Introduction

Persons with influenza like illness was first reported in Mexico in April 2009, which subsequently confirmed to be novel H1N1 influenza virus [1]. In June 2009, the World Health Organization declared the new strain of swine-origin H1N1 as a pandemic [2]. This novel virus spread worldwide and had caused about 17,000 deaths by the start of 2010. Imported cases of pandemic (H1N1) 2009 was first identified in India in May, 2009 [3].At the end of June 2009, there were dramatic increase in number of cases reported all across India. With progression of pandemic lot of scare and heightened awareness occurred towards swine flu in Indian public. Compulsory and voluntary screening of travellers was done from epidemic hit countries at all major airports. Previous reports during SARS epidemic has shown that perceived susceptibility and favourable attitude increases compliance towards change in preventive health behaviour [4]. Better knowledge regarding the disease also helps better uptake of preventive measures [5]. During H1N1 pandemic, many health education and preventive measures were taken by our university such as 1) Knowledge regarding various precautions to be taken during epidemic by covering nose while sneezing or coughing, wash hand with soap and water after sneezing or coughing 2) H1N1 influenza virus, its vaccination,disease symptoms and self-protection measures were explained to students 3) Regular H1N1 screening was done for students in outpatient department 4) Knowledge regarding avoiding planning and attending group gathering was given to students. Students’ attitude and behaviour can influence the efficacy of preventive measures. Many studies had shown that hand hygiene remained the single most effective measure in preventing H1N1 influenza [7].

To see the impact of health education measures, we designed the questionnaire based survey among university students to assess the current practices regarding confirmed H1N1 cases, recent hand washing behaviour, relationship between hand washing frequency and flu like symptoms as well as attitude and perception regarding hand washing and knowledge of influenza virus and its vaccination.

Materials and Methods

Participants and procedure

Survey

Analysis

Results

Demographic characteristics of participants

General demographics details of subjects are outline in Table 1. Out of total 957 Respondents, 62.4% were males and 37.6% were females. Subjects were classified into three age categories: 18-25, 26-35 and 36-50 years. Majority of the participants (96.9%) belongs to age category between 18-25 years. Overall, 94.1% were students and 5.8% were healthcare workers participated.

Participants’ knowledge regarding H1N1 virus and its vaccination, current practices and protection from confirmed H1N1 cases

H1N1 was confirmed as a virus by 99% of subjects. Overall, 79.6% and 88.3% of respondents had correct knowledge regarding route of transmission and involvement of lung respectively. Responding to questions to current practices, self-protection and vaccination of H1N1, female participants have more knowledge compared to male counterpart as shown in table 1. In our study, more numbers of male participants were vaccinated against H1N1 influenza then there female counterparts but this difference was not found to be statistically significant (P value =0.194).

Figure 1

Table 1: Demographic characteristics, knowledge, transmission, current practices and self-protection of the participants

Information regarding hand washing behaviour, perceived susceptibility and severity

With respect to information regarding hand washing as effective preventive strategy, about 77.7% of the participants had come across such information in university campus. Increase frequency of hand washing was observed during epidemic, seen with more female participants compared with male counterparts. Moreover 53.2% of subjects reported to have considered hand washing as “more or less” effective means of preventing H1N1 infection. Males are more likely to perceive hand wash as effective means of preventing the infection (P value<0.01). Perceived severity was high but perceived susceptibility was “nor low, nor high” among participants. After gender stratification, both groups reported to have high perceived severity (P=0.778) but high perceived susceptibility was seen among females (P value<0.001) as shown in table 2.

Figure 2

Table 2: Reported hand washing behaviours, perceived susceptibility, effectiveness and severity towards H1N1

Intervariable correlations

Relationship between hand washing frequency and various variables

Discussion

To best of our knowledge, there were no institutilized based studies done in India to investigate knowledge, attitude and behaviour except few population based studies done from north India[9].The study, carried out after influenza epidemic in India, provides us with the opportunity to evaluate long term impact on students’ knowledge, perception and behavioural changes during peak epidemic period. Overall participant’s knowledge about virus, mode of transmission, system affection and its vaccination were found to be excellent. Participants were aware of the effective preventive strategies such as hand washing, usage of gloves and face mask. Female subjects were found to be more aware then male counterparts regarding confirmed H1N1 cases. The above findings suggested that mass campaign launched by our university was successful. Several previous studies also concluded that females are more amendable for behavioural changes in prevention of H1N1 influenza and SARS[10,11].In our study, personal susceptibility towards H1N1 acquisition difference was observed among gender, which was in line with previously published studies on SARS epidemic¹²,but interestingly perceived severity was found to be almost equal in both groups. Females were found to be more compliant towards using personal protection equipment while caring for H1N1 cases. The importance of using personal protection equipment while caring was demonstrated by study done by Matthew E. Wise et al, where in 40% of health care workers used gloves and 20% used N95 or surgical mask, got infected while caring for cases of H1N1¹³. Most of the students had knowledge regarding H1N1 vaccine (70%), overall females were found to be more knowledgeable than male counterparts. Maximum numbers of students were not vaccinated in our study, with almost equal proportion in both genders. Similar results were seen in study conducted by Mavros et al, where in 8% of the student got vaccine with majority (67%) were not vaccinated, concerning long term adverse effect of the vaccine and perception of the disease as mild. The possible low efficacy of H1N1 vaccine could be one of the reasons for not receiving the vaccine among majority in the present study. Participants having acquaintance with recent flu like symptoms, have acquired the flu like symptoms more frequently, similar results were observed by park et al. Present study, demonstrated better understanding, perception regarding H1N1 disease and hand washing practices in university students. Our study has some limitations, firstly, as this study was conducted post epidemic period, true assessment of perception regarding severity of the disease cannot be assessed and hand washing frequency practices during peak epidemic period could be different from post epidemic period. Secondly, flu like symptoms in students and their acquaintances might be due to upper respiratory tract infection or may be because of H1N1 influenza, so we were not able to differentiate between the two as we have not done laboratory confirmation.

Conclusion

We have received valuable information regarding student attitude and behaviour towards hand washing, perception and knowledge of H1N1 influenza and vaccination status. Mass education programme undertaken by our university in prevention of H1N1 was successful. This study demonstrated that behavioural response to pandemic are subject to change during and post pandemic period and we can prepare ourselves better for future epidemics.