
between dependent and independent variables.
Ethical approval was sought from airport
management after describing the importance of the
study and its public health impact. Informed written
consent was taken from all study participants.
Confidentiality of the respondents and collected data
was strictly maintained. Respondents were given the
right to withdraw from the interview if it is rendered
unsuitable to them.
Results
The study participants included 225 males and 201
females, giving a male-to-female ratio of 1:1. The age
range was 12 – 75 years, with median age 39 and mean
age 40 years. The majority of respondents (35%) were
from 26 to 40 years of age. The majority of
respondents arrived from Middle East (21.4%) and
United Kingdom (21%). Participants had varied
education levels. Among all the 426 participants, 54
(13%) were illiterate, 177 (41%) were undergraduate
(less than 14 years of education according to Pakistan’s
education system), 128 (30%) graduate (more than 14
years of education) and 27 (7%) were postgraduate
(more than 16 years of education). Among the 426
participants, 97 (23%) were office workers, 74 (17%)
were professionals (including doctors, engineers,
teachers, research officers and others), 85 (20%)
homemakers, 27 (6%) were self-employed, 39 (9%)
retired or those who stay at home, and 49 (12%) were
students.
Inferential Results
Detailed inferential results have been explained in
Table 2 below. The results revealed a significant
association between region of arrival of respondents
and noncompliance. Passengers arriving from
Afghanistan, France, United Kingdom and United
States of America were more likely to be noncompliant
to guidelines (p-value = 0.000). There was a
significant association between occupation of
participants and noncompliance. Homemakers and
retired or those stay at home were more likely to be
noncompliant (p-value = 0.000). A significant
association was observed between vaccination status
and noncompliance (p-value = 0.000). There was no
significant association between education level and
nationality of the respondent and noncompliance.
Table 1. Sociodemographic characteristics of study participants
Demographic characteristics
Sex
Male
Female
Age (in years)
12 – 25
26 – 40
41 – 55
56 – 70
70 +
Education Level
Illiterate
Primary
Undergraduate
Graduate
Postgraduate
Nationality
Pakistani
Dual
Marital Status
Married
Unmarried
Occupation
Home makers
Students
Laborer
Office Job
Professionals
Retired
Self Employed
Number
Percentage
225
201
53%
47%
63
151
145
52
15
15%
35%
34%
12%
4%
54
40
177
128
27
13%
9%
41%
30%
7%
221
205
52 %
48 %
256
170
60 %
40 %
85
49
54
97
74
39
27
20%
12%
13%
23%
17%
9%
6%
Figure 1. Number of travelers arrived from different countries of the world during study duration at Islamabad
International Airport
Countries of arrival
Saeed S, Chaudhry A, Baig Z, Akram K, Hussain Z, Khan M, Malik M, Ikram
A. Factors associated with noncompliance of COVID-19 guidelines
recommended by Government of Pakistan for international travelers
arriving at Islamabad International Airport, 1st June to 30th July 2021.
Global Biosecurity, 2022; 4(1).
AFGHANISTAN
AUSTRALIA
FRANCE
BISHKEK
GERMANY
CHINA
SOUTH AFRICA
TURKEY
CANADA
UNITED STATES OF AMERICA
UNITED KINGDOM
MIDDLE EAST
8 ( 1.8%)
11 (2.5 %)
15 (3.5 %)
15 (3.5 %)
19 ( 4.5 %)
19 (4.5 %)
37 (9 %)
37 (9%)
40 ( 9.3 %)
44 ( 10 %)
90 (21 %)
91 (21.4 %)
0
10
20
30
40
50
60
70
80
90
100
Number of Respondents
Table 2. Association of independent variables with noncompliance of guidelines among international travelers
arriving at Islamabad International Airport during June and July 2021
Variable
Occupation
Self employed
Homemakers
Laborer
Office Job
Professional
Retired / Stay at Home
Student
Vaccination
Vaccinated
Unvaccinated
Gender
Male
Female
Nationality
Dual
Pakistani
Education Level
Illiterate
Primary
Undergraduate
Graduate
Postgraduate
Arriving From
Afghanistan
Australia
Bishkek
Canada
China
France
Germany
Middle East
South Africa
Turkey
UK
USA
Discussion
Noncompliance of guidelines
Yes
No
8 (30%)
52 (61%)
15 (28%)
33 (34%)
43 (58%)
27 (69%)
10 (20%)
19 (70%)
33 (39%)
39 (72%)
65 (66%)
31 (42%)
12 (31%)
39 (80%)
221 (70%)
9 (8%)
96 (30%)
100 (92%)
87 (39%)
106 (53%)
138 (61%)
95 (47%)
98 (48%)
90 (41%)
107 (52%)
131 (59%)
21 (39%)
17 (42%)
78 (44%)
58 (45%)
14 (52%)
33 (61%)
23 (58%)
99 (56%)
70 (55%)
13 (48%)
5 (63%)
0 (0 %)
6 (40%)
10 (25%)
16 (84%)
2 (13%)
4 (21%)
39 (43%)
12 (32%)
19 (51%)
56 (62%)
24 (55%)
3 (37%)
11 (100%)
9 (60%)
30 (75%)
3 (16%)
13 (87%)
15 (79%)
52 (57%)
25 (68%)
18 (49%)
34 (38%)
20 (45%)
X2
p-value
49.5
0.000
96.3
0.000
5.776
0.016
2.162
0.141
1.37
0.849
71.7
0.000
The objective of this study was to identify factors
associated with noncompliance of recommended
Saeed S, Chaudhry A, Baig Z, Akram K, Hussain Z, Khan M, Malik M, Ikram
A. Factors associated with noncompliance of COVID-19 guidelines
recommended by Government of Pakistan for international travelers
arriving at Islamabad International Airport, 1st June to 30th July 2021.
Global Biosecurity, 2022; 4(1).
guidelines for COVID-19 in international travelers.
The results of the study revealed travelers arriving
from Afghanistan, United States of America and
United Kingdom were more likely to be noncompliant
as compared to travelers arriving from other
countries. The study results revealed that people
arriving from Middle East and Australia, irrespective
of their nationality, were most compliant, possibly due
to strict rules in their countries. Vaccinated people
were more noncompliant, probably due to perceived
feeling of being safe from getting infected post
vaccination. (10).
There is a dire need to emphasize education and
awareness at all levels. Vaccinated individuals need
awareness that even if they will not develop
complications or severe symptoms after getting
infected post-vaccination, they might act as carriers
and can infect others around (11). Awareness before
travel is also necessary. Individuals who perceive
COVID-19 as a serious threat and those who have
greater trust in science and scientists are more likely
to act in accordance with the proposed guidelines (12).
Above all, we need legislation and fines for strict
implementation of standard operating procedures.
Pakistan formulated guidelines for COVID-19
screening according to recommendations of
International Health Regulations (2005), but
compliance remains inadequate. The introduction of
mandatory restrictions is to enhance enforcement of
guidelines to safeguard our communities from any
new threat/variant entering Pakistan. Ministry of
National Health Services, Government of Pakistan is
working hard in its capacity to formulate and update
guidelines for COVID-19 prevention and protection,
but they will benefit only if imposed in true spirit. An
intrinsic feeling of duty to support authorities are
specifically important in this context. Non-compliant
travelers must be fined and strict actions are required
as at this moment we cannot afford any more burden
of disease in Pakistan. Numerous studies have
examined
compliance
with
public
health
recommendations during pandemic outbreaks (13).
Until now, however, no published studies have
included a full complement of demographic,
instrumental and normative factors in prior research.
The most important factor towards compliance is selfinterest or sense of duty (14). Awareness needs to be
created in the community that COVID-19 is something
that not only affects you, but can be more hazardous
to children and older adults (15).
Conclusion
The results of this study suggest that travelers
arriving from some specific countries, such as
Afghanistan, France, United States of America and
United Kingdom were more likely to be noncompliant
to recommended guidelines. Those from Afghanistan
were found to be noncompliant probably due to lack of
COVID-19 restrictions in their country. Those from
developed countries and vaccinated were more likely
to be noncompliant, possibly due to perceived feeling
of safety from infections, which indicates that medical
education and awareness are required at all levels. As
the COVID-19 pandemic is still progressing, we need
to research further. In order to determine the true
association of these variables with the outcome further
analytical studies are required.
Competing Interests
The authors have no competing interests to declare.
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How to cite this article: Saeed S, Chaudhry A, Baig Z, Akram K, Hussain Z, Khan M, Malik M, Ikram A. Factors associated with noncompliance
of COVID-19 guidelines recommended by Government of Pakistan for international travelers arriving at Islamabad International Airport, 1st
June to 30th July 2021. Global Biosecurity, 2022; 4(1).
Published: January 2022
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