Information delivery and the veterinarian-horse owner relationship in the context of Hendra virus in Australia.

Hendra virus (HeV) is an emerging bat-borne virus endemic in Australia that can be transmitted from horses to humans and has a high fatality rate for horses and people. Controversy surrounding HeV risk mitigation measures have strained the veterinarian-horse owner relationship. This study aimed to characterise the veterinarian-horse owner relationship in general and also in the context of HeV by analysing data derived from the 'Horse Owners and Hendra Virus: A Longitudinal Study to Evaluate Risk' (HHALTER) study. Australian horse owners were recruited via emails, social media and word-of-mouth for a series of five surveys that were administered online at six-monthly intervals over a two-year period to capture baseline knowledge, attitudes and practices of horse owners regarding HeV and any changes over time. In the current study, descriptive analyses of information sources were performed to understand the use of veterinarians as a HeV information source (Surveys 1 and 5; n = 1195 and n = 617). Ordinal logistic regression analyses were conducted to determine factors associated with the frequency of horse owner contact with a veterinarian (Survey 3; n = 636). This study found a relative increase over the study period in the proportion of horse owners who had used veterinarians as HeV information source in the last 12 months (from 51.9% to 88.3%). Owning more horses, being older, having a 'duty of care' for other people working with horses and deriving the main income from horse related business were factors associated with more frequent veterinary contact. Results suggest that traditional information sources such as workshops, information packs and risk training are likely to be used by horse owners. Smart phone applications should be considered for use in the future and require further investigation for horse health communication. The findings of this study may be helpful in optimising strategies for horse health information delivery.

Australian horse owners and their biosecurity practices in the context of Hendra virus.

In recent years, outbreaks of exotic as well as newly emerging infectious diseases have highlighted the importance of biosecurity for the Australian horse industry. As the first potentially fatal zoonosis transmissible from horses to humans in Australia, Hendra virus has emphasised the need to incorporate sound hygiene and general biosecurity practices into day-to-day horse management. Recommended measures are widely publicised, but implementation is at the discretion of the individual owner. This cross-sectional study aimed to determine current levels of biosecurity of horse owners and to identify factors influencing the uptake of practices utilising data from an online survey. Level of biosecurity (low, medium, high), as determined by horse owners' responses to a set of questions on the frequency of various biosecurity practices performed around healthy (9 items) and sick horses (10 items), was used as a composite outcome variable in ordinal logistic regression analyses. The majority of horse owners surveyed were female (90%), from the states of Queensland (45%) or New South Wales (37%), and were involved in either mainly competitive/equestrian sports (37%) or recreational horse activities (35%). Seventy-five percent of owners indicated that they follow at least one-third of the recommended practices regularly when handling their horses, resulting in medium to high levels of biosecurity. Main factors associated with a higher level of biosecurity were high self-rated standard of biosecurity, access to personal protective equipment, absence of flying foxes in the local area, a good sense of control over Hendra virus risk, likelihood of discussing a sick horse with a veterinarian and likelihood of suspecting Hendra virus in a sick horse. Comparison of the outcome variable with the self-rated standard of biosecurity showed that over- as well as underestimation occurred. This highlights the need for continuous communication and education to enhance awareness and understanding of what biosecurity is and how it aligns with good horsemanship. Overall, strengthened biosecurity practices will help to improve animal as well as human health and increase preparedness for future disease outbreaks.

"We've learned to live with it"-A qualitative study of Australian horse owners' attitudes, perceptions and practices in response to Hendra virus.

Hendra virus causes sporadic zoonotic disease in Australia following spill over from flying foxes to horses and from horses to people. Prevention and risk mitigation strategies such as vaccination of horses or biosecurity and property management measures are widely publicised, but hinge on initiative and action taken by horse owners as they mediate management, care and treatment of their animals. Hence, underlying beliefs, values and attitudes of horse owners influence their uptake of recommended risk mitigation measures. We used a qualitative approach to investigate attitudes, perceptions and self-reported practices of horse owners in response to Hendra virus to gain a deeper understanding of their decision-making around prevention measures. Data presented here derive from a series of in-depth interviews with 27 horse owners from Hendra virus 'hot spot' areas in New South Wales and Queensland. Interviews explored previous experience, perceptions and resulting behaviour as well as communication around Hendra virus. All interviews were recorded, transcribed verbatim and analysed in NVivo using thematic analysis. Analysis revealed four major themes: perception of Hendra virus as a risk and factors influencing this perception, Hendra virus risk mitigation strategies implemented by horse owners, perceived motivators and barriers of these strategies, and interaction of perceived risk, motivators and barriers in the decision-making process. Although Hendra virus disease was perceived as a serious threat to the health of horses and humans, individual risk perception diverged among horse owners. Perceived severity, likelihood and unpredictability as well as awareness and knowledge of Hendra virus, trust in information obtained and information pathways, demographic characteristics and personal experience were the main factors influencing Hendra virus risk perceptions. Other key determinants of horse owners' decision-making process were attitudes towards Hendra virus risk mitigation measures as well as perceived motivators and barriers thereof. Horse owners' awareness of the necessity to consider individual Hendra virus risk and adequate risk management strategies was described as a learning process, which changed over time. However, different perceptions of risk, barriers and motivators in combination with a weighing up of advantages and disadvantages resulted in different behaviours. These findings demonstrate the multifactorial determinants of cognitive mediating processes and facilitate a better understanding of horse owners' perspectives on preventive horse health measures. Furthermore, they provide valuable feedback to industry and government stakeholders on how to improve effective risk communication and encourage uptake of recommended risk mitigation measures.

The use of a modified Delphi approach to engage stakeholders in zoonotic disease research priority setting.

BACKGROUND: After the 2011 cluster of Hendra virus cases in horses in Australia, public health targeted education initiatives at people in the equine industry to reduce human exposure to potentially infected horses. 'Horse owners and Hendra Virus: A Longitudinal cohort study To Evaluate Risk' aims to enhance public health measures through improved understanding of Hendra virus risk perception and risk mitigation strategies among horse owners and horse care providers. This paper describes the stakeholder consultation that was undertaken to ensure the cohort study outcomes were relevant to diverse groups who play a role in Hendra virus policy development and implementation. METHODS: A two-round modified Delphi study with online questionnaires was conducted. In round one, stakeholders identified priority research areas. In round two, stakeholders rated and ranked topics that emerged from thematic analysis of the round one responses. Round two data were analysed using logistic regression. RESULTS: Of the 255 stakeholders contacted, 101 responded to round one. Over 450 topics were proposed. These were organized into 18 themes. Approximately two thirds of the round one respondents participated in round two. 'Hendra virus-related risk awareness and perception', 'personal health and safety', 'emergency preparedness', 'risk prevention, mitigation, and biosecurity', and 'Hendra virus vaccination in horses--attitudes/uptake' were the top five areas identified according to probability of being ranked extremely important. CONCLUSIONS: In this study, a modified Delphi approach was effective in guiding research into Hendra virus, a zoonotic disease of animal and human health significance. The findings support the notion that stakeholders should be engaged in zoonotic disease research priority setting. Such consultation will help to ensure that research initiatives are relevant and useful to stakeholders in the position to make use of new findings.

Applying Bayesian network modelling to understand the links between on-farm biosecurity practice during the 2007 equine influenza outbreak and horse managers' perceptions of a subsequent outbreak.

Australia experienced its first ever outbreak of equine influenza in August 2007. Horses on 9359 premises were infected over a period of 5 months before the disease was successfully eradicated through the combination of horse movement controls, on-farm biosecurity and vaccination. In a previous premises-level case-control study of the 2007 equine influenza outbreak in Australia, the protective effect of several variables representing on-farm biosecurity practices were identified. Separately, factors associated with horse managers' perceptions of the effectiveness of biosecurity measures have been identified. In this analysis we applied additive Bayesian network modelling to describe the complex web of associations linking variables representing on-farm human behaviours during the 2007 equine influenza outbreak (compliance or lack thereof with advised personal biosecurity measures) and horse managers' perceptions of the effectiveness of such measures in the event of a subsequent outbreak. Heuristic structure discovery enabled identification of a robust statistical model for 31 variables representing biosecurity practices and perceptions of the owners and managers of 148 premises. The Bayesian graphical network model we present statistically describes the associations linking horse managers' on-farm biosecurity practices during an at-risk period in the 2007 outbreak and their perceptions of whether such measures will be effective in a future outbreak. Practice of barrier infection control measures were associated with a heightened perception of preparedness, whereas horse managers that considered their on-farm biosecurity to be more stringent during the outbreak period than normal practices had a heightened perception of the effectiveness of other measures such as controlling access to the premises. Past performance in an outbreak setting may indeed be a reliable predictor of future perceptions, and should be considered when targeting infection control guidance to horse owners and managers.

Coping support factors among Australians affected by terrorism: 2002 Bali bombing survivors speak.

OBJECTIVES: To examine terrorism survivors' perceptions of factors likely to promote coping and recovery, and to determine whether coping supports vary according to demographic, physical and mental health, incident-exposure and bereavement variables. DESIGN, SETTING AND PARTICIPANTS: Individuals directly exposed to and/or bereaved by the 2002 Bali bombings and who had participated in a New South Wales Health therapeutic support program completed cross-sectional telephone interviews during July-November 2010. Spoken passages were categorised into coping support themes. Advocated supports were then examined by demographic, physical and mental health, incident-exposure and bereavement variables. MAIN OUTCOME MEASURES: Based on their experiences, respondents identified personal, social and service-related factors that they believed would optimally support future survivors of terrorism. RESULTS: Of the 81 people contacted, 55 (68%) participated, providing a total of 114 comments. Thirty-two respondents were women, and 54 had lost relatives or friends in the bombing. Mean age was 50 years (range, 20-73 years). Four meaningful coping support themes emerged, with excellent inter-rater reliability: professional help and counselling; social support; proactive government response and policy; and personal coping strategies. Women were significantly more likely to advocate the need for proactive government response (P = 0.03). Men were more likely to endorse the use of personal coping strategies (P < 0.01). Respondents diagnosed with a mental health condition since the bombings were significantly less likely to advocate social support processes (P = 0.04). CONCLUSIONS: Our findings highlight the perceived value of counselling-related services for terrorism-affected groups. Male survivors may benefit more from mental health interventions that initially build on problem-focused forms of coping, including brief education about reactions and periodic check-ups. Proactive government health and support services that allow simplified and longer-term access were consistently identified as priority areas.

Perceptions of vulnerability to a future outbreak: a study of horse managers affected by the first Australian equine influenza outbreak.

BACKGROUND: A growing body of work shows the benefits of applying social cognitive behavioural theory to investigate infection control and biosecurity practices. Protection motivation theory has been used to predict protective health behaviours. The theory outlines that a perception of a lack of vulnerability to a disease contributes to a reduced threat appraisal, which results in poorer motivation, and is linked to poorer compliance with advised health protective behaviours. This study, conducted following the first-ever outbreak of equine influenza in Australia in 2007, identified factors associated with horse managers' perceived vulnerability to a future equine influenza outbreak. RESULTS: Of the 200 respondents, 31.9% perceived themselves to be very vulnerable, 36.6% vulnerable and 31.4% not vulnerable to a future outbreak of equine influenza. Multivariable logistic regression modelling revealed that managers involved in horse racing and those on rural horse premises perceived themselves to have low levels of vulnerability. Managers of horse premises that experienced infection in their horses in 2007 and those seeking infection control information from specific sources reported increased levels of perceived vulnerability to a future outbreak. CONCLUSION: Different groups across the horse industry perceived differing levels of vulnerability to a future outbreak. Increased vulnerability contributes to favourable infection control behaviour and hence these findings are important for understanding uptake of recommended infection control measures. Future biosecurity communication strategies should be delivered through information sources suitable for the horse racing and rural sectors.

Long-term health and wellbeing of people affected by the 2002 Bali bombing.

OBJECTIVE: To examine the physical and mental health status of individuals directly affected by the 2002 Bali bombing, 8 years after the incident. DESIGN, SETTING AND PARTICIPANTS: Cross-sectional study of people directly exposed to and/or bereaved by the 2002 Bali bombing who had participated in a New South Wales Health therapeutic support program. Telephone interviews were conducted during July - November 2010. The sample was weighted to reflect the population of interest, registered participants in the program (n = 115). MAIN OUTCOME MEASURES: Self-rated physical health, personal resilience (Connor-Davidson Resilience Scale), past-03 psychological distress and daily functioning (Kessler Psychological Distress Scale), and traumatic stress-related symptoms (Primary Care PTSD Screen). RESULTS: Of 81 individuals contacted, 55 responded (68%). Mean age of respondents was 50 years (range, 20-73 years), 32 were female, and seven were physically injured in the bombing. Most (45/55) reported good physical health, but 12 were experiencing high or very high levels of psychological distress. Being injured in the attack was associated with current functional impairment (P = 0.04) and very high levels of distress (P = 0.005). Lower distress was associated with perceived family support (P> = 0.03) and being in a marital or de facto relationship (P = 0.02). Complicated grief factors were consistently associated with high psychological distress, traumatic stress-related symptoms and lower personal resilience. CONCLUSIONS: Eight years after the bombing, directly affected individuals had good physical health but relatively high rates of psychological distress. Marital or de facto relationships and perceived family support appear to be protective factors against long-term distress. Bereavement factors were the strongest correlates of trauma symptoms and distress. Outreach and screening programs incorporating complicated grief items may be useful in the longer-term support of such individuals.

Untangling the complex inter-relationships between horse managers' perceptions of effectiveness of biosecurity practices using Bayesian graphical modelling.

On-farm biosecurity practices have been promoted in many animal industries to protect animal populations from infections. Current approaches based on regression modelling techniques for assessing biosecurity perceptions and practices are limited for analysis of the interrelationships between multivariate data. A suitable approach, which does not require background knowledge of relationships, is provided by Bayesian network modelling. Here we apply such an approach to explore the complex interrelationships between the variables representing horse managers' perceptions of effectiveness of on-farm biosecurity practices. The dataset was derived from interviews conducted with 200 horse managers in Australia after the 2007 equine influenza outbreak. Using established computationally intensive techniques, an optimal graphical statistical model was identified whose structure was objectively determined, directly from the observed data. This methodology is directly analogous to multivariate regression (i.e. multiple response variables). First, an optimal model structure was identified using an exact (exhaustive) search algorithm, followed by pruning the selected model for over-fitting by the parametric bootstrapping approach. Perceptions about effectiveness of movement restrictions and access control were linked but were generally segregated from the perceptions about effectiveness of personal and equipment hygiene. Horse managers believing in the effectiveness of complying with movement restrictions in stopping equine influenza spread onto their premises were also more likely to believe in the effectiveness of reducing their own contact with other horses and curtailing professional visits. Similarly, the variables representing the effectiveness of disinfecting vehicles, using a disinfectant footbath, changing into clean clothes on arrival at the premises and washing hands before contact with managed horses were clustered together. In contrast, horse managers believing in the effectiveness of disinfecting vehicles (hygiene measure) were less likely to believe in the effectiveness of controlling who has access to managed horses (access control). The findings of this analysis provide new insights into the relationships between perceptions of effectiveness of different biosecurity measures. Different extension education strategies might be required for horse managers believing more strongly in the effectiveness of access control or hygiene measures.

Crying wolf? Impact of the H1N1 2009 influenza pandemic on anticipated public response to a future pandemic.

OBJECTIVE: To determine changes in public threat perception and anticipated compliance with health-protective behaviours in response to a future pandemic; using data collected before and after the H1N1 2009 influenza pandemic. DESIGN, SETTING AND PARTICIPANTS: Repeat cross-sectional computer-assisted telephone surveys with representative samples of the general New South Wales population in 2007 (2081 participants) and 2010 (2038 participants). MAIN OUTCOME MEASURES: Perceived likelihood of a future pandemic in Australia; concern that respondents or their families would be affected; degree of change made to life because of the possibility of a pandemic; and willingness to comply with health-protective behaviours (to be vaccinated, to be isolated if necessary, and to wear a face mask). RESULTS: In 2007, 14.9% of the general population considered that an influenza pandemic would be highly likely to occur in future; this proportion rose to 42.8% in 2010 (odds ratio [OR], 4.96; 95% CI, 3.99-6.16; P < 0.001). Conversely, in the same period concern that respondents or their families would be directly affected by a future pandemic dropped from 45.5% to 32.5% (OR, 0.57; 95% CI, 0.44-0.74; P < 0.001). Willingness to be vaccinated against influenza in a future pandemic decreased from 75.4% to 64.6% (OR, 0.69; 95% CI, 0.55-0.86; P < 0.001). A general decrease in willingness to be vaccinated was noted across all age groups, most notably for those aged 35-44 years. CONCLUSIONS: Data collected before and after the H1N1 2009 influenza pandemic indicated significant shifts in public threat perception and anticipated response to a future pandemic. The H1N1 2009 pandemic has altered public perceptions of the probability of a pandemic in the future, but has left the public feeling less vulnerable. Shifts in perception have the potential to reduce future public compliance with health-protective measures, including critical elements of the public health response, such as vaccination.

Factors influencing psychological distress during a disease epidemic: data from Australia's first outbreak of equine influenza.

BACKGROUND: In 2007 Australia experienced its first outbreak of highly infectious equine influenza. Government disease control measures were put in place to control, contain, and eradicate the disease; these measures included movement restrictions and quarantining of properties. This study was conducted to assess the psycho-social impacts of this disease, and this paper reports the prevalence of, and factors influencing, psychological distress during this outbreak. METHODS: Data were collected using an online survey, with a link directed to the affected population via a number of industry groups. Psychological distress, as determined by the Kessler 10 Psychological Distress Scale, was the main outcome measure. RESULTS: In total, 2760 people participated in this study. Extremely high levels of non-specific psychological distress were reported by respondents in this study, with 34% reporting high psychological distress (K10 > 22), compared to levels of around 12% in the Australian general population. Analysis, using backward stepwise binary logistic regression analysis, revealed that those living in high risk infection (red) zones (OR = 2.00; 95% CI: 1.57-2.55; p < 0.001) and disease buffer (amber) zones (OR = 1.83; 95% CI: 1.36-2.46; p < 0.001) were at much greater risk of high psychological distress than those living in uninfected (white zones). Although prevalence of high psychological distress was greater in infected EI zones and States, elevated levels of psychological distress were experienced in horse-owners nationally. Statistical analysis indicated that certain groups were more vulnerable to high psychological distress; specifically younger people, and those with lower levels of formal educational qualifications. Respondents whose principal source of income was from horse-related industry were more than twice as likely to have high psychological distress than those whose primary source of income was not linked to horse-related industry (OR = 2.23; 95% CI: 1.82-2.73; p < 0.001). CONCLUSION: Although, methodologically, this study had good internal validity, it has limited generalisability because it was not possible to identify, bound, or sample the target population accurately. However, this study is the first to collect psychological distress data from an affected population during such a disease outbreak and has potential to inform those involved in assessing the potential psychological impacts of human infectious diseases, such as pandemic influenza.