People likely to alter lifestyles to cut risk in a pandemic, study finds

Jul 26, 2007 (CIDRAP News) – A recently published survey of Europeans and Asians showed that, when faced with an influenza pandemic, most would avoid mass transit and limit shopping to essentials, and many would avoid other public places, including restaurants, theaters, and the workplace.

The study, published online Jul 20 in Emerging Infectious Diseases, found that "avoidance of public transportation was consistently reported across the region as the most likely precautionary behavior," with about 75% of respondents choosing that option.

Reactions to other risk-avoidance measures varied by region. For example, 79% of Europeans would likely avoid places of entertainment such as cinemas, restaurants, and theaters, while only 33% of Asians said they would. And 52% of Asians said they would stay home from work, compared with 35% of Europeans.

The researchers also discovered that responses varied little for a hypothetically severe pandemic versus a milder one.

Survey specifics
In late 2005, European researchers did telephone surveys in five European countries (Denmark, Spain, Great Britain, the Netherlands, and Poland) and three Asian regions (Singapore, Hong Kong, and Guangdong, China). They chose the Asian locales specifically because they had experienced outbreaks of SARS (severe acute respiratory syndrome) in 2003, which may have influenced citizens' perception of what might be high-risk activities during a pandemic.

A total of 3,436 people answered the survey, which represented 42% of those called (ranging from 21% in Great Britain to 81% in Poland). The number of regional participants ranged from 401 in Great Britain and Hong Kong to 502 in Poland.

Respondents were asked to choose the riskiest among six different places during a hypothetical pandemic:

  • Public transportation
  • Entertainment venues
  • Stores
  • Work or school
  • Hospital
  • Home

Then, after given a scenario of either a mild or more severe pandemic, participants were also asked to choose which of these risk-avoiding behaviors they would likely adopt in a pandemic:

  • Avoid public transportation
  • Avoid going out for entertainment
  • Limit shopping to the essentials
  • Take leave from work
  • Keep children out of school, even if it remains open
  • Limit physical contact with friends and family
  • Avoid seeing doctors, even when sick from something unrelated to flu
  • Stay indoors at all times

To prevent respondents from forgetting some of the options and to limit the length of the call, interviewers asked for feedback on only three randomly selected items from each of these lists. This reduced the pool of people who were asked about each potentially risky place to about 1,700, and to about 1,300 for each precautionary behavior. Only 349 were asked about keeping kids out of school, because this question was asked of only parents of schoolchildren.

"The main limitation of this sampling method," the authors write, "is that it effectively reduces our sample size, but we expect sampling bias to be minimal because options (risky places and precautionary actions) were allocated randomly."

Regional differences and similarities
In six of the eight countries, public transportation was seen as the riskiest place in a pandemic, followed by places of entertainment. In China and Singapore, those selections were reversed. But in all countries, the home rated as the safest place.

As far as precautionary behaviors, 79% of Europeans and 74% of Asians would avoid public transportation; the same percentage of Europeans but only 33% of Asians would avoid public entertainment settings. Other measures ranked lower: limiting shopping (69% in Europe, 59% in Asia), staying home from work (35% and 52%), keeping children from school (59% and 39%), limiting contact with family and friends (45% and 52%), avoiding physicians (22% and 34%), and staying indoors (24% and 35%).

The authors highlight several findings:

  • Asians were far less prone than Europeans to avoid entertainment venues, in spite of rating such places as riskier during a pandemic than did their European counterparts (52% to 43%).
  • Individual characteristics such as age, sex, vaccine status, and health status had little effect on what precautions people said they would take, with three notable exceptions:
    • Younger respondents were less likely to avoid places of entertainment and less likely to show up for work.
    • Compared with those not employed full time (eg, retirees, homemakers, and students), fewer employed respondents reported being likely to avoid places of mass transit, entertainment, and work, or to stay at home.
    • Respondents with higher education levels were more likely than their less educated counterparts to avoid entertainment and shopping establishments.
  • This survey of the general public found about the same percentage tending toward not reporting to work in a pandemic—about half—as a study among US healthcare workers published last year in BMC Public Health (see link below).
  • The higher percentage of Asians expressing reluctance to visit a physician during a pandemic "may have been related to their increased awareness of SARS, which was often acquired in a healthcare setting," the authors write.
  • Respondents' perception of risk was not associated with precautionary actions, except in the case of avoiding public transportation.

Survey's strengths and weaknesses
The authors list two limitations of this type of study, saying, "The main drawback of this type of survey is the difficulty validating results," citing as an example the wide range of response rates: 21% to 81%. However, they mention that "the similarity in findings between regions suggests that the low participation rate in some regions did not bias the findings.

"Second," they write, "because of the hypothetical nature of the questionnaire, concluding that persons actually would respond in the way that they have indicated here is not possible." They point out, though, that their findings coincide with unpublished data from a study conducted among the Chinese community in the Netherlands just after the SARS epidemic. In that study, many had avoided travel to SARS-affected areas and avoided large gatherings.

"One of the strengths of our study," the authors write, "was its multicountry approach; with few exceptions, the patterns of potential precautionary actions were similar among respondents in each region."

Estimating health and economic effects
"Knowledge of what persons are likely to do," the authors say, "can be used to estimate the health and economic effects of various pandemic influenza scenarios. We describe what proportion will take precautionary actions as well as the socioeconomic background of these persons, which would be useful for improving communication efforts by public health official and clinicians in response to an outbreak."

The authors conclude: "Although the quantitative nature of the results may be difficult to validate, the qualitative findings are likely more robust. A new influenza pandemic would most likely result in persons' limiting their use of public transportation, entertainment, and shopping for nonessentials."

These findings coincide at least in part with a Mar 22 report from the Trust for America's Health (see links below), which estimated that states most heavily dependent on entertainment and tourism dollars will be hit hardest economically by a pandemic.

Sadique MZ, Edmunds WJ, Smith RD, et al. Precautionary behavior in response to perceived threat of pandemic influenza. Emerg Infect Dis 2007 Sep;13(9) [Full text]

See also:

2006 BMC Public Health article on survey of US healthcare workers
http://www.biomedcentral.com/content/pdf/1471-2458-6-99.pdf

Trust for America's Health report (links to news release and full report)
http://healthyamericans.org/reports/flurecession

Mar 22, 2007, CIDRAP News story "Pandemic could cause deep, uneven recession, group predicts"

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