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Global Journal of Health Science
Vol. 4, No. 2; March 2012
Pandemic Influenza A (H1N1) and Its Prevention: A Cross Sectional
Study on Patients’ Knowledge, Attitude and Practice among Patients
Attending Primary Health Care Clinic in Kuala Lumpur, Malaysia
Associate Prof. Dr. Latiffah A Latiff (Corresponding author)
Department of Community Health, Faculty of Medicine and Health Sciences
Universiti Putra Malaysia (UPM)
Tel: 603-8947-2537
Email: latiffahl@gmail.com
Dr. Saadat Parhizkar
Department of Public Health, Faculty of Health
Yasuj University of Health and Medical Sciences, Iran
Dr. Huda Zainuddin, Goh M Chun, Mohammad Ali A Rahiman
Nur Liyana N Ramli & Kerk L Yun
Department of Community Health, Faculty of Medicine and Health Sciences
University Putra Malaysia
Received: December 14, 2011
doi:10.5539/gjhs.v4n2p95
Accepted: December 28, 2011
Published: March 1, 2012
URL: http://dx.doi.org/10.5539/gjhs.v4n2p95
Abstract
The World Health Organization confirmed that the novel influenza A, H1N1 as a pandemic on 11 June 2009.
After less than three months, 182 countries were affected by the pandemic accounting for about 150,000 infected
cases and 3000 mortality. Successful H1N1 pandemic management strategies’ shaped by making changes in
health behavior. The aim of this study was to document patients’ knowledge, attitudes and practices (KAP)
regarding the pandemic influenza A (H1N1) and its prevention. We performed a cross-sectional study on
knowledge, attitudes and practices (KAP) on preventive measures of Influenza A (H1N1) involving 322 patients
attending Klinik Kesihatan Jinjang, a primary health care clinic in Kuala Lumpur, Malaysia from May 10 to 26,
2010 using a face to face interview with a structured pre-tested questionnaire. The majority of the respondents
were females (56.8%), Malays (43.2%) aged between 18-27 years old (28.9%). There were significant
association between knowledge on the complication of H1N1, effectiveness of the treatment, preventive
measures of Influenza A (H1N1) and race (p<0.001) and educational level (p<0.001). There were also significant
associations between attitude scores of these patients and their gender (p=0.03), and educational level (p=0.001).
Practice scores related to H1N1 were found to be significantly associated with race (p<0.001) and educational
level (p<0.001). The significant associations were observed between knowledge and attitude (p<0.001),
knowledge and practices (p<0.001), as well as attitude and practices related to H1N1 (p<0.001). Knowledge has
a crucial effect on patients’ attitude and practice particularly in a pandemic spread. So health policy makers
should attempt to disseminate information about preventive measures to community in order to improve their
preventive practices during pandemics.
Keywords: Attitude, Influenza A (H1N1), Knowledge, Malaysia, Practice, Primary health centre
1. Introduction
By April 2009, the sever cases of pneumonia were occurred in Mexico which proceeded by influenza virus and
then spread to North America. The cause of that pneumonia identified and noted which it quickly evolved into a
pandemic (Van et al., 2009). Evidence that this strain could pass from human to human led the World Health
Organization to quickly raise its pandemic alert level to Phase 6 on 11 June, 2009, it has since spread widely
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across the globe with substantial clinical impact (WHO, 2009). During the first wave of A (H1N1) influenza in
Malaysia, 14,912 cases were reported from May 15, 2009 until Jun 4, 2010 and a total number of 88 deaths were
recorded across the country in 2010 (Ministry of Health Malaysia; 2010). Effective pandemic management
requires support from the population at risk for measures undertaken to mitigate the pandemic's spread. Previous
studies during the Severe Acute Respiratory Syndrome (SARS) outbreak in 2003 have shown that individual
beliefs and perceptions play an important role in subsequent desired behavioral change (Tang and Wong, 2003;
Lau et al., 2003). Higher perception on effectiveness of measures undertaken (Lau et al., 2003; Tang and Wong,
2004) and higher perceived threat of the disease led to higher rates of positive behavioral change, and better
knowledge also increased the uptake of preventive measures (Leung et al., 2004; Leung et al., 2005). Similarly,
in an anticipated H5N1 epidemic, these factors also influenced both self and community protective behavior
(Lau et al., 2007) During the current influenza pandemic, studies have found that the individual's emotional
status mediates behavioral response (Jones and Salathe, 2009) ) and that perceived severity and susceptibility to
disease and perceived effectiveness of specific behaviors resulted in the corresponding recommended behavior
changes (Rubin et al., 2009; Seale et al., 2009). To increase positive perceptions, clear dissemination of
information is vital to reduce misconceptions (Lau et al., 2009). It is therefore important to perform behavioral
studies in different populations to understand the determinants that influence behaviors. However, there have
been few studies (Mohd Shahriman et al., 2009; Zairina et al., 2011) on the knowledge, attitudes and practices
towards the influenza A pandemic in Malaysia. As such, there is a need to understand the factors influencing
such behavioral changes to promote effective management of influenza A pandemics in this country. Therefore,
this study was conducted to identify the knowledge, attitude and practice (KAP) associated with complications
of H1N1, effectiveness of treatment, preventive measures and health promotion of Influenza A (H1N1) among
patients attending Klinik Kesihatan Jinjang in Kuala Lumpur, Malaysia in 2010.
2. Materials and Methods
We conducted a cross-sectional study in Klinik Kesihatan Jinjang, Kuala Lumpur for 16 days duration (from
May 10 to 26, 2010). The study protocol was approved by the Medical Research Ethics Committee of Faculty of
Medicine and Health Sciences, Universiti Putra Malaysia (UPM) and permission from the director of Kuala
Lumpur Federal Territory Health Department and Klinik Kesihatan Jinjang were obtained to collect the data.
Participants (n=322) were randomly selected from the attendees of Klinik Kesihatan Jinjang, Kuala Lumpur
according to their attendance number in the clinic and written consent was obtained from them. Eligible
participants were 18 years of age or older.
2.1 Data Collection Tool
We developed a questionnaire to assess the knowledge, attitudes and practices (KAP) regarding pandemic
influenza A which was administered to each participant by face to face interview. The questionnaire was adopted
from previous studies done by researchers (Rubin et al., 2009; Goodwin et al., 2009), and was pilot tested among
30 patients from another clinic (Klinik Kesihatan Pantai) with similar profiles to prove its reliability. The
questionnaire was consisted of 4 parts: A: demographic characteristics, B: knowledge C: attitudes and D:
practices of participants using both open and close questions. The questionnaire collected information on basic
demographic data on age, sex, ethnicity and education level as well as questions on knowledge, attitudes, and
practices on pandemic influenza A (H1N1). Questions on knowledge were used to assess the respondent’s
general knowledge on pandemic influenza A and on the recommended preventive measures. Questions on
attitudes were used to assess perceptions towards pandemic influenza A and these preventive measures.
Questions on practices were used to assess the actual compliance and practices of these measures. Respondents’
were asked to rate their agreement with the statements in the questionnaire, which were scored either yes/no or
on a 4 point Likert scale.
A score of 1 was given for a correct response. The incorrect response and “don’t know” was classified as an
incorrect response and received a “0” score. In the attitude section, responses were measured on a rating scales
ranging from 1 to 4 with 1 = strongly disagree, 2 = disagree, 3 = agree, and 4 = strongly agree. The higher score
on the scale of ≥3 scores indicated a greater positive attitude toward those statements. The higher practice scale
of >50% of action indicated that participants were more likely to practice well with reference to those practices.
Respondents who scored above the mean value were considered to have high level of knowledge, positive
attitudes and good practices respectively while score below the mean value was considered having low level of
knowledge, negative attitudes and poor practices.
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2.2 Statistical Analysis
For the purpose of analysis, the individual scores were summed up to yield a total score. All statistical analyses
were performed using SPSS 16 for Windows (SPSS Inc, Chicago, IL), with the level of significance set at 5%.
Age was computed from the information on date of birth and date of interview. Chi-squared tests of significance
were used to find the association of knowledge, attitude and behavior in relation to different age groups and
different educational levels.
3. Results
The demographic profile of the participants is shown in Table 1. Majority of the respondents were females
(56.8%), Malays (43.2%) aged between 18-27 years old (28.9%). Most of the respondents had completed
secondary school education (49%) followed by pre-university level of education (28.6%). Majority of
respondents (61.8%) were working either in public or private organizations in the period of study.
<Table 1>
Table 2 presents the responses of the study participants on H1N1 pandemic influenza A (H1N1) and its
preventive measures. The finding showed that majority of patients (80.7%) believed that H1N1 can spread
through air contact, while just one third of them agreed that touching is the other method of transmission.
Majority of participants knew that covering one’s nose or mouth when sneezing (85.4%) and wearing mask
(76.7) can prevent the spread of H1N1. A major portion of respondents (93.2%) believed that either washing
hand with soap and water after coughing/ sneezing or avoiding crowded places are helpful in prevention of
spreading H1N1.Less than Half of the respondents believed that either each H1N1 patients will experience the
complications or every H1N1 infected person will die because of it.
<Table 2>
Result (Figure 1) showed that half of the patients had good knowledge level towards pandemic influenza A
(H1N1). Majority of respondents (76.4%) also had positive attitudes regarding preventive measures of influenza.
Subsequently, 55.3% of the respondents showed a good practice on preventive measures of influenza (Figure 1).
The level of respondents’ knowledge regarding H1N1 was not associated with different age groups, genders as
well as employee status. However, there was a statistically significant associations between both race (p <0.001)
and educational level (p <0.001) with knowledge regarding H1N1 (Table 3).
The level of respondents’ attitude regarding H1N1 were not associated with respondents’ age, race and
employment status, even though there were statistically significant associations between both gender (p <0.001)
and educational level of patients (p <0.05) with their attitudes regarding H1N1 (Table 3).
The respondents’ practices regarding H1N1 prevention were not associated with respondents’ age, race (p
<0.001) and employment status, though there were statistically significant associations between race and
educational level of participants (p <0.001) with their practices regarding H1N1.
<Table 3>
There were significant association between knowledge and attitude (p<0.001), knowledge and practices
(p<0.001), (Table 4) as well as attitude and practices related to H1N1 (p<0.001).
<Table 5>
4. Discussion
The results of the present survey depicts a range of knowledge, attitudes and self reported behavioural patterns
concerning H1N1 among a sample of adult population in a primary health care clinic in Malaysia. This study
investigated the levels of knowledge, attitudes and practices regarding H1N1 and should provide scientific
support to assist health sector authorities’ in developing strategies and health education campaigns to prevent
transmission of H1N1. Guidelines and recommendations have been developed to prevent and control the spread
of H1N1 during pandemic threat (WHO, 2009). Successful containment or control of pandemic influenza will
rely on early recognition of sustained human-to-human transmission which requires a system for outbreak
detection, rapid data collection, analysis, assessment and timely reporting.
The current study revealed significant relationships between race, educational level and knowledge level which
were consistent with the study conducted by Sukprasert and his colleagues in Thailand (2009). On the other
hand, the result showed no significant associations between some demographic characteristics (e.g. age, gender
and working status) and knowledge level that consistently was similar to other study done among rural
population in Jempol, Malaysia (Mohd Shahriman et al., 2009). Similarly, the results indicated that gender, and
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Vol. 4, No. 2; March 2012
educational level significantly associated with knowledge level that was also highlighted in the study done by
Marshall (2009) in South Australia where women were found to be more likely than men to report high concerns
about the threat of pandemic influenza A (H1N1). Janahi and his colleagues (2011) in Bahrain also reported that
higher education and older age have positively correlated with an increase in the general knowledge about the
virus and the disease. Both race and educational level were found to have been associated significantly with
practices regarding H1N1 prevention.
Both practices and knowledge level towards preventive measures on H1N1 were only affected by different types
of races and education levels. The reasons may be because the campaigns were done in Malay or English
language, which most of the other races do not understand, thus, they do not get the knowledge needed to
practice the preventive measures recommended by the Ministry of Health.
The triad of knowledge, attitudes and practices in combination governs all aspects of life in human societies, and
all three pillars together make up the dynamic system of life itself. Therefore, they were linked all together in a
way so that any increase in knowledge, changes in attitudes towards prevention of Influenza A H1N1 as well as
changes in the kinds of practices that were followed regarding prevention of H1N1.
There was significant association between knowledge and attitude (p=0.001). This was consistent with the result
of study done in Jempol, situated in Negeri Sembilan, about 200km away from Kuala Lumpur (Mohd Shahriman
et al., 2009). There was also significant association between knowledge and practices. Meanwhile, in a study
done among Thai medical students, Wisedjinda (2009) reported that there was no significant correlation between
knowledge and practices. The other researcher (Sukprasert et al., 2009) also stated that there was no significant
association between knowledge and practices. There was also significant association between attitude and
practices (p=0.001). This concurred with the findings of Wisedjinda (2009) and Zairina et al., (2011) confirming
a significant association between attitude and practices. This study has some limitation as the study population
was only confined to adults and limited in one health centre which its generalizability is questionable. Although
results in this study are useful in pandemic preparedness, the community response may change over time as
compared to the time of study. This study was a cross sectional survey and may not have been able to assess the
true association between knowledge and practices. Thus future study with different study design should be
considered for validation.
5. Conclusion
Knowledge has significant influence on attitude and practices in a pandemic spread of Influenza A (H1N1), and
personal experience influences individual’s practices and behaviors. It is suggested that education measurement
is one of the important keys of pandemic containment strategies. Efforts should be targeted at inculcating
relevant knowledge and educating the general population to improve practices in the current pandemic, as well
as for future epidemics. Therefore, in the future, educational programs should focus on improving good practices
for containing community transmission of pandemic influenza A (H1N1).
Acknowledgements
The authors would like to express their highest appreciation to Ministry of Health, Malaysia and all the officers
and staffs at district health offices, district hospitals and state health department in the state of Pahang, Malaysia
for full cooperation in providing information and data for the purpose of this study
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Table 1. Socio-demographic characteristics of respondents (n=322)
Social demographic characteristic
Age Group
Gender
Race
Education Level
Working status
Frequency
Percentage (%)
18-27
93
28.9
28-37
66
20.5
38-47
62
19.3
48-57
49
15.1
58 and above
43
13.4
Missing data
9
2.8
Male
139
43.2
Female
183
56.8
Malay
139
43.2
Chinese
123
38.2
Indian
49
15.2
Others
11
3.4
No formal education or completed primary
education (primary school)
72
22.4
Completed secondary education (high school)
158
49.0
STPM * and above
92
28.6
Working
199
61.8
Not working
123
38.2
STPM * Stand for: Sijil Tinggi Persekolahan Malaysia that meaning: Malaysia Higher School Certificate
Table 2. Patients’ knowledge regarding pandemic influenza A (H1N1) and its preventive measure (%)
No:
Question
Yes
No
Not Sure
1
H1N1 can spread through air contact
80.7
6.2
13.1
2
H1N1 can spread through touching
36.3
34.2
29.5
3
Wearing mask can prevent the spread of H1N1
76.7
21.1
2.2
4
Covering your nose or mouth when sneezing can prevent the spread
of H1N1
85.4
12.4
2.2
5
Washing hand with soap and water after coughing/ sneezing can
prevent the spread of H1N1
93.2
5.9
0.9
6
Avoiding crowded places help prevent the spread of H1N1
81.4
15.2
3.4
7
Every H1N1 infected person will experience complications
43.8
24.8
31.4
8
Every H1N1 infected person will die because of it
26.7
47.8
25.5
9
Quarantine at home is able to heal the infected person from H1N1
52.8
25.2
22
10
The purpose of quarantine at home is just to avoid the spread of
H1N1 virus
81
5
14
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Table 3. The association between knowledge, attitudes and practices regarding Influenza A (H1N1) and
socio-demographic characteristics
Socio-demographi
c characteristics
Knowledge Level
Good
X²
Poor
42 (45.2%)
28-37
28 (42.4%)
38-47
37 (59.7%)
48-57
26 (53.1%)
>58
24 (55.8%)
Male
71 (51.1%)
Female
90 (49.2%)
23.7
62
Race
Malay
51 (36.7%)
Chinese
80 (65.0%)
Indian
27 (55.1%)
Others
3 (27.3%)
No Formal
Education or
Completed Primary
Education
Completed
Secondary
Education
STPM or Higher
4.61
2
25
(18.0%)
33
(26.8%)
15
(30.6%)
3 (27.3%)
38.4
63
Educational Level
69
(49.6%)
75
(41.0%)
41
(29.5%)
79
(64.2%)
18
(36.7%)
6
(54.5%)
13.2
70
<0.0
01
0.00
1
26
(36.1%)
46
(63.9%)
46
(63.9%)
26
(36.1%)
86 (54.4%)
72
(45.6%)
39 (24.75)
119
(75.3%)
73
(46.2%)
85
(53.8%)
23 (25.0%)
69
(75.0%)
11
(12.0%)
81
(88.0%)
25
(27.2%)
67
(72.8%)
Working
58 (47.2%)
Not
Working
103
(51.8%)
0.42
2
65
(52.8%)
96
(48.2%)
Published by Canadian Center of Science and Education
0.64
3
32
(26.0%)
44
(22.1%)
91
(74.0%)
155
(77.9%)
0.42
3
59
(48.0%)
85
(42.7%)
0.1
42
2.39
5
0.1
22
34.1
61
<0.
001
22.2
99
<0.
001
0.84
9
0.3
57
98
(70.5%)
44
(35.8%)
31
(63.3%)
5
(45.5%)
20
(27.8%)
0.64
5
6.88
2
70
(50.4%)
108
(59.0%)
52 (72.2%)
Working Status
p
54
(58.1%)
45
(68.2%)
29
(46.8%)
25
(51.0%)
23
(53.5%)
0.20
2
114
(82.0%)
90
(73.2%)
34
(69.4%)
8
(72.7%)
X²
Poor
0.03
0
98
(70.5%)
148
(80.9%)
<0.0
01
88
(63.3%)
43
(35.0%)
22
(44.9%)
8
(72.7%)
39
(41.9%)
21
(31.8%)
33
(53.2%)
24
(49.0%)
20
(46.5%)
4.71
2
41 (29.5
%)
35
(19.1%)
Practice Level
0.52
1
72
(77.4%)
55
(83.3%)
44
(71.0%)
36
(73.5%)
34
(79.1%)
0.73
6
68
(48.9%)
93
(50.8%)
p
Good
3.22
7
21
(22.6%)
11
(16.7%)
18
(29.0%)
13
(26.5%)
9 (20.9%)
0.11
4
X²
Negative
0.24
2
51
(54.8%)
38
(57.6%)
25
(40.3%)
23
(46.9%)
19
(4.2%)
Gend
er
Attitude Level
Positive
5.47
1
Age Group
18-27
p
64
(52.0%)
114
(57.3%)
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Table 4. Association between respondents’ knowledge level with attitude and practice among respondents
regarding Influenza A (H1N1)
Attitude
Measurements
Knowl
edge
Level
Total
Negative
Positive
Low
52
(32.3%)
109
(67.7%)
161
(100%)
High
24
(14.9%)
137
(85.1%)
161
(100%)
76
(23.6%)
246
(76.4%)
322
(100%)
Total
Practice
P
value
X²
13.5
0
<0.00
1
Total
Bad
Good
95
(59.0%)
66
(41.0%)
161
(100%)
49
(30.4%)
112
(69.6%)
161
(100%)
144
(44.7%)
178
(55.3%)
322
(100%)
X²
P
value
26.58
<0.00
1
Table 5. Association between attitude and practice among respondents regarding Influenza A (H1N1)
Practice
Measurements
Attitude
Total
Bad
Good
Negative
55 (72.4%)
21 (27.6%)
76 (100%)
Positive
89 (36.2%)
157 (63.8%)
246 (100%)
144 (44.7%)
178 (55.3%)
322 (100%)
Total
X²
P value
30.760
<0.001
7 6.4
80
70
60
50
55 .3
50
4 4.7
50
40
2 3.6
30
20
10
0
K n o wled g e
A ttitu d e
G o od
P rac tic e
P oor
Figure 1. Knowledge, Attitude and Practice regarding preventive measures of H1N1 (%)
102
ISSN 1916-9639
E-ISSN 1916-9647