Factor Analysis of a Novel Scoring-Based Instrument on Forecasting Malaysian Travelers’ Behavioral Preparedness for Travel-Related Infectious Diseases

Document Type : Original Article


Department of Community Health, Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Kuala Lumpur, Malaysia


Introduction: Preparedness for the prevention of travel-related infectious diseases among Malaysian international travelers has yet to be explored. With no such data, health programs to empower travelers on behavioral responses towards travel-related illnesses will be ineffective. The current study aimed to develop and validate a new scoring-based instrument measuring Malaysian international travelers’ preparedness in terms of their risk perception (RP), attitude, and practices (RisPAK-Q) towards travel-related infectious diseases using factor analysis.
Methods: The newly developed instrument was tested among 200 Malaysian international travelers based on the systematic random sampling method. The number of domains, model-fit index, construct validity, and internal consistency for this instrument were determined using exploratory and confirmatory factor analysis (CFA).
Results: Twenty-two out of 34 questions were retained, and the following 5 domains were extracted: RP, pre-travel attitude (PTA), during-travel attitude (DTA), general traveling practice, and food practice (FP). All 22 questions had factor loadings of above 0.6. All 5 domains achieved a stable model fit index with good convergent and discriminant construct validity of above 0.5 indicated by the average variance extracted (AVE) with all of the maximum shared variance (MSV) values below their corresponding AVEs. All domains also had high internal consistency with a composite reliability (CR) of above 0.7.
Conclusion: The RisPAK-Q containing 22 questions in 5 domains is a valid and reliable instrument for measuring the preparedness of Malaysian travelers for travel-related infectious diseases and can be used in a subsequent larger study.


  1. Knobler S, Mahmoud A, Lemon S. The Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities: Workshop Summary. Washington (DC): National Academies Press; 2006.
  2. World Tourism Organization (UNWTO). World Tourism Barometer. 2017:13.
  3. World Tourism Organization (UNWTO). 2017 International Tourism Results: The Highest in Seven Years. http://media.unwto.org/press-release/2018-01-15/2017-international-tourism-results-highest-seven-years. 2018.
  4. Allen KC. Tracking the traveler without a passport: perspective on surveillance of imported disease. J Travel Med. 2014;21(5):295-297. doi:10.1111/jtm.12143.
  5. Talbot EA, Chen LH, Sanford C, McCarthy A, Leder K. Travel medicine research priorities: establishing an evidence base. J Travel Med. 2010;17(6):410-415. doi:10.1111/j.1708-8305.2010.00466.x.
  6. Behrens RH, Carroll B. The challenges of disease risk ascertainment using accessible data sources for numbers of travelers. J Travel Med. 2013;20(5):296-302. doi:10.1111/jtm.12062.
  7. Leder K, Torresi J, Libman MD, et al. GeoSentinel surveillance of illness in returned travelers, 2007-2011. Ann Intern Med. 2013;158(6):456-468. doi:10.7326/0003-4819-158-6-201303190-00005.
  8. Stoddard ST, Morrison AC, Vazquez-Prokopec GM, et al. The role of human movement in the transmission of vector-borne pathogens. PLoS Negl Trop Dis. 2009;3(7):e481. doi:10.1371/journal.pntd.0000481.
  9. Liu SJ, Sharapov U, Klevens M. Patient awareness of need for hepatitis a vaccination (prophylaxis) before international travel. J Travel Med. 2015;22(3):174-178. doi:10.1111/jtm.12186.
  10. Warne B, Weld LH, Cramer JP, et al. Travel-related infection in European travelers, EuroTravNet 2011. J Travel Med. 2014;21(4):248- 254. doi:10.1111/jtm.12120.
  11. Bettinghaus EP. Health promotion and the knowledge-attitude-behavior continuum. Prev Med. 1986;15(5):475-491. doi:10.1016/0091-7435(86)90025-3.
  12. Ferrer R, Klein WM. Risk perceptions and health behavior. Curr Opin Psychol. 2015;5:85-89. doi:10.1016/j.copsyc.2015.03.012.
  13. Hassali MA, Saleem F, Shafie AA, et al. Perception towards health promotion activities: Findings from a community survey in the state of Penang, Malaysia. Malaysian J Public Health Med. 2012;12(2):6- 14.
  14. Pfeil A, Mutsch M, Hatz C, Szucs TD. A cross-sectional survey to evaluate knowledge, attitudes and practices (KAP) regarding seasonal influenza vaccination among European travellers to resource-limited destinations. BMC Public Health. 2010;10:402. doi:10.1186/1471-2458-10-402.
  15. DeVellis RF. Scale Development: Theory and Applications. Thousand Oaks, Calif: Sage Publications; 2003.
  16. MacCallum RC, Widaman KF, Zhang S, Hong S. Sample size in factor analysis. Psychol Methods. 1999;4(1):84-99. doi:10.1037/1082- 989X.4.1.84.
  17. Byrne BM. Structural Equation Modeling With AMOS: Basic Concepts, Applications, and Programming. 2nd ed. New York: Routledge; 2010.
  18. Hof M. Questionnaire evaluation with factor analysis and Cronbach’s alpha. http://www.let.rug.nl/nerbonne/teach/rema-stats-meth-seminar/student-papers/MHof-QuestionnaireEvaluation- 2012-Cronbach-FactAnalysis.pdf. Published 2012
  19. Malhotra NK, Birks DF. Marketing Research: An Applied Approach. 3rd ed. London: Prentice Hall/Financial Times; 2007.
  20. Hair JF Jr, Black WC, Babin BJ, Anderson RE, Tatham RL. Multivariate Data Analysis. Pearson; 2010.
  21. Ratnam I, Torresi J, Matchett E, et al. Development and validation of an instrument to assess the risk of developing viral infections in Australian travelers during international travel. J Travel Med. 2011;18(4):262-270. doi:10.1111/j.1708-8305.2011.00533.x.
  22. Mahmood MI, Shah SA, Ahmad N, Rosli NM. Cancer Screening Perception Scale: Development and Construct Validation. J Cancer Educ. 2018;33(2):269-277. doi:10.1007/s13187-016-1081-7.
  23. Raval VV, Ward RM, Raval PH, Trivedi SS. Confirmatory and Exploratory Factor Analyses of Parental Authority Questionnaire in Urban India. J Child Fam Stud. 2013;22(5):707-718. doi:10.1007/ s10826-012-9624-y.
  24. Squires JE, Estabrooks CA, Newburn-Cook CV, Gierl M. Validation of the conceptual research utilization scale: an application of the standards for educational and psychological testing in healthcare. BMC Health Serv Res. 2011;11:107. doi:10.1186/1472-6963-11-107.
  25. Williams B, Onsman A, Brown T. Exploratory factor analysis: A five-step guide for novices. Australasian Journal of Paramedicine. 2012;8(3):1-13.
  26. Stretcher V, Rosenstock IM. The Health Belief Model. In: Glanz K, Lewis FM, Rimer BK, eds. Health Behaviour and Health Education: Theory, Research and Practice. San Francisco: Jossey-Bass; 1997.
  27. Provost S, Soto JC. Perception and knowledge about some infectious diseases among travelers from Quebec, Canada. J Travel Med. 2002;9(4):184-189. doi:10.2310/7060.2002.24550.
  28. Zimmermann R, Hattendorf J, Blum J, Nuesch R, Hatz C. Risk perception of travelers to tropical and subtropical countries visiting a swiss travel health center. J Travel Med. 2013;20(1):3-10. doi:10.1111/j.1708-8305.2012.00671.x.
  29. Hartjes LB, Baumann LC, Henriques JB. Travel health risk perceptions and prevention behaviors of US study abroad students. J Travel Med. 2009;16(5):338-343. doi:10.1111/j.1708-8305.2009.00322.x.
  30. El-Ghitany EM, Mohamed Abdelmohsen MA, Farghaly AG, Abd El-Gawwad E, Abd El-Wahab EW. Travel Health Survey: Risk Perception, Health-Seeking Behavior, and Subjective Evaluation of Travel Health Services in Egypt. Int J Travel Medicine Glob Health. 2018;6(1):16-24. doi:10.15171/ijtmgh.2018.04.
  31. Hamer DH, Connor BA. Travel health knowledge, attitudes and practices among United States travelers. J Travel Med. 2004;11(1):23- 26. doi:10.2310/7060.2004.13577.
  32. Piyaphanee W, Wattanagoon Y, Silachamroon U, Mansanguan C, Wichianprasat P, Walker E. Knowledge, attitudes, and practices among foreign backpackers toward malaria risk in southeast Asia. J Travel Med. 2009;16(2):101-106. doi:10.1111/j.1708-8305.2008.00282.x.
  33. Barber JS. The Theory of Planned Behaviour: considering drives, proximity and dynamics. Vienna Yearb Popul Res. 2011;9:31-35. doi:10.1553/populationyearbook2011s31.
  34. Alghamdi AH, Ibrahim AM, Al-Ghamdi MS, Ryan ET, Al-Raddadi R. Travel Health in the Kingdom of Saudi Arabia: Perception and Practice of Saudi Travelers. International Journal Of Health Research And Innovation. 2014;2(2):25-39.
  35. Zuckerman JN. Principles and Practice of Travel Medicine. Wiley; 2001. doi:10.1002/0470842512.
  36. Chien PM, Sharifpour M, Ritchie BW, Watson B. Travelers’ Health Risk Perceptions and Protective Behavior: A Psychological Approach. J Travel Res. 2017;56(6):744-759. doi:10.1177/0047287516665479.
  37. Chen CM, Tsai JS, Chen SH, Lee HT. Knowledge, attitudes, and practices concerning infection control among travelers between Taiwan and mainland China. Asia Pac J Public Health. 2011;23(5):712-720. doi:10.1177/1010539511419118.
  38. Han P, Balaban V, Marano C. Travel characteristics and risk-taking attitudes in youths traveling to nonindustrialized countries. J Travel Med. 2010;17(5):316-321. doi:10.1111/j.1708-8305.2010.00444.x.
  39. Omer F, Hassan N, Hussain H, Mana S, Awad O. Travel health, gaps in knowledge, attitudes, and practices among Dubai travellers, Dubai UAE. Int J Prev Med Res. 2015;1(3):126-131.
  40. Ismayl G, Abdel Hadi H, Hussein A, et al. Practices and attitudes to prevention of travel-related infectious diseases in United Arab Emirates. Int J Travel Medicine Glob Health. 2016;4(1):13-18. doi:10.20286/ijtmgh-040113.
  41. Al-Abri SS, Abdel-Hady DM, Al-Abaidani IS. Knowledge, attitudes, and practices regarding travel health among Muscat International Airport travelers in Oman: Identifying the gaps and addressing the challenges. J Epidemiol Glob Health. 2016;6(2):67-75. doi:10.1016/j.jegh.2016.02.003.
  42. Wilder-Smith A, Khairullah NS, Song JH, Chen CY, Torresi J. Travel health knowledge, attitudes and practices among Australasian travelers. J Travel Med. 2004;11(1):9-15. doi:10.2310/7060.2004.13600.
  43. Toovey S, Jamieson A, Holloway M. Travelers’ knowledge, attitudes and practices on the prevention of infectious diseases: results from a study at Johannesburg International Airport. J Travel Med. 2004;11(1):16-22. doi:10.2310/7060.2004.13587.
  44. Furlong WJ, Feeny DH, Torrance GW, Barr RD. The Health Utilities Index (HUI) system for assessing health-related quality of life in clinical studies. Ann Med. 2001;33(5):375-384. doi:10.3109/07853890109002092.
  45. Yost J, Dobbins M, Traynor R, DeCorby K, Workentine S, Greco L. Tools to support evidence-informed public health decision making. BMC Public Health. 2014;14:728. doi:10.1186/1471-2458-14-728.
  46. Wang XT, Simons F, Bredart S. Social cues and verbal framing in risky choice. J Behav Decis Mak. 2001;14(1):1-15. doi:10.1002/1099- 0771(200101)14:13.0.CO;2-N.
  47. Krosnick JA, Judd CM, Wittenbrink B. The measurement of attitudes. In: Allbarracin D, Johnson BT, Zanna MP, eds. Handbook of attitudes and attitude change. Mahwah, NJ: Erlbaum; 2005:21-76.
  48. Potaka L, Cochrane S. Developing bilingual questionnaires: Experiences from New Zealand in the development of the 2001 Maori language survey. J Off Stat. 2004;20(2):289-300.
  49. Antshel KM. Integrating culture as a means of improving treatment adherence in the Latino population. Psychol Health Med. 2002;7(4):435-449. doi:10.1080/1354850021000015258.
  50. Paulhus DL. Socially Desirable Responding: The Evolution of a Construct. In: Braun HI, Jackson DN, Wiley DE, eds. The Role of Constructs in Psychological and Educational Measurement. New Jersey: Lawrence Erlbaum Associates Publishers; 2002:49-69.
  51. Toft N, Jorgensen E, Hojsgaard S. Diagnosing diagnostic tests: evaluating the assumptions underlying the estimation of sensitivity and specificity in the absence of a gold standard. Prev Vet Med. 2005;68(1):19-33. doi:10.1016/j.prevetmed.2005.01.006.