Introduction

Background

Quarantine is action taken to protect public health and minimize social and economic damage by managing the influx and spread of public health risk factors that may occur due to overseas infectious diseases [1]. The importance of entry screening has recently been given increased emphasis as the recent rise in international travel has increased the possibility of the international spread of infectious diseases [2,3]. Actually, a study to evaluate the effectiveness of quarantine during the COVID-19 pandemic [3] found that countries that implemented strengthened point-of-entry screening and quarantine measures suffered less public health impact and economic losses [4-7], indicating the need for systematic policies and training for effective quarantine responses [8].

In particular, when people travel by air, the travel period is generally shorter than the incubation periods of infectious diseases, so only initial non-specific symptoms are manifested during flight [2,3,9]. Therefore, quarantine officials’ competency to detect and screen for infectious diseases early from the entry stage is very important, and they also need to have the ability to comprehensively evaluate the extent and epidemiological characteristics of overseas outbreaks of infectious diseases [2,3,9]. However, the job series of quarantine officials in Republic of Korea are not limited to health and medical professionals, but also include various other occupations such as administrative workers and technicians as well as public health and nursing positions [3]. Therefore, to ensure that quarantine officials will respond appropriately to public health crisis situations, quarantine work regarding not only infectious diseases but also other tasks, including work related to bioterrorism, specimens, and patient transport, should be standardized and practical training for this quarantine work should be provided [3,10,11].

Previous studies on education on infectious diseases for public officials at public health centers and healthcare professionals showed that competency enhancement training for healthcare professionals involved in infectious disease control is essentially required after the COVID-19 pandemic [12,13]. Additionally, in a previous study that examined the level of satisfaction with practical training for each core competency among health and quarantine majors, the participants showed the highest level of satisfaction with practical training in epidemiology, indicating that there is a need for the development of practical training on epidemiology education [11]. In addition, a study to investigate educational needs for COVID-19 infection control training among 119 paramedics also found that there is a need for education that includes systematic and practical training on emerging infectious diseases [14].

As described above, since quarantine inspections at borders are very important, it is necessary to identify and evaluate quarantine officials’ core competencies for responding to public health crisis situations, and systematically enhance them through practical training. However, training for quarantine officials is currently implemented as a one-time completion system by entrusting their training to the Korea Human Resource Development Institute for Ministry of Health and Welfare. Additionally, field training and tabletop exercise are required to be conducted at least once a year in accordance with Article 30, Paragraph 2 of the Quarantine Act and the Quarantine Work Guidelines. However, this training is not simultaneously provided to all quarantine officials at the same location, but it is implemented separately for each quarantine station in cooperation with the five Regional Centers for Disease Control and Prevention and there has been a lack of domestic research conducted with quarantine officials on their job duties and competency enhancement training for them.

Therefore, this study conducted a preliminary research for the development of a program for strengthening the public health crisis competency of aircraft quarantine officials. Specifically, this study attempted to analyze quarantine officials’ duties related to public health crisis response, examine the perceived importance and performance levels of duties related to public health crises among quarantine officials, and identify their educational needs based on the relative priorities of the duties. Through these analyses, the present study sought to provide basic data for the development of a public health crisis training program for quarantine officials in the future.

Aims and objectives

This study aimed to examine the importance and performance levels of educational topics on the duties related to public health crisis response of aircraft quarantine officials, and identify their educational needs by using Importance-Performance Analysis (IPA) and Borich needs assessment. The specific objectives of this research are as follows:

1) To examine the importance and performance levels of duties related to public health crises according to general characteristics among aircraft quarantine officials;

2) to identify educational needs for public health crisis training among aircraft quarantine officials by using IPA;

3) to identify the priorities of educational needs for public health crisis training among aircraft quarantine officials by using Borich needs assessment.

Methods

Study design

This study is a descriptive survey study to examine differences in the importance and performance levels for duties related to public health crisis response among aircraft quarantine officials, and identify their educational needs regarding public health crises by using IPA and Borich needs assessment.

Participants

The participants of this study were quarantine officials in Korea who had experience in aircraft quarantine work and completed both the basic and advanced quarantine practice training courses. Only individuals who voluntarily agreed to participate in the study after having been fully informed of the purpose and content of the study were included in this study. The sample size was calculated using G*Power 3.1.9 software with an effect size of 0.3, a significance level of .05, and a power of .90, and the minimal sample size for a paired t-test for this study was calculated to be 119 people. Considering a dropout rate of 10%, the sample size was determined as a total of 132 people. A total of 121 people were finally included in the analysis, excluding 11 people due to insufficient responses to the questionnaire.

Measurement

To derive educational topics in order to identify educational needs regarding public health crisis response education among aircraft quarantine officials, this study used the 2024 Quarantine Work Guidelines of the Korea Disease Control and Prevention Agency(KDCA) along with the results of job analysis of quarantine officials conducted by government-funded research projects related to the development of education and training for quarantine officials [15,16].

The researcher is a central epidemiology investigator who was engaged in aircraft quarantine work and in charge of education and training for quarantine officials, derived educational topics comprised of 16 items in 4 major categories related to public health crisis response from the 2024 Quarantine Work Guidelines, and verified the content validity of a questionnaire on the educational topics through consultation with 6 experts (1 health researcher, 2 central epidemiology investigators, 1 infection control nurse, and 2 quarantine officials). The Item-Content Validity Index (I-CVI) ranged from 0.9 to 1.0, indicating that all the items were valid for the study. The final tool was used after the verification of face validity by two aircraft quarantine officials, and it consisted of 16 questions in total: 5 questions on epidemiological investigations of infectious diseases, 3 questions on infectious disease specimen collection, 5 questions on quarantine management of patients with suspected infectious diseases, 1 question on environmental management, and 2 questions on chemical and biological terrorism.

The survey questionnaire used in this study consisted of 25 items in total, including 5 questions on general characteristics and 4 questions on the education curriculum in addition to the above-mentioned 16 items. The importance and performance levels for the items about duties related to public health crisis were evaluated on a 5-point scale. The importance level was rated on a 5-point scale (1 point = Not important at all, 2 points = Slightly important, 3 points = Moderately important, 4 points = Important, and 5 points = Very important), and the performance level was also rated on a 5-point scale (1 point = Very poor, 2 points = Poor, 3 points = Moderate, 4 points = Good, and 5 points = Very good). As a result of verifying the reliability of questionnaire items, for the importance level for public health crises, the Chronbach ɑ value was .89, and for the performance level for public health crises, the Chronbach ɑ value was .93

Data collection

Data were collected from October 10 to 15, 2024, and the distribution of questionnaires for the study was conducted after the researcher received permission for the study from Quarantine Divisions 1 and 2 of the National Quarantine Station at Incheon Airport. The researcher personally explained the purpose of the study and obtained written informed consent from the participants before distributing self-administered questionnaires. To ensure the confidentiality of the responses, participants were asked to complete the questionnaires and submit them individually after putting them in sealed envelopes provided in a public area.

Data analysis

The collected data were analyzed using SPSS/WIN 26.0. The general characteristics of the participants were analyzed using frequencies, percentages, means, and standard deviations. The importance and performance levels of the items of public health crisis training according to the general characteristics of the participants were analyzed using t-tests and ANOVA, and post hoc analysis was performed using the Scheffé test. Differences in the importance and performance levels were analyzed using the paired t-test. In addition, IPA and Borich needs assessment were used to analyze quarantine officials’ educational needs for public health crisis training.

IPA is a method to determine the relative levels of importance and performance for each attribute by evaluating the importance and performance levels of each attribute [17], and a plane is divided into four quadrants by the X-axis and Y-axis using the average values of importance and performance. Quadrant Ⅰ (Keep up good work) is an area where items with high importance and performance levels are located, and for the items in Quadrant Ⅰ, it is recommended to maintain the current status. Quadrant Ⅱ (Concentrate here) is an area where items with a high level importance but a low level of performance are located, and this quadrant represents the area that should be given the highest priority in education. Quadrant Ⅲ (Low Priority) is an area where items with low importance and performance levels are located, and for the items in Quadrant Ⅲ, mid- to long-term improvement is desirable. Quadrant Ⅳ (Possible Overkill) is an area that includes items whose current state is evaluated as excessive, and it is regarded as an area that includes items for which it would be more efficient to reduce improvement efforts or shift focus from them to other items [18].

In Borich needs assessment, the educational needs score is calculated using the required competence level (RCL), the present competence level (PCL), the mean of RCL (MCL), and the total number of items (N), and Borich’s educational needs formula is as follows: ｛∑(RCL-PCL) x MCL｝/N [19]. In this study, RCL and PCL correspond to the level of importance and the level of performance, respectively, and in the case of Borich educational needs, as the level of importance is higher and as the level of performance is lower, the score for educational needs becomes higher.

Ethical considerations

This study was conducted after receiving approval from the Institutional Review Board of the Korea Disease Control and Prevention Agency under the Ministry of Health and Welfare (IRB No: KDCA-2024-04-05). The researcher explained the purpose of the study and ethical considerations in research to the eligible participants who expressed interest in participating in the study. Then, when the participants expressed intention to participate in the study after having been fully informed of the purpose and ethical considerations of the study, written informed consent was obtained from them after sufficiently explaining the confidentiality of personal information and their right to withdraw at any time during the study without any disadvantages. In addition, to minimize adverse effects from research participation, data was collected anonymously to protect personal information and maintain confidentiality.

Results

General characteristics of the participants

With respect to the general characteristics of the participants, they consisted of 32 males (26.4%) and 89 females (73.6%). The average age of the participants was 38.1 years, and in terms of age groups, the participants included 41 people aged 29 or under (33.9%), 29 people aged 30 to 39 (24.0%), 18 people aged 40 to 49 (14.9%), and 33 people aged 50 or over (27.3%). The average length of public servant career was 151.71 months (approximately 12.6 years). Among the total participants, 8 people (6.6%) worked as a public servant for 12 months, 31 people (25.6%) for 1 to 3 years, 20 people (16.5%) for 3 to 5 years, 17 people (14.0%) for 5 to 10 years, 13 people (10.7%) for 10 to 20 years, and 32 people (26.4%) for 20 years or more. The average length of aircraft quarantine career was 71.92 months (approximately 5.9 years). 12 people (9.9%) worked as an aircraft quarantine official for less than 1 year, 10 people (8.3%) for 1 to 3 years, 48 people (39.7%) for 3 to 5 years, 33 people (27.3%) for 5 to 10 years, 8 people (6.6%) for 10 to 20 years, and 10 people (8.3%) for 20 years or more. Regarding the job series of quarantine officials, among the participants, 73 people (60.3%) were public health officials, 44 people (36.4%) were administrative officials, 1 person (0.8%) was an IT (information and technology) official, and 3 people (2.5%) worked in other areas (Table 1).

Educational needs analysis

The analysis of educational needs regarding the education curriculum for quarantine officials revealed that 71 quarantine officials (58.7%) had received education on epidemiology during quarantine-related training, but 50 quarantine officials (41.3%) had not received education on epidemiology. In addition, 22 quarantine officers (18.2%) had completed simulation education, including infectious disease education, while 99 quarantine officers (81.8%) had no experience with simulation education. Regarding appropriate education time for educational topics related to public health crises, the average expected education time was 1.89 hours, but 1 hour was considered appropriate by 43 people (35.5%), 2 hours by 48 people (39.7%), and 3 hours by 30 people (24.8%). Among all the educational methods for education regarding public health crises, lectures accounted for 33.9%, discussions 15.5%, practical training 45.9%, and others (such as quizzes) 4.6% (Table 2).

Differences in the importance and performance levels for duties regarding public health crises according to general characteristics

As a result of analyzing the differences in the importance and performance levels for duties related to public health crises according to the general characteristics of the participants, there was no significant difference in the importance level according to sex (t=0.49, p=.628), age (t=1.20, p=.283), public servant career (F=1.11, p=.362), quarantine career (F=1.16, p=.333), and major classification (t=-0.10, p=.918). The performance level for duties related to public health crisis situations was significantly different according to sex, and it was higher among males than females (t=-2.12, p=.049). However, there were no significant differences in the performance level according to age (F=1.50, p=.311), public servant career (t=2.12, p=.068), quarantine career (F=1.70, p=.141), and major classification (t=0.80, p=.428)(Table 3).

Importance-performance analysis for duties related to public health crises

An Importance-Performance Analysis was performed by placing performance on the X-axis and importance on the Y-axis and arranging quadrants on the IPA matrix by dividing the matrix into quadrants using the average importance score of 4.06 points and the average performance score of 3.19 points, As a result, Item 5, ‘Epidemiological investigation of emerging infectious diseases’ was found to be included in the Quadrant Ⅱ, the area of ‘Concentrate here’, where items with a high level of importance level and a low level of performance are located. In addition, the items with high performance and importance levels that were included in the area of ‘Keep up good work’ were as follows: Item 11 ‘Occurrence of a social disaster during the isolation of suspected patient’, Item 12 ‘Occurrence of a natural disaster during the isolation of suspected patient’, Item 13 ‘Occurrence of an emergency situation during the isolation of suspected patient’, Item 6 ‘Respiratory infectious disease specimen collection’, Item 15 ‘Use of bioterrorism multi-detection kits, specimen collection, and transportation’, Item 16 ‘Administrative procedures related to bioterrorism’, Item 9 ‘Negative pressure isolation flow and procedures’, Item 14 ‘Infectious waste management and environmental disinfection’, Item 1 ‘Epidemiology investigation of respiratory quarantine infectious diseases’, and Item 10 ‘Donning and doffing personal protective equipment (PPE)’ (Figure 1).

Borich needs analysis for public health crisis education

To examine the educational needs for public health crisis education among aircraft quarantine officials, the Borich needs assessment model was applied. As a result of performing a paired t-test to verify the difference between the expected level and the current level for each of the public health crisis education items, four out of 16 items showed significant differences. As a result of calculating the Borich needs scores and deriving priority items, the top five priority items were derived as follows: Item 5 ‘Epidemiology investigation of emerging infectious disease’, Item 11 ‘Occurrence of a social disaster during the isolation of suspected patient’, Item 10 ‘Donning and doffing personal protective equipment (PPE)’, and Item 1 ‘Epidemiology investigation of respiratory quarantine infectious diseases’ (Table 4).

Discussion

This study is a survey research to investigate the perceived importance and performance levels for duties related to public health crises among quarantine officials, and to derive educational needs for the educational topics of education on public health crises through IPA in order to provide basic data for developing a training program to strengthen quarantine officials’ competencies for responding to public health crises.

The major results of this study are discussed as follows. In this study, the average importance score for quarantine officials’ duties related to public health crises among aircraft quarantine officials was 4.06±0.47 points, and the average performance score was 3.19±0.71 points. These results are thought to reflect the increased social demand for strengthening public health crisis response competency due to overseas infectious diseases and disasters following COVID-19 [2] and the increased perceived importance level of public health crisis response competency among quarantine officials. However, the performance level was found to be relatively lower compared to the perceived importance level, and this result is thought to be due to the lowered public health crisis level in Korea after the end of the COVID-19 pandemic [20].

There was no difference in importance and performance levels according to general characteristics, which is consistent with the results of a prior study showing that there was no significant difference in the educational effect of tabletop exercise according to career plan after implementing tabletop exercise for epidemiological investigations of infectious diseases for public health crisis response [21]. In addition, as shown by previous studies that investigated public health crisis competency among public health center officials, and reported that it is primarily required to secure expertise regarding infectious diseases [12,13,22], it is thought that since public officials responsible for public health crisis response who inevitably get to react sensitively to field situations are well aware of the importance of expertise regarding infectious diseases through a systematic training system, there was no difference in the importance and performance levels for public health crisis competency according to career [23].

In the IPA analysis for quarantine officials’ public health crisis competencies, the competency for epidemiological investigation of emerging infectious diseases was derived as an item that belonged to the area requiring improvement (Quadrant Ⅱ: ‘Concentrate here’), where items with a high level of importance but a low level of performance are located. When a public health crisis due to an infectious disease occurs, epidemiological investigation is an important activity as an initial response for tracing the source of infection and preparing for the outbreak [21,24]. Th above-described finding of this study is consistent with a prior study reporting that there was a high educational need for ‘understanding epidemiological investigation’ in a survey on educational needs regarding infectious disease crisis response education among physicians [2]. When the epidemiological investigation items were classified by infection route, epidemiological investigation for emerging infectious diseases was derived as a high priority item. This result can be attributed to the fact that the first patient with confirmed COVID-19 entered Korea through Incheon Airport, and the outbreak of emerging infectious diseases is expected to become more frequent in the future due to the increase of international travel, antibiotic overuse and drug resistance, and changes in the ecological environment[25-27]. Thus, derivation of epidemiological investigation of emerging infectious diseases as a high priority item suggests that epidemiological investigation training based on the response guidelines for emerging infectious disease outbreaks that may occur in the future should be implemented as the first priority in training for quarantine officials [21,24,26,27].

Regarding specialized training programs for quarantine officials, as of 2024, a total of 4 courses and 6 sessions of specialized training courses are being operated by the Korea Human Resource Development Institute for Ministry of Health and Welfare, which is an organization entrusted with the training for quarantine officials, and specifically, the training courses include the basic quarantine practice course (2 sessions), advanced quarantine practice course (2 sessions), quarantine officials’ competency enhancement course (1 session), and quarantine station manager training (1 session) [3]. However, it has been reported that since this training is managed as a one-time completion system, there are difficulties in continuously strengthening the competencies of quarantine officials [3]. Thus, in order to strengthen quarantine officials’ professional expertise by strengthening their field response competency, research related to training for epidemiological investigation of emerging infectious diseases has been actively conducted with the staff of the Korea Disease Control and Prevention Agency(KDCA) and medical institutions [23,27]. However, although there is also training implemented within the National Quarantine Station of the Korea Disease Control and Prevention Agency in addition to outsourced training, training within the National Quarantine Station is provided not simultaneously for all quarantine officials but separately for individual quarantine stations in cooperation with Regional Centers for Disease Control and Prevention, and most of the training is conducted mainly in the form of discussion and tabletop exercise based on guidelines rather than scenario-based training [3,24]. Therefore, there is a need to apply appropriate methods for education and training regarding the performance of practical and standardized epidemiological investigations [3,24].

Among the items included in the area of ‘Keep up good work’, the area where both the importance and performance levels are high, the item with the highest educational need was the competency for dealing with the occurrence of a social disaster during the isolation of a suspected patientThis result can be attributed to the fact that, as a result of changes in the quarantine environment after the outbreaks of MERS and COVID-19, facilities for observation in quarantine were created outside and inside quarantine stations for the temporary negative isolation and observation of suspected cases, and an all-round quarantine system was implemented in which quarantine inspections, screening, facility quarantine, diagnostic testing, and patient transport were all carried out simultaneously instead of the existing method in which patient transport to a hospital is performed immediately after quarantine inspections [28]. The finding is consistent with the results of a previous study showing that there is a need to develop an algorithm based on a SOP (standard operating procedure) by organizing the standards and procedures for quarantine work, and provide training and education on the developed algorithm in order to actively respond to changes in the quarantine environment [3].

In this regard, in the case of training for aircraft quarantine officials, as shown in a study on epidemiological investigators’ experiences in responding to infectious diseases, aircraft quarantine officials may have difficulties due to role conflicts resulting from various cases even if there are guidelines for infectious disease response [13,23]. Therefore, in implementing training related to responding to disasters occurring during the isolation of suspected cases, it is necessary to establish a practical training strategy, such as an on-the-job training system and simulation training based on various cases [3].

The ‘Low-priority’ area with low levels of importance and performance included vector-borne infectious disease specimen collection. Among quarantinable infectious diseases, vector-borne infectious diseases include human infection with zoonotic influenzaand mosquito-borne diseases. However, due to the invasive testing methods, not all quarantine officials but some quarantine officers with nursing or clinical pathology licenses have performed these tasks, which is thought to be the reason for the low importance and performance levels of vector-borne infectious disease specimen collection.

The area of ‘Possible overkill’, which is the area where items with low importance but high performance are located, was found to include the competencies for epidemiological investigations of waterborne and foodborne infectious diseases, vector-borne infectious diseases, and mosquito-borne infectious diseases. In the case of cholera, dengue fever, and MERS among the quarantine infectious diseases, if a symptomatic case occurs, an epidemiological investigation is immediately conducted, and the patient is placed in isolation based on the case classification by an epidemiologist or public health doctor [24]. Regarding the collection of specimens for waterborne and foodborne infectious diseases, when a suspected cholera patient occurs and a pathogen is detected through the testing of specimens collected from the means of transportation (a plane toilet and a tray table), a disinfection order or recommendation is notified to the relevant airline [29]. It is thought that since this work is currently continuously performed, the performance level of this duty was rated as high.

The main significance of the present study lies in the fact that this research systematically analyzed educational needs for public health crisis training by using IPA, and systematically prioritized the competencies requiring improvement in order to enhance the job competency of aircraft quarantine officials in the post-COVID-19 era. However, because this study was conducted with a limited number of aircraft quarantine officials, there are limitations in generalizing the research results to all quarantine officials. Therefore, it is necessary to conduct a survey by expanding the population to include all quarantine officials, and follow-up research is needed to develop a practical training program based on the results of this study, and evaluate its effectiveness.

Conclusions

This study identified the topics of training regarding public health crises that may arise during aircraft quarantine, and analyzed the educational needs of currently working aircraft quarantine officials. In addition, the study aimed to provide a theoretical basis for strengthening aircraft quarantine officials’ public health crisis response competency, and the results of this study will hopefully serve as basic data for the development of training programs for quarantine officials in the future.

Among quarantine officials, both the perceived performance and importance levels of competencies regarding public health crises were found to be high, but the level of perceived importance was higher compared to the level of performance. As a result of IPA and Borich needs assessment, were found to be ‘Epidemiology investigation of emerging infectious diseases’ and ‘Occurrence of a social disaster during the isolation of suspected patient’ were identified as the items with the highest educational needs for public health crisis training.

Based on the research findings, the following suggestions are made. First, it is suggested that replication research should be conducted with all quarantine officials working in quarantine stations by including not only aircraft quarantine officials but also port quarantine officials. Second, to enhance the public health crisis response competency of aircraft quarantine officials, further research should be conducted to develop practical training programs regarding epidemiological investigations of emerging infectious diseases and the occurrence of a social disaster during the isolation of suspected cases, which were identified as the items with the highest educational needs, and to evaluate their effectiveness.

Figure 1.

Importance-performance analysis matrix

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