As globalization has advanced in recent years, many overseas volunteers have worked in low and middle-income countries. Traveling abroad and staying in an unfamiliar environment with inadequate medical infrastructure exposes volunteers to a wide range of health risks [1]. Travelers are usually advised by physicians to receive health information and medical advice prior to their travel in order to deal with possible local diseases [2] [3]. However, self-protection against infectious diseases that can occur during travel is affected by the individual’s risk perception, and the severity of disease [4].

Disease risk perception while volunteering abroad is an important factor in volunteer-work risk assessment because it influences the implementation of safety and health measures. For this reason, it is necessary to provide travelers with preventive education in advance so that they can assess and manage the disease risks that may occur at the destination and minimize those risks [5]. However, the relationship between disease knowledge, risk perceptions and self-management skills is unclear.

The aim of this study was to clarify the relationships among disease knowledge and symptoms, disease risk perception, and self-management skills.

Of the 192 respondents to the questionnaires, 189 were valid responses (three questionnaires were incomplete) with 88 men (46.6%), 97 women (51.3%) and four unknown sex (2.1%) (Table 1). The average age of respondents was 34.2 ± 12.5 years old, with a mode of 20 years old. Volunteers were assigned to Latin America (35.4%), Africa (25.4%), Asia (16.9%), Oceania (11.6%), the Middle East (2.1%), and unknown (8.5%). Many of the planned volunteer activities were human resource tasks related to local educational activities, followed by health, medical care and social work (19%). Health care professionals were 21% of participants.

This study is the first study in Japanese volunteers that investigated the relationship among disease knowledge, risk perception and self-management skills expected after the assignment using the risk perception scale.

Only one-fifth of volunteers were involved in the health care and medical profession, but all volunteers had taken health lecture on infectious diseases, health care and dental diseases during the training before taking this survey. However not all of the participants knew about the seven major diseases that commonly occur during overseas travel. About 40% of volunteers knew about more dangerous diseases such as malaria and dengue fever. Knowledge of these diseases was probably lower than other diseases because not all volunteers planned to go the countries affected by malaria, so they may not have learned about this disease. However although 89.4% of the participants would work in the countries affected by dengue fever, 42.9% of participants did not understand the risk posed by this disease. The global incidence of dengue fever has increased dramatically over recent decades as a major cause of serious illness in some Asian and Latin American countries (24). Acquisition of knowledge about dengue fever is necessary in future health education of volunteers.

We found two robust factors in factor analysis: Dread is composed of four items of severity of consequences, dreadfulness, catastrophic potential, and immediacy of effect (Cronbach’s α coefficient is 0.81); Factor 2, termed Unknown, was knowledge about risks by exposed people, knowledge about risk by scientists, and control over risk (Cronbach’s α coefficient = 0.77). Since the risk characteristics used in this study were different from previous studies [14] [15] [18] [19], the results were also slightly different. However, the concepts indicating the respective risks were contained within similar constituent factors. The factor analysis explained 62.2% of the variance, which was slightly higher than that in those previous studies, and it could explain the overall risk perception to some extent, and indicates the scale has reasonable validity [14] [15] [19].

There was no strong correlation between disease knowledge and disease risk perception or self-management skills. Disease knowledge and Unknown factor

scores were slightly negatively correlated with three disease categories: dengue fever, digestive disease and dermatitis. In other words, the more participants thought they did not know about these diseases, the stronger the image of the unknown.

A high SMS score was associated with lower Unknown score of malaria, digestive diseases, dermatitis, and dental disorders. For the mean value of all diseases, higher SMS scores were associated with lower Unknown scores. Several studies reported that people with higher self-management skills were less likely to drop out of smoking cessation campaigns, and diabetics with higher self-management skills were able to manage their diet and exercise [17] [20]. People with high self-management skills are more aware of common diseases in Japan, such as diarrhea, dermatitis, and dental disorders, in order to focus on prevention before diseases occur. In addition, malaria is a dangerous and well-known disease that people with high self-management skills are likely to have researched before departure.

Disease knowledge and self-management skill affect disease-related concerns and dread, coping with anxiety, constructive attitudes and approaches, as well as coping with disease-related negative emotions [21]. We thought that higher disease knowledge and higher self-management skills would be associated with a lower Dread score. However, with the exception of dental disease, there was no difference in Dread score regardless of disease knowledge or self-management skills. The respondents in this study did not expect to develop dental disease in their assignment countries, but the group with high disease knowledge could understand the risks and difficulties of this condition. Actually, dental problems are common in overseas volunteers, because caries tends to occur when living in areas without potable water or hygienic conditions in developing countries [22] [23]. It is reported that pre-travel dental treatment is important to avoid the risk of local dental treatment in British volunteers [22].

A factor space diagram created a cognitive risk map by plotting 13 risk items in quadrants or factor spaces defined by the two factors, Dread and Unknown. In this cognitive risk map, smoking, heroin use, alcohol, fireworks, air travel, and diabetes were all in the high Dread and low Unknown quadrants. Compared to another study of Japanese people by Mihashi, alcohol, smoking, drug use, and diabetes would be placed in the lower two quadrants (low Dread and low Unknown factor spaces) [14]. Since this study found that the respondents were going to developing countries, the Dread scores were higher for all items. Because the participants were people who were in training before going to volunteer in developing countries, importantly risk perception varies by race [24] and also depends on when it was measured and the characteristics of the respondents.

Risk cognitive maps in which the risk located is in the upper left of quadrant four (high Dread factor and low Unknown factor), suggests that the prediction of risk status is appropriate [14] [15]. In our results, all the diseases were positioned in the lower left of quadrant four, which suggests volunteers were afraid of the disease and were not underestimating the risks. However, comparing the risks of each one, there is a cognitive gap in the perception that the risk of malaria and dengue fever were lower than the risk from smoking. Although 37% of all responders would travel to Africa and Oceania where malaria is a higher risk the dread score of malaria was lower than that of smoking and fireworks. It is possible they would perceive malaria as preventable by taking chemoprophylaxis and using personal preventive means even though neither are 100% effective [25].

This study found that the perception of risk from a disease differs depending on self-management skills and disease knowledge. Risk perception for diseases with high lethality such as malaria and dengue fever were different compared to the lower lethality diseases such as dermatitis d dental disease. People tend to underestimate the probability of risks that have a relatively high probability of occurrence and to over-estimate a high risk with a small probability that rarely occurs [18]. However, people with self-management skills and disease knowledge will have higher risk awareness of common diseases including high lethality diseases. Therefore, it is important to give not only preventive knowledge but also education in self-management skills before traveling. Takahashi et al., who developed the SMS scale, stated that self-management skills include emotional skills, such as encouraging oneself by manipulating thoughts, and non-emotional skills, such as facilitating the execution of actions through strategic thinking. This scale has items consisting of information gathering for appropriate decision making, planning for achieving objectives, and self-evaluation. Considering this scale, it is necessary to acquire the ability to be able to recognize by oneself how to act on disease knowledge in actual overseas situations. The next research that needs to be done will be done in health behavior research to investigate how volunteer can predict disease and how volunteer can take action.

This study had several limitations. First, we cannot generalize our findings from our volunteer target population. Second, the questionnaire may have introduced responder bias, as certain types of volunteers may have been more likely to complete the survey compared to others. The scale used in this study was for measurement of general risk and not for the risk of disease during travel across activities. It may be not as valid and reliable for risk of disease. However, this is the first study to measure the disease perception, the disease knowledge, and the self-management skills for Japanese overseas volunteers before dispatch. Furthermore, more research is necessary to verify the reliability and validity of the risk perception scale in order to support their health.

Higher self-management skills were associated with lower “Unknown” factor of risk perception, while higher disease knowledge was associated with higher “Dread” factor of risk perception. Self-management skills and disease knowledge will enable higher risk awareness of common diseases and high lethality diseases. Therefore, it is important to give not only preventive knowledge but also education on self-management skills.

We would like to thank the participants and staff at Japanese International Cooperation Agency Komagane Training Center and Nihonmatsu Training Center. Sarah E. Porter PhD, MPH, MS, RN provided editorial assistance.

The authors declare no conflicts of interest regarding the publication of this paper.

Sasayama, K., Gilmour, S. and Ota, E. (2021) Factors Affecting Disease Risk Perception and Self-Management Behaviors among Japanese Long-Term Overseas Volunteers. Health, 13, 16-30. https://doi.org/10.4236/health.2021.131002