Abstract
Background:
Public health emergencies have a significant impact on the health of citizens, the local economy, and society as a whole. Currently, in many parts of China, there is a widespread lack of the knowledge and skills required for emergency preparedness and self-rescue. By carrying out targeted health education and intervention activities, and by popularizing the knowledge and skills in health emergencies, the abilities of citizens to respond to public health emergencies and protect themselves, reduce property damage, and eliminate unnecessary panic may be greatly improved.
Objectives:
The knowledge and skills of the public to respond to public health emergencies after an intervention in Sichuan province were surveyed. The conditions before and after the intervention were compared, and the effect of the intervention was evaluated.
Methods:
Four counties in Sichuan province were selected for baseline survey by means of a multistage random sampling method. Among the districts and counties, one of each was selected for baseline survey as an intervention group and another of each were selected as controls. After 1 year of intervention, respondents were selected from the intervention group by means of the method used for the baseline survey for effect evaluation. Results: After statistical analysis, it was shown that, after the intervention, the total awareness rate of knowledge to respond to public health emergencies increased from 42.6% to 58.4% among men and from 42.9% to 55.8% among women, both significant differences (p < .001). It was also shown that the total awareness rates of the 18–35, 36–45, 46–60, and 60+ age-groups, respectively, increased from 44.5%, 43.7%, 42.2%, and 37.8% to 62.1%, 56.0%, 56.8%, and 51.9%, which were also significant differences (p < .001). Intervention, educational level, occupation, discussion with the families, and disaster experience were the main influential factors for the knowledge and skills of sudden public health events.
Conclusions:
The study results show that, after the intervention in Sichuan province, the knowledge and skills of the public to respond to public health emergencies were significantly improved. It is also shown that health education interventions must be developed in accordance with geographical features, the educational level of the population, age characteristics, and other factors.
The term public health emergencies refers to major infectious diseases, unexplained group illnesses, major food and occupational poisoning, and other events which have serious impacts on public health and which in turn may cause severe damage to public health (People’s Republic of China State Council Order 2013). Characterized by sudden and serious harm to public property, emergencies may not only have a serious impact on the health of citizens but may also greatly endanger the regional economic development and social stability as well as national security.
It is an important responsibility of the government and an important measure for protecting the life and health of the public and maintaining social stability to enhance the residents’ abilities to respond to public health emergencies and to reduce the damage caused to residents due to public health emergencies. In 1977, U.S. Congress initiated a “seismic risk reduction project” and the U.S. Federal Emergency Management Agency and American Red Cross have launched “emergency preparedness projects for community and family” as well as a “community disaster education project,” so as to guide and educate the public on emergency supplies preparation, development of a family escape plan, and preparation of a family escape package. The Japanese government has attached great importance to national disaster prevention quality education, popularized and included earthquake prevention and disaster mitigation into the curriculum of national education, and organized simulated earthquake drills in many cities, thus providing citizens with extensive knowledge in earthquake prevention and disaster mitigation (Ren 2005). The intervention modes commonly used by the public in other counties to respond to public health emergencies generally include teaching intervention (Mack et al. 2006), volunteer training (Matthews et al. 2005), “trainer training” (Orfaly et al. 2005), and situational drills (Miller et al. 2006).
At present in China, research regarding the intervention of the public to respond to public health emergencies has yet to be carried out, which significantly affects the capacity of the people to respond to public health emergencies. Providing the public with the basic knowledge related to public health emergencies in the daily work is the most powerful weapon to deal with emergencies because a strong social foundation may be formed during the process. From 2008 to 2010, the China Health Education Center undertook a special study of “public knowledge to respond to public health emergencies and skills intervention” in the health industry, in order to explore appropriate health education intervention strategies. This article forms a part of this study.
Respondents and Methods
Respondents
The respondents of the study were urban and rural residents over the age of 18 in the intervention districts and counties of Sichuan province.
Method
Sampling method
The multistage stratified random sampling method was used. First stage, based on the total number of various types of public health emergencies reported in the first half of 2008, the districts (cities) and counties (villages) of Sichuan province were divided into two categories, that is, those with a large number of reported cases and those with a small number. Then one district or county at the intermediate level was selected from each category, and a total of two sample areas (cities) and two sample counties (villages) were identified. Second stage: Two streets/townships were selected from each sample district/county via systematic sampling, and the specific procedure was as shown below: Sampling of streets: All of the streets in the sample district were sequenced according to the first letter in the name, then numbered (1, 2 … N). The sampling interval K was determined. K = total number (N) of all streets in the sample district/number of streets selected from the sample district (if indivisible, the roundoff number would be taken). The sample street was determined. We drew one piece of paper money (Ren Min Bi [RMB]) and took the mantissa of its serial number (the places were the same as the sampling interval K) as random digits. If the random digits were greater than K, then the random digit was divided by K so as to obtain the remainder as R; if the random digits were less than K, then the random digit was directly used as R. R was the serial number of the first sample street and R + K was the serial number of the second sample street. Sampling of townships
Based on economic development level, the townships in each sample county were classified into three categories: developed, general, and undeveloped. We then selected one township from each of the general and undeveloped categories by lottery, meaning that two townships were sampled from each sample county. Third stage: Two neighborhood committees/administrative villages were, respectively, sampled from each sample street/township via the systematic sampling method, and the specific procedure was the same as the sampling method in the preceding stage. Fourth stage: A total of 135 families were sampled from each neighborhood committee/administrative village via the systematic sampling method, and the specific procedure was as follows:
If the total number of residents was less than 135 families included in the neighborhood committee/administrative village, we first sampled all families and then determined the remaining samples from the nearest adjacent neighborhood committee/administrative village, to reach 135 families as the total number of samples; if the total number of residents was more than 135 families, then 135 families were directly sampled via the systematic sampling method. Fifth stage: One adult who was at least 18 years old was selected from each family as the respondent and registered. Then, 125 subjects were selected from the 135 respondents mentioned above for questionnaire survey.
Survey method
The survey contents of the study include the following: basic situation and response to earthquake, floods, fires, food poisoning, traffic accidents, chemical accidents, and radioactive accidents. The questionnaire was designed by the researcher after consulting relevant literature and data originating from both China and other countries and was revised and improved through expert discussions and on-site preliminary experiments. The investigators conducted household survey by means of face-to-face inquiry after receiving uniform training. The baseline survey was conducted from September to December 2008, and the effect assessment survey was conducted from May to July 2010.
Intervention method
One district and one county were selected from the four districts/counties of the baseline survey as the intervention group, and the subjects were all permanent residents in the intervention district/county. First, the intervention implementers received training. Twenty-five health education professionals were required from the training in each district/county. One key staff of health education was trained, respectively, for each community, school, enterprise, hotel, dance hall, cinema, and any other public place in the district/county. The intervention activities included the following: Publicity and advocacy by mass media and popularization of knowledge and skills involving dealing with sudden public health events. Local TV stations were employed to broadcast public service announcements to show the public how to deal with sudden public health events (DVDs provided by the state-level project group), and the public service announcements were broadcast at least once per week. Popular science articles, prizes for Q&A, and other methods related to response to sudden public health events were published in the main local newspapers, and the publication was presented at least once per month. Advertisements: We made use of public bus advertisements as well as those on digital mobile taxi television sets, elevator television sets, sides of large trucks as well as large screens in hospitals, supermarkets, transportation stations and other public places with large crowds of people to spread knowledge of dealing with sudden public health events. The publicity was conducted at least once every quarter year and the publicity was continued for 1 week every time. The publicity materials, such as brochures, folds, wall maps, and public service announcement DVDs, were provided by the state-level project group. Distribution of publicity materials in major places: We took all sample families in the baseline survey as the center and distributed, posted, and broadcast the public materials (folds, brochures, wall maps, public service announcements, etc.) throughout the community and in the nearby communities, hospitals, schools, enterprises, shopping malls, cinemas, restaurants, transportation station, and other nearby public places. Door-to-door publicity: The key staff, who had received specialized training, visited the sample families and interpreted the knowledge related to sudden public health events face to face with the members of the families, according to the Public Security Education Guide. The major subjects were elderly persons and those with low cultural levels. Lectures and publicity activities: We gave lectures and held publicity activities in communities, schools, enterprises, and other public places. The content included the knowledge and skills required to deal with sudden public health events, psychological crisis interventions of the group, and so on. These activities were held once every half year, and there were at least 80 participants each time. Simulation drills: We contacted local public security education bases and organized simulation drills involving escape and self-rescue for students and employees at least once.
The effect evaluation and survey were conducted using the same method and tools as the intervention activities that had been implemented for 1 year.
Statistical method
A database was established using EpiData3.0 software. Double-entry check and logic error detection were conducted for the questionnaire. Data management and statistical analysis were performed using Statistical Package for the Social Sciences 13.0 software. The awareness of knowledge was represented by awareness rate, and it was considered that a person was aware of the knowledge after he or she correctly answered at least 80% of all questions on the survey. The comparison of rate/constituent ratio was inspected using χ2 and multivariate analysis was conducted using logistic regression.
Quality Control
The investigators were trained and the survey methods and indicator interpretation were unified in order to ensure the consistency of the survey. Problems in the survey were identified and corrected in a timely manner before the survey was performed. Quality control personnel were assigned to inspect the questionnaire for leakage of work after completion of the survey. The questionnaire entry process was then inspected by means of the parallel double-entry method.
Results
Basic Situations
A total of 1,000 and 608 people were surveyed before and after the intervention. Respective amounts of 994 and 602 copies of valid questionnaires were received before and after the intervention with efficiency of 99.4% and 99%. There were no statistical differences in the nationality, educational level, marital status, and other demographic characteristics of the respondents before and after intervention. After the intervention, the proportion of the female group over the age of 46 was higher than that before the intervention (Table 1).
Basic Situation of Respondents, n (%).
Note. Comparison of the situations before and after the intervention.
*p < .05. ***p < .001.
Awareness Rate of Knowledge and Skills to Respond to Public Health Emergencies Among Respondents of Different Genders Before and After the Intervention
The awareness rate of knowledge to respond to public health emergencies significantly increased among both men and women, with the exception of flood events (Table 2). Among the other events, the increases in awareness rates to respond to food poisoning, chemical accidents, and traffic accidents were quite high among men, respectively, increasing by 23.1%, 22.9%, and 20.3%; the increase in awareness rate to respond to fire was high among women, with an increase of 20.8%.
Awareness Rate of Knowledge and Skills to Respond to Public Health Emergencies Among Respondents of Different Genders Before and After the Intervention, n (%).
Note. Comparison of the situations before and after the intervention.
*p < .05. **p < .01. ***p < .001.
The awareness rates to respond to flood among men before and after the intervention were 14.7% and 21.5%, respectively, a significant increase; however, the awareness rate among women before and after the intervention did not change.
The total awareness rate among men increased from 42.6% to 58.4% and among women from 42.9% to 55.8%, thus the increase rate of men was greater than that of women.
Awareness Rate of Knowledge and Skills to Respond to Public Health Emergencies Among Respondents of Different Age-Groups Before and After the Intervention
The awareness rate of knowledge to respond to public health emergencies after the intervention was significantly higher than that before the intervention, with the exceptions of traffic accidents and radiological accidents among respondents in the 18–35 age-group; among the other types of emergency, the increase rates of knowledge of this group to respond to chemical accidents, food poisoning, and fire were quite high, with respective increases of 29.1%, 25.6%, and 24.9% (Table 3).
Awareness Rate of Knowledge and Skills to Respond to Public Health Emergencies Among Respondents of Different Age-Groups, n (%).
Note. Comparison of the situations before and after the intervention.
*p < .05. **p < .01. ***p < .001.
The awareness rates of knowledge to respond to public health emergencies were significantly higher than those before the intervention, with the exceptions of floods and radiological accidents among respondents in the 36–45 age-group; among the other types of emergencies, the increase rates of knowledge to respond to chemical accidents, fires, and traffic accidents were quite high, with respective increases of 21.7%, 17.4%, and 15.8%.
The awareness rates of knowledge to respond to public health emergencies were significantly higher than those before the intervention, with the exception of floods among respondents in the 40–60 age-group; among the other types of emergencies, the increase rates of knowledge to respond to flood poisoning, fires, and traffic accidents were quite large, with respective increases of 29.1%, 20.9%, and 20.1%.
The awareness rates of knowledge to respond to public health emergencies were significantly higher than those before the intervention, with the exceptions of earthquakes, floods, and fires among respondents in the 60+ age-group; among the other types of emergencies, the increase rates of knowledge to respond to radiological accidents, traffic accidents, and food poisoning were quite high, with respective increases of 27.7%, 24.0%, and 18.3%.
The total awareness rate of knowledge to respond to public health emergencies reduced with the increase in age, both before and after the intervention; among these increases, the increase rate was largest in the 28–35 age-group, at 17.6%, and was smallest in the 36–45 age-group, at 12.3%.
Analysis of Factors Influencing Knowledge and Skills to Respond to Public Health Emergencies
Marks were assigned to the title of every part, including earthquake, flood, fire, food poisoning, traffic accident, chemical accident, and radiation accident (Table 4). The correct answer was rewarded with 1 point, while an incorrect answer resulted in 0 points. The total points of all the titles were the total points for the knowledge and skills related to sudden public health events.
Multiple Linear Regression Analysis of Influential Factors for Knowledge and Skills of Sudden Public Health Events.
We took the total points of the knowledge and skills of sudden public health events as the dependent variable, then considered aspects such as intervention, gender, age, educational level, occupation, experience in disaster, discussion with families about how to deal with disaster events, and abandon drills as independent variables, and conducted multiple linear regression analyses using the stepwise method.
The results showed intervention, educational level, occupation, discussion with the families, and disaster experience were the main influential factors for the knowledge and skills of sudden public health events. Among these, if educational level was high, then more points would be obtained; compared with the officers and general salesmen, the agricultural labors received relatively low marks, while other practitioners received relatively high marks; those who had discussions with their families about how to deal with disaster events received marks that were much higher than those who had not; and those who had experienced disaster received marks that were much higher than those who had not. When the aforesaid factors were controlled, the marks after intervention were higher than those before intervention.
Discussion
Related studies show that throughout the world there is a widespread lack of the knowledge and skills required for emergency preparedness and self-rescue. In February 2002, an earthquake with a magnitude of 6.0 occurred in Afyon, Turkey. After the earthquake, the results of a survey of 812 people showed that 83% of the injured were caused due to improper escape (Hulya et al. 2005). After the tsunami which occurred in the Indian Ocean, the survey results of 65 people showed that the awareness level of people for tsunamis was very low, as only 2 people were aware that a tsunami may occur after an earthquake, and 47.7% of the respondents began to flee only after seeing the tsunami (Hirokazu et al. 2006). In China, the study results of public emergency and self-help abilities in Wenzhou city of Zhejiang province showed that more than 90% of the public were not aware of the specific methods of operation of artificial respiration, and 47.8% of the public were completely unaware that the mouth and nose should be covered when crawling forward in the case of a fire (Min and An-yi 2005). In the urban district, suburbs and rural area of Nanchang city, the respective cognitive accuracy rates of people to respond to public health emergencies were 67.9%, 59.2%, and 43.7% (Fei-fei, Tong, and Xiao-ming 2005).
The baseline findings of the study showed that the level of knowledge and skills of the citizens in Sichuan province to respond to public health emergencies were quite low (Li et al. 2010), and the most important factors included the level of education and the differences between rural and urban areas (Li et al. 2011). The results of this article will be used to assist in the development of scientific health education and behavior intervention strategies, as well as the development of different types of communication materials suitable for urban and rural residents with special emphasis on the needs and characteristics of the low education-level population. Face-to-face explanation and viewing of audio–video materials will be combined with text messaging, the Internet, electronic display, and other new media, so as to widely spread relevant knowledge of self-rescue, disaster prevention, and mitigation methods to the public.
As for different genders, the respective total awareness rates of men and women before and after the intervention were 58.4% and 55.8%. The increase rate of men (15.8%) was greater than that of women (12.9%), showing that the acceptance level and effect of interventions among men were greater than those among women. Both domestic and international studies have shown (Cheng et al. 2012; Soffer et al. 2011) that, relative to women, men have a higher level of knowledge and a lower risk of suffering from the impact of unexpected events. The reason for this may be due to the different roles and status of men and women in response to emergencies, as well as a high cognitive level and wide knowledge among men. Both before and after the intervention, the awareness rates of men and women to respond to flood were lower than those of other public health emergencies, which may be due to the topography of Sichuan province (a mountainous area in western mainland Chinese), as well as a small probability of flood and limited amount of attention to this topic (Chai et al. 2010). This observation is also a sign that future interventions must be performed according to the local conditions, and the intervention contents and measures must be determined based on the geographical, economic, social, and cultural characteristics of the specific location.
As for differences among the various age-groups, the total awareness rate of knowledge to respond to public health emergencies decreased with the increase of age both before and after the intervention, which was consistent with the research results, which showed that the older age-group had a low level of knowledge (Ostad et al. 2012) and poor health status after disasters Collins, Jimenez, and Grineski (2013). After the intervention, the increase of awareness rate in the 18–35 age-group (17.6%) was > the 46–60 age-group (14.6%) > the 60+ age-group (14.1%) > the 36–45 age-group (12.3%). The reason for which the increase of the 36–45 age-group was lowest may be due to the fact that the people in this group were on the “upcurve” of their career and were required to support their parents and raise their children, thus having to deal with high living pressure and little spare time (Jun-xiu 2010). After the intervention, the awareness rate of those in the 18–35 age-group to respond to traffic accidents did not increase significantly, but the awareness rate of the people in this group was still higher than those of the other age-groups, both before and after the intervention, which was similar to the research results of Qiang, Jin-ying, and Yi-qun (2002). The reason for this may be due to the fact that younger age-groups had more contact with urban traffic.
The survey results of successful evacuees in the “9/11” event showed that risk awareness, emergency training, familiarity with the building, health status, and footwear were the main factors affecting evacuation (Gershon et al. 2007). The results of this study showed intervention, educational level, occupation, discussion with the families, and disaster experience were the main influential factors for the knowledge and skills of sudden public health events. As indicated by the multivariate linear regression analysis results, the educational level was positively correlated to the score of knowledge related to dealing with sudden public health events. The scores of the agriculture laborers were relatively low, which was associated with the remote locations of the rural areas in which they resided, undeveloped economy, limited availability of information, and insufficient health resources. The research results also showed that those who discussed with their families about dealing with disaster events and those who had experienced disasters achieved high scores of knowledge related to dealing with sudden public health events. In additional to these influential factors, intervention was also a significant influential factor for improving the awareness rate, with the knowledge level after intervention being 3.362 times that before intervention. The “comprehensive intervention measure” in the study was constituted by the wide spreading by mass media, as well as interpersonal communication and individual coaching for focus groups. The results revealed that intervention with “points linked to the entire area” improved the residents’ knowledge and skills for dealing with sudden public health events and was quite significant for response to sudden emergency, self-rescue in emergency, and disaster prevention/reduction. Furthermore, the results also suggest that the characteristics and demands of people with different educational levels should be considered, specific intervention strategies should be taken, and direct and simple spreading methods without too much information should be adopted for people with low educational levels. In conclusion, the results provide experience and references to carry out related health education and behavior intervention studies in the future.
Limitations
Disaster events, especially natural disasters, are closely related to region, climate, and other natural geographical factors, thus appropriate contents must be selected for investigation and intervention according to the specific circumstances of the survey area. For example, flood is one of the natural disasters that occurs quite infrequently in the Sichuan region due to the fact that the region consists mostly of mountainous topography; however, the probability of landside and debris flow occurring as a result of rainfall is quite large, but these contents were not included in the survey. Second, the application and implementation cycle of the project are quite lengthy, and new media communication methods have yet to be integrated into the project design, thus the contents of this field were not involved while designing the project and developing programs. Traditional media was still the main mode to promote health ideas.
Conclusion
The overall level of knowledge and skills of the public to respond to public health emergencies in Sichuan province is relatively low. Comprehensive interventions that focus on public communication and combine interpersonal communication and organizational communication may effectively improve the level of knowledge of the target population. Education level is an important factor influencing the knowledge and skills of the public to respond to public health emergencies, and appropriate comprehensive intervention strategies should be made in combination with the geographical features and the educational level of the target population.
Footnotes
Authors’ Note
All of the authors declare solemnly: the submission is an original manuscript that has not been published or submitted for publication in whole or part to any other publishing source. The survey content was told to all subjects and their answers would be kept secret.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported by “intervention research on knowledge and skills of the public to respond to public health emergencies” (Grant number: 200802022) with a total funding of ¼318 million.