Calculate a 90 Confidence Interval for the Proportion of Family Members Who Come Down With H1n1

1. Enquiry
2. Public perceptions,...
3. Public perceptions, feet, and behaviour change in relation to the swine influenza outbreak: cross sectional telephone survey

Inquiry

Public perceptions, anxiety, and behaviour alter in relation to the swine flu outbreak: cross sectional telephone survey

BMJ 2009; 339 doi: https://doi.org/ten.1136/bmj.b2651 (Published 02 July 2009) Cite this as: BMJ 2009;339:b2651

1. G James Rubin , senior inquiry swain1,
2. Richard Amlôt , research fellowtwo,
3. Lisa Page , clinical lecturer1,
4. Simon Wessely , professor of epidemiological and liaison psychiatryone

1. ¹Male monarch's College London, Institute of Psychiatry, Department of Psychological Medicine, Weston Education Centre, London SE5 9RJ
2. ²Wellness Protection Agency, Emergency Response Department, Porton Downwardly, Wiltshire

1. Correspondence to: G James Rubin g.rubin{at}iop.kcl.ac.u.k.

• Accustomed 23 June 2009

Abstract

Objective To appraise whether perceptions of the swine flu outbreak predicted changes in behaviour among members of the public in England, Scotland, and Wales.

Pattern Cantankerous sectional telephone survey using random digit dialling.

Setting Interviews by telephone betwixt 8 and 12 May.

Participants 997 adults aged 18 or more who had heard of swine flu and spoke English language.

Main outcome measures Recommended alter in behaviour (increases in handwashing and surface cleaning or plans made with a "flu friend") and avoidance behaviours (engaged in one or more than of half dozen behaviours such as fugitive large crowds or public send).

Results 37.viii% of participants (n=377) reported performing any recommended behaviour change "over the past four days . . . considering of swine flu." 4.9% (n=49) had carried out any abstention behaviour. Decision-making for personal details and anxiety, recommended changes were associated with perceptions that swine flu is severe, that the take chances of catching it is high gamble, that the outbreak will continue for a long time, that the government can exist trusted, that proficient information has been provided, that people can control their risk of catching swine influenza, and that specific behaviours are effective in reducing the gamble. Being uncertain nearly the outbreak and believing that the outbreak had been exaggerated were associated with a lower likelihood of modify. The strongest predictor of behaviour alter was ethnicity, with participants from ethnic minority groups beingness more likely to make recommended changes (odds ratio iii.2, 95% conviction interval ii.0 to five.3) and carry out abstention behaviours (4.1, 2.0 to 8.4).

Conclusions The results back up efforts to inform the public almost specific actions that tin can reduce the risks from swine influenza and to communicate about the authorities'southward plans and resources. Tackling the perception that the outbreak has been "over-hyped" may be difficult but worthwhile. Additional research is required into differing reactions to the outbreak among ethnic groups.

Introduction

In April 2009 a new strain of flu virus, A/H1N1, ordinarily referred to as "swine flu," began to spread in several countries around the globe. Evidence that this new strain could pass from human to human led the World Health Organization to speedily enhance its pandemic alarm level to stage 5, representing "a potent signal that a pandemic is imminent and that the fourth dimension to finalise the organization, communication and implementation of the planned mitigation measures is curt."1 This was subsequently raised to stage 6, indicating that a full global pandemic was under way. Given the lack of any specific vaccine against swine flu, mitigation measures in the United Kingdom have so far focused on identifying, treating, and isolating people who have the disease and educating the public about the steps that individuals can take to reduce the risk of transmission. These recommendations include using tissues when sneezing, washing hands regularly with soap and water, and setting upward a network of "flu friends" to provide mutual help should someone go ill.2 three

Encouraging the public to undertake specific behaviours related to hygiene has proved useful in containing previous outbreaks of infectious disease.4 Motivating the public to prefer such behaviours can be difficult. Studies of how people responded to the outbreak of severe acute respiratory syndrome in 2002 advise that perceptions or beliefs near an outbreak may be important in determining compliance with official communication. In particular the literature on severe acute respiratory syndrome suggests that people may exist more probable to comply with wellness related recommendations if they believe that the recommended behaviours are effective,5 half-dozen they perceive a high likelihood that they may be affected by the outbreak,6 7 8 they perceive that the illness has astringent consequences,half-dozen they believe that the illness is difficult to care for,9 and they believe that the government is providing clear and sufficient information almost the outbreak and can be trusted to control the spread of infection.7 In addition, higher levels of anxiety or worry may be associated with an increment in behaviour changes.5 10

In addition to these factors, two others may exist relevant in determining whether people prefer precautionary behaviour in response to an outbreak. Firstly, a sense of public distrust exists about journalists and the sensationalising of health related stories.xi People may neglect to heed official advice conveyed through the media if they believe that this is "just some other health scare." Secondly, many scientific uncertainties environment swine flu.12 Such uncertainty may influence whether people undertake precautionary behaviours.13

Understanding the office of specific perceptions in motivating people to appoint in precautionary behaviour may help health communicators to better their letters well-nigh outbreaks of new infectious disease generally and swine flu specifically.

To assess the associations between perceptions and anxiety about swine flu and behaviour alter relating to swine flu we carried out a cross sectional telephone survey of a large, demographically representative sample of the population of England, Scotland, and Wales. This survey provided a snapshot of public concerns and behaviours at the start of the swine flu outbreak, during a period of scientific doubtfulness most the risks posed by the virus.

Methods

UK involvement in the swine influenza outbreak

Intense media reporting in the United kingdom about the swine influenza outbreak began on 25 Apr 2009 and peaked on thirty April after WHO raised its pandemic alarm status to 5. The get-go 2 cases of swine flu in the U.k. were confirmed on 27 Apr. By 12 May, the date on which our data collection finished, 65 people in the United kingdom of great britain and northern ireland had been confirmed as having swine flu and several schools had been closed equally a precautionary measure. During this time a major advertising campaign was started by the authorities to provide the public with data and advice. This included an information leaflet sent to every home in the country, which discussed, amid other things, the nature of swine flu, what the regime had done to set for a pandemic, and what individuals could practise to protect themselves and others.three On 11 June, after we had completed our data collection, WHO raised its pandemic alarm status to stage vi.

Cross sectional telephone survey

Between 8 and 12 May Ipsos MORI carried out a telephone survey of 1000 residents of England, Scotland, and Wales, using random digit dialling. This sample size provided the states with a sample error of about plus or minus 3%. Proportional quota sampling was used to ensure that respondents were demographically representative of the general population, with quotas based on age, sex, work status, region, and social course. Each interview lasted twenty minutes. To reduce selection bias, participants were initially informed that the survey related to "issues currently facing the UK" and were only informed that the real issue was swine flu later on we had obtained verbal consent to proceed. Respondents were required to be 18 years or older, to speak English, and to have heard of swine flu.

Behaviours

Participants were asked nine questions nearly recent behaviours. Six related to avoidance of places or activities, behaviours that had not been recommended by the authorities. Three related to activities that had been recommended—namely, increased cleaning or disinfecting of surfaces, washing hands with soap and h2o more oft than usual, and discussing with a friend or family member what to do if either person caught swine flu. Eight of the questions were phrased as "Over the by four days, I have . . . because of swine flu." The ninth question, relating to discussing plans, did not specify a fourth dimension frame. Tabular array 1⇓ lists the full detail wordings. Permitted responses for each question were yes, no, or does not apply. As a supplementary question we also asked "In the by 24 hours, how many times have y'all done your hands with lather and water? That does not include having a shower, a bath, or doing the washing up."

Table 1

 Behavioural responses to swine flu outbreak

Perceived efficacy of behaviours

Six items assessed whether participants believed that a specific action reduced their risk of catching swine flu, with possible response options being strongly concord (scored as 5), tend to agree (iv), neither agree nor disagree (3), tend to disagree (ii), or strongly disagree (1). Tabular array 2⇓ gives the wording for these questions.

Table 2

 Perceived efficacy of various behavioural responses to swine influenza. Values are numbers (percentages) of participants

Anxiety

Anxiety was assessed using the six item version of the validated country trait feet inventory.14 The preamble specified that respondents should respond with respect to how they had been feeling over the past iv days in relation to swine flu. This calibration provided scores of between six (least anxiety) and 24 (most feet). We categorised people who scored 12 or more as having anxiety about swine flu, and those who scored 18 or more than equally having high feet about swine flu.xv

Perceptions

Thirty ix items were used to assess cardinal themes of how people perceived the swine flu outbreak. Perception items were phrased every bit statements, with response options ranging from strongly hold (5) to strongly disagree (1). Exploratory factor assay using principal axis factoring and varimax rotation suggested that nine factors were present in the data. All factors were readily interpretable by examining those items with loadings greater than 0.four. Six of the factors were used to course scales (box).

Perception scales used in the analyses, with examples of items

Trust in the authorities (five items)

• In general, I think the authorities are acting in the public'southward best interest in dealing with the swine influenza outbreak (Cronbach'south α 0.81)

Likelihood of infection (v items)

• I believe there is currently a high take chances of catching swine influenza in the shops I get to (Cronbach's α 0.fourscore)

Severity of affliction (5 items)

• I recollect that if I take hold of swine influenza it will have major consequences for my life (Cronbach's α 0.seventy)

Exaggeration of the hazard (four items)

• I think that the media have over-exaggerated the risks of communicable swine influenza (Cronbach's α 0.62)

Timeline for the outbreak (three items)

• In my stance, this swine flu outbreak is going to keep for a long time (Cronbach's α 0.74)

Proficient information (three items)

• Overall, the information I accept heard most swine flu has been clear (Cronbach'due south α 0.75)

Scores on these scales were calculated as the mean of the relevant items. Cronbach's α scores of less than 0.6 for the remaining iii factors prevented united states from forming scales. Instead we used the unmarried item that we thought all-time summarised the factor in the analysis. These related to dubiousness ("I practise not empathise what is happening with this swine influenza outbreak"), control ("I think that if I am careful, I can reduce my hazard of catching swine flu"), and lack of treatments ("I think there is goose egg that tin be done to treat people with swine flu").

Personal and other variables

Personal variables consisted of sex, historic period, working status, household income, children aged 0 to iv in the household, educational level, ethnicity, and the presence of whatsoever chronic disease or disability diagnosed past a md. We likewise asked whether respondents had received the government's leaflet on swine flu and, if so, whether they had read information technology.

Analyses

We calculated two main outcomes; whether the participant had engaged in any of the 6 avoidance behaviours (tabular array ane) and whether the participant had engaged in any of the iii recommended behaviours (table 1). Binary logistic regressions were used to calculate the univariate associations between personal characteristics and the chief outcomes. We used t tests to investigate the association between anxiety levels and the primary outcomes. Two sets of binary logistic regressions were used to assess the univariate associations between perception variables and primary outcomes, and also the multivariate associations adjusting for significant personal variables and anxiety. We calculated t tests and odds ratios to assess whether receiving or reading the authorities'south swine influenza leaflet was associated with behaviour outcomes or anxiety.

Weighting the information by age, sex, working status, region, and social grade did not alter the prevalence of any behaviour outcome by more than ane%. Nosotros therefore carried out analyses using unweighted data.

Results

Overall, fourteen 297 potential respondents were contacted. Of these, 9451 refused to participate, 3575 asked to be chosen back later but declined to brand an appointment, and 123 fabricated an appointment but could non be included during the information collection menstruation. Of the rest, 93 were ineligible to participate (including 37 who reported that they had not heard of swine flu) and 55 were out of quota, leaving thou eligible people who were interviewed. Of these, three reported that they or a family unit fellow member had been advised to take antiviral drugs considering of exposure to swine influenza and were therefore excluded from analyses.

Behaviour outcomes, anxiety, and perceived efficacy of behaviours

Table ane lists the behaviour changes reported in response to the swine flu outbreak. Xl nine people (4.9%) reported engaging in one or other course of avoidance behaviour, whereas 377 (37.8%) said that they had carried out ane or more of the three recommended behaviours. In total, 237 (23.8%) scored 12 or more on the six item state trait anxiety inventory, suggesting anxiety about swine flu. Of these, 21 (two.i%) scored 18 or more, suggesting loftier feet. Table 2 lists the perceived efficacy of the six behaviours asked almost.

Association between personal variables and behaviour

Tabular array iii⇓ shows the associations between personal variables and behaviour. Women, people aged 18 to 24, and parents of young children were significantly more than likely to follow recommended behaviours. Participants who were non employed, were poor, had an annual household income of less than £30 000, or had no educational qualifications were significantly more than likely to adopt avoidance behaviours. The largest furnishings were for participants from not-white ethnic backgrounds, who were significantly more likely than white participants to adopt both recommended behaviours (odds ratio 3.2, 95% confidence interval 2.0 to 5.3) and avoidance behaviours (4.1, 2.0 to eight.4). Further analyses showed that ethnicity remained a significant predictor for recommended behaviours (2.vi, 1.4 to four.seven) and avoidance behaviours (four.nine, 1.eight to 13.1) even afterwards adjusting for age, sex, education, young children in the household, income, and working status.

Table three

 Association betwixt personal variables and behaviour during swine influenza outbreak

Association between anxiety and behaviour

Participants who had carried out one or more than recommended behaviours had significantly higher levels of anxiety than participants who had not (hateful difference 1.7, 95% confidence interval 1.three to 2.i, t=eight.five, df=995, P<0.001). Similarly, participants who had carried out one or more than abstention behaviours had significantly higher levels of anxiety than those who had not (two.vi, ane.seven to 3.5, t=v.8, df=995, P<0.001).

Association between perceptions and behaviour

Tabular array iv⇓ shows the mean scores for the perception factors and the univariate and multivariate associations between perceptions and behaviour change. Adjusting for all significant personal variables in table 3 and for anxiety, all perceptions apart from those relating to the availability of treatments for swine flu were associated with carrying out one or more recommended behaviours. Although perceptions relating to likelihood, severity, exaggeration, timeline, and dubiousness also showed significant univariate associations with conveying out one or more avoidance behaviours, just likelihood and severity remained significant subsequently adjusting for personal variables and anxiety.

Table four

 Association betwixt perception variables and behaviour during swine influenza outbreak

Perceived efficacy of specific behaviours as a predictor of behaviour change

Binary logistic regressions showed significant univariate associations between perceived efficacy of reducing the number of people met in a twenty-four hour period and adopting one or more avoidance behaviours (odds ratio 1.8, 95% confidence interval:1.4 to ii.three), perceived efficacy of fugitive public transport and reducing the amount of public transport used (2.2, 1.4 to 3.5), perceived efficacy of cleaning or disinfecting things that might be touched and increasing the amount of cleaning or disinfection of things (ii.two, ane.7 to 2.8), and perceived efficacy of washing hands regularly with lather and h2o and really washing hands more regularly (1.8, 1.5 to two.ii). Although the strength of these associations was reduced by adjusting for historic period, sex, working condition, household income, educational level, ethnicity, young children in the house, and anxiety, all four remained significant.

Effects of the leaflet on behaviours and anxiety

At the time of the survey, 392 participants said that they had received the government'due south leaflet about swine flu (39.3%), and 255 (25.half-dozen%) said they had read it. No significant differences were found between participants who had or had not received the leaflet in terms of anxiety (mean difference −0.3, 95% conviction interval −0.vii to 0.08, t=one.half-dozen, df=995, P=0.12), whether they had adopted one or more of the recommended behaviours (odds ratio 0.ix, 95% confidence interval 0.vii to 1.2), or whether they had adopted 1 or more than of the avoidance behaviours (0.5, 0.3 to 1.0). Comparing participants who had read the leaflet with those who had not did not alter the results for the behaviour outcomes. Participants who had read the leaflet were, withal, significantly less anxious than the combined group who had either non read the leaflet or not received information technology (hateful divergence −0.5, 95% confidence interval −0.9 to −0.05, t=2.2, df=995, P=0.03).

Give-and-take

Our results propose that less than ii weeks later WHO responded to the swine flu outbreak by raising its pandemic alarm status to 5 and in the face of intense media coverage and a major government ad campaign, public responses to swine influenza were muted. Anxiety about the outbreak was low, with only 24% of participants reporting whatever anxiety and only 2% reporting high anxiety. Behaviour changes were also limited. Virtually people reported that they had not inverse the frequency of their hand washing (72%), increased the amount that they cleaned or disinfected things (83%), or discussed plans with a "flu friend" (85%). In fact most people (62%) had done none of these things. There was also little evidence that people were using behaviours with potentially damaging social or economical implications,xvi with fewer than 5% reporting that they had avoided people or places every bit a consequence of the outbreak. These results add to an extensive body of work that rebuts any suggestion that the public'southward offset response when faced with a novel threat is to over-react or panic.17 In practice, disarming the public that the threat is real is ofttimes a more pressing task for public health agencies than providing reassurance.

The function of perceptions

The associations identified between perceptions most the outbreak and behaviour change provide some insight into factors that could be targeted to improve rates of compliance with official recommendations. Every bit might exist expected,6 7 8 xviii believing that there is currently a high chance of catching swine flu and that communicable information technology will have severe consequences were both associated with behaviour modify. Perceiving that the outbreak would continue for a long time was also a predictor of whether someone carried out recommended behaviours, presumably because this indicated a higher level of risk over the longer term.

Less uncertainty about the outbreak and perceptions that the overall information given out was articulate, consistent, and helpful were besides associated with an increased likelihood of undertaking recommended changes to behaviour. The importance of reducing uncertainty and providing clear information has been suggested before11 19 and although most accounts accept focused on this as a way of reducing anxiety, these factors tin can too touch behavioural responses during major incidents.20 In this study the mean scores of scales for "good information" and "uncertainty" suggested that public wellness communicators had some success in preventing confusion and in conveying a consistent ready of comprehensible letters, which in turn seem to have increased rates of recommended behaviour modify.

Informing the public almost a potential health risk is never free of context. Previous warnings or alerts that take seemingly come up to zilch may determine how people perceive the present situation.11 17 The high mean score on our exaggeration scale suggests that this may take been the case in the early stages of the swine influenza outbreak. Every bit might be expected, the perception that the incident had been hyped up was associated with a lower likelihood of behaviour change. Correcting such perceptions in the short term may not exist like shooting fish in a barrel.17 A long history of well intentioned health warnings from the government and scientists have left the public uncertain about the relative importance of each new alert, while a constant flow of "urgent" health warnings based on limited, if any, evidence are carried on a daily basis by the U.k. media.21 Information technology is therefore unsurprising that 68% of our respondents agreed with ane particular in our exaggeration calibration, "I call back that the media have over-exaggerated the risks of communicable swine flu."

A more encouraging finding was that the authorities notwithstanding received a relatively high score for trust (mean score three.9 of 5). Our finding that participants with higher trust in the regime and the responding agencies were more likely to follow their recommendations seems logical and corresponds with evidence of a similar relation during the severe acute respiratory syndrome outbreak.seven

Finally, almost of our sample agreed that if they were careful they could reduce their risk of catching swine flu. This perception was associated with an increased probability of taking action. Fatalistic assumptions that "there is nothing y'all can exercise" take been observed in some people during previous incidents22 only did not pose a major problem in this example. More than specific perceptions as to which particular deportment are effective in reducing the risk revealed an interesting blueprint. Whereas over fourscore% of participants believed that the hygiene measures recommended by the regime were effective, effectually half of respondents also believed the same about avoiding other people or public transport. The perceived efficacy of such actions was associated with actually performing them. These data propose that should recommendations for social distancing exist required in this or whatsoever futurity outbreak, the public is likely to view such measures equally effective.

The role of personal variables

Behaviour modify among our sample was partly predicted by several personal variables. Similar effects to those reported here have been observed for sexual practice,5 six x parental status,20 and low socioeconomic status,23 although the effect of age, with younger adults beingness more likely to take action, is opposite to the effect observed in several studies on severe acute respiratory syndrome.five 6 vii 10 Of most interest was the association betwixt ethnicity and behaviour change, an association that was credible even afterward adjusting for socioeconomic variables. We did not accept enough participants from ethnic minorities to carry out subgroup analyses and to identify which, if any, indigenous groups were reacting about to the outbreak. Previous research has found that worry and abstention behaviours relating to terrorism are more than common amongst minority groups in full general than in white respondents, suggesting that this issue may be due to shared perceptions of vulnerability or low levels of control.24 More enquiry on the causes of this phenomenon is required.

The impact of the swine flu leaflet

Our results propose that the government's swine flu leaflet had limited if any impact on behaviour change, although reading the leaflet was associated with lower feet. These analyses do not imply that the data in the leaflet was ineffective: information technology might be that the widespread media campaign that preceded delivery of the leaflet meant that the public was already well informed about swine flu by the time of our survey. At the same time the effects of the leaflet on the utilise of tissues or on health behaviours amid people with flu-like symptoms was non assessed in this study. Finally, we were just able to assess the effects of the leaflet during a menstruation of relatively low swine flu transmission in the United kingdom.

Methodological issues

Investigating public perceptions in the immediate aftermath of a major incident presents several challenges.25 Ideally, a randomly selected sample of the public should be interviewed, with efforts fabricated to ensure a expert response charge per unit and comparisons made with the known distribution of central variables in the population to assess the presence of non-response bias. Maximising response rates takes time, withal.26 Yet later on a major incident, data on perceptions and behaviours must be collected chop-chop if they are to have whatsoever impact on policy.25 Because speed was important, nosotros elected to use random digit dialling with quota sampling so that the demographic distribution of our sample matched that of the population of England, Scotland, and Wales. In exercise the utilise of quotas prevented only 55 potential respondents from participating. The depression response rate (vii%) may exist of more than concern, although as participants were non informed of the survey topic until consent had been obtained, any non-response bias on the basis of interest in the topic should have been minimal. Given the nature of this telephone survey, nosotros were unable to obtain whatever data about non-responders with which to assess potential bias.

Aside from design bug, another upshot with our written report was the selection of primary outcome measure. Behaviour change is not the same as compliance with official advice. For case, some people who reported not increasing their hand washing none the less may have complied with advice to wash hands "often,"iii whereas others who did increase their hand washing may withal accept fallen short of the optimal frequency. If "often" is defined as 10 times or more a day4 then 41.three% of our sample met the criterion for compliance. If defined as five or more times a day,27 and then 76.9% met the benchmark. Using compliance rather than behaviour change every bit the upshot might have resulted in a different set of findings. However, while such data are of importance to disease modellers and policy makers, from the perspective of assessing public responses to an incident, behaviour change is the central indicator to consider. Compliance past default among people who often wash their hands is of bottom involvement.

Our selection of behaviour outcome measures deliberately avoided two of the central factors communicated to the public during the outbreak: the use of tissues when sneezing and what to practise if flu-like symptoms develop. Given our sample size and the prevalence of flu at the time of the survey, we were unable to assess the ready of behaviours regarding flu-like symptoms. Use of tissues was not included as this is important for the protection of others rather than oneself and hence may be qualitatively dissimilar in terms of its relation with predictor variables.

A caveat is also required near the perception scales that we used. Although the items incorporated in these scales had face validity, clustered appropriately during factor analysis, and produced adequate internal reliability their psychometric properties take yet to be determined fully. In particular, those measures based on single items should be regarded with caution. Further studies to expand and refine these scales and to examination their properties in different situations are ongoing.

Finally, the cross sectional nature of our data ways that we may take underestimated the strength of the associations between some risk factors and behaviour change. For example, engaging in precautionary behaviours may serve to reduce anxiety or reduce someone'due south perceived risk of catching swine influenza. The true role of these variables in motivating behaviour change may therefore have been stronger than our results imply. For other analyses we may accept overestimated the strength of associations. For example, successful behaviour modify may increase someone's belief that they accept control over the adventure, artificially inflating our approximate of this effect.

Conclusions

Early epidemiological assessments suggest that the transmissibility of swine influenza is at the lower end of estimates obtained for previous pandemics, whereas its case fatality ratio is comparable to that reported in the 1958 pandemic.12 Withal, it remains possible that evolution of the virus or seasonal effects might alter both its transmissibility and its severity in the coming months.12 Should swine flu develop into a more serious public wellness problem, so understanding what factors are associated with adaptive behaviour changes among the full general public may assistance communicators to devise more constructive public health messages. Equally, agreement how the public responds to reports of a potential pandemic may also be useful in identifying ways of encouraging behaviour alter during the early stages of any future outbreak of infectious disease.

Our results largely endorse the current policy of providing the public with clear, consistent information, which focuses on the applied things that people tin practise to reduce their chance and which maintains trust by explicitly discussing the current level of knowledge, preparation, and resources bachelor to tackle the outbreak. Emphasising the efficacy of recommended actions and the possible duration of the outbreak may help to better compliance further. The perception that government warnings or media stories stand for scare mongering may be difficult to tackle but requires further attention. If the present swine flu outbreak does non issue in high levels of morbidity, withal, it is likely that the current response will be seen by some equally yet another example of scientists and media "crying wolf." Finally, the large differences between ethnic groups in terms of behaviour change were of interest. Further research to confirm and explore these differences is required.

What is already known on this topic

• Encouraging people to adopt specific behaviours such equally paw washing may help to reduce whatsoever furnishings of an flu pandemic

• During the outbreak of severe acute respiratory syndrome, show suggested that specific perceptions of the outbreak were associated with people'south willingness to make these changes to their behaviour

What this study adds

• In the early stages of the swine flu outbreak, relatively few people made recommended changes to their behaviour, despite widespread advertizement and media coverage

• Factors associated with an increased likelihood of making these changes included perceptions that swine flu is astringent, the risk of catching it is high, the outbreak will continue for a long time, the authorities can be trusted, and people tin control their hazard

• Being uncertain about the outbreak and believing that it had been exaggerated were associated with a lower likelihood of alter

Notes

Cite this equally: BMJ 2009;339:b2651

Footnotes

• We thank Julia Clark, Michele Corrado, and Meghann Jones (Ipsos MORI); Sandro Galea (University of Michigan); John Simpson, John Stephenson, Virginia Murray, Iain Mallett, and Helen Maguire (Health Protection Agency); the participants of the Britain's Scientific Pandemic Influenza Committee's Behavioural and Communications Group; and many others for their timely and useful communication on wording of the questions and the survey pattern. Data collection was done by interviewers working for Ipsos MORI.

• Contributors: GJR had the original idea for the study and developed the written report design with RA, LP, and SW. GJR carried out the analyses and wrote the first draft of the newspaper. All authors contributed to further drafts and had full access to all the data. SW is guarantor.

• Funding: This written report was supported by the National Institute for Wellness Research, every bit part of a career development research training fellowship awarded to GJR. RA is supported as a full time employee of the Wellness Protection Agency. SW is funded by the NIHR Biomedical Inquiry Eye for Mental Health, the South London and Maudsley NHS Foundation Trust, and the Constitute of Psychiatry, King's College London. The funders played no part in the written report pattern; the collection, analysis, or interpretation of the data; the writing of the report; or the decision to submit the manuscript for publication. The views expressed in this publication are those of the authors and not necessarily those of their funders or employers.

• Competing interests: None declared.

• Upstanding approving: This study was approved past Male monarch's College London's Psychiatry, Nursing and Midwifery Research Ethics Committee (PNM/08/09-102).

• Data sharing: Full top line results for the survey are available from GJR at thou.rubin{at}iop.kcl.ac.uk .

This is an open-admission article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Source: https://www.bmj.com/content/339/bmj.b2651

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