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November 2003, Vol 93, No. 11 | American Journal of Public Health 1887-1888
© 2003 American Public Health Association

RESEARCH AND PRACTICE

An Outbreak of the Severe Acute Respiratory Syndrome: Predictors of Health Behaviors and Effect of Community Prevention Measures in Hong Kong, China

Catherine S. K. Tang, PhD and Chi-yan Wong, MSSc

Catherine S. K. Tang and Chi-yan Wong are with the Chinese University of Hong Kong, Shatin, NT, Hong Kong, China.

Correspondence: Requests for reprints should be sent to Catherine S.K. Tang, PhD, Department of Psychology, The Chinese University of Hong Kong, Shatin, NT, Hong Kong, China (e-mail: ctang{at}cuhk.edu.hk).


   INTRODUCTION
TOP
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 References
 
The current global outbreak of the severe acute respiratory syndrome (SARS) poses an international public health threat.1 Hong Kong, China, remains one of the most severely affected areas. We aimed to identify psychosocial factors associated with SARS preventive health behaviors and to assess whether preventive health behaviors increased after launching SARS community prevention activities.


   METHODS
TOP
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 References
 
We telephone interviewed 1002 adult Chinese in wave 1 (March 17–18, 2003), which represented the early stage of the SARS outbreak in Hong Kong. A separate sample of 1329 adult Chinese were also telephone interviewed in wave 2 (March 29–April 1, 2003), which represented a period of vigorous communitywide SARS prevention activities by local health authorities. Response rates of the participants, calculated as percentages of completes to completes plus refusals, were 53% and 65% for waves 1 and 2, respectively. These two samples were comparable in various demographic information. The overall age distribution was 20% for 18 to 29 years, 50% for 30 to 49 years, 15% for 50 to 59 years, and 15% for 60 years or older.

We used key concepts of psychosocial models of health behaviors2–4 to design our survey, which included the following measures.

Practice of Preventive Health Behaviors
Local health authorities have recommended the following preventive health behaviors to prevent the contracting and spreading of SARS: maintaining good personal hygiene, developing a healthy lifestyle, ensuring good ventilation, and wearing face masks. We asked participants in wave 1 to indicate how often in the past week they had practiced at least 1 of the above preventive health behaviors. In wave 2, we specifically asked participants how often they wore face masks to prevent contracting SARS during the last week. Participants responded with (1) never, (2) only a few times, (3) sometimes, or (4) almost all the time. We classified the first 3 responses as inconsistent preventive health behaviors (coded as 0) and "almost all the time" as consistent preventive health behaviors (coded as 1).

Perceived Knowledge About SARS, Susceptibility to SARS, and Self-Efficacy in Performing the Suggested Preventive Health Behaviors
These 3 psychosocial factors were each measured by 1 item. Participants indicated their perceptions on 4-point scales, with high scores representing high levels of these factors.

Attitudes Toward SARS Prevention Measures
Participants in wave 2 were assessed on their attitudes toward SARS community prevention measures by 5 items (on 4-point scales): (1) whether enough information was provided, (2) whether health guidelines were clear, (3) whether they believed that the suggested preventive health behaviors were effective, (4) whether they were satisfied with the government, and (5) whether they had confidence in the government’s ability to control the spread of SARS. High scores corresponded to very favorable attitudes. The {alpha} value for this scale was .73.

Demographics
All participants were asked about their age, education, income, and employment status.


   RESULTS
TOP
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 References
 
We used SPSS 10.0 (SPSS Inc, Chicago, Ill) statistical software to conduct data analyses. The rates of preventive health behaviors for waves 1 and 2 are presented in Table 1Go. Results of a logistic regression analysis indicated that higher rates of preventive health behaviors in wave 1 (before exposure to SARS community prevention measures) were significantly related to greater perceived susceptibility to contracting SARS (odds ratio [OR] = 1.468; 95% confidence interval [CI] = 1.089, 1.979), greater self-efficacy in performing the preventive health behaviors (OR = 2.304; 95% CI = 1.672, 3.175), and older age (OR = 1.125; 95% CI = 1.063, 1.190).


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  		TABLE 1—— Rates of Preventive Health Behaviors
 
The practice of SARS-specific preventive health behaviors (wearing of face masks) in wave 2 was expressed as a function of preventive health behaviors before exposure to SARS community prevention measures and attitudes toward these measures. The probability of preexposure preventive health behaviors was calculated from estimated coefficients of various psychosocial and demographic factors as derived from wave 1. Results of the logistic regression analysis indicated that higher rates of preventive health behaviors in wave 2 were associated with more favorable attitudes toward prevention measures (OR = 1.493; 95% CI = 1.097, 2.033) and higher probability of preexposure preventive health behaviors (OR = 2.662; 95% CI = 2.154, 3.289; Table 2Go). The marginal effect of favorable attitudes toward prevention measures was estimated to be a 9.2% increase in preventive health behaviors in wave 2 with 1-unit change in these attitudes (measured on 4-point scale). In waves 1 and 2, 32.7% and 61.2%, respectively, of the participants reported consistent practice of preventive health behaviors (OR = 3.245; 95% CI = 2.735, 3.852; power = 1.00).


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  		TABLE 2—— Logistic Regression Results on Preventive Health Behaviors
 

   DISCUSSION
TOP
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
References
 
Our results were supportive of the contribution of perceived susceptibility,2 selfefficacy,4 and age5–7 in predicting the practice of preventive health behaviors. Favorable attitudes toward SARS prevention measures also were associated with higher rates of SARS-specific preventive health behaviors. Furthermore, we supported that community-level prevention measures against SARS were related to significant increases (28.5%) in individuals’ practice of the recommended preventive health behaviors. We suggest that SARS community prevention activities should focus on the perception of personal vulnerability as well as the promotion of self-efficacy and favorable attitudes toward prevention measures. Finally, it should be noted that increases in the suggested preventive health behaviors might have been influenced by other extraneous factors in addition to being exposed to SARS community prevention measures.


   Footnotes
 
Contributors
Both authors contributed to the conception and design of the study, data analysis, and interpretation of findings. C. S. K. Tang took the lead in writing the brief.

Human Participant Protection
No protocol approval was needed for this study.

Peer Reviewed

Accepted for publication June 5, 2003.


   References
TOP
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 References
 
1. World Health Organization. Update 27: One month into the global SARS outbreak: status of the outbreak and lessons for the immediate future. Available at: http://www.who.int/csr/sars/archive/2003_04_11/en. Accessed April 11, 2003.

2. Rosenstock IM, Strecher VJ, Becker MH. Social learning theory and the health belief model. Health Educ Q.1988;15:175–183.[Web of Science][Medline]

3. Ajzen I, Fishbein M. Understanding Attitudes and Predicting Social Behavior. Englewood Cliffs, NJ: Prentice-Hall; 1980.

4. Bandura A. Self-Efficacy: The Exercise of Control. New York, NY: WH Freeman Co; 1997.

5. Berrigan D, Dodd K, Troiano RP, Krebs-Smith SM, Barbash RB. Patterns of health behaviors in US adults. Prev Med.2003;36:615–623.[Web of Science][Medline]

6. Pappas G. Elucidating the relationships between race, socioeconomic status, and health. Am J Public Health. 1994;84:892–893.[Free Full Text]

7. Shi L. Socio-demographic characteristics and individual health behaviors. South Med J.1998;91:933–941.[Web of Science][Medline]




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