Public Perceptions of and Behavioral Changes in Response to the H1N1 Flu Outbreak
Public Perceptions of and Behavioral Changes in Response to the H1N1 Flu Outbreak
Abstract & Commentary
By Dónal P. O'Mathúna, PhD. Dr. O'Mathúna is Senior Lecturer in Ethics, Decision- Making & Evidence, School of Nursing, Dublin City University, Ireland; he reports no financial relationship to this field of study.
Synopsis: A telephone survey revealed that the UK general public had a relatively low level of anxiety about H1N1 flu, and also made relatively few behavioral changes to reduce the risk of transmission. People's likelihood to make changes was associated with a number of perceptions regarding H1N1 flu (swine flu).
Source: Rubin GJ, et al. Public perceptions, anxiety, and behaviour change in relation to the swine flu outbreak: Cross sectional telephone survey. BMJ 2009;339:b2651.
This article reports on the results of a telephone survey about "swine flu" (caused by the novel H1N1 virus) conducted in England, Scotland, and Wales in May 2009, about a month after the outbreak was first reported. Almost 1,000 adult members of the public participated in the survey. Of the participants, 37.8% reported performing any of the recommended behavioral changes over the previous four days because of H1N1 flu. These recommendations included using tissues when sneezing, washing hands regularly with soap and water, or setting up a network of "flu friends" to provide mutual assistance if anyone should become sick. Only 4.9% of participants reported carrying out any social avoidance behavior because of H1N1 flu (like avoiding public places).
Thirty-nine items were included in the survey to assess key perceptions about H1N1 flu and how they were related to behavior changes. Making the recommended changes was associated with perceptions that H1N1 flu is severe, that the risk of catching it is high, that the outbreak will continue for a long period of time, that the authorities can be trusted, that good information has been provided, that people can control their risk of catching H1N1 flu, and that specific behaviors are effective in reducing the risk. On the other hand, people were less likely to make the recommended changes if they scored high in "uncertainty" about the outbreak and if they perceived that the outbreak had been exaggerated or hyped up. The strongest predictor of behavior change was ethnicity, with participants from ethnic minorities being more likely to make recommended changes (odds ratio [OR], 3.2; 95% confidence interval [CI], 2.0-5.3) and carry out avoidance behaviors (OR, 4.1; 95% CI, 2.0-8.4).
The authors concluded that their results support efforts to inform the public about H1N1 flu and specific actions that can reduce its risks. They also noted that tackling the perception that the outbreak has been "over-hyped" will be difficult, but should be undertaken. The association between ethnicity and behavioral responses warrants further research.
Commentary
In the United Kingdom (UK), media coverage of H1N1 flu began on April 25, 2009, and peaked on April 30 when the World Health Organization (WHO) raised its pandemic alert status to 5. This survey was conducted between May 8 and 12. At that time, 65 people in the UK had been confirmed as having H1N1 flu. The survey was conducted after the UK government carried out a large-scale public awareness campaign. This included an information leaflet sent to every home explaining H1N1 flu, the government's response, and how individuals could protect themselves and others from infection. The WHO raised its alert to level 6 on June 11, after this survey had been completed.
The survey used random digit dialing and proportional sampling to ensure respondents were representative of the general population. Participants were asked nine questions about recent behaviors, three of which had been recommended by the government to reduce risk of H1N1 flu and six which had not. Six items asked how strongly respondents believed specific behaviors reduced their risk of contracting H1N1 flu. The six-item version of the validated State Trait Anxiety Inventory was used specifically in relation to H1N1 flu. Thirty-nine items asked about perceptions related to H1N1 flu, which were grouped into six categories: trust in authorities, likelihood of infection, severity of illness, exaggeration of risk, timeline of the outbreak, and good information.
Less than two weeks after the WHO alert was raised to level 5, and several dozen cases were confirmed in the UK, public anxiety was relatively low in the UK. About 24% reported some anxiety about H1N1 flu, but only 2% reported high anxiety. Behavioral changes were also limited. Most (62%) had not changed any relevant behavior. Most people did not change the frequency of hand washing (72%), disinfecting items (83%), or developing "flu friends" (83%).
Regarding the government information leaflet, 39.3% reported receiving the leaflet and 25.6% said they had read it. No significant differences were found between those who had received the leaflet and those who had not in terms of anxiety, adopting recommended behaviors, or adopting avoidance behaviors. However, the group who had read the leaflet were significantly less anxious than those who had not read the leaflet (P = 0.03).
These results confirm other findings that the public's first response to a novel threat is not over-reaction or panic. The authors concluded that, "In practice, convincing the public that the threat is real is often a more pressing task for public health agencies than providing reassurance." The data on public perceptions offer some insight into how recommendations could be delivered more effectively. The higher the perception of the seriousness of the outbreak, the higher the rate of compliance with the recommendations. Information that was clear and removed uncertainty also increased compliance and reduced anxiety. Those who did not adopt recommended changes were more likely to perceive government health warnings as being exaggerated.
The survey had some limitations because it was designed and delivered very quickly in the immediate aftermath of the H1N1 flu outbreak. However, it provided helpful information on the public response immediately after the outbreak and a government education campaign. The effectiveness of this campaign appears to have been relatively limited, although those who read the leaflet did have reduced anxiety. The campaign also used other media, so the influence of any one portion would be difficult to separate from the others.
Health care professionals can play an important role in clarifying and explaining the information provided in such campaigns, and reinforcing the importance of adopting health-promoting behaviors. Asking patients about their perceptions of H1N1 flu can help elucidate whether they may be more or less likely to adopt public health recommendations.
A telephone survey revealed that the UK general public had a relatively low level of anxiety about H1N1 flu, and also made relatively few behavioral changes to reduce the risk of transmission. People's likelihood to make changes was associated with a number of perceptions regarding H1N1 flu (swine flu).Subscribe Now for Access
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