To our knowledge, this is the first study that focuses on understanding the public's awareness of and attitudes toward influenza A (H7N9). In a previous study designed to assess the implications of public understanding of avian influenza, researchers found that the majority of participants did not believe a pandemic would occur, and believed that dealing with the disease was the responsibility of the government . Opinions about the credibility of health information varied from distrust to belief in the credibility of information released by the local health department . Our current study demonstrated that 69.72% of participants worried about being infected with the A/H7N9. Despite the fact that the majority of participants (73.03%) thought the H7N9 information published by the government was accurate and transparent, over one-fifth (20.28%) complained it was not timely enough, and 20.76% thought some information was intentionally concealed by the government. Furthermore, when asked “do you believe that the government can control the H7N9 epidemic?”, nearly one-third of participants (30.28%) responded with “hard to say”. These findings reflect some distrust in the announcements of the health department. This may be because the public did not accept the long interval between the time when cases were identified and the time that information was released to public, as well as the increasing number of cases and infected areas.
We found that after the emergence of H7N9, a majority of participants actively searched for information about H7N9, and the primary method of obtaining information was using the internet. This result is consistent with other studies that indicated that the internet is increasingly used by the public as the most important source of health-related information . Furthermore, our data also indicate that different methods of obtaining information were significantly associated with different demographic variables. For example, younger and more educated participants were significantly more likely to use the internet, while female and higher-income participants were significantly more likely to watch TV. Females were also more likely to read a newspaper for information. Although few participants (13.72%) chose “listen to the radio”, older participants were more likely to get information from the radio than younger participants. This suggests that the transmission of heath information should consider the demographic characteristics of the target audience in determining which methods to emphasize. In addition, it is worth noting that among the young participants, over one-fifth chose “ask friends” rather than seeking a more formal information source. This should be addressed in targeting intervention efforts specifically at young people.
Our study demonstrated that most subjects (80.76%) reported washing their hands more often than usual. Similar findings were also reported at the beginning of the H1N1 influenza pandemic in Hong Kong , and in the United Kingdom, 28% of subjects reported changing their hand washing behavior as a result of H1N1 influenza . We also found that of participants 68.27% reported ventilating rooms more frequently than before, and nearly half (48.76%) cancelled or postponed their social events because of A/H7N9. When viewed together, the data from these studies implies that preventative health behaviors become more prevalent during infectious disease epidemics. Furthermore, our data revealed that men were less likely to adopt comprehensive precautionary measures against H7N9, such as washing hands and reducing social events. A deeper understanding of the root causes of such differential risk behavior can help inform the development of dissemination strategies directed at different subgroups. Several previous studies have also indicated that men are less likely to follow behavioral recommendations (such as hand washing) to prevent the transmission of H1N1 influenza, SARS, and other infectious diseases [17–19]. Therefore, men need special targeting for health education, especially to improve their knowledge of influenza, because knowledge of influenza and perceived effectiveness of personal hygiene practices (PHPs) has been shown to be associated with PHPs .
We found that more than one-third of participants stated that after the emergence of H7N9, they no longer bought chickens or other poultry to eat. A previous study has revealed that perceived theoretical threat from poultry was associated with less buying of live poultry . We should be aware that the prolonged warning that a future pandemic could be sparked by avian influenza viruses is likely to cause pandemic fatigue in the public, and would probably not change their perception of avian influenza risk and associated protective behavior . Some causal beliefs and lay perceptions of avian influenza contradicted public health efforts at control . Therefore, more effort should be made to improve compliance of proper preventive measures and reduce panic among the public. In addition, because the Guangzhou population faces risks from the high prevalence of exposure during purchase and poultry rearing , better management for raising and selling poultry in Guangzhou is needed.
The high proportion (84.00%) of participants indicating a willingness to receive H7N9 vaccine if it is available bodes well for influenza prevention through vaccination in Guangzhou. Of those whose response was “no”, the primary reason for unwillingness to accept a vaccine was concern about the safety of the new vaccine. A similar finding was also observed during the pH1N1 pandemic in Hong Kong, which indicated that perceived risk from the pH1N1 vaccine could inhibit pH1N1 vaccine uptake . These results suggest that some participants lacked an understanding of the process of developing influenza vaccine based on the probability of strains. While we only studied a small subset of the population in Guangzhou, if these results were found to be representative, educational materials distributed about the novel influenza vaccine should focus on its safety record, manufacturing, and the similarities between seasonal influenza vaccination and the H7N9 vaccine. These efforts could help to dispel these fears, considering that we found that participants who had received influenza vaccine within recent three years were nearly two times more likely to accept H7N9 vaccine compared with those who had not.
Although the interviewees responded a relative high willingness to receive H7N9 vaccine, in the past three years, only 33.17% actually received the seasonal influenza vaccine. This implied that the current high willingness of accepting vaccine may be attributed to the high case fatality rate of H7N9 reported, and a high proportion of participants fearing they will be infected. As indicated in this study, worry was found to be the strongest predictor of vaccination uptake. Consistent with our finding, Liao et al. also reported that perceived low risk from pH1N1 could inhibit pH1N1 vaccine uptake . That means if the public believes that the severity of A/H7N9 is lower, the acceptance rate may decline. During the early stage of the pH1N1 pandemic (May-June, 2009), international studies assessing willingness to receive the pH1N1 vaccine indicated rates that ranged from 36.9%  to 49.6% . However, national data from Australia collected in November and December 2009, when the public believed that the pandemic was coming to an end , showed that there had only been a 14% uptake of the vaccine . Therefore, combining our finding with previous published literatures suggests that when levels of worry are generally low, acting to increase the volume of mass media and advertising coverage is likely to increase the perceived efficacy of recommended behaviors, which, in turn, is likely to increase their vaccination uptake.
We showed that in response to “once H7N9 outbreaks in Guangzhou”, participants’ main concerns included “how to protect my family from infection?”, “what is the current epidemic situation?”, “is the vaccination available? Is it safe?”, “is there any effective drug treatment?”, and “how to conduct home disinfection?”. This is similar to Aihua et al., who reported that during the 2009 H1N1 influenza pandemic, the public's primary concern was effective and easy-to-operate preventive measures . Therefore, these information needs should be taken into account in future health education campaigns.
Some limitations of this study must be acknowledged. First, our subjects were employees of food production and operation, and we recognize the limitations of applying the results of this study to the general population. Second, this survey measured the participants’ views at a specific point in time; therefore, the attitudes and practices reflected the information available at that time. Third, some of the questions in our questionnaire had Likert-type response options, which restricted the preferences of participants to a few options. A fourth limitation is inherent to the study design: the use of convenience sampling - as opposed to random sampling - imposes some inherent selection bias and diminishes the internal validity.