To the best of our knowledge, this is the first study to investigate asbestos awareness and associated sociodemographic characteristics in St. Kitts and Nevis. The findings of this study may provide useful information to policymakers about the level of asbestos awareness in St. Kitts and Nevis. The findings may also be used to inform government, public health officials, and other stakeholders on public health interventions, awareness, and policy initiatives on asbestos.

In this cross-sectional national online survey, we investigated the level of asbestos knowledge and attitudes of 1009 adults. We found that > 70% of participants considered asbestos exposure to be a general public concern and that it was the duty of the government to prevent it. However, only 54% of the respondents considered a total asbestos ban to be the best option to prevent asbestos exposure. Supporters of a total asbestos ban were those with a higher level of asbestos knowledge. As reflected in the average score of asbestos knowledge of 3.65, the respondents answered an average of 52.1% of questions correctly regarding asbestos hazards, exposure scenarios, and adverse health outcomes. The lack of sufficient asbestos knowledge may impede campaigns for an asbestos ban even where asbestos exposure is already a public concern.

However, a high proportion (70%) of respondents agreed that asbestos exposure is a general public concern in St. Kitts and Nevis. A similarly high proportion (71%) of respondents agreed that it was the government’s duty to prevent asbestos exposure. In most countries, the health sector represents a critical area of government responsibility [31]. Government health departments and related agencies are responsible for monitoring, protecting, and improving the health of residents and citizens [31]. Many residents and citizens of the country of St. Kitts and Nevis also regard the government as the responsible party for protecting people’s health and welfare [32]. Residents in St. Kitts and Nevis may also feel that the government has the resources and expertise to identify, remove, and prevent asbestos exposure, whereas the general public does not have that expertise.

In our question regarding the best option to avoid asbestos exposure (question 10), the answer choices were as follows: (a) to ban the use and import of all asbestos products and materials from entering St. Kitts and Nevis, (b) to wear personal protective equipment, and (c) I do not know. Whereas the majority of respondents agreed that asbestos exposure was a general public concern and that its prevention was the duty of the government, only 54% of participants selected a total asbestos ban as the best option to prevent asbestos exposure. Of the remaining participants, 13% selected wearing personal protective equipment as the best option, and 33% selected “I do not know.” This finding suggests that people may lack awareness of the pros and cons of potential solutions. They may not know anyone who has been diagnosed with an asbestos-related disease. Overlooking solutions to prevent asbestos exposure could also be due to scarcity or lack of epidemiological data and diagnosis of asbestos-related diseases [12]. Even among people who are aware of asbestos hazards, the cost, endurance, and performance of alternatives to asbestos may guide people away from selecting an asbestos ban as the best option [33]. However, our findings showed that a higher level of asbestos knowledge was associated with attitudes toward an asbestos ban: people with higher levels of asbestos knowledge were more likely to select a total ban as the best option to eliminate exposure risks. More asbestos knowledge could help people understand the difference between banning asbestos and wearing personal protective equipment as solutions to preventing asbestos-related diseases.

We found that the level of asbestos knowledge was significantly related to age, education, residential area, and occupation. Specifically, higher levels of asbestos knowledge were found in people aged ≥ 30 years, with higher education, living in St. Kitts, and working in the government. While age was a significant predictor in our study, it was not found significant in a previous study in Turkey [28]. However, age is related to the accessibility of higher education in St. Kitts and Nevis. University enrollment is expensive for most Kittitians and Nevisians, and it is difficult to attain higher levels of education until later years in life, when one can have saved up enough money to secure a loan or to pay for university-level education overseas or through distance learning via the internet. Meanwhile, our findings that education level and residential area are significant factors are consistent with the Turkish study, which recruited 760 hospital patients and their relatives and reported a higher level of asbestos knowledge and awareness among those who lived in an urban area, had graduated from a university, and were employed or retired [28].

Education level is among the most important predictors of health literacy [34, 35]. Higher educational attainment represents greater ability to understand, search for, and acquire scientific information and skills. Health literacy is also higher among people living in urban areas than those in rural areas [36]. Given that St. Kitts is the legislative and commercial capital, it is considered more urban than Nevis. Another potential factor in our finding that Kittitians were more knowledgeable and aware of asbestos was a number of news reports related to suspected asbestos exposure in government institutions (e.g., National Information and Communications Technology Centre) [37], schools (e.g., Irishtown Primary School and Cayon High School) [38], and public facilities (e.g., water pipes). For example, on Saturday, April 26, 2014, the Ministry of Education released a statement to inform parents and guardians of students attending the Basseterre High School in St. Kitts that there would be no school on Monday, April 28 [39]. The temporary closure of the secondary school was speculated to be due to asbestos contamination, which became a well-publicized issue in this region [40]. In another incident, the government announced and implemented an island-wide project on St. Kitts in 2019 to replace the asbestos pipes in the existing water transportation system with polyvinyl chloride pipes [41]. It is likely due to these occasional events of suspected asbestos exposure in government buildings, institutions, and facilities that the government workers in our sample were generally more aware of asbestos compared with people working in the private sector.

We did not find a significant gender difference in the participants’ responses to the questions about whether the general public should be concerned about asbestos in their daily lives or whether it is the government’s duty to prevent asbestos exposure. However, we did find a significant gender difference in answers to the question concerning the best option to prevent asbestos exposure. A higher proportion of women than men agreed that the best option for asbestos exposure was a total asbestos ban. Women are more experienced with changes in the living environment (e.g., needing to manage resources), which leads them to be more concerned about environmental hazards and more willing to adopt environmental behaviors (e.g., being plastic-free) and actively engage in environmental health issues [42]. St. Kitts and Nevis is a matriarchal society, and nearly half of all households (47%) are headed by single women [43]. The eventual closure of the asbestos-contaminated school in St. Kitts may have heightened parents’, and particularly mothers’, concerns about potential asbestos exposure in schools.

Now is the time to raise awareness regarding asbestos hazards and ban asbestos in St. Kitts and Nevis. The first policy recommended by the World Health Organization for the elimination of asbestos-related diseases is to stop the use of all types of asbestos [44]. Banning asbestos production, export, and import would significantly reduce asbestos-related mortality globally, not only in occupational settings but also in households and other non-occupational settings [45]. St. Kitts and Nevis does not produce asbestos. Therefore, the government of St. Kitts and Nevis should proactively fight against the incidence and mortality of asbestos-related diseases, including adopting and ratifying the ILO Convention No. 162 and the Basel Convention as well as conducting extensive asbestos exposure prevention awareness campaigns.

There were a number of limitations in our study. First, the study design was cross-sectional, and causal conclusions should not be inferred. Second, participants completed questionnaires anonymously via the internet, and we had difficulty reaching certain types of participants, such as adults without internet access, who are illiterate, and who are older and have low technological literacy. This may have led to selection bias, with more health-oriented and more conscientious respondents opting to participate in the study. If so, this limitation could mean reduced generalizability of the results to the general population. In the initial stages of study development, we had planned to conduct formal in-person questionnaire interviews, but when the COVID-19 pandemic occurred, many governments, including St. Kitts and Nevis, imposed movement restrictions. These were not limited to international air travel but also included “stay-at-home” and social distancing policies. We had no choice but to implement and conduct the survey online. Third, due to the questionnaire structure, participants were not required to explain their choice of not wanting to ban asbestos imports. However, we could recognize that residents with higher levels of asbestos knowledge had higher odds of selecting a total asbestos ban and vice versa. This finding indicates that participants lacking knowledge of asbestos would not select banning asbestos as the best option for preventing exposure.

Currently, the political will and policies of the country have not been geared toward an asbestos ban. Many people are unaware of the intangible costs of asbestos, especially asbestos-related diseases and death. The lack of appropriate tools and equipment to identify asbestos and asbestos-related diseases hinders promotion of the asbestos hazard. Small and under-resourced countries engaging in international trade are especially vulnerable to economic pressure from powerful asbestos-exporting countries. The failure of countries to ban asbestos reflects the enormous power of the asbestos industry and its political allies who act against the best interests of public health and place short-term profits ahead of human well-being [46, 47].