Systematic Review Report

SystematicReviewReport
D1.1
1stReportingperiod WP1PopulationBehaviourduringepidemics ResponsiblePartner:ISS Duedateofthedeliverable:M6(July31st2012) Actualsubmissiondate:M7(August31st2012)
Disseminationlevel:PU
TELLMETransparentcommunicationinEpidemics:LearningLessonsfrom
experience,deliveringeffectiveMessages,providingEvidence.Projectcofunded bytheEuropeanCommissionwithinthe7thFrameworkProgrammeHEALTH theme
D1.1Systematicreviewofstudiesaddressingpopulationbehavioursduringinfectiousoutbreaksandreviewofoutbreak communicationin2009pandemic TELLMEprojectGA:278723
TableofContents
EXECUTIVESUMMARYI.............................................................................................................................................................4 . Populationbehaviouralresponsetoinfectiousdiseasesoutbreaksamonggeneralpopulation..................4 1.POPULATIONBEHAVIOURALRESPONSETOINFECTIOUSDISEASESOUTBREAKS....................................5 1.1Introduction..............................................................................................................................................................................5 1.2Methods......................................................................................................................................................................................5 1.2.1Criteriaforconsideringstudiesforthisreview............................................................................................5 1.2.2Searchmethodsforidentificationofstudies.................................................................................................5 1.2.3Datacollectionandanalysis..................................................................................................................................5 1.3Resultsofquantitativemetaanalysis............................................................................................................................8 1.4Protectivebehaviouragainstinfectiousdiseasesoutbreakandcomplianceamonggeneral population.........................................................................................................................................................................................8 1.4.1Demographicfactorsassociatedtoprotectivebehaviours......................................................................8 1.4.2Psychologicalfactorsassociatedwithcarryingouttheprotectivebehaviours...........................12 1.4.3Trust.............................................................................................................................................................................15 1.4.4Knowledge.................................................................................................................................................................16 1.4.5Discussion..................................................................................................................................................................16 1.5Pandemicinfluenzavaccinationandcomplianceamonggeneralpopulation...........................................18 . 1.5.1Demographicfactorsassociatedwithvaccination...................................................................................18 1.5.2Previousvaccinationagainstseasonalinfluenza......................................................................................20 1.5.3Psychologicalfactorsassociatedwithpharmacologicalmeasures...................................................20 1.5.4Knowledge.................................................................................................................................................................22 1.5.5Sourcesofinformation.........................................................................................................................................23 1.5.6Discussion..................................................................................................................................................................23 1.6Limitations..............................................................................................................................................................................25 CONCLUSIONSANDRECOMMENDATIONS......................................................................................................................25 EXECUTIVESUMMARYII.........................................................................................................................................................28 Outbreakcommunicationduring2009H1N1pandemic...........................................................................................28 2.OUTBREAKCOMMUNICATIONDURING2009H1N1PANDEMIC.....................................................................29 2.1Introduction...........................................................................................................................................................................29 2.2Methods...................................................................................................................................................................................29 2.2.1Searchmethodsforidentificationofstudies..............................................................................................29 2.3Communicationduring2009H1N1pandemic........................................................................................................30 2.3.1OpinionsandperceptionofthegeneralpublicabouttheH1N1pandemic...................................30 2.3.2Traditionalmedianewscoverage,andpublicresponse........................................................................34
2.3.3Newscoverageandnewmediainformationseekingandpublicresponse...................................38 2.3.4Cryingawolf?...........................................................................................................................................................41 2.3.5Internalcommunication......................................................................................................................................42 2.3.6Discussion..................................................................................................................................................................43 2.4Lessonslearnt,exercisesundertakenbyvariouscountriesandinternationalorganizations............45 2.4.1Internalcommunication......................................................................................................................................46 2.4.2Communicationwiththegeneralpublic...................................................................................................48 2.4.3Communicationtothemedia............................................................................................................................48 2.4.4Communicationonvaccination........................................................................................................................48 2.4.5Effectivecommunication.....................................................................................................................................49 2.4.6Planningcommunication....................................................................................................................................51 . 2.4.7Areasforaction.......................................................................................................................................................51 CONCLUSIONSANDRECOMMENDATIONS......................................................................................................................55 ACKNOWLEDGEMENTS...........................................................................................................................................................57 CONTRIBUTORSOFAUTHORS..............................................................................................................................................57 BIBLIOGRAPHY.PART1...........................................................................................................................................................58 BIBLIOGRAPHY.PART2...........................................................................................................................................................66 RESULTSOFQUANTITATIVEMETAANALYSIS............................................................................................................79 CHARACTERISTICSOFSTUDIES...........................................................................................................................................90 Tab.1.Characteristicsofincludedstudies.......................................................................................................................90 Tab.2.Characteristicofexcludedstudies......................................................................................................................107 Tab3.Factorsassociatedtoprotectivebehavior.......................................................................................................107 Appendix1.Electronicsearchstrategies.......................................................................................................................109
EXECUTIVESUMMARYI Populationbehaviouralresponsetoinfectiousdiseasesoutbreaksamonggeneral population

Introduction Whenanoutbreakofpandemicinfluenzaoccurs,highrelevanceassumestheunderstandingoffactorsthat couldinfluencethebehaviorofpeopleinordertodecreasetheriskofinfection,transmission,anddisease severity.Thisinformationrepresentthemainkeysofhealthpoliciesandcommunicationstrategieswhose designandimplementationaimsatminimizingboththeimpactandspreadofthedisease.Theaimofthis review is therefore to select empirical research results in order to improve the conceptual framework, whichcanfacilitatecommunicationguidelinesduringtheoutbreakofaninfectiousdisease. Methods MEDLINE,Cinahl,EMBASEandtheCochraneCentralRegisterofControlledTrials(CochraneLibrary)were used as references for studies on severe acute respiratory syndrome (SARS), avian influenza/flu, H5N1, swine influenza/flu, H1N1, and pandemics. The studies that were selected for the purposes of this deliverable on the basis of reporting behavioural responses among general population during infectious diseasesoutbreaksandassociationsbetweenaprotectivemeasureorvaccination(reported,intended,or actual behaviour) against outbreak disease and demographic factors, knowledge, attitudes, perceptions, andbehaviours.Metaanalysismakesreferencetopertinentvariablesonly. Results Sixtypapersmetthestudyinclusioncriteria.Anumberofvariablequalitystudiesondifferentpopulations were carried out considering different infectious disease outbreaks. The research highlighted several demographic differences in behaviour: older people and women are associated with higher chances of adoptingprotectivebehaviorswhileolderpeopleandmenareassociatedtovaccineuptake.Thereisalso evidencethatgreaterlevelsofperceivedsusceptibilityandperceivedseverityofthediseasestogetherwith agreaterbeliefintheeffectivenessofrecommendedbehaviorstoprotectagainstthediseasevaccination includedcanbepreciouspredictors.Evidencehasalsoshownthatgreaterlevelsofanxietyandtrustin authorities are associated with protective behaviours. Past behaviours are strongly associated whit vaccination. Conclusions The findings suggest that both intervention studies and communication strategies should focus on particular demographic groups and on raising levels of pandemic diseaseperceived threat and individual/communitybeliefintheeffectivenessofprotectivemeasures. 4
1.POPULATIONBEHAVIOURALRESPONSETOINFECTIOUSDISEASESOUTBREAKS
1.1Introduction
Pandemics have occurred periodically; to limit the spread of disease, WHO recommends the use of non pharmaceutical interventions (NPIs), and vaccination. However, a compliance approach is based on community understanding of required control measures as well as their important role in disease mitigation.Whenanoutbreakofpandemicinfluenzafinallyoccurs,theunderstandingofthosefactorsthat could influence the peoples behaviour and thus lower the risk of infection, transmission, and disease severity, is highly relevant. This information represents the most precious health policies communication strategiesaimedatminimizingboththeimpactandspreadofthedisease.Theprincipalaimofthisreview isthereforetoselectempiricalresearchresultsinordertoimprovetheconceptualframework,whichcan facilitateinterventionguidelines.Thisreviewcoversdiseasescharacterizedbytheirpandemicorpotential pandemicstatus.SevereAcuteRespiratorySyndrome(SARS)spreadingfromChinato37countriesaround the world. Avian influenza was considered as a potential pandemic threat. In addition, a novel strain of H1N1influenza,knownasswineflu,wasisolatedintheUKin2009andfinallyspreadtoover100countries aroundtheworld.
1.2Methods
1.2.1Criteriaforconsideringstudiesforthisreview Thestudiesincludedinthisreviewhaveacrosssectionalstudydesign,takingunderconsiderationthe generalpopulationirrespectiveofdemographicssuchasage,gender,ethnicity,nationality,andsoon. 1.2.2Searchmethodsforidentificationofstudies Wehavebeenconsideringthemaininfectiousoutbreaksduringthelasttenyears,inaccordancewithWHO Global Alert and Response (GAR). The present report is based on a systematic search in the: MEDLINE; Cinahl;EMBASEandtheCochraneCentralRegisterofControlledTrials(CochraneLibrary). The search has been conducted from 2002 to present day, though initially we did not use a language restriction(seeAppendix1.Electronicsearchstrategies).Wealsoproceededwithscanningthereferences ofallincludedarticlestoidentifyotherpotentiallyrelevantstudies. 1.2.3Datacollectionandanalysis Selectionofstudies Twoauthorsfirstscreenedthetitlesandtheabstractsfromthewholecomprehensiveliterature,laterwe retrieved full text of any potentially relevant report and carefully examined them with the following eligibilitycriteria,fortheirinclusioninthisstudy: 5
a) Population:generalpopulation(excludingpatientgroups,healthcareworkers,etc.). b) Behaviour: preventive, avoidant, or management of pandemic disease, behaviors and vaccination againstinfluenzapandemic. c) Demographiccharacteristicsandpsychologicalvariableswerealsoincludedaswellasassociations betweentheseandbehaviors(reported,intended,orverifiedbehavior)werethenintegrated. d) Date:from2002topresent. e) Studydesign:crosssectionalstudies. f) Language:English. Dataextractionandmanagement Anauthorretrieveddatafromeachincludedstudy:generalinformation(title,authors,source,publication status, publication date); details of study (location, recruitment methods of participants, response rate); participants (description, geographical location, age, gender, ethnicity, socioeconomic status); outcomes (methodsformeasuringoutcomes,toolsusedtomeasureoutcomes)andfinalresults. Analysis Data synthesis began with a narrative overview of the findings in the form of a table gathering the extractedresultssystematicallyandhighlightingrelevantbehaviorsduringapandemicsuchaspreventive and avoidant vaccination or disease behaviours management. The attitudinal and demographic factors assessedineachstudywerelaterrecordedbeforeexaminingtheassociationsbetweenthesefactorsand thebehaviors.Whenpossible,aquantitativeanalysiswasperformedpoolingtheprevalenceestimates byusingstandardmetaanalytictechniques.Allofthereportedconfidenceintervals(CIs)representthe95% CIs. Data were analyzed using Stata 11.0 and a pooled estimate of prevalence was calculated by using a randomeffects model with inversevariance weighting. Statistical heterogeneity between and within groups was measured by using the 2 test for heterogeneity. Since we expected to find important heterogeneityamongstudies,weusedmetaregressionanalysistoidentifysubgroupsinwhichpoolingis acceptableinordertoinvestigatetheextenttowhichheterogeneityamongstudiesisrelatedtodifferent studycharacteristics. Resultsofthesearch Overall,wescanned6087titlesandabstractsofpotentiallyrelevantstudies,6023ofwhichwereexcluded onthebasisofnotfulfillingatleastoneoftheeligibilitycriteria,describedintheprevioussection.Intotal, 69fullpaperswereretrievedandafinalnumberof60wereincluded(Fig.1).Thestudiesweretherefore heterogeneous,carriedoutindifferentcountrieswithdifferingpopulationsandmethods.Thestudieswere of variable quality (see Tab. 1. Characteristics of included studies, and Tab. 2. Characteristic of excluded studies).
Thefinalselectionactuallyincluded36papersonH1N1,5papersonH5N1,14papersonSARSand4papers onahypotheticalinfluenzapandemic.Atotalof16studieswerecarriedoutinEurope(Francen=2;Greece n=1;Germanyn=3;Italyn=2;TheNederlandn=5;UKn=3),onestudyinSaudiArabiaandanotheronein Israel.Moreover,atotalof11studieswerecarriedoutintheUnitedStates,8studiesinAustraliaand22 studies in Asia (China n=3, Hong Kong n=12, Singapore n=2, India n=1, Taiwan n=3, among Asian populationsn=1,).Finally,3oftheselectedstudieswerecarriedoutinternationally. Nearly all studies examined the mediating role of perception, attitudes and beliefs (n=60). Twentythree studies were concentrated on factors associated with vaccination uptake, and 47 on carrying out preventiveand/oravoidantbehaviors.Onlyafewwerebasedonexplicittheoreticalframework(n=7) 1 .
Fig1.Flowofinformationthroughthedifferentphasesofareview. The results for demographic factors have been presented considering age, gender, ethnicity, educational level and other socioeconomic factors such as employment and marital status. The results for psychologicalfactorswerelaterpresentedaccordingtothestructureoftheHealthBeliefModel(Janzetal 1984;Rosenstocketal1988),theProtectionMotivationTheoryPMT(Rogers1975and1983),theTheory ofPlannedBehaviourTPB(Ajzen1991;Armitageetal2001),andtheExtendedParallelProcessModel EPPM (Witte, 2000). The first one theorised that peoples beliefs about whether or not they were susceptible to disease and their perceptions of the benefits of trying to avoid it influenced their
1
Theseadduptomorethan60assomestudiesexaminedmorethanonetypeofissues.
readiness to act. The second one explored the relation between behaviour and beliefs, attitudes and intentions,assumingthatattitudeisthemostimportantdeterminantofbehaviouritself. Metaanalysis was presented following these preliminary results; as for the studies that could not be pooledweusedprevalencemeasuresreportedbytheauthors.
1.3Resultsofquantitativemetaanalysis
MetaanalysisresultstobeconsideredAdInterim;asamatteroffact,althoughavariableeffectmodel has been adopted, heterogeneity was high in any variable. Such an outcome made further analysis necessaryinordertoevaluatetheweightofstudiesonthepooledestimates.Werecalculatedthepooled prevalenceestimatesconductingasensitivityanalysisbyexaminingtheeffectonthemostheterogeneous studiesexclusion.Thestudiesincludedinthemetaanalysisare51though,foranyconsideredvariable,the numberofincludedstudiescanevendiffer(seeResultsofquantitativemetaanalysis).
1.4Protectivebehaviouragainstinfectiousdiseasesoutbreakandcomplianceamong generalpopulation
Fromthe57papersincludedinthisreview,atotalof33studiesfocusonpreventivebehavioursandtheir related factors. The studies concern different outbreak diseases of the last ten years; in particular, 16 studieswereabouttheA/H1N1pandemic,sixstudieswereonpandemicavianinfluenza,14concernedthe SARS epidemic, and four studies were relevant to an hypothetical pandemic influenza. Nineteen studies wereconductedinAsiaticregions(Chinan=1,HongKongn=12;Indian=1;Singaporen=2;Taiwann=3),one in Saudi Arabia, four studies in the US, five in Australia and eight studies were carried out in Europe (Germanyn=2;Italyn=2;Netherlandsn=3;UKn=1),whileonlythreewereinternationalstudies. 1.4.1Demographicfactorsassociatedtoprotectivebehaviours Age A survey carried out in Singapore and Hong Kong examining agerelated behaviours against SARS have foundthatolderpeoplearemorelikelytoundertakeprecautionarybehaviours(handwashing,respiratory hygiene, mask wearing, using utensils, and washing after touching contaminated surfaces) to protect themselvesfrominfection(Lauetal2003;Leungetal2003;Quahetal2004;Tangetal2004;Tangetal 2003). Olderpeopleresultedmorelikelytoreporttheintentionofselfprotectivebehavioursalsointheeventof anoutbreakofavianinfluenza(Lauetal2007a),H1N1(Balkyetal2010;Bultsetaal2011)orinthecaseof an influenza pandemic in the future (Barr et al 2008). A study carried out during H1N1 showed that the intention to adopt protective measures increased with age (van der Weerd et al 2011). The association betweenolderageandbehaviourcouldbeexplainedbythefactthatolderpeoplefeelmorevulnerableto 8
apossibleinfluenzapandemic(Barretal2008).Astudyonahypotheticalinfluenzapandemichasshown thatyoungerpersonswerelesslikelytoavoidentertainment(Sadiqueetal2007). However, in contrast with the abovementioned findings, the pattern of agerelated behaviors was different when the threat of the 2009 swine flu pandemic was studied. In this case, people aged 1824 were found to be more likely to adopt recommended behaviours (hand washing, cleaning surfaces, and gettingaflufriend)thanolderpeopleintheUK(Rubinetal2009). Nevertheless,olderpeopleweremorelikelytoadoptpreventivebehaviourssuchasavoidingpublicplaces duringtheSARSoutbreak(Lauetal2003)andstayingawayfromcrowdswhenanavianfluoutbreakoccurs (Lauetal2007a).Olderpeoplewerealsoassociatedwithincreasedprobabilityofreportingavoidanceof crowded places and rescheduling of travel plans during H1N1 pandemic outbreak (Crowling et al 2010). Actually, an Australian survey revealed lower levels of willingness to isolate oneself or even wear a face maskinyoungerpeople(especiallyaged1624group)(Tayloretal2009). A study carried out in Australia did not find any difference in the intentions to comply with quarantine betweenagegroups(Eastwoodetal2009).Evenifsomeevidenceshowsthatincreasingageisassociated withagreaterpossibilityofcarryingoutpreventivebehaviours,eventually,thereisnoclearindicatorasto whichistherealeffectofageonpreventivebehaviouralpatterns. Gender In Hong Kong and Singapore women were found to be more likely than men to adopt precautionary behaviourstoprotectagainstSARSandH1N1(Lauetal2003;Leungetal2003;Leungetal2004;Quahetal 2004;Tangetal2004;Linetal2011;Crowlingetal2010;Miaoetal2012).Thesebehavioursincludedhand washing, respiratory hygiene, mask wearing, using utensils and washing after touching contaminated surfaces. The likelihood of women to follow recommended behaviours (hand washing, cleaning surfaces, andgettingaflufriend)wasgreaterthaninmenintheeventofaH1N1pandemic(Crowlingetal2010; Rubinetal2009;Pratietal2011;vaderWeederetal2011).Thesametrendingenderdependentbehavior wasfoundinsurveyscarriedoutintheUSandinHongKongintheearlystagesoftheH1N1outbreak;here, womenweremorelikelythanmentoadoptavoidantbehaviors(Lauetal2010b). Theoriginofthegenderrelateddifferentialbehaviorcouldbethereforeexplainedbytheobservationthat womenperceivethemselvesasmoresusceptibletoSARSforexamplethanmen(Brugetal2004). Women,infact,whenaskedtoreporttheirintentionsintheeventofafuturepandemic,wereobservedto bemorelikelythanmentocomplywithhomequarantinerestrictionsinAustralia(Eastwoodetal2009). OntheotherhandastudycarriedoutinSaudiArabiaduringH1N1influenzapandemicshowedthatahigh level of precautionary measures was taken by men (Balky et al 2010). Even in the UK, no difference was 9
observed between men and womens avoidant behaviors (Rubin et al 2009). Other studies evidenced no genderdifferencesintheintentionstowearafacemask(Barretal2008;Tayloretal2009)inAustraliaorto useafacemaskinTheNetherlandsandHongKongduringSARS(Brugetal2004;Tangetal2004). As already discussed for agerelated factors, a proportion of studies do not find any gender differences. Nevertheless, the pattern of reported results highlighted that when there is a significant difference in behaviors,womenareconsistentlymorelikelythanmentoundertakeprotectiveandavoidantmeasures. Ethnicity As a matter of fact, the results on the adoption of many precautionary measures have always been influenced by the geographical areas where the studies were carried out. For example, Europeans were morelikelythanAsianstoreportthattheywouldkeeptheirchildrenawayfromschool,eventhoughthe same Europeans were less likely to report that they would avoid seeing physicians (Sadique et al 2007). However,astudyperformedintheUKrevealedthatparticipantsfromnonwhiteethnicbackgroundwere more likely to carry out protective action or to adopt avoidant behaviors, compared to participants of a white ethnic background (e.g., avoiding large crowds or public transport) (Rubin et al 2009). In Australia, individualsspeakingalanguageotherthanEnglish werelessinclinedtodeclaretheirintentiontoweara maskandtobevaccinated,quarantinedortoisolatethemselvesinthecaseofanoutbreakofpandemicflu (Barr et al 2008; Taylor et al 2009). In contrast, in Singapore (Qua et al 2004) no clear association was observedbetweenethnicityandprecautionarybehaviour. Onlyafewstudieshaveconsideredtherelationshipbetweenethnicityandbehaviourduringapandemic. Thismaybeduetothedifficultiesinadoptingstudydesignsensuringethnicalhomogeneityofsamplesor eventothescarceavailabilityofliteratureonsuchaspecificargument;wethereforeascertaininsufficient evidence to draw any definitive conclusions about the role of ethnicity in affecting pandemicrelated behaviours. Educationallevel In several studies carried out in Hong Kong, higher educational levels of individuals were found to be associatedwitha greater chancetoadoptprecautionarybehaviourstoprotectagainstSARS (Leung et al 2003;Leungetal2004;Tangetal2004),avianinfluenza(Lauetal2007a),andH1N1(Balkyetal2010).The list on these behaviors included hand washing, respiratory hygiene, mask wearing, using utensils, and washingaftertouchingcontaminatedsurfaces.Inthesameway,agreaterintentiontowearafacemaskin the event of pandemic influenza was observed in more highly educated people in studies performed in Australia(Barretal2008). OtherstudiescarriedoutinHongKongobservedahigherlikelihoodtoavoidpublicplacesduringtheSARS outbreakinmoreeducatedpeople(Lauetal2003;Leungetal2003).Astudyontheintentiontocomply 10
with quarantine restrictions during a pandemic influenza, has shown evidence that people with high educationallevelsweremorelikelytoreportintendedcompliance(Barretal2008). Inasurveyonahypotheticalpandemicflu,therespondentswithhighereducationallevelsreportedbeing morelikelytoavoidentertainmentandshoppingthandidthosewithlowereducationallevels(Sadiqueet al 2007). Similarly, an Australian survey showed that people with higher levels of formal education were morelikelytoreporthighwillingnesstoisolatethemselvesfromothersifneededandtowearafacemask (Tayloretal2009).However,otherstudiesconductedinHongKongandTheNetherlandsfailedtodetect significant association between educational level and the reported use of mask or hand washing (Tang e Wong 2003; Blendon et al 2004). Eventually, a general tendency of more educated people undertaking protectiveandavoidantbehavior,isreportedinliteratureonly. Othersocioeconomicfactors Some studies conducted in the UK during the H1N1 pandemic has found out that unemployed, poorer peopleorpersonshavingnoeducationalqualifications,weremorelikelytoundertakeavoidantbehaviours, e.g.,avoidinglargecrowdsorpublictransport(Rubinetal2009).Furthermore,aDutchstudy(Bultsetal 2011) conducted among unemployed people has shown a significantly higher intention to comply with preventivemeasures.AnItaliansurvey,showedthatpeoplesufferingfromeconomichardshipweremore likely to clean objects, to wash hands and use tissues when sneezing (Prati et al 2011). The retirees in Taiwanwerestillmorelikelytoincreasehandhygienepracticethanstudents(Miaoetal2012). Moreover, in another research performed in Australia people who were employed but not able to work fromhomedidnotfullyrecognizethequarantinerestrictions(Eastwoodetal2009);inaddition,peoplein fulltimeemploymentwerelesslikelythanotherstoavoidgoingoutinHongKongduringH1N1(Lauetal 2010b).Inastudyonahypotheticalpandemicinfluenza,onlyafewemployedpeoplereportedbeinglikely toavoidpublictransportation,entertainmentvenues,andwork(Sadiqueetal2007). The influence of marital status is not examined in many studies. However, one study in Hong Kong observedthatmarriedpeoplehadgreaterchancetowearfacemasksagainstSARS(Tangetal2004);alsoa Hong Kong study found out that married people often reported the intention to comply with quarantine policiesintheeventofanavianinfluenzaoutbreak(Lauetal2007a).Inthesameway,theHongKongstudy carriedoutduring H5N1influenzashowedthatthoserespondentswhowere notcurrentlymarriedwere lesslikelythanotherstoadoptpreventivebehaviors(Lauetal2010a). Inoppositionthementionedstudies,otherworksfailedtoobtainanassociationbetweenthemaritalstatus andthereporteduseoffacemask,handwashingandotherprecautionarybehaviors(Lauetal2008;Leung etal2003;Leungetal2004).Inthesestudies,theassociationbetweenmaritalstatusandbehaviouriseven inconclusive. 11
1.4.2Psychologicalfactorsassociatedwithcarryingouttheprotectivebehaviours Threatappraisal Perceivedsusceptibilitytothedisease In order to classify the perception of susceptibility, the following types of assessment were considered: worryaboutdevelopingdisease,likelihoodofdevelopingdisease,andchancesofdisease.Withtheaimto assess personal perceived susceptibility, some studies also included the analysis of association between perceivedsusceptibilityofanindividualsfamilyorcommunity. Associations between perceptions of risk and carrying out preventive behaviours have been found in studiesconductedintheUS,theUK,HongKong,Australia,andTheNetherlands.DuringtheSARSepidemic, greater perception of risk was associated with certain protective behaviours such as likelihood of hand washing(Brugetal2004;Lauetal2003;Tangetal2003;Leungetal2004);disinfectingthehome/objects or cleaning (Lau et al 2003), mask wearing (Tang et al 2003). Similar associations with adopting other precautionary behaviours to protect against SARS including hand washing, respiratory hygiene, mask wearing, using utensils, and washing after touching contaminated surfaces (Barr te al 2008; Leung et al 2003) have also been found. Anticipated preventive behaviour in case of humantohuman transmission wasalsorelatedtoahigherperceivedsusceptibilitytoH5N1infectionforoneselforone'sfamily(Lauetal 2007a). Furthermore, preventive measures were taken more often among people having a higher perceivedsusceptibility(deZwartetal2010). Similar precautionary behaviours (hand washing, mask wearing an cleaning things or disinfecting home) were associate during H1N1 pandemic (Rubin et al 2009; van der Weerd et al 2011; Prati et al 2011). PerceivingH1N1tobemoretransmissiblethanavianinfluenzawassignificantlyassociatedwithincreased hand hygiene practice, suggesting that such relative susceptibility (i.e., perceived risk of H1N1 infection relativetoavianinfluenza)maybemoreinfluentialinpeoplesbehaviouralchange(Miaoetal2012).Only in a few studies was observed no association between perceived susceptibility and precautionary behaviours.Forexample,perceivedsusceptibilitytoavianfludidnotcorrelatewithhandwashinginone study(Lauetal2007b)andnoassociationwasfoundbetweenperceivedlikelihoodofcontractingSARSand the adoption of precautionary behavior (Qua et al 2004). Furthermore, in a Taiwanese national survey, perceivedlikelihoodofcontractingH1N1inthefuturewasnotsignificantlyassociatedwithincreasedhand hygienepractice. A larger susceptibility for SARS and influenza was perceived in association with avoidant behavior. In an Australianstudywasobservedthatindividualswithgreaterperceptionsoftheriskofpandemicinfluenza weremorelikelytoreportanintentiontocomplywithquarantinerestrictions(Barretal2008).Similarly, another survey conduct in Australia showed that people reporting higher levels of concern about the
12
possibilitytobeaffectedbypandemicinfluenza,weremorelikelytoreporthighwillingnesstowearaface maskorisolatethemselveswhenneeded(Tayloretal2009). IntheUK,arelationwasfoundbetweenagreaterperceivedsusceptibilitytoH1N1influenzaandavoiding public places (Rubin et al 2009). In the early weeks of the H1N1 pandemic, a study carried out in both Europe and Malaysia found that individuals who perceived themselves to be at risk of developing H1N1 virusweremorelikelytosaythattheyhadreducedtheiruseofpublictransportorcancelled/delayedtheir flights(Goodwineetal2011;Rubinetal2009;Sadiqueetal2007).ThoseindividualsintheUSandCanada whoperceivedthemselvestobemoresusceptibletoSARSwerefoundtobemorelikelytohaveconsulted a health professional or a website for information than those who perceived themselves to be less susceptible (Blendon et al 2004). Nevertheless, it is always important to emphasize the fact that the attitudes and the behaviors declared by the respondents and the deriving observed associations are stronglydependentonwhethertheepidemicwasinitsrisingorinitsdecliningphase.Forexample,Lauand colleagues(2003)studiedriskperceptionofSARSinHongKongduringtheoutbreakwithtensurveysand observedchangesbothintheriskperceptionandintheprecautionarybehaviour.Thesesurveysprovided evidencethatperceivedsusceptibilityusuallydeclinedinthesecondphaseoftheepidemictogetherwith thenumberofnewinfections.Duringtheinitialphaseoftheepidemicwithrisingfiguresofnewcases therewasasharpincreaseinpreventivemeasures. Perceivedseverityofdisease Constructs of perceived severity was assessed in the studies by including the chances of dying from the disease, its infectivity and risk factors estimates. Some studies report clear association between greater perceivedseverityofthediseaseandtheadoptionofbothprecautionaryandavoidantbehavior. AsurveyconductedintheUKhasshownthatthecommonbeliefofH1N1asthemostseverediseasewas associatedwithagreaterlikelihoodtocarryouthandwashing,disinfectingorgettingaflufriend(Rubinet al 2009; Bults et al 2011). An Italian study (Prati et al 2011) showed that perceived severity predicted recommendedbehaviours(cleaning,disinfectingobjects,washinghandmoreoftenthanusual,usingtissue when sneezing, social distancing). Those who felt that avian flu might be more severe than SARS were observedtobemorepronetoinfluenzavaccineuptakeandmaskwearinginHongKong(Lauetal2008).In contrast, other studies did not find any association between the likelihood of surviving SARS and the adoptionofprecautionarybehavioursinHongKong(Leungetal2003;Tangetal2004)oroftheuseofface masks(Tangetal2004). ThosewhobelievedinhigherfatalityratesandgreaterimpactonindividualsofavianfluthanSARSwere more likely to report avoidance behaviours (not going out, keeping children off school, avoiding crowds, avoidinghospitals,andtravelling)inastudycarriedoutinHongKong(Lauetal2007a;Lauetal2007b).A
13
higher perceived impact of H1N1 was also associated with avoidant behaviors (such as avoiding large crowdsandpublictransport)(Rubinetal2009). Stateofanxietyandemotionaldistress Somestudiesevaluatedthestateofanxiety,asmeasuredbytheStateTraitAnxietyInventory(STAI).High levelsofpanicanddistressinthegeneralpublicwerereportedduringandaftertheSARSepidemicinHong Kong(Lauetal2003).ThelevelofanxietyinSingaporeduringtheSARSoutbreakwashighormoderatein 45%oftherespondentswhile24%demonstratedhighlevelofanxietyintheUK(Rubinetal2009;Leunget al2003,Quaetal2004). More specifically, other studies assessed the emotional distress as described by the presence of panic, depressionorfurtheremotionaldisturbs,beingequalto6%,20%and32%respectivelyduringtheH1N1, H5N1andSARScrisisinHongKong(Lauetal2010b;Lauetal2009;Lauetal2007b;Koetal2006;Lauetal 2006). Studies carried out in Asian countries (Hong Kong, Singapore) have found that the likelihood to adopt recommendedprecautionarybehavioursagainstSARS(handwashing,coughhygiene,maskwearing,using utensils,andwashingaftertouchingcontaminatedsurfaces)wasassociatedwithhigherindividuallevelsof general anxiety (Leung et al 2003, Qua et al 2004), such an association has been highlighted within two studiesconductedinHongKongconcerningtheH1N1pandemic(Lauetal2007b;Lauetal2010a). In a study conducted at the Netherlands, it was found out high anxiety was associated with taking preventive measuresand strongintentiontocomply(Bultsetal2011). Moreover,thelikelihoodtocarry outavoidantbehaviourswasobservedinthoseindividualsaffectedbyemotionaldistressintheUK(Rubin et al 2009). A study performed in Hong Kong evidenced a greater association between increased anxiety and increased frequency of avoidance measures (Crowling et al 2010). Such avoidance behaviours were associatedwithnegativepsychologicalresponses;emotionalelementsmaythereforebestronglyinvolved inmakingthedecisions(Lauetal2010b). On the contrary, a study in earlier stage of H1N1 in Hong Kong showed a negative correlation between state anxiety and hygiene that has not been reported in previous epidemics. Some authors explain this evidencewiththefactthatagreateruseofhygienemeasureshelpsindividualstoreassurethemselvesthat theywouldbeprotectedagainstinfection,leadingtoloweranxiety(Crowlingetal2010). Copingappraisal Perceivedefficacyofbehaviour Perceived efficacy of behavior was assessed in the studies by how far the respondents believed that the behaviour would protect them from disease. The hand washing was recognized as the main effective
14
measurefollowedbyavoidingcrowdedplaceandbytheuseoffacemask(Kiviniemietal2011;Lauetal 2009; Lau et al 2007a; Lau et al 2003). In a study based in the UK, some protective behaviours (hand washing,makingflufriendplans,cleaningsurfaces)reportedtohavebeencarriedout,werefoundtobe associatedwiththebeliefoftheirefficacyinprotectingagainstH1N1(Rubinetal2009).Itisnoteworthy thefactthatinarecentTaiwanesestudytheparticipantswhoperceivedhandwashingtobeveryeffective weremorelikelytoincreaseit,butnotthosewhomerelyregardeditaseffective(Miaoetal2012).Alsoin thisstudywerefoundthatperceiveddifficultyofhandwashingaftercomingincontactwithpossiblyH1N1 contaminatedobjectsorsurfaceswasamongthestrongestfactorsassociatedwithincreasedhandwashing (Miaoetal2012).AnotherstudycarriedoutinHongKongdemonstratedarelationbetweendisinfecting the home and frequent hand washing with their perceived efficacy in protecting against SARS (Lau et al 2003).Furthermore,aninteractionbetweenthepossibilityofavianinfluenzaoutbreakandtheefficacyof hand washing, was also shown (Lau et al 2007a). An association has been found in Hong Kong between thosewhofeltavoidingpublicplacesasaneffectivemeasureagainstSARS(Lauetal2003)andvoluntary quarantine(Lauetal2007a).Anassociationwasalsoobservedbetweenthosewhobelievedintheefficacy offacemaskuseandreportedintentionstowearoneintheeventofanavianinfluenzapandemic(Lauetal 2007a).SimilarconnectionwasobservedintheUKbetweentheperceivedefficacyofavoidantbehaviours inprotectingagainstH1N1andindividualsreportinghavingadoptedthem(Rubinetal2009). Perceivedselfefficacy Perceivedselfefficacywasassessedinthestudiesbyaskingrespondentstoindicatethedegreewithwhich they felt capable of carrying out the required behaviours. Some studies performed in Hong Kong with adults, older adults, and adolescents, evidenced that a greater perceived selfefficacy to adopt precautionarybehavioursandtowearmaskswasrelatedwiththeadoptionofthesepreventivebehaviours (Tang et al 2004; Tang et al 2003). A higher level of selfefficacy was a predictor of taking preventive measuresinaDutchstudy(Bultsetal2011). 1.4.3Trust A British study (Rubin et al 2009) has reported that government recommended preventive health behaviours,allthepeoplewhotrustedtheauthoritiesadoptedthosemeasures. As a matter of fact, trust in the government has shown a key role during the severe acute respiratory syndrome epidemic in China in 2003, for example. Attitudes towards the governments SARS prevention measuresincludingconfidenceinthegovernmentsabilitytocontrolthespreadofSARSwerelinkedto theengagementofpreventivehealthbehaviours(Tangetal2003).AstudyconductedinSingaporeshowed that the high level of trust regardless low level of knowledge could imply the government control of publicmeasures(Deurenbergyapetal2005).Moreover,Singaporeanpeoplewhothoughtthatauthorities
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were open to communication were more inclined to practice high number of SARS preventive measures (Quahetal2009). 1.4.4Knowledge In studies conducted among Chinese general population during H1N1, a possible relation between knowledge, risk perception and practices, was found to indicate that a high level of knowledge may be importanttoenableindividualstohavebetterattitudesandpracticesininfluenzariskreduction(Linetal 2011).Similarly,thehighfrequencyofprecautionarymeasureswasassociatedamongpeoplewithelevated level of knowledge. In addition, an Indian study showed a positive association between knowledge and protective behaviours during the influenza H1N1 outbreak (Kamate et al 2010). In a study carried out in HongKongduringtheH5N1influenza,anumberofmisconceptions(suchasthoserelatedtolongdistance airbornetransmissionsandpoultrymeat),wereidentified,whilethoughdecreasedovertimetheones relatedtoinsectbites,werestillhighlyprevalent(Lauetal2010a). We should also consider how the belief in waterborne transmission was significantly associated with the high number of anticipated behavioural responses (Lau et al 2010). In addition, Leung et al (2004) found outthatagreaterknowledgeaboutthetransmissionroutesofSARS(inHongKong),predictedtheadoption of more precautionary measures. Finally, a study conducted in Australia gave proof about the strong associationbetweenademonstratedbasicknowledgeofpandemicinfluenza(comparedtothelackofsuch knowledge)andthewillingnesstocomplywithhomequarantine(Eastwoodetal2009). 1.4.5Discussion Thefirstpartofthisstudyaimedatdemonstratinghowimportantthesociodemographiccharacteristics together with psychological factors have been on the scenario of preventive behaviors global disease outbreak. Some conceptual frameworks, as the Theory of Planned Behaviour (TPB), Health Belief Model HBM), the Protection Motivation Theory (PMT), and the Extended Parallel Process Model (EPPM)were useful to introduce and make a theoretical analysis of the psychological factors. Actually, understanding those precious aspects has been important to highlight any effective communication strategy that could reduceboththespreadandtheimpactofinfectiouspandemicoutbreaks. AnumberoffactorshavebeenfoundtofosterNPIsbehaviouramongthegeneralpublic(seeTab3.Factors associatedtoprotectivebehavior.): Beingelderlypeople Beingwoman Havingahigheducationlevel Perceivedefficacyofthebehaviour Perceivedsusceptibilitytothedisease 16
Perceivedseverityofthedisease Perceivedselfefficacytoadoptbehavior Trustintheauthorities Havingahighlevelofknowledge Havingahighlevelofanxiety
Regardless the sociocultural different responses to pandemic diseases, some similar factors have influenced the behaviours and/or the intentions of global population. Some of the sociodemographic variables have been associated with the action of preventive and avoidant behaviours. More specifically, studieshavefoundthatwomenaremoreinclinedtoputthosepreventivebehavioursintopractice. Age factor is another precious element of this review: generally speaking, old people are more likely to adoptprotectivemeasuresthanyoungpeople.Onlyonestudyamongthoseweconsideredhasfounda positivecorrelationbetweenbeingyoungandpreventivebehaviourssuchashandwashingmore,cleaning surfaces more or getting a flu friend (Rubin et al 2009). On the contrary, a study conducted in Australia gaveproofthatageisnotapredictivefactor(Eastwoodetal2009). Generallyspeaking,peoplehavingahigheducationlevelaremorelikelytoadoptpreventiveoravoidant behaviours,thoughtwostudieshaveshownthatnodirectcorrelationcouldbefoundbetweeneducation andsuchpositivebehavioursduringtheSARSepidemic(TangeWong2003;Blendonetal2004). Some psychological factors were associated with protective behaviours. Evidence has been found that perceiving oneself to be more susceptible to SARS, avian flu, H1N1, or pandemic influenza can be associatedwithundertakingpreventive,andavoidantbehaviourstoprotectoneself.Thereisalsoevidence thatperceivedseverityofdiseaseisassociatedwithcarriedoutpreventiveandavoidantbehaviours.These results can be better explained if related with the abovementioned models, particularly the HBM, the PMT,andtheEPPMdescribingtheimportantroleofthreatperceptionindeterminingbehaviour. Afactor,closelyassociatedwiththeadoptionofprotectivebehaviours,istheperceivedeffectivenessofthe samemeasureswhosepracticecanbefosteredbytherealcapabilityofproducingthedesiredresults.This review has also given the proof that a high level of anxiety is associated with the implementation of preventive/avoidantbehaviours.Knowledgeaswellseemstobecorrelatedtotheimplementationofsuch measurestogetherwiththewillingnesstocomplywithhomequarantine. Finally, a key factor for putting into practice the preventive behaviours as a whole is the trust for institutionsandthesatisfactionwiththereceivedcommunicationsaboutthedisease.Trustandeffective communicationareofparticularimportanceespeciallyinthecaseofapandemicfatalitywhentheroleof
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theinstitutionsistoprovideinformationontheprogressoftheepidemicitself,onthemeasurestobeput inplaceandontheavailablehealthtreatments.
1.5Pandemicinfluenzavaccinationandcomplianceamonggeneralpopulation
Amongthe60articlesofthisreview,23ofthemhavefocusedonthefactorsrelatedtovaccinationorthe intentiontobevaccinated.MostofthestudieswereconcentratedonH1N1vaccination(n=20),onestudy wasonavianinfluenzaandtwowereaboutanhypotheticalpandemicinfluenzavaccination.Twelvewere about both H1N1 and seasonal influenza vaccination. The studies were carried out in the following countries 2 :Australia(n=4),USA(n=6)France(n=2), Germany (n=1),Greece(n=1),Italy(n=2);Netherlands (n=2),UK(n=1),Israel(n=1),India(n=1),HongKong(n=3),Malaysia(n=1),andChina(n=1) 3 . 1.5.1Demographicfactorsassociatedwithvaccination Age The included studies showed that the influence of age on general publics intentions and behaviours toward vaccination is varied, even though great part of these studies pointed out that older people are morelikelytogetvaccinated.ManystudiesinFrance,Germany,Greece,Israel,UK,andtheUSfoundthat olderpeoplearemorelikelytobevaccinated(Schwarzingeretal2010;Walteretal2011;Sypsaetal2009; Velanetal2011;Myersetal2011;Maureretal2009).Furthermore,somestudiescarriedoutintheUS, FranceandGermanyfoundthattheintentionofbeingvaccinatedagainstnovelH1N1increasedwithage (Maurer et al 2009; Vaux et al 2011; Walter et al 2011). Also according to Schwarzinger et al (2010), vaccinationacceptancewassignificantlylowerinadultsunder35andincreasedwithage.AnItalianstudy (Ferranteetal2011)showedthatindividualsinthemiddleagegroup(3549years)werelesslikelytoget vaccinated. Onthecontrary,onestudycarriedoutintheUSandothertwoinAustraliafoundthatyoungerpeopleare morelikelybevaccinated(Garlaceetal2011;Eastwoodetal2009;Sealeetal2010). Gender In general, studies pointed out that women were less likely to accept vaccination, or show intention to vaccinate as compared to men. Two studies carried out in Germany and Israel showed lower vaccine acceptanceratesamongwomen(Walteretal2011;Velanetal2011). Moreover, in five studies conducted in Greece, France, Italy, the Netherlands and Australia, women respondents were less willing to get vaccinated than men (Sypsa et al 2009; Schwarzinger et al 2010; Ferranteetal2011;Zijtregtopetal2010;Eastwoodetal2009).
2 3
Inalphabeticalorder. Theseadduptomorethan23assomestudieswereconductedmorethanonecountry.
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Insomestudiesanyassociationbetweenpandemicvaccinationcoverageandgender(Vauxetal2011),or betweenvaccineuptakeandgenderwasfound(Sealeetal2010). Ethnicity Evidenceofethnicityinfluenceonvaccinationintentionisalsovaried.InastudyconductedintheUSwhite peoplehadhigherH1N1vaccinecoveragethanbothHispanicsandblackpeople.Furthermore,inastudy carried out in Israel, very low H1N1 vaccination compliance rates were found among Israeli Arabs, even though,aspointedoutbytheauthors,Arabpopulationisstronglyunderrepresentedinthisstudy(Velanet al2011). Ontheotherhand,twostudiescarriedoutintheUSandAustraliaandothertwointheUKshowedthat peoplefromethnicminoritiesweremorelikelytobevaccinated(Quinnetal2009;Sealeetal2010;Rubin etal2010;Myersetal2011). Educationallevel ThreestudiesconductedintheUS,FranceandGermanyshowedthathighereducationwasassociatedwith H1N1 vaccine uptake (Santibanez et al 2012; Vaux et al 2011; Walter et al 2011). On the contrary, if we considertheintentionofbeingvaccinated,twostudiesshowedthatgraduatedpeoplefromhighschoolor withundergraduatedegreesatuniversitywerelesswilling togetvaccinated thanothers (Zijtregtop etal 2010;Schwarzinger etal2010).In conclusion,anyassociationbetween educationallevelandvaccination uptakeinanIsraelistudy(Velanetal2011)orbetweeneducationallevelandtheintentiontowardvaccine uptakeinanyAustralianstudywasfound(Sealeetal2010). Asforpreventivebehaviours,literatureanalyzedinthisreviewshowsthatrelianceofvaccinationuptake oneducationiscontroversial. Othersocioeconomicfactors With regard to income, a US study found a significantly association between receipt of H1N1 influenza vaccineandahigherincomelevel(Santibanezetal2012).Moreover,onestudyconductedinFrance(Vaux etal2011)suggestedthatahigherprofessionalandmanagerialoccupation,oranintermediateoccupation or retirement (compared to manual labor) were indicative of greater vaccine uptake. On the contrary, a studycarriedoutintheUKshowedthatunemployedparticipantsweremorelikelytobevaccinated(Myers etal2011). Another variable was associated with vaccination uptake. In fact, living in a household with one or more childrenisassociatedwithhigherlevelofvaccination(Sypsaetal2009;Vauxetal2011).Alsothepresence of only one child in a household was associated with a higher acceptance when compared with both
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households with no children and those with more than one child (Schwarzinger et al 2010). This may suggestthatcompliancewithpandemicvaccinationcampaignwashigherinfamilieswithchildren. Also,housingareaseemstohaveaninfluenceonvaccinecompliance.AFrenchstudyfoundthatA/H1N1 vaccineacceptancewasloweramongrespondentslivinginsmalltownswith20,000to100,000inhabitants (Schwarzingeretal2010).Similarly,negativeassociationwithvaccineuptakeofpeoplelivinginacitywith more than 500,000 inhabitants was found in a German study (Walter et al 2011). On the contrary, Asian populationwasmorelikelytobevaccinatedagainst2009H1N1influenzawhenresidinginanurbanarea thaninaruralone(Wongetal2010). 1.5.2Previousvaccinationagainstseasonalinfluenza The evidence of association between previous vaccination against seasonal influenza and intentions and behaviours toward pandemic vaccine is confirmed in several studies. A US study suggests a strong relationshipbetweenthestatedprobabilityofbeingvaccinatedagainstnovelH1N1andseasonalinfluenza vaccine uptake. In this study, the probability of pandemic influenza vaccination was two times higher amongvaccinatedpeoplethanamongunvaccinatedpeople.Thispositiveassociationwasmostlyexpressed by people aged 65 yearsand over (Maurer et al 2009). Other four studies carried out in Europe (France, Germany, Greece, The Netherlands) and two in Australia pointed out that people vaccinated against seasonalinfluenzaweremorelikelytobevaccinatedagainstpandemicinfluenza(Vauxetal2011;Walteret al2011;Sypsaetal2009;Zijtregtopetal2010;Eastwoodetal2009;Sealeetal2010). Similarly, those who had received seasonal influenza vaccine in the same year or at least once in the previousthreeyearswerealsomorelikelytogettheH1N1vaccineinFranceandintheUS(Schwarzingeret al 2010; Garlace et al 2011). Moreover, the history of seasonal influenza vaccine was significantly associatedwithbehaviouralintentiontotakeupH1N1vaccineinHongKong(Lauetal2010c). In general it seemed that beliefs about seasonal influenza vaccine would influence novel H1N1 vaccine uptake(Sealeetal2010;Maureretal2009;Sypsaetal2009). 1.5.3Psychologicalfactorsassociatedwithpharmacologicalmeasures Threatappraisal Perceivedsusceptibilitytothedisease In the US studies respondents who believed to be likely to get sick with influenza if not vaccinated had significantly higher H1N1 influenza vaccine coverage than those who did not agree with this opinion (Santibanez et al 2012). Another US study (Quinn et al 2009) found that people who declared they have accepted a seasonal vaccination annually or in the last years had a higher perception of personal consequencesthanthosewhoaffirmedtheyhavebeenvaccinatedonceortwiceornever.
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Respondents concern over the risk related to infection was associated with the mentioned intention of gettingvaccinated(Sypsaetal2009;Sealeetal2010;Wongetal2010;Horneyetal2010;Rubinetal2010; Schwarzingeretal2010;Myersetal2011).Inthesameway,alowpersonalperceivedsusceptibilitywas associatedwithanegativeintentiontobevaccinated(Zijtregtopetal2010). InsomestudiesconductedintheUSandHongKong,susceptibilityperceptionswerenotassociatedwith pandemicinfluenzavaccineuptake(Garlaceetal2011;Lauetal2010c). Although these two studies do not stress any association between perceived susceptibility and vaccine compliance, several studies carried out in different countries (three in the US, Australia, Asia, France, Greece, the Netherlands, and UK) considered perceived susceptibility as an important factor in choosing vaccineuptake. Perceivedseverityofdisease Respondents with a higher perception of the severity of influenzapandemic disease were significantly morelikelytoacceptvaccination(Eastwoodetal2009;Sypsaetal2009;Schwarzingeretal2010;Zijtregtop et al 2010; Ferrante et al 2011; Myers et al 2011). Moreover, respondents who already faced a case of H1N1 influenzapandemic disease in their close relationships (family members and/or work colleagues) weremorelikelytoaccepttheH1N1vaccine(Schwarzingeretal2010;Wongetal2010). According to previous studies on H1N1pandemic, a study conducted on avian influenza showed that a higherperceptionoftheseveritywasassociatedwithintentionofvaccineuptake(Lauetal2008). Ontheotherhand,onlytwostudiesdidnotstresssuchassociation.Inparticular,aHongKongstudyabout severityperceptionofinfluenzapandemicdiseasewasnotfoundtobeassociatedwithvaccineuptake(Lau etal2010c).Furthermore,astudycarriedoutinAustraliadidnotfindanydifferenceinvaccineacceptance betweenparticipantswhoreportedcasesofH1N1amongtheirfriendsorfamilymembersandthosewho didnot(Sealeetal2010). Copingappraisal Perceivedefficacyandsafetyofvaccine InastudyconductedintheUS,aboutthreequarters(74%)ofrespondentsconferredtoinfluenzavaccinea certainoratleastsomewhateffectiveness.Respondentswhobelievedvaccinewaseffectiveinpreventing influenza had significantly higher influenza vaccination coverage (Santibanez et al 2012). The same result emerged from a study carried out during the avian influenza outbreak (Lau et al 2008), which showed people who believed vaccination would have been effective in preventing influenza transmission to be morelikelythanotherstoreceivevaccination.
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Asfarassafetyofpandemicvaccinationisconcerned,inastudyconductedintheUS,vaccinesafetybeliefs werefoundtobedecisivedeterminantsofH1N1vaccineuptake.Infact,thosewhobelievedthattheH1N1 vaccinewassafeweremorelikelytogetvaccinated(Garlaceetal2011).AmongIndianpopulationvaccine wasconsideredthemosteffectivemethodforH1N1influenzaprevention(Kamateetal2010). Perceivedbarrierstohavingthevaccine Among those who expressed the intention not to be vaccinated, concern about the side effects of vaccination becomes relevant. Santibanez et al (2012) found out that 31% of respondents declared they wereverysomewhatworriedaboutgettingsickfromH1N1influenzavaccine.Insomestudiesconducted in France and Greece, one of the main reasons respondents did not accept vaccination was the fear of vaccinesideeffects(Schwarzingeretal2010;Sypsaetal2009).Inthesameway,Walteretal(2012)found out that concern about the safety of the pandemic vaccines was identified as the main obstacle to vaccination. Lauetal(2010c)foundoutthatoneofthefactorsassociatedwithintentiontotakeupH1N1vaccinewould be the price of vaccination. To conclude, Wong et al (2010) demonstrated that, when Muslims were in doubt whether to be immunized against H1N1 influenza or not, concern that vaccine could be halal was greaterthansafetyconcerns. Trust Somestudiesinvestigatedthetrustininstitutionstowardvaccinationmatter.InaUSstudy,respondents whowouldacceptvaccinehadahigherleveloftrustinthegovernmentthanthosewhorefused(Quinnet al 2009). In a study carried out in the Netherlands higher level of trust in the government increased the intentiontoacceptvaccination(vanderWeerdetal2011). Similarly, there was also a significant difference in the number of respondents who agreed that official authoritieshadinformedthepopulationopenlyandhonestlyaboutpandemicinfluenzavaccination,when comparingvaccinatedwithunvaccinatedrespondents(Walteretal2012). AgainintheUS,ithasbeenfoundthat14%ofpeoplewhowouldnotgetthevaccinedeclarednottotrust information provided by public health officials concerning vaccine safety (Garlace et al 2011). In a study carriedoutinIsraelwasobservedaprominentmanifestationofmistrustamongIsraeliArabs(Velanetal 2011). 1.5.4Knowledge A German study (Walter et al. 2012) showed that 92% of vaccinated respondents had fully or partially agreedtobesufficientlyinformedinordertomakeabalanceddecisionovervaccination,whileonly78%of thenonvaccinatedrespondentsfeltwellinformed.
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AUSstudypointedoutthatknowledgeaboutH1N1vaccine,byfollowingnewsclosely,andriskperception wereassociatedwithvaccinationintention.Thisstudyalsoshowedthatchangesininfluenzaterminology duringtheinitialstagesofthepandemiccausedsomeconfusionamonggeneralpublic(Jehnetal2011). Ontheotherhand,astudycarriedoutamongAsianpopulationfoundthatknowledgeonthe2009H1N1 influenzawasnotasignificantindexforvaccinationintention,andsuggestedthatdisseminatingknowledge aloneisinsufficient(Wongetal2010). 1.5.5Sourcesofinformation A study conducted in the US (Maurer et al 2010) showed that respondents were equally likely to report healthcareproviders,CDC/publichealthdepartments,andnewsreportsasthemostinfluentialinformation source for deciding whether to be vaccinated against pandemic influenza or not. Uptake of pandemic vaccine was higher among adults who declared employers or healthcare providers were their most influential information sources and was lower among those declaring none of the above. Moreover, Maurer et al (2010) found out that perceived safety and value pandemic vaccine were generally higher amongadultswhomostlyreliedoninformationfromhealthcareprovidersandpublichealthofficials.Yet, considerable doubts remained about safety and value of pandemic vaccine among people who relied mostlyonalternativeinformationsources(Maureretal2010). InastudycarriedoutinGermany,Walteretal(2012)foundoutthattheuseofradioortelevisionaswellas familyandfriendsasmainsourceofinformationwereassociatedwithlowervaccineuptake.Incontrast, the association between vaccine uptake and the search of information on vaccination was found when physiciansorofficialmaterialswereusedasmainsourceofinformation. A positive advice from a primary care physician significantly increased acceptability of vaccination; however, in the case of a positive advice by other health care professionals, this was not confirmed (Schwarzingeretal2010;Sealeetal2010;Ferranteetal2011). AstudyconductedinArizona(Jehnetal2011)showedthatmostofthepeoplewhoweremorelikelyto receivetheH1N1vaccine,expressedtheintentiontogotoafamilydoctortogetvaccinated. 1.5.6Discussion The second objective of this review concerns the identification of sociodemographic and psychological variables related to the acceptance of vaccination in the event of a pandemic. The data gathered in this reporthaveshownhowthecompliancetovaccination,particularlyagainsttheH1N1pandemicinfluenza, remainsverylow,asitistheavailability(intention)tobevaccinated. Anumberoffactorshavebeenfoundtofostervaccinationacceptanceamongthegeneralpublic(seeTab3. Factorsassociatedtoprotectivebehaviour): 23
Previoushistoryoftheseasonalinfluenzavaccinationuptake Receivinganadvice/informationfromprimarycarephysicians Beingelderlypeople Perceivedsafetyofthevaccine Perceivedefficacyofthevaccine Perceivedsusceptibilitytothedisease Perceivedseverityofthedisease Trustinauthorities Presenceofchildreninthehousehold Costofthevaccine
Otherfactorsnegativelyaffectedthevaccinationacceptance: Beingwoman Thefearthatthevaccinecouldcausediseaseorsideeffects
Among the sociodemographic factors, age is associated with a higher intent to get vaccinated. Even if a studyconductedintheU.SandtwoAustralianstudiesgaveproofthatyoungpeoplearemorelikelytobe vaccinated,oldpeoplegenerallyappeartobemorelikelythanthem(Garlaceetal2011;Sealeetal2010 andEastwoodetal2009).Genderfactoraswellcanbelinkedtotheintentiontobevaccinated:women werelesswillingtogetvaccinatedthanmen.Anothervariableassociatedwithvaccinationisthepresence ofchildreninthehousehold.Therolesofethnicity,educationallevel,andincomelevel,fromtheliterature analyzed in this review, are instead controversial. On the other hand is clear the influence of past behaviour,infactthosewhohavebeenvaccinatedinthepastagainstseasonalinfluenzaweremorelikely tobevaccinatedagainstpandemicinfluenza.Inagreementwiththeabovementionedtheories,perceived severityandaboveallperceivedvulnerabilitywerepositivelylinkedtotheintentiontoadoptprotective measuresandtoacceptvaccination;suchacorrelationwasalsohighlightedinarecentsystematicreview onthistopic.(Breweretal2007). Beliefs in the effectiveness of the vaccine are strongly associated with influenza vaccination or with the intentiontogetavaccination.Manystudieshavefocusedonthesafetyandefficacyofthevaccineasthe mostimportantfactorsinthedecisiontobeimmunized(Wongetal2010;Lauetal2009;Eastwoodetal 2010). Ontheotherhand,thelowacceptanceofpandemicvaccinationshowedgreatfearsaboutthesafetyofthe H1N1 vaccine and general mistrust of new vaccines. In particular, the public attention focused on the potential adverse effects of the vaccine. Trust and institutional communication therefore are the fundamental keys in vaccination. Finally, many studies have shown that behaviors, attitudes, and advice 24
from primary care physicians were strongly associated with their patients immunization behavior for seasonalinfluenzaorwiththeintentiontogetavaccination(Maureretal2009;Schwarzingeretal2010; Sealeetal2010;Ferranteetal2011;Jehnetal2011;Walteretal2012).However,mostrespondentsinthis studieswerenotadvisedtogetvaccinated.HCWsreportedaverylowuptakeratewhiletheyusuallywere thefirstprioritygrouptoaccesspandemicvaccines.
1.6Limitations
The studies included in this review are heterogeneous and regarded different populations per different infectiousdisease.Thesurveyswereconductedindifferentstagesoftheepidemicandmosthadshortdata collection periods and therefore can only provide a snapshot of intentions and behaviors at a particular time. Furthermore, measurement of the psychological constructs included in the studies was heterogeneous.Asforthepreventivebehaviors,studiescomingfromdifferentcountrieshavefocusedon different epidemics, while studies concerning vaccination have given attention to H1N1 influenza. As for the crosssectional study design we were not able to infer causality. Furthermore, crosssectional studies sufferfromproblemsofstudydesignanddatacollection methodology.In particular,most ofthestudies have been using telephone surveys, a method subject to reporting bias leading to undesirable behaviors results.Despitetheselimitationsthefindingsfrommanydifferentcountriesareremarkablyconsistentand supportedbysimilarstudiesconductedbydifferentauthors(Godinetal1996;Breweretal2006;Chapman etal2006;Stefanoffetal2010;Bishetal2010and2011).
CONCLUSIONSANDRECOMMENDATIONS
We can actually conclude that some of the sociodemographic factors are related to both the implementation of protective behaviors and the compliance to vaccination. Older people are generally morewillingtouptakevaccinationandputintopracticeprotectivebehaviors.Menweremorelikelytoget vaccination while women were more likely to comply recommended behaviors. The use of audience segmentation for communication messages that consider demographic, ethnic, cultural and social differences also may allow for more effective and targeted communication to promote influenza vaccinationandrecommendedbehaviors(Slateretal1991;Wongetal2010;Velanetal2011;Santibanez etal2012). Several studies showed that during the H1N1 pandemic, communication inequalities in the population werecorrelatedwithdifferencesinknowledgeofH1N1itselfintermsofvirustransmissionandsignsand symptoms of infection. The relationship between this knowledge and both level of education and home ownership found in this studies, suggests the need for public officials to integrate information about the
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characteristics of communities and individuals, with a particular focus on socioeconomic level in their communicationplanningefforts(Savoiaetal2012). Publichealthmessagesareoftensubjecttodifferentinterpretationthatmayconsiderablyvaryaccording to individual perception of the risk or trust in the government together with the different abilities in understandingandinterpretingdataandinformation,especiallyinacontextofuncertainty(vanderWeerd etal2011;Kiviniemietal2011).Thiscouldbecarriedoutinpartnershipwithproviders,communityleaders orcommunityandfaithbasedorganizationsusingavarietyofstrategiesincludingsocialmedia(Reissman etal2006;TaskForceonCommunityPreventiveServices,2000;Vaughanetal2009). Demographicdifferencesinopinionsaboutrecommendedbehavior,influenzavaccineanddiseasesuggest thatimprovingcommunicationstrategieswithinthesegroupsmayimprovevaccinationcoverageandthe implementationofprotectivebehaviors. Vaccineacceptanceiscorrelatedtoseasonalvaccineuptakeandtheexpertsadviceisdecisiveandalways a significant factor. Making appropriate health information available to the general public is a priority in emergency situations. For this purpose, an effective contribution could come from the cooperation of health professionals. In fact, different studies have shown that one of the most trusted sources are the generalpractitionersandfamilypediatricians(Schwarzingeretal2010;Sealeetal2010;Maureretal2010; Ferranteetal2011;Jehnetal2011;Walteretal2012).Thisconfirmsthatinvolvingfamilydoctorsinthe communicationstrategiesisimportantfordesigningeffectivecommunication.Trustininstitutions,clarity andtransparencyinthecommunicationareimportantfactorsfortheadoptionofprotectivebehaviorsand vaccinationcompliance. DuringH1N1pandemicoutbreak,representativesofmanyinternationalhealthinstitutespredictedaworst casescenariowithlargenumbersoffatalcases,basedoninfluenzapandemicsinthepastandearlyreports concerning the new Influenza virus. In the following months, local viral transmission in many countries remainedrelativelylimitedandgovernmentsannouncedthatthepandemicappearedtobemild.Following such claims, there was a significant decrease in perceived reliability of information received by the government:inthebeginningthegeneralpublicbelievedthepandemicwouldbesevereaspronouncedby thegovernmentthoughthisturnedouttobemild.Asamatteroffact,rebuildingtrustinrecommendations ofpublichealthauthoritiesandaddressingcommonmisinformationaboutimmunizationagainstpandemic influenzaitisarealcommunicationchallengewhenpreparingforfuturepandemicsituations(Walteretal 2012). Somepsychologicalfactorsasperceivedsusceptibility,perceivedseverityandperceivedefficacyofvaccine orbehaviorcanbepredictiveofboththeimplementationofproperbehaviorsandvaccinationuptake.This conclusion suggests that the concomitant worry of an actual pandemic might be sufficient to increase 26
publichealthcompliancetorequiredlevels,asnotedinHongKongduringSARS(Lauetal2003).Also,Rubin etal(2010)claimthatduringafutureoutbreak,raisinglevelsofworryaboutthepossibilityofcatchinga diseasefromlowlevelsislikelytoincreaseuptakeofbehavioralrecommendations.Althoughtheadoption ofsuchanapproachmightseemcompelling,thereisevidencethatinterventionsthatincreaseperceived threatcanbeineffectiveiftheyincreaseanxietytosuchanextent,leadingtheindividualtodenialoreven avoidanceoftheissueitself(Middaughetal2008;Reissmanetal2006).Inordertoavoidthis,messages about risk should not be alarmist and should be combined with advice about how to manage this risk effectively(Witteetal2000). Emphasizing the efficacy of recommended behaviors in any future campaign should therefore help to maximize the campaigns impact on those behaviors, but Rubin et al (2010) suggest that communicating theefficacyofaspecificbehaviormayhaveanimpactonthatbehavioralone.Moreover,theresultsabout vaccination indicate the importance of highlighting the risks of not being vaccinated and the benefits of vaccinationthusexplicitlyacknowledgingandtacklingsafetyconcerns(Bishetal2011). In conclusion, the data suggest that public health officials should take into account differences in populationsubgroupsastheydeveloppubliccommunicationstrategiesinordertoavoidortoexacerbate inequalities. Public officials need to develop methods and strategies (i.e., rapid surveys) to test their messages and assess their impact on the population (Savoia et al 2012). These might include developing messages able to create a feeling of trust in the government as well as selecting nongovernmental channels of communication such as communitybased organizations, community leaders, or family networkstofacilitatethediffusionofeffectivemessagesamongallsocialgroups. In general, future health promotion strategies will be more effective if they adopted some of the basic principlesofattitudechange(Panagopoulouetal2011): Peoplewouldchangetheirbehavioriftheybelievethattheycouldgetmorebenefitsthanlosses. Peoplewouldchangetheirbehavioriftheybelievethattheyareatrisk;theimportancepeoplegive totheirchangedbehaviorisdirectlyproportionaltotheseverityoftheriskitself. Peoplewouldchangetheirbehavioriftheybelievethattheycandoit. Peoplewouldchangetheirbehavioriftheybelievethatotherpeopleexpectthemtochange.
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EXECUTIVESUMMARYII
Outbreakcommunicationduring2009H1N1pandemic
Introduction In a health crisis situation, as it did in 2009 with the outbreak of the H1N1 or swine flu virus, communicationhasbecomeacentralissuetomanagetherisk.Appropriatecommunicationandeducation will ensure the public, health care professionals and stakeholders know how to best protect their health and the health of others. It will also inspire continued confidence in the authoritiess response to the pandemicsituation.Clear,consistentandcoordinatedmessagingacrossthefullrangeofcommunication channels,tailoredtotheneedsofspecificaudiences,iscrucialtomaintainthepublictrustandtoensure essentialcomplianceandsupporttotheeffectivemanagementofapandemic. Methods MEDLINE, Cinahl, EMBASE, Google Scholar, World Health Organization Library Information System (WHOLIS),SystemforInformationonGreyLiterature(OpenSIGLE),NetworkedDigitalLibraryofThesesand Dissertations,ProQuestDigitalDissertations,DissertationAbstracts(NorthAmericanandEuropeantheses) and Electronic Theses Online Service (Ethos), were used as references for studies. Also, references of all includedarticlestoidentifyotherpotentiallyrelevantstudieswereexamined. Results Regardingthepublic,thecommunicatorshavetotakeinconsiderationthatinformationdistributionisnot onesizefit allandmustbetailored tothecommunicationpreferencesofthosewhoneedtohave the information (Klein et al 2010). H1N1 attracted greater media coverage especially during the spring 2009 when the novel virus emerged and spread around the world. The media, but also the health authorities, had been accused of exaggerating risks and contributing to public worry and confusion. The H1N1 pandemic also showed several examples of mediated risk conflicts, where statements or demands from stakeholdersledtoachangeintherecommendationsmadebypublichealthauthorities.Inthisoccasion someagenciesusednewandsocialmediaasmainwaysofcommunication. Conclusion Communicationwasindicatedasacomplexissuethatneededfurtherimprovement.Thechallengeswere to respond to the various public concerns and to achieve a high level of transparency over the disease burden. The existing WHO outbreak communication principles of early announcement, trust and transparency achieve this to a certain extent. However, additional work is required to develop practices and principles to ensure visibility and legitimacy of communication. Choosing the best channels of communication,targetingprimaryaudiencesandfindingspokespeoplewhoprovidelegitimacyaresomeof theissuethatneedtobeexplicitlyaddressed. 28
2.OUTBREAKCOMMUNICATIONDURING2009H1N1PANDEMIC
2.1Introduction
In a health crisis situation, as it did in 2009 with the outbreak of the H1N1 or swine flu virus, communicationhasbecomeacentralissuetomanagetherisk.Appropriatecommunicationsandeducation will ensure the public, health care professionals and stakeholders know how to best protect their health and the health of others. It will also inspire continued confidence in the authoritys response to the pandemicsituation. Fromtheperspectiveofhealthcareprofessionals,healthauthoritiesandotherkeystakeholders,effective coordinationofmessagingwillhelptoensuretheyarereceivingtimelyandrelevantinformationtorespond to a pandemic appropriately and effectively. Pandemic communications must incorporate a number of criticalelementstobeeffective: Keepthemessageconsistent Establishacrediblevoice Buildtrustanddemonstrateempathyandcaring
Furthermore, the risk communication strategies must acknowledge the importance not just of openness butalsooftransparencyinthewayinwhichassessmentsaremadeanddecisionstaken. Clear,consistentandcoordinatedmessagingacrossthefullrangeofcommunicationchannels,tailoredto theneedsofspecificaudiences,iscrucialtomaintainthepublictrustandtoensureessentialcompliance andsupporttotheeffectivemanagementofapandemic.
2.2Methods
2.2.1Searchmethodsforidentificationofstudies Thesecondpartofthepresentreportisbasedonasystematicresearchinthe:MEDLINE;Cinahl;EMBASE. Initially,wedidnotadoptanylanguagerestriction(seeAppendix1.ElectronicsearchstrategiesWealso searchedforH1N1ORpandemicAND Communication;H1N1ORpandemicANDpreparednesson:a) GoogleScholar(weobtained29.800resultsbutwelimitedthescreeningtothefirst500results);b)World Health Organization Library Information System (WHOLIS); c) System for Information on Grey Literature (OpenSIGLE);d)NetworkedDigitalLibraryofThesesandDissertations;e)ProQuestDigitalDissertations; f)Dissertation Abstracts (North American and European theses), in the British Library; and g) Electronic ThesesOnlineService(Ethos). Weexaminedreferencesofallincludedarticlestoidentifyotherpotentiallyrelevantstudies.
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Datacollectionandanalysis The author checked all titles and abstracts obtained from the comprehensive literature research, and retrieved the full text of potentially relevant reports. An author review extracted data for each included study: general information (title, authors, source, publication status, publication date); details of study (location, methods of recruitment of participants, response rate); participants (description, geographical location, age, gender, ethnicity, socioeconomic grouping); outcomes (methods for measuring outcomes, tools used to measure outcomes) and results. Data synthesis began with a narrative overview of the findingsintheshapeofatablesystematicallysummarizingtheextractedresults.
2.3Communicationduring2009H1N1pandemic
2.3.1OpinionsandperceptionofthegeneralpublicabouttheH1N1pandemic Afirststeptowardanychangeismadeoftheacquisitionofknowledgeandinformationonagivenmatter concerninghealth(ProchaskaandDiClemente,1982).Inthefirstpartofthisreportwesawhowknowledge isassociatedwiththeadoptionofprotectivebehaviors(Linetal2011;Kamateetal2010;Lauetal2010; Eastwood et al 2009; Leung et al 2004) and the vaccine uptake (Walter et al 2012; Jehn et al 2011). Therefore,communicationisessentialtofacilitatethisprocess.Greatpartofstudiesanalyzingpopulation knowledgeinvestigateaspectsconcerningH1N1virustransmissionmodes,symptomsrelatedtothem,and, aswesawearlier,theknowledgeofthemainmeasurestocontrolthespreadofvirus. As expected, the level of knowledge acquired over the H1N1 pandemic influenza increases with time, as well as the level of satisfaction on information received (Lin et al 2011; Walter et al 2012; Rubin net al 2010). Moreover, in general it seems it exist a positive association between knowledge and educational level(Walteretal2012;Savoiaetal2012;Aburtoetal2010;Kamateetal2010).Furthermore,intheUS Savoia et al (2012) found out that ethnicity, age, language spoken at home, home ownership, and communitycohesion(trustinthecommunity),allindividuallydemonstratedapositiveassociationwiththe knowledge about signs and symptoms of H1N1 infection. In particular, white people showed a greater likelihoodofbeingatahigherlevelofknowledgethannonwhitepeople. AremarkabledatashowedthatinaUSstudyrespondentsweremorefamiliarwithtermsconcerningswine flu (94%) than they were with the H1N1 (86%). Also familiarity with influenza terms appeared to vary accordingtotheagegroupsand,particularly,forH1N1.Infact,olderrespondentswerelessfamiliar(79%) whencomparedwithrespondentsaged35to64years(90%).Changesininfluenzaterminologyduringthe initialstagesofpandemicappearedtocausesomeconfusion.Moreover,only66%ofrespondentsdeclared thatthetermsH1N1andswineflureferredtothesamevirus(Jehnetal2011).Furthermore,inanIndian study83%ofrespondentsaffirmedtohaveheardaboutswinefluwhereasonly40%knewabouttheH1N1
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virus,and81%didnotthinkthatthetermsswinefluandH1N1referredtothesamething(Kamateet al2010). H1N1virustransmissionmodes A study carried out in Mexico shows that 85% of respondents correctly identified close contact with infected people, 30% identified contact with contaminated surfaces and approximately 10% identified sharingutensilsasamodeofH1N1virustransmission.Butagreaterpercentageofrespondentswithalow socioeconomic level did not know any transmission mode related to the middle and highest socio economic level. Furthermore, nearly one fifth of respondents in this study, with a low socioeconomic status,declaredmessageswerecontradictoryorconfusing(Aburtoetal2010). AUSstudy(Savoiaetal2012)showedthat69%ofpeoplehadahighlevelofknowledgeandrecognizedthe correct mechanism of H1N1 virus transmission. In this study ethnicity was associated with knowledge, whitepeoplebeingmorelikelytohavemoreknowledgethanblackpeopleandHispanics.Asotherstudies showed, knowledge level is associated with a high education level and household income. Moreover, a studycarriedoutbyLininChina(2011)showedthatthosewithahigheducationlevelweremorelikelyto knowtransmissionroutescomparedtootherpeople. SymptomsassociatedwithH1N1infection A study carried out in Mexico, pointed out that 70% of individuals could cite fever and at least two additional symptoms. Fever (80%), headache (70%), cough (40%), and sore throat (20%) were the most commonly cited (Aburto et al 2010). This study showed also that the order of the H1N1 facts listed in messagescorrespondedtothefrequencywithwhichrespondentsreportedthosefacts(Aburtoetal2010). Theseresultsareconsistentwithstudiesreportingthatpeoplehavedifficultyinrememberingmorethana fewmainmessages(Keselmanetal2005;Rubinetal2010)andthatpeopleinsuchsituationcouldbethe causeofhighlevelsofconcerns,suchaspandemic,furtherhinderingrecallability(Covelloetal2001). With regard to vaccination, a study carried out in China (Lin et al 2011 ), found that 72%of participants knewthatH1N1vaccinationwasfreeofchargeand68%wereinformedaboutthestatesinitialvaccination strategy. In a study conducted in Arizona about 80% of respondents was aware of vaccine availability against H1N1 (Jehn et al 2011). In a Saudi Arabia study it came out that nearly onehalf (47%) of participantsthoughttherewasavaccineavailableforthediseaseatthetimeofthesurvey,eventhoughit wasnotavailableyet. ThefindingsinSavoiastudy(2012)showedthatduringtheH1N1pandemiccommunicationinequalitiesin theUSpopulationwerecorrelatedwithdifferencesinknowledgeofH1N1.Therelationshipbetweenthis knowledge and both level of education and home ownership found in this study suggests the need for
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authorities to use information about the characteristics of communities and individuals, with a particular attentiononthesocioeconomicstatusintheircommunicationplanningefforts. Misconceptions AstudycarriedoutinHongKongduringtheearlyphaseoftheH1N1influenzaepidemicshowedahigher number of misconceptions among the general public. The results showed that 43% of all respondents wrongly believed that the new H1N1 influenza was a type of avian flu. The prevalence of unconfirmed beliefs related to transmission modes was high: via eating wellcooked pork (7%), via longdistance airborneaerosols(e.g.fromonebuildingtoanother)(39%),viainsectbites(25%),orviawatersources (39%).Mostofrespondents(66%)hadatleastoneoftheforementionedmisconceptionsorunconfirmed beliefs (Lau et al 2009). A following study, conducted in July 2009, Lau et al (2010) showed that 59% of respondents gave at least one item response corresponding to a misconception about model of H1N1 transmission. A Mexican study showed that few respondents (1.5%) reported the erroneous belief that handling pork products would transmit infection (Aburto et al 2010). In China, Lin et al (2011), found out that 30% of public wrongly believed that H1N1 was food borne, which was associated with the previous knowledge abouttheavianfluandthenewH1N1fluinthegeneralpopulation. InastudycarriedoutinSaudiArabiaalargenumberofparticipantsmistakenlybelievedthatthedisease wasanimmunodeficiencydisease(28%),andalthoughmostpeoplereportedaccurateinformationabout thetransmissionmode,43%statedthatsexualcontactwasamodeoftransmission(Balkyetal2011). Moreover,inHongKongatotalof39%ofpeoplewronglybelievedthatinfluenzavaccineagainstseasonal flu could effectively or very effectively protect one against the new H1N1 virus, and 43% believed that therearenoeffectivedrugsavailabletotreatthedisease(Lauetal2009). Vaccination Personalbeliefsabouttransmissionandvaccinationplayedanimportantroleinappraisingandresponding totheauthorityrecommendations. In a comment posted in online news in Canada people showed concern on H1N1 vaccine. Most of commentsrefertohighconcernthanalowone(106vs.39comments).Fourmainconcernscontributedto increase fear of the vaccine: fear of adjuvant, in particular, commentators were suspicious of the H1N1 vaccineadjuvant,squalene;fearofmercury;amaincauseoffearaboutthevaccinestemmedfromwhat wasperceivedtobeinsufficientsafetytestedandthelackofinformationaboutside effects.Peoplealso showed mistrust on pharmaceutical companies. Commentators seemed annoyed that pharmaceutical companieswouldfinanciallyprofitbypublichealthcrisis(HenrichandHolmes,2011).
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InafocusgroupcarriedoutinUKpeopleexpresseddoubtsabouteffectivenessofvaccination,andargued thatitcouldbeunnecessaryaspeoplebuildupanaturalimmunitytofluviruses.Moreover,theperceived barrier to get vaccine was about safety concerns, and especially the development process (Teasdale and Yardley,2011). Personalprotectivemeasures InastudyconductedintheUK,participantsgenerallyfeltthatsomeadvicelikeworkingifingoodhealth were common sense and advisable to put into practice. Moreover, they expressed doubts about the effectiveness of the recommendations to stay at home in presence of symptoms, considering that virus transmission is mainly aerial. In addition, people felt guilty and anxious about their missing work, considering that pandemic was relatively mild (Teasdale and Yardley, 2011). Similarly, in a focus group conducted in New Zealand the economic pressures to go to work instead of staying at home were the greaterconcern(Grayetal2012). On the Canadian newssites commentators remind or educate other people about basic ways to prevent disease transmission and infection. Also, many comments proposed a healthy diet and/or dietary supplementsasanalternativetovaccination(HenrichandHolmes,2011). Trustinauthorities TheCanadiannewscommentatorspostedtwohundredandfiftytwocommentswerethegovernmentwas criticized(only66commentswerepositive).Thegovernmentwasblamedforageneralincompetency,the mishandling of the pandemic being just one more example which showed its ineptitude. Also the governmentwasaccusedoftakingtoolittleactiontopreventandcontrolthepandemic,particularlywith regardtothehandlingoftheH1N1vaccineintermsofacquisition,promotionanddispensingofthevaccine (HenrichandHolmes,2011).Amongcommentswhichexpressmistrust,therewerethreemainlyreasons. The first was that Government was motivated by politics. People claimed that the Government was conducted only by economic/financial reasons, and criticized it for financially supporting pharmacy industry. A final concern, though less frequently mentioned than the other subthemes, concerned governmentmistrustandgovernmentclaimsaboutvaccinesafety(HenrichandHolmes,2011). Finally,aqualitativestudycarriedoutinNewZealandshowedthatpeoplefelttheywerenotbeinggivenall thefacts(fromtheauthorities)andthatthisaffectedtheircapabilitytomakeinformeddecisions(Greyetal 2012). Evenifitisimportanttostressthatpeoplearemorelikelytopostcommentswhentheydisagreewitha news story or feel discontent about an issue, thus biasing our understanding of public opinions, this elementwasusefultounderstandwhatissuescouldaffectpeoplesdecisionmaking(HenrichandHolmes, 2011).
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Informationsource Television and radio were the most common sources of H1N1 information in Mexico. In particular, more than90%ofrespondentsdeclaredtoreceiveinformationfromtheTVandover30%fromtheradio.Less than7%ofthemdeclaredtoaccessinformationfromMinistryofHealthwebsite.Theaccesstowebsiteas sourceofinformationseemstobeassociatedwithahighersocioeconomicstatus(Aburtoetal2010). Differentstudiesshowedthatthemainsourcesofinformationwerethemassmedia,suchastelevisionand radio, as well as the print media, such as newspaper or magazine (Walter et al 2012; Jehn et al 2011; Horneyetal2010;HiltonandSmith2010).TheInternetwasusedasasourceofinformation(range),mainly amongyoungpeopleandamongpeoplewithahighereducationlevel(Walteretal2012;Jehnetal2011) On the other hand, an Italian study (Ferrante et al 2011) it came out the most believable source of information,whichpeoplewouldcontactincaseofneed,were:GPsandfamilypediatrician(81%),internet (12%),andotherhealthpractitioners.TV,radio,newspapers,magazinesanddedicatedtoll.Freetelephone services were mentioned by less than 4%. The same results were found in a study conducted in Arizona (Jehnetal2011),werethemedicalprofessionalwasthemostcredibilitysource,eveniffollowedbylocal televisionnews88%,nationaltelevision85%,andpublichealthofficials75%. An interesting point of view come from a focus group study conducted in the New Zealand (Gray et al 2012). Even though participants reported a variety of media sources (like newspapers, TV, radio and the internet), theirmainsourceofinformationwastheirworkplaceand/orcommunity. Itseemedthatwhen peoplefaceuncertainty,theyturntootherstoreducetheirinsecurity;theseareoftenfamilyandfriends, butalsohealthagenciesorGPswithwhomtheyhaveadirectrelationship(Paton,2008). TV was still the predominant source of information. Nevertheless, the impact of risk communication messages is dependent not only on the way to reach it but also on the publics trust on the source, understanding,andaccuracyofmessages.Nonetheless,theuseoftheInternetwasfoundtobelowwhen compared with other information sources. Moreover, the Internet does not seem to be effective in reachingcertainpopulationgroupssuchaselderlypeopleorthosewithaloweducationallevel(Walteret al2012;Savoiaetal2012). 2.3.2Traditionalmedianewscoverage,andpublicresponse During both the spring and summer of 2009, the general alarm and uncertainty over the emergence of H1N1 was spread through the news media. While some agencies such as the World Health Organization (WHO) and the Centre for Disease Control and Prevention (CDC) were providing risk and precaution informationtothepublic,thenewswassensationalizedbythemedia.
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Table1.MajorH1N1relatedevents Month March Day 18 Event Mexicanauthoritiesbeginpickingupcases"influenzalikeillness".Intheweekspriortothe firstrecordedH1N1death. LocalmediainMexicowasreportinganincreaseininstancesofflulikeillnesses. A39yearoldwomansufferingfromanacuterespiratorydiesinOaxaca,Mexico. TheCDCconfirm7casesofH1N1inCaliforniaandTexas. Mexicanauthoritiesspeakforthefirsttimeofan"epidemic". TheWHOwarnsthatthevirushaspandemicpotential. FirstcasesconfirmedinEurope(inSpainandScotland). TheWHOrisealertlevelto4onascaleof6. Theepidemiccontinuestoprogress,affectingallfivecontinentsintheworld,fromNew ZealandtoIsraeltoCostaRica. FDAapprovestheCDCsH1N1test. ThefirstconfirmeddeathintheUnitedStates. WHOraisesto5itslevelofalertcallingoncountriestoprepareforan"imminent"pandemic. WHOofficiallyreferstothisdiseaseasNewInfluenzaA(H1N1). ThefirstconfirmedcaseofH1N1 inAsiaisrecordedinHongKong. WHOsaysithas"nodoubt"thatasuccessfulvaccineagainsttheH1N1viruscouldbe developedwithinthenextsixmonths. WHOreports1490casesfrom21countriesand30deaths. 34countrieshaveofficiallyreported7520casesofinfluenzaH1N1infectionand65deaths. WHOreports10243casesin41countriesand80deaths. WHODirectorGeneraldeclaresthattheworldisnowatthestartofthe2009influenza pandemic(phase6). DenmarkreportsthefirstcaseofH1N1resistancetofludrug,Tamiflu. TheWHOstatesthatH1N1isthemostprevalentglobalflustrain. TheFDAapprovesH1N1vaccine.
April
12 23 24 25 27 28
29
May
5 15 20 June 11 29 August September 28 15
Sources:WorldHealthOrganizationWHO;CentreforDiseaseControlandPreventionCDC;FoodandDrugAdministrationFDA.
Aswesaw,concernandfearcanbeassociatedwiththeadoptionofpreventivebehaviors.Indeed,many studies showed how these factors can be useful in planning communication activities (Witte et al 2000), even though we know less about the effects of fear appeals in news coverage. However, studies investigatedtheeffectsofnewscoverageofthe2009H1N1pandemicinthegeneralpublic. Astudyconductedduringthefirstdaysofthepandemiccollected3979mediaarticlesfrom31European countries.Thisstudyshowedtwopeaksinthemediacoverage.ThefirstonewasonApril27th,thedaythe WHO raised the level of influenza pandemic alert to phase 4; the second one was linked to the WHOs declaration of phase 5 of pandemic alert. National and international public health authorities were
35
identified as the main source of information in 75% of the articles, and the overall tone (94%) of these articleswasneutral,andspeadfactualinformationonly(70%)(Duncanetal2009). ABritishnewspapercoverageshowedthatmostarticles(46%)werepublishedduringthefirstpeakinthe UKcases.Approximately27%ofthearticlesappearedinAprilMay2009showingthatconcernsabouta potentially pandemic grew and the number of reported cases began to increase worldwide (Hilton et al 2011;Olowokureetal2012). Furthermore,aUKstudyfoundthat,ingeneral,increasesinWestMidlandsregionalnewspapercoverage about H1N1, preceded increases in the number of people tested. The increase was linked to a positive association between volume of schoolrelated articles and the number of laboratoryconfirmed cases of H1N1(Olowokureetal2012).IntheUK,theinterestinH1N1pandemicdecreasedfromSeptember(21%), despiteasecondpeakofcasesintheUKsincethenormalfluseasoncamearound(Hiltonetal2011).A studyconductedinthemainUSnationalprintandelectronicnewscoverageduringthefirstfivemonthsof H1N1 outbreak, showed that the heaviest coverage emerged during May 2009, and that different terms wereusedtoreferaboutthevirus(includingH1N1,swineflu,andinfluenzaA).Themostusedtermwas swineflu(95%),followedbyH1N1(75%)andinfluenzaA.Thelasttermwasrarelyused,thoughused bytheWHOandtheCDC(Goodalletal2011).SimilarresultswerefoundinanAustralianstudy(Fogartyet al2011).AlsoastudycarriedoutonmediacoverageinOntario,showedthatduringthefirstperiodmedia attentionoccurredbetweenApril27andMay1,2009whencasesofH1N1firstoccurredinMexicoandthe UnitedStatesand,soonafter,inCanadaandOntario.BymidSeptember,mediaattentiontoH1N1began totrendupwardsonceagain,andincreasedmediainterestinvariousfacetsofthestoryinanticipationof thesecondwaveexpectedinthefall(Laing,2011). Thecontentanalysis(Goodalletal2011;Fogartyetal2011)showedthattheseverityofthepandemicwas reportedinahighernumberofnews(from63%to86%).Thiswascommunicatedthroughthedescription ofdailytalliesofinfectionandmortality.Thestoriespointedoutthatinfectionrateswereseriousandthey couldturnintohospitalizationanddeath(Goodalletal2011;Fogartyetal2011;Hiltonetal2011;Rachulet al2011).Coveragealsoreferredtothespreadusingdescriptivelanguagewithepidemiologicalterms,but moreover some statements provided commentary that suggested rapidly spreading outbreaks difficult to contain(Fogartyetal2011). Theseriousnesswasalsocommunicatedincomparisonwithothervirussuchasseasonalflu,avianfluand SARS(Goodalletal2011;Fogartyetal2011;Hiltonetal2011).YettherewasdisagreementwhetherH1N1 wassimilar,lesssevereormoreseverethanotherfamiliarvirus.Differentnewsstressedtheneedforcalm responses.Inaddition,23%ofstatementsassuredpeoplethatthegovernmentwashandlingthesituation byelaboratingonitsowncurrentandproposedactions(Fogartyetal2011).
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Thenewsalsoreferredtoadvicesaboutwhatpeoplecoulddo toreduceor prevent thespreadofH1N1 (e.g.handwashing,gettingvaccinated)(Goodalletal2011;Fogartyetal2011;Hiltonetal2011).Mostof thesenews(77%)didnotmakeexplicitstatementabouttheeffectivenessoftheseactions.Thethingsgot even worse about the statement on community actions (e.g. quarantine or school closure). In fact, most articles(89%)donotspecifytheimportanceandtheeffectivenessofsuchactions(Goodalletal2011). InGoodallstudy(2011)around30%ofthearticlesimpliedthatonlyparticulargroupweresusceptible(7% inaFogartystudy),stressingthefactthattheriskgroupwasnotincludedinthosetraditionallyvulnerable toseasonalflu.Inparticular,statementsindicatedgreaterdiseaseburdenofH1N1amongpeopleunder25 years,followedbypregnantwomenandpeoplewithchronicillnesses.Onthecontrary,inaCanadianstudy themostcommonlygroupidentifiedatgreaterrisktocontracttheviruswasthehealthprofessionalone (Rachul et al 2011). In the UK articles paid attention to people at high risk. This corresponded with the introductionoftheH1N1vaccinationprogramaddressedtopeopleathighriskofdevelopingH1N1(Hilton etal2011). ACanadianpaperexaminedthediscussiononthenewsprintarticlesaboutvaccineandvaccinationagainst H1N1virus(Rachuletal2011).Thisstudyfoundthatmostmediacoverageoccurredduringthatfirstmonth of vaccination program in Canada. Great part of news provided reasons in support of vaccination (72%), while18%providedreasonsagainstgettingvaccinated.Unfortunately,onlylessthanonethirdofarticles providedevidenceorsuggestedeffectiveness(Rachuletal2011;Goodalletal2011). Among news that provided reasons against vaccination uptake, only 7% stated or suggested scientific evidenceagainstgettingvaccinated(Rachuletal2011).AlsointheUSthereweredebatesaboutvaccine safety(19%),anditsavailability(11%)(Goodalletal2011).IntheUKduringthesummersomenewspapers paidattentiononthedevelopmentofavaccine,butthisissueattractedrelativelylittlepresscoverage,and ingeneral,veryfewarticlesdiscussedpotentialsideeffectsofavaccine,thevaccinesafety,orstatedthat thevaccinehadbeenadequatelytestedornottested(Hiltonetal2011).InaRachulstudythementioned risks associated with the H1N1 vaccination were: development of autism in children (2.6%), allergic reaction(2.1%),GuillainBarrsyndrome(2.1%),variousneurologicalconditions(1.7%),andexpectedflu likesymptoms(1.7%). Approximately 33% of stories mentioned public fear of H1N1. But among them, great part affirm in populationthereisanunjustifiedexcessivefear.Inparticular,somestatementsreportedthattheviruswas not severe, as it seemed at first, when direct statements that implied the level of fear were disproportionate,andadvisedthepublicnottopanic.Onlyafewarticlesemphasizedpessimismoverboth theunpredictabilityandrapidspreadofthevirus,statingthatpeoplehadtherighttobefearful.
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The studies showed that latest news were less likely to talk about fear than stories appearing earlier (Goodall et al 2011; Fogarty et al 2011). Finally, the Australian study showed that most statements were madebyreporters(54%);afurther21%bydelegatesofthegovernmentand12%bypublichealthexperts. Theremaining13%wasacombinationofgeneralpublicstatementsandcommentsfromoverseasofficials, athletesorotherstakeholders(Fogartyetal2011). Mediacoverageandpublicresponse Afewstudieswereincludedinthisreviewtoassesswhetherthechangesinthevolumeofmediacoverage onH1N1wereassociatedwithchangesinpeoplebehaviorsorworries. ThefindingsofaCanadianstudydeterminedthatthelevelofconcern,amonggeneralpopulation,showsa clear relationship between the rise and fall of concern with the level of media attention (Laing, 2011). Similarly,aUKstudy(Rubinetal1010)foundthatthelevelofconcerninthepopulationremainsgenerally low, despite a very high level of media reporting. However, the percentage of people who affirm to be worried to catch a H1N1 is associated with the total volume of media reporting relating to H1N1. In particular,thenumberroseduringMay2009,whentheWHOdeclarationofafullpandemicoccurred,and inmidJulyatthehigherpeakofthesummersurgeoftheoutbreak.Asmallincreasewasobservedwiththe startofthewintersurgeoftheoutbreakandthestartofthevaccinationcampaign. Rubinetal(2010)alsofoundoutthatexposuretothemedianewsoradvertisingwasassociatedwiththe adoptionofsomepreventivebehaviors(likeusingtissuesorbuyingsanitizinggel),butlowerprobabilityof avoidingpublictransportorusingNationalHealthServices(NHS). AnotherstudycarriedoutinMalaysiashowedthatinviewofanintensemediacoverageofdeadpeople number related to H1N1 there was an increase of fear (being in contact with people who contracted influenza, or people returning from overseas, fear of hospital visits, and even fear of eating in public places), and an increase of avoidance behaviors (avoiding public/crowded places, public transport, and goingabroad).Theapparentreductionofsomeavoidancebehaviorsasthenumberofdeathsdeclined may indicate a decrease in risk perception, with a consequent decline in the adoption of preventive measures(Wongetal2010). 2.3.3Newscoverageandnewmediainformationseekingandpublicresponse Theinformationgiventomostofthepublicinstitutionsispackagedtoserveunidirectionalannouncements. Onlineresources,ontheotherhand,areconsideredasamoreinteractivecommunication,wherepeople canshareinformationandfillknowledgegapsonhealthmatters. A study focused on the analysis of information, provided both online and in newspapers on the H1N1, foundthattheattentiononthisissueincreasedrapidlyinconjunctionwiththefirstWHOannouncementof
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thepresenceofinfluenzaH1N1casesinMexicoandUS.Theanalysisoflanguageinswineflublogentries and newspaper articles on H1N1 show a higher use of healthrelated words, deathrelated words, and anxietyrelated words. The attention paid to H1N1 occurs most rapidly in Wikipedia, then in blogs and finallyinnewspaper.Thefindingssuggestedthatpublicreactionwasvisibleinonlineinformationseeking before it was visible in the amount of newspaper coverage (Tauscszik et al 2012). In addition, a study conducted on Google showed that the main enquiry peak was observed when the WHO announced the emergence of the novel H1N1 virus, although it had been featured on the news media for some time (Nougairde et al 2010). Another study carried out in Wales found that Google News search for news articles H1N1releted showed the highest concentration when the WHO raised the level of influenza pandemicalerttophase4andlatertophase5(respectivelyApril27and29).Alsoahighperiodofmedia activityoccurredinconjunctionwiththelaunchofinfluenzavaccineintheUK(Keramarouetal2011). Astudysimulatedasearchforgenericinformationonpandemicflubyusinggenericwebsearchenginesin fourEnglishspeakingcountries.TheresultsshowedthatmostwebsiteswerefromPublicHealthAgencies and from news providers (37% and 40% respectively). This study showed an overall high probability of finding on the web appropriate information regarding hand washing and main steps of the respiratory etiquetteconsistentwithWHOrecommendations,whileotherrecommendationsregardingbehaviorsthat canpreventtransmissionofinfluenzaH1N1influenzawererarelyfoundthroughagenericwebsearchon pandemicflu(Gesualdoetal2010).Thestudyisusefultounderstandthemaintopicpostedonlinebythe public on the Yahoo! Answers during H1N1 outbreak, showed that people were concerned about overall issuesofgeneralhealthcareforpreventingH1N1(Kimetal2012).Mostpartofthesubjectsincludedinthe categories supported those conventional clinical questions including disease, therapy, symptoms, prognosis,preventionandcontrol,andetiology.Asecondclassificationgeneratedinterestingclassessuch asfeel,doubt,emotion,help,learning,andreply,whichdisplaytherealfrustrationofpeoplewhoseekout fluinformation. Thisfindingcouldsuggestthatpeoplewhopostquestionsarenotonlyseekingformedicalinformationbut also for emotional support learning how to manage the disease. This study has also identified the main reference sources to help getting the right information to people through peerquestioners about the H1N1.Thefindingsindicatedthatpeopleprimarilycaresaboutcommercialsourcesfortheirinformationon H1N1,ratherthanWikipediaorYouTube.ThissuggestedthatpeopleseekinfforH1N1informationonline frequentlyreferstomoreaccessibleinformationsources.Amuchmorehearteningsetofresultsshowed that references to a .gov site (of which the CDC and the US Food and Drug Administration are most signified)arealmostascommonasreferencestoa.com(Kimetal2012). A study conducted on comments posted on the three main Canadian online news sites (Henrich and Holmes, 2011) showed that there were nearly twice as many comments reflecting low fear (n=212) 39
comparedtohighfear(n=125).ThereasonsforalowfearonH1N1weresubstantiallythree:afewdeaths number;H1N1wasnotdifferentfromseasonalflu;seasonalfluwasmoredeadlythanH1N1.Ontheother hand,commentsreflectingahighleveloffearwerecharacterizedfrom:H1N1wasanewdisease;thevirus wouldmutate;youngadultsweredying;andfinallyH1n1wouldshowedhighmortalityandmorbidity. AstudycarriedoutFromMayuntilDecember2009(Chewetal2010),whichusedTwittertomonitoring publicperceptionsduringtheH1N1pandemic,showedthatH1N1relatedtweetvolumematchedwiththe mostimportantH1N1newsevents.Forexample,totheWHOspandemiclevel6announcementinJune11, butalsowhenanactorfromHarryPotterhasbeenrecoveredfromH1N1.Anincreaseoftweetvolume was observed also following the arrival of H1N1 vaccinations in the United States on October 6 and regarding vaccination experiences (Chew et al 2010). A content analysis found six content categories resulted from data: resources (like H1N1 news, information or updates), direct or indirect personal experience, personal opinion, jokes/parodies, marketing for H1N1related products, and unrelated posts (Chew et al 2010). Almost all tweets (90%) provided references to information they were providing, allowing others to confirm the trustworthiness of the material. But, public health and government authoritiessuchastheCDCandtheWHOwererarelyreferenceddirectlybyusers(1.5%oflinks). AnotherstudythatanalyzedtheuseofTwitterintheUS(Signorinietal2011),foundthattheTwitterusers initialinterestinantiviraldrugsdroppedataboutthesametimeashealthauthoritiesindicatedthatmost caseswererelativelymildinnature,despitethefactthatoverallthenumberofcaseswasstillincreasing. Also,interestinhandhygieneandfacemasksseemedtobetimedwithpublichealthmessagesfromthe CDCabouttheoutbreakinearlyMay. An infodemiology study of information and search activity on the Internet showed that, as new vaccines and treatments were developed, search activity for supplements increased. Concerns about vaccination safetyandefficacymayhavedirectedindividualstolookforalternativeandnaturalwaysofpreventingor treatingthedisease.Inparticular,perceivedunmetneedsfromconventionalmedicalsystemscanprompt individuals to seek alternative therapies. This suggested that public health agencies should provide informationaboutsupplementsontheirwebsitesinthecontextofspecificillnesses(Hilletal2011). These findings highlight the role of online tools in rapid, widespread communication in emergencies. ConsideringthelargenumberofpeoplewhouseWebresourcesforseekinghealthinformation,thesetools provetobeessentialfordisseminatinginformationandinteractingwiththegoalofservinghealthrelated informationquestions. Several authors underline that these tools can be used for near realtime infodemiology or infoveillance studies(Eysenbach,2009)forpublichealth,andallowinghealthauthoritiestobecomeawareofitandto respondtorealorperceivedconcernsraisedbythepublic(Chewetal2010;Tauscziketal2012). 40
Antivaccinationwebsites Internetallowsindividuals'accesstospecializedmedicalscientificinformationpreviouslyavailableonlyto health professionals. And during 2009 H1N1 pandemic, the antivaccination movements spread doubts aboutthesafetyandeffectivenessofpandemicinfluenzavaccines.Thelowsafetyofvaccineswasraised regardingthe2009H1N1vaccinealsoinantivaccinationwebsites.Arecentarticleanalyzedthecontentsof 25 antivaccination sites showing that one specific theme did not appear in previous analyses.. This includedassertionofamanufacturedorexaggeratedthreattoboostvaccination.TheH1N1outbreakof 2009 and the campaign to promote widespread vaccination of vulnerable populations were deemed as manufacturedthreats.Thisnewtheme,emergingasaspecificreactiontotheH1N1influenzavaccination promotion, was present on 44% of the sites in the current study, though it was absent from any of the earlierstudies(Bean,2011). Bean study (2011) also showed that the other themes which appeared on the antivaccination websites regarded: safety and effectiveness of vaccine. About 76% of all websites included content that asserted thatvaccinecausesdamage,illness,ordeath.Anissueaboutpoisons,additive,andingredientswaspresent on80%ofthesites.Also,84%ofthewebsitesmentionedconspiracytheory.A52%ofsitesreferredtothat vaccination was promoted only for financial reasons. About 44% of the websites also noted that vaccine mandates were an example of excessive government control. And finally, alternative treatments, like homeopathy,chiropractic,andfurtheralternativevaccination,werementionedfrom20%ofthiswebsites. 2.3.4Cryingawolf? Despiteusingthemediaasakeyinformationsource,itwasalsocommonamongpeopletoexpressdistrust overtheinformationprovidedbythe mediaand thereasonsbehindmediacoverage.Aqualitativestudy showed that participants were skeptics about the veracity of media reports. Indeed, there was a strong feeling that the New Zealand media had a central role in overhyping pandemic risk. Public distrust in mediaandthesensationalizingofhealthrelatedstoriescanalsobeanobstacletotaketheriskseriously and to undertake precautionary measures. A belief that risk has been overstated is associated with an increasedsenseoffrustrationandareductioninthelikelihoodthatpeoplewillprepareintheshortterm (Grayetal2012). The commentators of online news in Canada generally characterized the media as irresponsible (260 comments,withonly45commentscreditingthemediawithresponsiblereporting).Themaincriticismsof themediawerethosereportinglackedcontextandfacts,andthepresenceoftoomisinformation.There was also an element of mistrust, with some suspicions that the media overhyping stories in order to increase readership/viewership and consequently create a false sense of alarm. If the information conveyedbythemediaisdeemedinadequateormistrusted,thenthepublicmaybelesslikelytoaccept themessages(HenrichandHolmes,2011). 41
Moreover,inafocusgroupconductedintheUK,themediacoverageofH1N1wasdescribedbymanyof the participants as scaremongering. They expressed concern about the way media deliberately tried to induceunnecessarypanic.Nevertheless,peoplealsojudgedthatexaggerativejournalismtendedtohavea greater influence on others than on oneself (Hilton and Smith 2010). Also, a strong theme emerged in a focusgroupstudy;itwasacommongeneralskepticismtowardsmediamessagesaboutthepandemic.In particular,advertisingandnewssurroundingthepandemicwasseenasamplifiedandsomethingcausing unnecessarypanic(TeasdaleandYardley;2011). 2.3.5Internalcommunication Theinternalcommunicationisafundamentalissueduringcrisissituationwhenanorganizationisstruggling todealwitharapidlydevelopingandcomplexsituation.Somepaperfacetheinternalcommunicationissue from different points of view, particularly about information sharing among the various health agencies, andaboutinformationneedsofHCWs. Regarding the sources of information, the widest part of Emergencies Department (ED) personnel in US reportedthattheyobtainedinformationaboutH1N1pandemicfrommultiplesources(88%),internaland external(e.g.Internet,fromtheirownhealthcareservice,andothermediasources).TheCDCwascitedas themostoftenusedsiteforinformation.Inthisstudy,about40%ofEDstafffeltthattheywerereceiving mixed messages, but the majority (88%) were confident that the hospital had provided them with the informationandequipmenttoprotectthemandtheirfamilyfromtheH1N1virus(Kleinetal2010). AstudycarriedoutinKentucky(Howardetal2012)examinedtheroleofLocalHealthDepartment(LHD)in disseminating information among local health care professional, in particular among primary care practitioners,andpharmacists.Thesurveyshowedthat72%ofthemdidnotreceiveinformationfromthe LHD regarding H1N1, also in a situation with confirmed cases (71%). In addition, LHDs were more apt to communicate with physicians than pharmacists, despite both groups were playing critical roles in the protectionandcontrolofhealthcommunities. A survey conducted in Quebec among primary care practitioners found that about 85% of them encountered difficulties or experienced frustrations in their practice during H1N1 pandemic. In addition, more than 50% reported issues with the topdown management process, communication processes (clinical practice guidelines dissemination and communication routes), and patient management at the public health level. In particular, a slow communication process, an overwhelming number of communication sources, and an overwhelming number of divergent messages, sometimes lacking clarity, wereidentifiedasthemainproblems(Nhanetal2012). According with the Crisis and emergency risk communication (CERC) (CDC, 2006) a timely information to thepublicisacentralcomponentofemergencyresponse.Inaccordwiththisindicationastudyassessed 42
theresponseofHealthdepartmentstoprovideonlineinformationwithintwentyfourhoursafterapublic health emergency declaration. This study showed that the 46 out of 51 states had at least some specific information on H1N1 on their web sites, and the information was generally easy to access. Thirty sites includedinformationforhealthcareproviders;fourteenprovidedtheirowncontent,andsixteenlinkedto theCDCinformation.Slightlyoverhalfhadpressreleasespostedontheirsites.Ninestateshadinformation or a link to information in another language on their home pages. In contrast to what was observed for states,only34%(52outof153)oflocalhealthdepartmentWebsitessampledprovidedanyinformation specifictoH1N1withintwentyfourhoursafterthedeclarationofapublichealthemergency.Morethan half(54%)accomplishedthisbylinkingtotheCDCortheirrespectivestatehealthdepartmentwebsites. Lessactivecommunicationwasnotedforlocalhealthdepartments:only14%hadpostedapressrelease (Ringeletal2009). Abouttheinformationalandeducationalneed,twostudiesconductedinQuebecandtheUShighlightsthat primary care physician (like family practitioners, general internists, pediatricians) needed additional information,inparticularrelatedtoinfectioncontrolmeasures,influenzavaccineanditsadministration,in generalandforspecificriskgroups(Clarketal2011;Nhanetal2012). 2.3.6Discussion Aboutthepopulation The Protection Motivation Theory and Extended Parallel Process Model (Rogers 1975 and 1983; Witte, 2000) suggested that individuals will engage in adaptive behaviour if they perceive a significant and relevant threat, and perceived that the proposed solution will effectively avoid the threat. However, the resultsofthisreviewshowedthatlittlenewsaddressedallfourrecommendedcomponentsofthreatand efficacy (severity, susceptibility, individual and collective efficacy) (Witte et al 1992), which could potentially reduce the likelihood of readers or viewers responding adaptively (Goodall et al 2011). Furthermore,inordertoimprovefuturepandemicpreparedness,thefindingssuggestthatattemptsshould bemade.Inparticularitiscrucialtoelicitandaddresscommondoubtsandconcerns,toreduceperceived barriers to recommended behaviours, to emphasize the benefits and to find ways to support people to adopt them, also considering the likely contextual factors that may affect perceptions of the advice (Teasdale and Yardley 2011). The communicators have to take in consideration that information distributionisnotonesizefitallandmustbetailoredtothecommunicationpreferencesofthosewho need to have the information (Klein et al 2010). It is widely recognized that the information alone is not sufficienttomotivatepeopletobeprepared.Thewayinwhichinformationispresentedorconveyedisan importantfactorindetermininganindividualsresponse.Peoplewantedmessagesaboutspecificactions that they could have taken to protect themselves and their families and to mitigate any consequences. Theywantedtransparentandhonestcommunicationwherebothgoodandbadnewsisconveyed.There
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wasadesireacrossallgroupsforclearandspecificinformation,suchasinfectionand/ordeathratesand definingsymptoms.Thisreflectsafailuretodistinguishbetweenthepandemicanditsconsequencesand highlightstheimportanceofdoingsofortheriskcommunication(Grayetal2012). Aboutthestrategy AssuggestedbyDuncan(2009),intheearlyphasesofapandemic,thepublichealthcommunicationseems tobeappropriate.InparticularthenationalandinternationalHealthAuthoritiesfollowthesuggestionof theWHOsOutbreakCommunicationGuidelinesorCDCsadviceontheneedtoannounceearly,orBe firstengagingwiththemediaproactivelyassoonastheybecomeawareofamajorpublichealthevent, such as the emergence of a new virus (WHO, 2005; CDC, 2006). In general, H1N1 attracted greater newspapercoverageespeciallyduringthespring2009whenthenovelvirusemergedandspreadaround theworld.ThemediacoveragewasalsofollowingthemajoreventsrelatedtoH1N1pandemic.Later,the mediahadbeenaccused ofexaggeratingrisks,but alsothehealthauthorities,andcontributingtopublic worry.IntheEUcountriesoccurredakindofregretamongmembersofthepressaftertherelativelymild course of the pandemic. Some also accused epidemiologists and public health authorities of having overstatedthethreat(NerlichandKoteyko,2012). Whilst a systematic analysis of newsprint media coverage has found no evidence of exaggerating the contentofreporting(Hiltonetal2012;Duncanetal2009),inqualitativestudiesparticipantsfoundthatthe highlevelsofH1N1coveragedisconcertedandcreatedafalsesenseofalarm(TeasdaleandYardley,2011; Gray et al 2012; Hilton and Smith, 2010; Henrich and Holmes, 2011). This seems to correspond with the agenda setting model which refers that there is a strong correlation between the emphasis that mass mediaputoncertainissues(e.g.,basedonrelativeplacementoramountofcoverage)andtheimportance attributedtotheseissuesbymassaudiences(McCombsandShaw,1972;ScheufeleandTewksbury,2007). Butnotonly,infactitisinterestingthatparticipantstothefocusgroupwereaskedtodescribetheirimages of H1N1. Usually, they reported images of Mexico, pigs, and people wearing face masks. Some participantsmentionedmoredramaticimagesincluding:chaos,death,bordersandairportsclosingand peoplebeingquarantined.Manyoftheseimagesappearedtohavecomedirectlyfromthemediaandit wascommonforparticipantstostatethattheyhadseentheseimagesonTV,orinthenewspapers(Hilton andSmith,2010). The H1N1 pandemic also showed several examples of mediated risk conflicts, where statements or demandsfromstakeholdersledtoachangeintherecommendationsmadebypublichealthauthorities.For example,on28AprilBesser,theactingheadoftheCentersforDiseaseControlandPrevention,approved CDC recommendations that schools should close if one student or staff member came down with confirmedflu,andstayclosedfor14days.Butthisdecisionwasntcompletelyappreciatedforthepolitical ramifications.Inparticularattheeducationdepartment,werentsatisfiedthattheyhadntbeenconsulted. 44
Finally,Besserwashandedguidelineswithamildrevision:closureforoneweekfollowedbyreassessment (Maher,2010). Aboutnewandsocialmedia In response to the H1N1 pandemic, some health agencies decided to use the social media. The CDC in particularusedanykindofnewsmedia.CDCstartedwithpodcast,RSSfeeds,Facebook,MySpace,Flickr, andTwitterinfirstinstance.Thenincreaseditsactiontoofferbuttonsandbadges,apilotmobiletexting program, YouTube videos, widgets and pilot syndicate Web pages (Reynolds, 2010 A video about the Symptoms of H1N1 (Swine Flu) uploaded on YouTube on the 28th of April was viewed by 2.130.028 people,mostofthevisitswereduringthesameuploadingdaythoughtherewereonly140349viewersfor aneducationalvideocalledCleanhandstopreventflu. Howeverageneralconsiderationcanbemade:sometimesthesenewadvancedtoolsareusedaccordingly tooldtraditionalcommunicationstrategies.TheNHSpublishedonYouTubeavideocalledCatchit.Binit. Killit,viewedby12787people.Mostofthepeopleviewedthisvideoduringthefirstdayofpublication: (30thApril2009).Ontheotherhand,aparodyversionuploadedinthesamedaybyaYouTubeuser,drowed 138365viewers,almostfifteentimesmorethantheoriginalone.Thisdoesntmeanthatthebestwayto communicateistoprovidefunnyvideosduringacrisistimebuttofoundakeyformoreeffectiveweb2.0 communicationstrategy. It is paradigmatic what Barbara Reynolds (the crisis communication senior advisor in the Office of the Director,CentersforDiseaseControlandPrevention)said:CDCmadetheconsciousdecisiontomaintain its scientific integrity in its messaging through these new media (e.g., it used simple but still formal language,notjargon)andalsorespectthenormsofthesocialnetworksitjoined(Reynolds,2010).
2.4Lessonslearnt,exercisesundertakenbyvariouscountriesandinternational organizations
Conflusion(theaggregationofstreamingtogetherofmultipleconfusingitems,asinaconfluenceofconfusion)is
whatthepublicisfeelinginresponsetotheseeminglyendlessstreamofcontradictorynewsaboutH1N1influenza PicardA.,TheGlobeandMail,October9,2009
Thefundamentaldifficultiesarethatthemessageswillbemorenumerousandmorecomplex, andtheprecisecontentofthemessagesisuncertainfornowandwilldependonthespecificsofhowthepublichealth situationunfolds ExecutiveOfficeofthePresidentoftheUnitedStates,2009
Inthecaseofapandemic,appropriatecommunicationandeducationensurethatthepublic,healthcare professionalsandstakeholdersknowhowtobestprotecttheirhealthandthehealthofothers.Timelyand 45
accurate communication is essential to inform and educate, so addressing concerns and reactions to a spreading pandemic. Also, effective communication is considered to be essential not only to provide advice, information and reassurance, but also to encourage individuals to take personal preventative actionsandtoasksupportfornecessarynationalresponses,andtobuildandmaintaintheirconfidencein thegovernmentresponseduringapandemic. Pandemic influenza communication has been based on a strategic risk communication approach, and consistedoffiveprinciples(WHO,2004,2005a;2005b;CDC,2007):buildingtrust,announcingearly,being transparent, respecting public concerns and planning in advance. These goals were to address and meet the communication expectations of the public and the partners, including government officials, medical professionals,andthepublic. Thecommunicationstrategyincludedflexibilityandproactivecommunicationinresponsetotheevolving situation,managinguncertainty,andacknowledgingwhatwasunknown,aswellaswhatwasknown.The communicationstrategywasfocusedonfewobjectives:providinginformationtohelphealthcareservices, addressingthepublictomanagethenewvirus,marketingandadvertisingtacticsforinfectionprevention behaviours, personal preparedness, and over the time, a call to action for people and HCWs to get vaccinated. Iftheguidelinesandtheobjectivesappearedclear,moredifficultwastomanageacomplexsituationthat requires an understanding of the broader political, social and cultural environment in which communication occurs (Abraham, 2009). H1N1 pandemic management stimulated a number of controversiesaroundtheworldin2009and,althoughworldmediacoveragefadedin2010,thedebateis stillgoingon. 2.4.1Internalcommunication The internal communication is a fundamental key during crisis situation, and at the same time it is particularly critical; in fact, coordinating communication on both at vertical and horizontal level could be complicate. Within this scenario, the international organizations, such as the WHO and the CDC/ECDC playedapreciousroleinregularlyupdatinghealthprofessionalstoaddressactionandconcernsonspecific questions(EUConferenceReport,2011). From many countries and agencies the need to improve internal communication emerged (Sweet, 2009; Deirdre Hine 2010; Tay et al 2010; WHO Europe, 2010; WHO, 2011; Greco et al 2011). For example, in Canada advanced work with national and international partners formed important links that were useful during the H1N1 response. But, the messages provided across federal, provincial, and territorial jurisdictions werent always consistent. The reviewers indicate that is necessary to improve coordination amongdifferentapproaches,communicationandmarketingtools,tacticsandmessaging.Inparticular,the 46
WHO(2010)suggestedthatthefollowingareneededtoimprovecommunicationeffectivenesswithinthe healthcaresystem: Developmentofverticalnetworksbetweentheministriesofhealthandhealthcareworkers New communication tools (e.g. established through the internet) should be considered, as they haveprovedtobehelpful Coordination within a hospital benefits from choosing one person to disseminate information, primarilynecessaryforearlyidentificationofcases,butalsoduringotherstagesoftheresponse Moreover,thecommunicationstrategiesforthehealthcaresectorshouldthereforetakeintoaccountthe possibledifferencesinexpectations,andexplainclearlytherationaleforthedecisionaswellascustomize themessagestodifferenthealthcareworkeraudiences(Tayetal2010). Othercriticalelementsweretheinformationandthecommunicationaboutvaccine,andtherelatedissues, suchasthesafetyofadjuvants,thevaccinationofpregnantwomenandseriousadverseeventsfollowing pandemicvaccination.Alessonlearntfrommostcountriesisthatmorecommunicationonvaccinesafety datawasneededatthetimethevaccinationwasimplemented(EUConferenceReport,2011;DH/NHSFlu Resilience, 2010). Furthermore, healthcare professionals were considered as the keystone for reliable informationspeadingaboutvaccinesandantivirals.Forthisreasonitisthereforefundamentaltoexplore particularneedsandconcernsofhealthcareprofessionals,focusingonthedesignoffuturecommunications strategies(EuropeanMedicinesAgency,2011). IntheUKappearedoffundamentalimportancetoinvolveprofessionalhealthbodiesindiscussionableto create sources of direct clinical advice for health professionals during a pandemic. This may be most appropriatelyhostedbyoneormoreoftheprofessionalbodies(DeirdreHine2010).Thedevelopmentof CDCguidanceisanexampleofthiscollaborativecommunicationandsharingofinformationthattookplace betweenCDC,HHS,otherfederalagencies,andexternalpartners(CDC,2010).Thisprocessisparticularly important since there have been several instances in which recommendations have been controversial, particularlythoseregardinghospitalinfectioncontrol,whichhavesometimesbeenbasedonhypothetical concerns rather than epidemiological data. Some of these recommendations generated controversy and evenoutrightoppositionfromcaregivers.Forexample,CDCsrecommendationforuseofN95respirators by those caring for hospitalized 2009H1N1 patients is discordant with the views of several other expert bodies. Such conflicts can generate confusion and anxiety at many levels in the hospital workplace, impairing effective compliance with proper infection control, and undermining physician confidence in healthagenciesandpublicconfidenceinlocalinfectioncontrolmeasuresatatimewhenconfidencelevels needtobemaximized(USPresident2009;SocialstyrelsenandSwedishCivilContingencyAgency,2011).
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2.4.2Communicationwiththegeneralpublic
Theinstitutionsmustget[]learntocommunicatewithpublicandnottothepublic EU,2010 Ticklethepublic,makeemgrin,themoreyoutickle,themoreyouwin; teachthepublic,youllnevergetrich,youlllivelikebeggaranddieinditch OldjingleonthejournalismODohertyTheDublinreviewofbooks
ThedifficultiesfoundincommunicationduringH1N1pandemic,inducedsomeagenciestothinkthatinthe future,scienceandresearchmaywanttofocusmoreonfirmlydeterminingapandemicsvirulencebefore communicatingittothepublic(PublichealthagencyofCanadaandHealthCanada,2010).Butitisbynow evidentthatthisapproachisunsuccessful(WHO,2005;CDC2007).Itisimportanttobearinmindthatany futurepandemicwilltakeplaceinamultisourceenvironmentandthereforeawaitandseeapproachmay notbethebestonetotakewiththegeneralpublic. National health agencies put a great effort in developing a clear, consistent and coordinated communication across the full range of communication channels, tailored to the needs of specific audiences, even if these activities have been implemented with great variability in the various countries. Thiswasconsideredcrucialformaintainingpublictrust,complianceandsupportessentialtotheeffective managementofapandemic. 2.4.3Communicationtothemedia Mediastandardsandvaluesdifferfromthoseofthescientificandhealthcommunities.Themajorgoalsof the media are to be first, write stories with impact, win prizes, impress sources, figure out what is really happening,tellstoriesinacompellingway,andgetonthefrontpage.Theseaimsdonotproperlycoincide with the health experts goal of educating the public and gaining public confidence, understanding, and cooperating(Fineberg,2008).Forthisreasonitisimportanttoengageatrustyrelationshipwithjournalists tobetterguaranteegoodworkingrelationshipduringacrisis.Havingconsistentnewsbriefingsandworking to establish a collaborative relationship with the media during this time, is important to maximize communication through traditional media (Tay et al 2010). The European Union recommended also the constitution of a selected group of available experts to answer question from journalists, as well as the availabilityofspokesperson,factorsbothconsideredessential(EU,2010). 2.4.4Communicationonvaccination A particular challenge in communication about the vaccination program derived from public uncertainty regarding the safety of H1N1 vaccines. Some myths and rumours circulated widely on the Internet and throughviralemailsclaimingunsubstantiatedproblemsassociatedwithvaccination.Althoughmainstream 48
media generally discredited such claims, alternative media sources perpetuated myths and often used sensationalismtosustainviewerinterest.Publichealthorganizationssoughttocountertheserumourswith frequentupdates,includingfactualinformationaboutwhatwasbeingfoundthroughsafetymonitoringand through disseminating tools and information to health care providers and other sources of consumer information(Schuchatetal2011). Rapidresponsestrategiesareneededtocombatnegativerumoursaboutthevaccineandcoverage,aswell ascriticismsinmassmedia.Hence,theinformationmustbetransparenttoearnpeoplestrust.Activities and messages should reflect an appropriate understanding of the information needs and communication practices required for each audience (PAHO, 2009). The nationals programming must proactively address safetyconcernsandadverseevents,aswellasrespondtoantivaccinationmessages(Levineetal2010). Finally, Levine et al (2010) reported that in Israel and not only National priority groups for pandemic vaccineweredifferentthanthoseforseasonalvaccine,thusleadingtosomeconfusion.Prioritygroupsand vaccinationstrategiesaswellmaybedifferentamongcountries. During the World Influenza Congress in Singapore, it was highlighted that poor communication may also underliepoorinfluenzavaccineuptakebyhealthcareworkersdespiterecommendationsthattheyshould bevaccinatedtoprotectthehighriskpatientswithwhomtheymayhavecontact(Petrovsky,2010). InSweden,whereoversixtypercentofthepopulationgettingvaccinated,thefactorsthatledtogreater probability that a person would decide to uptake the pandemic vaccination were: a higher degree of perceived risk of being infected; a higher degree of anxiety about this form of influenza; and a higher degreeoftrustintheauthorities.Furthermore,thosewhodecidednottobevaccinatedthoughtthatthe authoritieswereexaggeratingtherisksassociatedwiththepandemic.Indeed,oneofthemostimportant questions for future preparedness is the need to maintain the public's confidence in the authority (SocialstyrelsenandSwedishCivilContingencyAgency,2011). 2.4.5Effectivecommunication Language Some reviewer suggested that some of the terminology used during the pandemic was not widely understood by the public. The scale of the governments planning assumptions did nothing to allay the widespreadbeliefthatapandemicmeantaveryseveredisease,ratherthanreferring,asitdoes,tothe geographical nature of its spread. Also, the use of the terms containment and reasonable worst case should be reconsidered as they can be easily misunderstood (Deirdre Hine, 2010; EU Conference report, 2011).Thisrequiresthatagenciesshouldreviewtheiruseoflanguageduringpandemicstoensurethatit accuratelyconveystheaimsoftheresponseeffortsandthelevelsofrisk.
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Mediachannels
Duringtheeventsauthoritiesshouldengagethemosteffectivechannelforreachingthegeneralpopulation and the specific risk groups. Communication strategies were based on the use of different media and communication channels. Among the traditional ones t television and radio (including community broadcasts), the printed press, and announcements on public thoroughfares were the most commonly used. Furthermore, new online communication technologies (including social networks) and mobile telephones have found to be effective. However, their use was mainly limited to urban areas and was selectivelydirectedtopeopleintheupperandmiddleclasswithhigheducationallevels(PAHO,2009). Spokespersons The countries adopted a single authoritative voice to provide information to the media (Deirdre Hine, 2010),ordifferenttypesofspokespersonswhohavecredibilitywiththetargetpopulation,thatcouldhelp totransmitpandemicinfluenzamessages(PublichealthagencyofCanadaandHealthCanada,2010;PAHO, 2009).MoststatesusedtheirChiefHealthOfficersastheirmainmediaspokesperson,allowingforanatural linkbetweendecisionmakingandpubliccommunicationresponsibilities(Weeramanthrietal2010). Targetingmessages Reachingaparticulargroupisessentialforaneffectivecommunication.InSweden,apublicopinionsurveys conducted during the pandemic found it hard to ensure that the message reached young people/young adults, and people whose mother tongue is not Swedish (Socialstyrelsen and Swedish Civil Contingency Agency,2011). Somecountriesusethesegmentedcommunicationtoreachtheneedofthedifferentpopulationtargetsor particular groups at risk, such as pregnant women, people with chronic diseases, and hardertoreach communitiesorthosewithspecificconcerns(DeirdreHine,2010;CDC,2010).GeneralPublicwasreached through the dissemination of numerous print materials in multiple languages or by their active downloading from institutional or health authorities websites. For the CDC, special audiences were identified for additional print materials including Native Americans, African Americans, Hispanics, young adults,firstresponders,andhealthcareworkers(CDC,2010). Timelycommunication Oneofthemainlessonlearntwastheimportanceofthestrategiesaimedtoprovideregularinformationon the latest developments of pandemic along with the public preventive measures. This has helped to prevent public panic and to promote personal protection against infection (Liang et al 2012). Another important factor for an effective communication was the timely and a transparent provision of updated informationinordertoeaseanxiety,andtoengagecitizenssuccessfullyinmeasurestocurbthespreadof thedisease(Tayetal2010).
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2.4.6Planningcommunication In many countries, a specific plan guided the communications and social marketing response during the H1N1pandemic(ExecutiveofficeofthePresidentoftheUS,2009;Sweet,2009; CDC,2010;Publichealth agencyofCanadaandHealthCanada,2010;DeirdreHine,2010;VanTametal2010;).Itappearedclear thatwithoutkeyactivities,suchasmediatrainingandcreativedevelopmentfortheadvertisingcampaign, itwouldhavebeenverydifficulttolaunchanyeffectivecampaign. Ingeneral,duringthefirstphaseofcommunicationthestrategyintendedtopromoteinfectionprevention behavioursincluding:frequenthandwashing,coughingintoonesarmnothand,stayinghomeifsick.These messageswerelatercomplementedwithpersonalpreparednessandimmunizationinformation. In some cases, a general plan including different responses and communication strategies based on different potential scenarios of the pandemic evolution were prepared in order to ensure preparedness andtocoveravarietyofcontingencies(ExecutiveofficeofthePresidentoftheUS,2009;Socialstyrelsen andSwedishCivilContingencyAgency,2011). Ontheotherhand,incaseofaH1N1pandemic,itwasobservedthattheabsenceofacomprehensiveand coherentcommunicationstrategycreatedconfusionleadingtolossofcredibilityamongthestakeholders andpublicalike(VanTametal2010). 2.4.7Areasforaction The expert reviewers (WHO Europe, 2010) found that the 20092010 response in the European Region sufferedofsomeproblematicareasandthusrequiredstrongeremphasisonthefollowingmainissues: Riskcommunicationingeneral,especiallyregardingvaccination Vertical communication within the health care system (with greater emphasis on frontline health careworkers) Duringthepandemicthe communicationwasdesignedonthereasonableworstcase.Thisassumption meantthattherewasanobviousgapbetweenwhatthegovernmentwassayingandwhatwasobservable ontheground,namelythatthediseasewasmildinmostcasesandthatmortalitylevelswerelow.Thisgap could have risked damaging the governments credibility and undermining public trust in the response (DeirdreHine,2010). AlsoinSwitzerland,inordertoraisepublicawareness,itwasdecidedtoadoptacommunicationstrategy based on a worst case scenario. But due to the lack of coordination between the various stakeholders, withinarelativelyshorttime,themessagesbecameconfused.Thedelayinthedeliveryofthevaccineand theextensiveacademicdiscussionswhichtookplaceaboutwhichvaccineforwhom?wereattheheartof
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thisconfusion.Tocomplicatemattersevenfurther,theescalationphasethenturnedintoadeescalation phase;clear,crediblecommunicationbecameclosetoimpossible(VanTametal2010). InAustralia,communicationhasbeeninconsistentpartlybecausedifferentpartsofthecountryhavegone throughthepandemicatdifferenttimesandofficialshavebeenfacedwiththechallengeofadjustingthe responsetocopewithaninfectionthathasnotbeenasdangerousastheworstcasescenarioexpectations thatunderpinnedplanning(Sweet,2009). Internalcommunication Duringthepandemicastrongefforttocoordinateinformationacrossdifferentlevelisneeded.However, there were cases where contradictory or slightly different messages were communicated based on national,regional,andlocallevel,butalsoamongcountriesandInternationalagencies.Thesedifferences ledtoconfusionaboutwhoseadvicetofollowamongcitizens.Forexample,whilethePublicHealthAgency ofCanadasadvicewasbasedonthebestscientificevidenceavailableatthetime,theapplicationofthis advice varied across the country due to differences in provincial legislation and policies. Only during the second wave, the federal and provincial/territorial governments collaborated on positions on masks and glovesandtriedtotakeacollectivedecisionsothatallwereapproachingtheissueinthesameway(Public healthagencyofCanadaandHealthCanada,2010). Communicatingriskanduncertainty Foralongtime,therewasconsiderableuncertaintyaboutthepandemicsdevelopmentandimpactandthe government,togheterwiththedevolvedadministrationswereinthechallengingpositionofsimultaneously asking the health services to prepare for the worst, while trying to reassure the public and accurately communicatethelevelofrisk. Theproblemofcommunicatinguncertainty,riskandshiftsinscientificthinkingisnotlimitedtothepublic orotherexternalstakeholders.Itisalsoproblematicwhencommunicatingfindings,evidenceandprocesses to decision makers and decision influencers (such as national agencies within the regional or local level) tryingtoensuretheapprovalofmessagestobecommunicatedtothegeneralpublic. In a crisis situation it is important to follow the communication principles which emphasize a focus on transparency and acknowledging uncertainty as well as the commitment to frequent updates if new informationemerges.Empathyandopennessarekeycomponentsofmessagedeliveryandcanevenhelp to sustain credibility of the investigation and response, even when information is limited and there are more questions than answers available (Schuchat et al 2011). Furthermore, the best practice in communicatingriskunderlinestheimportancenotjustofopennessbutalsooftransparencyinthewayin whichassessmentsaremadeanddecisionsaretaken(DeirdreHine,2010).
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Flexibilityofcommunication Inunpredictablesituationstheplanstatementsshouldbeveryquicklyrevised,andthestrategy,messages andmaterialsmightbepromptlyadaptedtofitthecircumstances(DeirdreHine2010). Proactiveandassertivecommunication From the results of the reviewed papers it could be highlighted that the agencies could have been more proactiveinidentifyingandchallenginginaccurateinformationoradviceandrespondingtoconcernsand misunderstandings.Amoreaggressivecommunicationscampaignthatfocusedondispellingconcernsthat the vaccine was not safe and had been rushed into production without the usual rigorous testing and licensing may have helped uptake rates. The communication with sections of the public with particular concernsmayalsohavebeenuseful,playinganimportantroleintacklingrumoursandmisunderstanding. (DeirdreHine2010). Targetingmessages Most of communication activities targeted the general population with guidance for specific populations coming later in the process. While a broad communication strategy is essential in keeping citizens informed, a more targeted approach may also be necessary to ensure higher risk groups or vulnerable populationstoreceivetimelyandspecificinformationnecessarytorespondtofacethepandemic(Public health agency of Canadaand Health Canada, 2010; Deirdre Hine 2010). Agencies must also acknowledge that the public are different and need to be involved in both the development and management of pandemic response initiatives, appropriate for different communities and sensitive to existing cultural practices(Grayetal2012). Newandsocialmedia The H1N1 was the first pandemic with a blogosphere and other rapid communication tools that were impossibletoignore(ECDC,2010).Newandsocialmediawereusedbothtodisseminateinformationand tomonitortheissuesofconcernfrompopulation,withtheaim,forexample,toidentifytheconcernsthat pregnantwomenhadaboutvaccination.Theirusewasdifferentamongcountriesandthebestpracticeof their application comes from to CDC. In the UK were used Facebook, Twitter and YouTube are primarily used to redirect people to National Health Service website rather than to engage in discussion (Deirdre Hine,2010).However,inothercountriestheuseofnewmedia,andsocialnetworksinparticular,islimited. Forthefuture,theWHOdeclaredthattheuseofnewinformationtechnologies,includingsocialnetworks, should be an essential part of strategic communications planning, including research, training and guidelinesforMemberStates(WHO,2011).
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Communicationwithmedia Different National Health Agencies started to consider that the journalists need to engage in a more proactivelyway. RecommendationsfromWHOexpertreviewers Theexpertreviewers(WHOEurope,2010)evidencedthetintheEuropeanRegiontheneedofaneffective communicationamonghealthcareprofessionals,thepublicandotherstakeholdersarerequired.Theareas thatmustbefurtherimplementedordevelopedwereidentifiedfromthefollowingcriticalpoints: Providingguidanceonstrategiesforeffectivecommunicationtothepublic,whichincludetraining needsofministryspokespersons Developing indicators to monitor the extent to which the information received by health care professionalsisappropriateanduseful Regardingriskcommunicationcapacity: Generalstrengtheningofriskcommunicationcapacityandcapabilityatthenational,regionaland locallevelsisneeded Thecommunicationonthecriteriaforthetransitionbetweenthephases(e.g.geographicalspread versustheseverityofdisease)needstobeimproved Needs for a rapid information flow from national to regional levels, including outbreak investigationfindings,surveillancedata,etc.toensureatimelyresponse Averycriticalissuewasidentifiedtobethecommunicationaboutpandemicvaccines: It is important to communicate to health care workers and the public the efficacy and safety of vaccinesincountriesthathaveaccesstothevaccineinaunifiedandeffectiveway Campaignsonvaccineefficacyandsafetyneedtobemoreaggressiveandruninatimelymanner, e.g.beforevaccinearrival Awareness and effective use of new information technologies and media (e.g. social media) is essentialthroughtheprovisionoftraining,guidelinesandresearch Inthisscenarioandforthefuture,theroleofInternationalagencies,suchasWHO,butalsonationalagency likeCDC,werefundamentaltoimprovecommunicationduringcrisis,inparticularfor: Supportthedevelopmentandreinforcementofriskcommunicationnetworks
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Revisethepandemicguidancewithrespecttothephases Improve flexibility of guidance by providing multiple scenarios for planning (e.g. mild/severe situations) and clearer guidance on actions that are required and are dependent upon possible differentsituationsfacedattheregionallevel
Furthermore, this expert review suggest that there are common thematic elements that should be considered as essential by individual Member States when revising, reformulating or updating national pandemic plans (and associated preparedness activities) during the postpandemic evaluation period. Theseare: Communication Coordination Capacity Adaptability(flexibility) Leadership MutualSupport
CALM
CONCLUSIONSANDRECOMMENDATIONS
In accord to WHO (2010), risk communication aims to promote a positive social response to pandemic interventions. It also aims to induce preventive action and appropriate behaviour change among populations.Thestrategiesutilizedduringtheinfluenzapandemic2009includedspeakingwithonevoice, involvingacademicexpertsandgovernmentofficialsintheeffort,andtargetingcoregroupsofpopulations at risk. The activities include awareness campaigns, advocacy, call centers, online response capacities, NGOandprivatesectorpartnerships.However,duringtheEuropeanworkshopinBrussels(2010)anumber of participants reported that communication was a major and complex issue that needed further improvement.Thechallengesweretorespondtothevariouspublicconcernsandtoachieveahighlevelof transparencyoverthediseaseburden.Itwasalsoemphasizedthatcommunicationonvaccineissuesshould receivehigherfocusinpandemicpreparedness,atalllevels(EUConferencereport,2011;RoperoAlvarez etal2012).
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To manage this complexity accordingly with Abraham (2009), successful communication requires an understanding of the broader political, social and cultural environment in which communication occurs. Communicatorsneedtoexplicitlydeveloptoolstoensurethevisibilityandlegitimacyoftheirmessageina crowded political environment. The existing WHO outbreak communication principles of early announcement, trust and transparency achieve this to a certain extent. However, additional work is requiredtodeveloppracticesandprinciplestoensurevisibilityandlegitimacyofcommunication.Choosing the best channels of communication, targeting primary audiences and finding spokespeople who provide legitimacyaresomeoftheissuethatneedtobeexplicitlyaddressed.Communicatorsskilledinbehaviour changecommunicationandsocialmobilizationownavarietyoftoolstodealwiththeseissuesandsothey areoftencalledonduringoutbreaks.Itwouldbebeneficialifthesetoolswereincorporatedintogeneral outbreakcommunicationprinciples(Abraham,2009). Finally, the news media tools and the novel information sources were also considered the basis for an informationrevolutioninpublichealth,particularlyinepidemiologyandsurveillance(i.e.,biosurveillance) (Eysenbach,2009).WiththewordofKhanetal(2010)thisInternetrevolutionwouldleadtoanincreased availability of electronic heathrelated information. Improved information technology have given public health practitioners unprecedented access to novel streams of information and the ability to establish social networks for analysis and dissemination. Capitalizing on this opportunity will require the public health community to change its organizational culture so that the uses of information are not limited to traditional surveillance and direct notification. Instead, we must collectively learn to share information, rewardthesharingandreuseofinformationacrossdomains,andexpandtheboundariesofpublichealthto multiplenewsectors.Thisisalsoforthepublichealthcommunication,methodsandevaluation.
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ACKNOWLEDGEMENTS
We acknowledge our colleagues from the Istituto Superiore di Sanit Resource Center, Ilaria Giovannelli andValerioOcchiodoroforthevaluablesupportprovidedforpapersresearchanddownload.
CONTRIBUTORSOFAUTHORS
1
ChiaraCattaneoconceptionanddesign,designofthestrategyresearch,eligibilitycriteria,datachecking,
readeligiblepapers,analysisandinterpretationofdata,reportwriter.
1
AntoninoBellaanalysisandinterpretationofmetaanalysisdata,statisticalmethodsandresultsofmeta
analysiswriter.
1
AntonellaLattanzidesignofthestrategyresearch,greyliteratureresearch,datachecking,criticalreview.
DonatoGrecoconceptionanddesign,datachecking,eligibilitycriteria,criticalreview.
2,3
ChiaraBassidesignofthestrategyresearch,conductedsearches,criticalreview. SimonaDiMariodesignofthestrategyresearch,criticalreview.
2,3
MariaLuisaMorodesignofthestrategyresearch,criticalreview. BarbaraDeMeiconceptionanddesign,workinggroupcreator. StefaniaSalmasoconceptionanddesign,workinggroupcreator.
1 2
NationalInstituteofHealthNationalCentreofEpidemiology,SurveillanceandHealthPromotion AziendaRegionaleSocioSanitariaEmiliaRomagna 3 CentroperlaValutazionedellEfficaciaedellAssistenzaSanitariaCeVEAS
57
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RESULTSOFQUANTITATIVEMETAANALYSIS
Peoplewhoreceivedvaccination.Percentagepool=12%(95%CI0.060.19)
Study
ID
ES (95% CI)
Weight
Galarce EM (2011)
0.20 (0.18, 0.22)
11.11
Jehn M (2011)
0.01 (0.00, 0.02)
11.21
Lau JTF (2008)
0.18 (0.14, 0.22)
10.70
Lin Y (2011)
0.11 (0.10, 0.11)
11.21
Santibanez TA (2012)
0.24 (0.24, 0.25)
11.22
Schwarzinger M (2010)
0.02 (0.01, 0.02)
11.21
Vaux (2011)
0.11 (0.10, 0.12)
11.21
Velan B (2011)
0.17 (0.14, 0.20)
10.91
Walter D (2011)
0.08 (0.08, 0.09)
11.22
Overall (I-squared = 99.9%, p = 0.000)
0.12 (0.06, 0.19)
100.00
NOTE: Weights are from random effects analysis
.1
.2
.5
D1.1Systematicreviewofstudiesaddressingpopulationbehavioursduringinfectiousoutbreaksandreviewofoutbreakcommunicationin2009pandemic TELLMEprojectGA:278723
Study ID
Peoplewhowouldreceivedvaccination.Percentagepool=42%(95%CI0.310.52)
% ES (95% CI) Weight
Barr M (2008) de Zwart O (2010) Eastwood (2009) Ferrante G (2011) Jehn M (2011) Kiviniemi MT (2011) Lau JTF (2010) Mauer J (2009) Mauer J (2010) Quinn SC (2009) Schwarzinger M (2010) Seale H (2010) Sypsa V (2009) van der Weerd (2011) Wong LP (2010) Zijtregtop EAM (2009) Overall (I-squared = 99.9%, p = 0.000) NOTE: Weights are from random effects analysis 0 .1 .2 .5 1
0.75 (0.74, 0.77) 0.05 (0.04, 0.06) 0.67 (0.64, 0.70) 0.22 (0.21, 0.23) 0.53 (0.49, 0.57) 0.64 (0.61, 0.67) 0.36 (0.30, 0.41) 0.50 (0.47, 0.52) 0.20 (0.19, 0.21) 0.09 (0.07, 0.10) 0.17 (0.15, 0.19) 0.50 (0.46, 0.54) 0.23 (0.22, 0.24) 0.43 (0.42, 0.44) 0.70 (0.67, 0.73) 0.66 (0.61, 0.70) 0.42 (0.31, 0.52)
6.26 6.28 6.24 6.27 6.23 6.24 6.17 6.26 6.27 6.27 6.27 6.22 6.27 6.27 6.25 6.22 100.00
Peoplewithahighlevelofperceivedrisk.Percentagepool=36%(95%CI0.180.55)
Study ID ES (95% CI)
% Weight
de Zwart O (2010) Eastwood (2009) Eastwood (2009) Jehn M (2011) Jones SC (2008) Kamate SK (2010) Lau JTF (2007) Lau JTF (2010) Lau JTF (2009) Quinn SC (2009) Schwarzinger M (2010) Seale H (2010) Walter D (2012) Wong LP (2010) Overall (I-squared = 99.9%, p = 0.000) NOTE: Weights are from random effects analysis 0 .1 .2 .5 1
0.90 (0.89, 0.91) 0.15 (0.13, 0.17) 0.20 (0.17, 0.23) 0.76 (0.73, 0.79) 0.11 (0.07, 0.15) 0.35 (0.31, 0.38) 0.74 (0.71, 0.77) 0.12 (0.08, 0.16) 0.13 (0.10, 0.15) 0.42 (0.40, 0.45) 0.36 (0.34, 0.37) 0.44 (0.40, 0.48) 0.18 (0.17, 0.19) 0.25 (0.23, 0.28) 0.36 (0.18, 0.55)
7.15 7.15 7.14 7.14 7.13 7.14 7.14 7.14 7.14 7.15 7.15 7.13 7.15 7.14 100.00
Peoplewithahighlevelofperceivedsusceptibility.Percentagepool=24%(95%CI0.180.30)
% Weight 3.82 3.86 3.87 3.89 3.85 3.88 3.73 3.84 3.84 3.87 3.84 3.88 3.88 3.80 3.87 3.83 3.86 3.87 3.87 3.88 3.83 3.85 3.78 3.78 3.86 3.87 100.00
Study ID Blendon RJ (2004) Blendon RJ (2004) Brug J (2004) de Zwart O (2010) Eastwood (2009) Ferrante G (2011) Goodwin R (2010) Jehn M (2011) Kamate SK (2010) Lau JTF (2010) Lau JTF (2007) Lau JTF (2010) Lau JTF (2003) Lau JTF (2010) Lau JTF (2009) Lau JTF (2007) Leung GM (2003) Quah SR (2004) Quinn SC (2009) Schwarzinger M (2010) Seale H (2009) Seale H (2010) Vartti AM (2009) Vartti AM (2009) Wong LP (2010) Zijtregtop EAM (2009) Overall (I-squared = 99.6%, p = 0.000) NOTE: Weights are from random effects analysis 0 .1 .2 .5 1
ES (95% CI) 0.32 (0.28, 0.36) 0.57 (0.54, 0.60) 0.05 (0.03, 0.07) 0.02 (0.02, 0.02) 0.25 (0.22, 0.28) 0.33 (0.32, 0.34) 0.25 (0.19, 0.31) 0.34 (0.31, 0.37) 0.35 (0.31, 0.38) 0.12 (0.10, 0.14) 0.41 (0.38, 0.45) 0.41 (0.40, 0.43) 0.09 (0.07, 0.10) 0.22 (0.18, 0.27) 0.07 (0.05, 0.10) 0.27 (0.23, 0.31) 0.31 (0.28, 0.34) 0.14 (0.12, 0.16) 0.14 (0.12, 0.16) 0.08 (0.07, 0.09) 0.21 (0.18, 0.25) 0.17 (0.14, 0.20) 0.29 (0.24, 0.34) 0.49 (0.44, 0.54) 0.19 (0.16, 0.21) 0.06 (0.04, 0.08) 0.24 (0.18, 0.30)
Peoplewithahighlevelofworry.Percentagepool=24%(95%CI0.180.30)
% Weight
Blendon RJ (2004) Brug J (2004) Ferrante G (2011) Goodwin R (2010) Lau JTF (2010) Lau JTF (2003) Lau JTF (2009) Lin Y (2011) Peng EYC (2010) Quinn SC (2009) Santibanez TA (2012) Schwarzinger M (2010) Vartti AM (2009) Vartti AM (2009) Wong LP (2010) Overall (I-squared = 99.6%, p = 0.000) NOTE: Weights are from random effects analysis 0 .1 .2 .5 1
0.35 (0.31, 0.39) 0.39 (0.34, 0.44) 0.26 (0.25, 0.27) 0.40 (0.33, 0.47) 0.15 (0.14, 0.16) 0.34 (0.31, 0.36) 0.16 (0.13, 0.19) 0.25 (0.24, 0.26) 0.60 (0.57, 0.63) 0.46 (0.44, 0.49) 0.31 (0.31, 0.32) 0.15 (0.14, 0.17) 0.91 (0.88, 0.94) 0.52 (0.47, 0.57) 0.34 (0.31, 0.37) 0.37 (0.31, 0.43)
6.59 6.50 6.79 6.21 6.79 6.73 6.69 6.80 6.72 6.73 6.81 6.78 6.68 6.49 6.70 100.00
Peoplewithahighlevelofworry.Percentagepool=37%(95%CI0.310.43)
% Weight
Blendon RJ (2004) Brug J (2004) Ferrante G (2011) Goodwin R (2010) Lau JTF (2010) Lau JTF (2003) Lau JTF (2009) Lin Y (2011) Peng EYC (2010) Quinn SC (2009) Santibanez TA (2012) Schwarzinger M (2010) Vartti AM (2009) Vartti AM (2009) Wong LP (2010) Overall (I-squared = 99.6%, p = 0.000) NOTE: Weights are from random effects analysis 0 .1 .2 .5 1
0.35 (0.31, 0.39) 0.39 (0.34, 0.44) 0.26 (0.25, 0.27) 0.40 (0.33, 0.47) 0.15 (0.14, 0.16) 0.34 (0.31, 0.36) 0.16 (0.13, 0.19) 0.25 (0.24, 0.26) 0.60 (0.57, 0.63) 0.46 (0.44, 0.49) 0.31 (0.31, 0.32) 0.15 (0.14, 0.17) 0.91 (0.88, 0.94) 0.52 (0.47, 0.57) 0.34 (0.31, 0.37) 0.37 (0.31, 0.43)
6.59 6.50 6.79 6.21 6.79 6.73 6.69 6.80 6.72 6.73 6.81 6.78 6.68 6.49 6.70 100.00
Peoplewithahighleveloftrust.Percentagepool=62%(95%CI0.500.74)
% Weight
Jones SC (2008) Kamate SK (2010) Lau JTF (2010) Lau JTF (2009) Peng EYC (2010) Quinn SC (2009) Seale H (2009) Seale H (2010) van der Weerd (2011) Overall (I-squared = 99.6%, p = 0.000)
0.55 (0.48, 0.62) 0.33 (0.29, 0.36) 0.92 (0.91, 0.94) 0.84 (0.81, 0.87) 0.70 (0.68, 0.73) 0.46 (0.43, 0.48) 0.58 (0.54, 0.62) 0.58 (0.54, 0.62) 0.61 (0.60, 0.62) 0.62 (0.50, 0.74)
10.84 11.13 11.19 11.14 11.16 11.17 11.06 11.09 11.21 100.00
NOTE: Weights are from random effects analysis 0 .1 .2 .5 1
Peoplewhoincreaseahandwashing.Percentagepool=57%(95%CI0.400.74)
% Weight
Balkhy HH (2010) Blendon RJ (2004) Brug J (2004) Jehn M (2011) Kamate SK (2010) Kiviniemi MT (2011) Lau JTF (2003) Lau JTF (2009) Leung GM (2004) Leung GM (2004) Lin Y (2011) Miao YY (2012) Quah SR (2004) Rubin GJ (2009) Seale H (2010) Vartti AM (2009) Vartti AM (2009) Overall (I-squared = 99.9%, p = 0.000) NOTE: Weights are from random effects analysis 0 .1 .2 .5 1
0.58 (0.55, 0.60) 0.39 (0.37, 0.41) 0.02 (0.01, 0.04) 0.92 (0.90, 0.94) 0.55 (0.51, 0.58) 0.98 (0.97, 0.99) 0.87 (0.85, 0.89) 0.74 (0.70, 0.77) 0.82 (0.79, 0.85) 0.82 (0.80, 0.84) 0.57 (0.56, 0.58) 0.77 (0.75, 0.80) 0.81 (0.79, 0.83) 0.28 (0.25, 0.31) 0.48 (0.44, 0.52) 0.06 (0.03, 0.08) 0.02 (0.00, 0.03) 0.57 (0.40, 0.74)
5.88 5.88 5.89 5.88 5.88 5.89 5.89 5.87 5.88 5.88 5.89 5.88 5.88 5.88 5.87 5.88 5.89 100.00
Peoplewhoavoidedcrowedplace.Percentagepool=29%(95%CI0.140.43)
Study ID ES (95% CI) % Weight
Blendon RJ (2004) Blendon RJ (2004) Brug J (2004) Jehn M (2011) Kamate SK (2010) Lau JTF (2010) Lau JTF (2003) Lau JTF (2009) Lin Y (2011) Rubin GJ (2009) Seale H (2010) Overall (I-squared = 99.9%, p = 0.000)
0.07 (0.05, 0.09) 0.14 (0.12, 0.16) 0.02 (0.01, 0.04) 0.45 (0.41, 0.49) 0.53 (0.49, 0.56) 0.55 (0.52, 0.58) 0.76 (0.73, 0.78) 0.09 (0.07, 0.12) 0.43 (0.42, 0.44) 0.04 (0.03, 0.05) 0.09 (0.06, 0.11) 0.29 (0.14, 0.43)
9.09 9.10 9.10 9.06 9.07 9.08 9.09 9.09 9.11 9.11 9.09 100.00
Peoplewhowearingfacemask.Percentagepool=21%(95%CI0.120.30)
% Weight
Blendon RJ (2004) Blendon RJ (2004) Brug J (2004) de Zwart O (2010) Lau JTF (2003) Lau JTF (2009) Leung GM (2004) Leung GM (2004) Quah SR (2004) Tang CS (2004) Vartti AM (2009) Vartti AM (2009) Overall (I-squared = 99.8%, p = 0.000)
0.03 (0.02, 0.04) 0.02 (0.01, 0.03) 0.04 (0.02, 0.06) 0.02 (0.02, 0.02) 0.64 (0.62, 0.67) 0.13 (0.11, 0.16) 0.79 (0.76, 0.82) 0.04 (0.03, 0.05) 0.04 (0.03, 0.05) 0.61 (0.59, 0.64) 0.10 (0.07, 0.13) 0.04 (0.02, 0.06) 0.21 (0.12, 0.30)
8.35 8.37 8.34 8.37 8.32 8.30 8.29 8.36 8.36 8.31 8.27 8.34 100.00
Peoplewhowillingnesswithquarantine.Percentagepool=85%(95%CI0.800.91)
% Weight
Barr M (2008) Blendon RJ (2004) Eastwood (2009) Jones SC (2008) Lau JTF (2010) Lau JTF (2007) Leung GM (2004) Leung GM (2004) Quah SR (2004) Seale H (2009) Overall (I-squared = 98.9%, p = 0.000)
0.70 (0.68, 0.72) 0.93 (0.91, 0.95) 0.94 (0.93, 0.95) 0.96 (0.93, 0.99) 0.88 (0.87, 0.89) 0.88 (0.85, 0.91) 0.93 (0.91, 0.95) 0.92 (0.90, 0.93) 0.72 (0.69, 0.74) 0.63 (0.59, 0.68) 0.85 (0.80, 0.91)
10.06 10.02 10.13 9.95 10.15 9.93 10.07 10.11 9.97 9.62 100.00
CHARACTERISTICSOFSTUDIES
Tab.1.Characteristicsofincludedstudies
Miao2012 Studydesign Methods Participants Country Disease Psychologicaltheory Behaviour Crosssectional Telephonesurvey n=1079,15yearsold Taiwan Swineflu Nonestated 77%increasehandhygiene
Outcomes:factorsassociated HandhygienepracticeassociatewithhealthbeliefsthatpH1N1wasmore withbehaviororintention transmissiblethanavianinfluenza;thatpH1N1wasslightlymoresevereinTaiwan comparedwithothercountries;thathandwashingwasveryeffectiveinpreventing pH1N1,andthathandwashingaftercontactwithpossiblypH1N1contaminated objectssurfaceswasnotvery/notdifficultatall Santibanez2012 Studydesign Methods Participants Country Disease Psychologicaltheory Behaviour Crosssectional Telephonesurvey n=55850,18yearsold US Swineflu Nonestated Vaccination:24.5%
Outcomes:factorsassociated Opinionsaboutinfluenzavaccineanddiseasevariedsignificantlybyraceethnicity, withbehaviororintention income,andeducationlevel Savoia2012 Studydesign Methods Participants Country Disease Psychologicaltheory Behaviour Crosssectional Telephonesurvey n=1569,18yearsold US Swineflu Nonestated Knowledgevssocioeconomicstatus
Outcomes:factorsassociated Levelofeducation andhomeownership,reliableindicatorsofsocioeconomicposition withbehaviororintention (SEP),wereassociatedwithknowledgeofH1N1.Levelofeducationwasfoundtobe directlyassociatedwithlevelofknowledgeaboutvirustransmission.Home ownershipversusrentingwasalsopositivelyassociatedwithknowledgeonthesigns
andsymptomsofH1N1infection Walter2012 Studydesign Methods Participants Country Disease Psychologicaltheory Behaviour Crosssectional Telephonesurvey n=13010,14yearsold Germany Swineflu Nonestated Informationseekingandvaccination
Outcomes:factorsassociated Respondentswhowerenotimmunisedagainstpandemicinfluenzastatedmore withbehaviororintention frequentlytobenotwellorpartiallynotwellinformedaboutthe diseasecomparedwiththoserespondentswhowereimmunised.Noassociation betweenanysourceusedtogatherinformationonthediseaseingeneralandthe uptakeofinfluenzaA(H1N1)vaccine Ferrante2011 Studydesign Methods Participants Country Disease Psychologicaltheory Behaviour Crosssectional Telephonesurvey n=4047,1869yearold Italy Swineflu Nonestated Peoplesopinionandbehaviors
Outcomes:factorsassociated Willingnesstobevaccinatedwasassociatedwithworryaboutpandemic,age,sex, withbehaviororintention havingachronicdiseaseandtimingoftheinterview Galarce2011 Studydesign Methods Participants Country Disease Psychologicaltheory Behaviour Crosssectional Onlinesurvey n=1569,18yearsold US Swineflu Nonestated Vaccinationratesandsociodemographicfactors
Outcomes:factorsassociated Vaccineuptakeisassociatedwithsociodemographicfactors;beliefsandseasonal withbehaviororintention vaccination.Stronglyassociatedwithage,urbanicity,perceivingtheA(H1N1)vaccine assafeandseasonalfluvaccineuptake.Perceptionsofsafetyandseasonflu vaccinationshowthestrongestassociationswithA(H1N1)uptake.Thereasonspeople gavetodeclinevaccinationvariedbyrespondentssociodemographicgroup.Black participantswerethemostlikelyethnic/racialgrouptoreportedhavingtriedtoget thevaccinebutfounditunavailable
91
Jehn2011 Studydesign Methods Participants Country Disease Psychologicaltheory Behaviour
Crosssectional Telephonesurvey n=727,18yearsold Arizona Swineflu Nonestated
Publicknowledge,perceptionsandpreparednessforthe2009influenzaA/H1N1 pandemic.ThesurveyhighlightedanumberofimportantmisconceptionsaboutH1N1 knowledge,treatmentoptionsandtransmissibility Outcomes:factorsassociated Knowledgeonvaccineavailability,H1N1newscloselyandriskperceptionassociate withbehaviororintention withvaccinationintention Kiviniemi2011 Studydesign Methods Participants Country Disease Psychologicaltheory Behaviour Crosssectional Telephonesurvey n=807,18yearsold NewYorkState Swineflu Nonestated
Individualsinterpretationofrecommendationsaboutprecautionarybehaviors, willingnesstocomply,andfactorspredictingwillingness Outcomes:factorsassociated Nopatternofdemographiccharacteristicsconsistentlypredictedwillingness. withbehaviororintention Perceivedefficacywasassociatedwithwillingnessforallrecommendations,and perceivedseveritywasassociatedwithwillingnessforsomerecommendations Lin2011 Studydesign Methods Participants Country Disease Psychologicaltheory Behaviour Crosssectional Telephonesurvey n=10669,18yearsold China Swineflu Nonestated Communityresponses
Outcomes:factorsassociated Farmersandthosewithlowereducationlevelwerelesslikelytoknowthemain withbehaviororintention transmissionroute(coughortalkfacetoface).Femaleandthosewithcollegeand aboveeducationhadhigherperceptionofriskandmorecompliancewithpreventive behaviors.Relationshipsbetweenknowledgeandriskperceptionandknowledgeand practiceswerefoundamongthestudysubjects.Takingupvaccinationareseveral relatedfactors,includingtheperceptionoflifedisturbed,thesafetyofA/H1N1 vaccine,theknowledgeoffreevaccinationpolicy,the statespriorityvaccinationstrategy,andtakingupseasonalinfluenzavaccinebehavior
92
Vaux2011 Studydesign Methods Participants Country Disease Psychologicaltheory Behaviour
Crosssectional Telephonesurvey n=8905,0yearsold France Swineflu Nonestated Vaccinationallagesgroup11,1%
Outcomes:factorsassociated Belongingtothe04yearsagegroup,tothe3064yearsagegroup,livingina withbehaviororintention householdwithoneormorechildrenaged<5years,with2ormorepersons,where theheadofthefamilyisuniversitygraduated(>2years),orwheretheheadofthe householdwasafarmer,hasahigherprofessionalandmanagerialoccupation,hasan intermediateoccupationorwasretired(comparedwithbeingamanualworker). Peoplevaccinatedagainstseasonalinfluenzaweremorelikelytobevaccinated againstpandemicinfluenza.Nosignificantassociationwasfoundbetweenthe pandemicvaccinationcoverageandbeingasubjectatriskofinfluenzacomplications, thetownsizeorgender Velan2011 Studydesign Methods Participants Country Disease Psychologicaltheory Behaviour Crosssectional Telephonesurvey n=501,18yearsold Israel Swineflu Nonestated Vaccination
Outcomes:factorsassociated Uptakeassociatedwith:beingmen;olderage;Jewish(comparedwithArab). withbehaviororintention Walter2011 Studydesign Methods Participants Country Disease Psychologicaltheory Behaviour Crosssectional Telephonesurvey n=1548,14yearsold Germany Swineflu Nonestated Vaccination8,1%
Outcomes:factorsassociated Intentiontobevaccinatedassociatedwith:sex,age,educationallevel,beingHCW withbehaviororintention Balkhy2010
93
Studydesign Methods Participants Country Disease Psychologicaltheory Behaviour
Crosssectional Interceptsurvey n=1548,18yearsold SaudiArabia Swineflu Nonestated Knowledge,attitudes,anduseofprecautionarymeasures
Outcomes:factorsassociated Educationlevelwastheonlysignificantpredictorofthelevelofconcern. withbehaviororintention Precautionarymeasureswereassociatewhoweremen,older,bettereducated,and moreknowledgeable. BauerleBass2010 Studydesign Methods Participants Country Disease Psychologicaltheory Behaviour Crosssectional Telephonesurvey n=1204,18yearsold Pennsylvania Hypotheticpandemicflu Nonestated Compliancewhitquarantine
Outcomes:factorsassociated Sex,age,educationallevel,ethnicity,socioeconomicand employingstatuswere withbehaviororintention associatedtocomplyquarantine. Lau2010a Studydesign Methods Participants Country Disease Psychologicaltheory Behaviour Crosssectional Telephonesurvey n=3527,1860 HongKong Avianflu Nonestated Changesinbehavioralandemotionalresponses
Outcomes:factorsassociated SARSexperienceandunconfirmedbeliefsaboutthetransmissionmodeswere withbehaviororintention associatedwithvariablesonanticipatedpreventivebehaviorsandemotionaldistress. Lau2010b Studydesign Methods Participants Country Disease Crosssectional Telephonesurvey N=999,18 HongKong Swineflu
94
Psychologicaltheory Behaviour
Nonestated Avoidancebehaviorsandnegativepsychologicalresponsesofthegeneralpopulation
Outcomes:factorsassociated Women,olderrespondents,thosehavingunconfirmedbeliefsaboutmodesof withbehaviororintention transmissions,andthosefeelingworriedandemotionallydistressedduetoH1N1 outbreakweremorelikelythanotherstoadoptsomeavoidancebehaviors.Those whoperceivedhighseverityandsusceptibilityofgettingH1N1anddoubtedthe adequacyofgovernmentalpreparednessweremorelikelythanotherstofeel emotionallydistressed.Cognitions,includingunconfirmedbeliefsaboutmodesof transmission,perceivedseverityandsusceptibilitywereassociatedwithsomeofthe avoidancebehaviorsandemotionaldistress. Lau2010c Studydesign Methods Participants Country Disease Psychologicaltheory Behaviour Crosssectional Telephonesurvey n=301,30yearsold HongKong Swineflu Healthbeliefmodel,protectionmotivationtheory Intention45%reducingto15%or5%withcostandsafetyissues
Outcomes:factorsassociated Intentiontobevaccinatedassociatedwith:perceptionsofthesideeffectsofthe withbehaviororintention vaccination;friendsandfamilyhavingbeenvaccinated. Cowling2010 Studydesign Methods Participants Country Disease Psychologicaltheory Behaviour Crosssectional Telephonesurvey n=12965,18yearsold Netherlands AvianInfluenza ProtectionMotivationTheory
Anxiety,riskperception,knowledgeonmodesoftransmission,andpreventive behaviors. Outcomes:factorsassociated Greateranxietywasassociatedwithlowerreporteduseofhygienemeasuresbut withbehaviororintention greatersocialdistancing.KnowledgethatH1N1couldbespreadbyindirectcontact wasassociatedwithgreateruseofhygienemeasuresandsocialdistancing. deZwart2010 Studydesign Methods Participants Country Disease Psychologicaltheory Crosssectional OnlineSurvey n=3840,18yearsold Netherlands AvianInfluenza ProtectionMotivationTheory
95
Behaviour
Perceivedvulnerability,riskperception,precautionarybehavior.
Outcomes:factorsassociated Associatewithtakingpreventivemeasures:timeofthesurvey,higherage,lowerlevel withbehaviororintention ofeducation,nonDutchethnicity,vaccinatedagainstinfluenza,higherperceived severity,higherperceivedvulnerability,higherselfefficacy,lowerlevelofknowledge, moreinformationaboutavianinfluenza,andthinkingmoreaboutAvianinfluenza. Selfefficacywasastrongerpredictorofprecautionarybehaviourforthosewhonever orseldomthinkaboutavianinfluenza. Kamate2010 Studydesign Methods Participants Country Disease Psychologicaltheory Behaviour Crosssectional Selfadministeredquestionnaire n=791,18yearsold Udaipur Swineflu Nonestated
Perceivedseriousnessofthedisease,perceiveefficacyofvariouspreventive measures,avoidanceandpreventivebehaviours. Outcomes:factorsassociated Knowledgedifferedsignificantlyaccordingtogender,agegroups,andeducational withbehaviororintention statusaswellasworkingstatus.Womenhadbetterattitudethanmen. Goodwin2010 Studydesign Methods Participants Country Disease Psychologicaltheory Behaviour Crosssectional OnlineSurvey n=186,19yearsold UE Swineflu Nonestated Worryandbehavioralresponses
Outcomes:factorsassociated Valuesandfamilyorfriendsperceptionofriskspredictedworryaboutinfection,while withbehaviororintention worrycorrelatedwiththepurchaseofpreparatorymaterials,alesserwillingnessto travelbypublictransport,anddifficultyinfocusingoneverydayactivities Horney2010 Studydesign Methods Participants Country Disease Psychologicaltheory Behaviour Crosssectional Inpersoninterview n=207,18yearsold NorthCarolina Swineflu Nonestated Knowledgeofandintentiontovaccination
Outcomes:factorsassociated ReportinggreatconcernaboutH1N1infection,receivingseasonalinfluenzavaccinein withbehaviororintention 200809,andintendingtoreceiveseasonalinfluenzavaccinein200910were
96
Schwarzinger2010 Studydesign Methods Participants Country Disease Psychologicaltheory Behaviour
associatedwithintentiontoreceivepandemicvaccine.Notassociatedwere knowledgeofvaccine,employment,havingchildrenunderage18,gender, race/ethnicityandage Crosssectional OnlineSurvey n=2253,1864yearsold France Swineflu Nonestated Intention17%
Outcomes:factorsassociated Tobevaccinatedassociatedwith:sex,haveonechild,highperceptionoftheseverity, withbehaviororintention uptakeseasonalvaccination Peng2010 Studydesign Methods Participants Country Disease Psychologicaltheory Behaviour Crosssectional Telephonesurvey n=1278,1889yearsold Taiwan Sars Nonestated Psychologicaldistress
Outcomes:factorsassociated MajorpredictorsofhigherlevelsofpessimismaftertheSARSepidemicincluded withbehaviororintention demographicfactors,perceptionofSARSandpreparedness,knowingpeopleor havingpersonalexperiencesofSARSrelateddiscrimination,individualworriesand psychiatricmorbidity.Thecorrelatesofsymptomaticcasesincludedage50years, seniorhighschoolgraduate,andworriesaboutrecurrenceofSARS. Seale2010 Studydesign Methods Participants Country Disease Psychologicaltheory Behaviour Crosssectional Interceptsurvey n=627,18yearsold Sidney Swineflu Nonestated Behaviouralchanges,acceptanceofvaccination
Outcomes:factorsassociated Participantswhowerevaccinatedagainsttheseasonalinfluenzaweremorelikelyto withbehaviororintention receivetheH1N1vaccine.Noassociationbetweengenderorlevelofeducationand intentiontoreceivetheH1N1vaccine.Nosignificantdifferenceinvaccineacceptance betweenparticipantswhoreportedcasesofH1N1whoreportedcasesofH1N1 amongsttheirfriendsorfamilymembersandthosewhodidnot.
97
deZwart2009 Studydesign Methods Participants Country Disease Psychologicaltheory Behaviour
Crosssectional Telephonesurvey n=3403,1875yearsold Europe(Denmark,Poland,TheNetherlands,Spain)andEastAsia(Singapore,province ofGuangdongChinaandHongKong) SARSandotherinfectiousdiseases Nonestated
Perceivedthreat,perceivedseverity,perceivedvulnerability,responseefficacy,and selfefficacy. Outcomes:factorsassociated Countrywasstronglyassociatedwithperceivedthreat. withbehaviororintention Quinn2009 Studydesign Methods Participants Country Disease Psychologicaltheory Behaviour Crosssectional OnlineSurvey N=1543,18yearsold US Swineflu HealthBeliefModel Intentionstotakeantiviralmedicationorhaveaswinefluvaccine
Outcomes:factorsassociated BeingHispanic,havinglesseducation,havinglowerperceptionsofpersonal withbehaviororintention consequences(susceptibilityandseveritycombined)andlowerperceptionofworry aboutthevaccineassociatedwithvaccineintentionBeingHispanicorWhite,lower perceptionofworryabouttheantiviralmedication,greatertrustingovernment, greaterperceivedpersonalconsequencesofillnessassociatedwithantiviraluse intention Lau2009 Studydesign Methods Participants Country Disease Psychologicaltheory Behaviour Crosssectional Telephonesurvey n=550,1860yearsold HongKong Swineflu Nonestated Communityresponsesandpreparedness.
Outcomes:factorsassociated withbehaviororintention Leung2004 Studydesign Methods Crosssectional Telephonesurvey
98
Participants Country Disease Psychologicaltheory Behaviour
n=705HongKongresidents,18yearsold;n=1201Singaporeresidents21years old HongKongandSingapore SARS Nonestated Precautionarymeasuresrecommended
Outcomes:factorsassociated Beingolder,female,moreeducated,higheranxiety,betterknowledge,greaterrisk withbehaviororintention perceptionsassociatedwithadopting Maurer2009 Studydesign Methods Participants Country Disease Psychologicaltheory Behaviour Crosssectional OnlineandWebTVsurvey n=2067,1891yearsold US Swineflu Nonestated Intentions50%
Outcomes:factorsassociated Intentiontobevaccinatedassociatedwith:beingolder withbehaviororintention Rubin2009 Studydesign Methods Participants Country Disease Psychologicaltheory Behaviour Crosssectional Telephonesurvey n=997,18yearsold UK Swineflu Nonestated Handwashing,surfacecleaning,flufriendplans,avoidantbehaviours
Outcomes:factorsassociated BeingnonWhite,higherperceived risk,higherperceivedseverity,trustinauthorities, withbehaviororintention higherperceivedefficacyofbehaviours Zijtregtop2009 Studydesign Methods Participants Country Disease Psychologicaltheory Behaviour Crosssectional Selfadministeredquestionnarie n=508,18yearsold Netherlands Swineflu Healthbeliefmodel Demographical,behaviouralandorganizationaldeterminantsandintentiontobe immunized
99
Outcomes:factorsassociated Negativeintentiontogetapandemicinfluenzavaccination:femalegender,high withbehaviororintention education,noinfluenzavaccinationin2008,andlivingwithoutpartnerwithchildren. Behaviouraldeterminantstogetvaccinated:lowpersonalriskofgettingpandemic influenzaatthismoment,andlowriskforpeopleinenvironmenttogetpandemic influenzaatthismoment. Barr2008 Studydesign Methods Participants Country Disease Psychologicaltheory Behaviour Crosssectional Telephonesurvey n=2081,16yearsold Australia Hypotheticpandemicflu Nonestated Intentions:vaccination,quarantine,facemaskuse
Outcomes:factorsassociated Higherlevelofperceivedthreatofpandemicinfluenza,olderage,morehighly withbehaviororintention educated.SpeaklanguageotherthanEnglishassociatedwithlesscompliance Jones2008 Studydesign Methods Participants Country Disease Psychologicaltheory Behaviour Crosssectional Telephonesurvey n=203,18yearsold Australia Avianflu(H5N1) Nonestated Vaccinationandfacemaskwearingwhensymptomatic
Outcomes:factorsassociated Perceivedseverityofavianfluandefficacyofvaccinationassociatedwithbeing withbehaviororintention vaccinated.Perceivedseverityassociatewithmaskwearing Lau2008 Studydesign Methods Participants Country Disease Psychologicaltheory Behaviour Crosssectional Telephonesurvey n=302,1860yearsold HongKong Avianflu Nonestated
Intentionstowearmask,handwashingmore,complywithquarantine,seekhelp promptly Outcomes:factorsassociated Concernabouttheirfamilyandage withbehaviororintention Lau2007a Studydesign Crosssectional
100
Methods Participants Country Disease Psychologicaltheory Behaviour
Telephonesurvey n=503,1860yearsold HongKong Avianflu Nonestated
Intentionstowearmask,handwashingmore,complywithquarantine,seekhelp promptly Outcomes:factorsassociated Beingolder,employed,higherperceivedsusceptibility,severity,worryandefficacy withbehaviororintention relatedtointentions Sadique2007 Studydesign Methods Participants Country Disease Psychologicaltheory Behaviour Crosssectional Telephonesurvey n=3436,1875yearsold Europe(Denmark,Spain,GreatBritain,TheNetherlands,Poland)andAsia (Guangdong,HongKong,Singapore) Hypotheticpandemicflu Nonestated Precautionay
Outcomes:factorsassociated Individualcharacteristicssuchasage,sex,selfreportedinfluenzavaccination,and withbehaviororintention healthstatushadlittleeffectonreportedprecautionarymeasures.Employment statusappearedtoaffectmanyoftheprecautionaryactions.Highereducationallevel andlivinginruralareaassociatedwithavoidingmeasures Lau2007b Studydesign Methods Participants Country Disease Psychologicaltheory Behaviour Crosssectional Telephonesurvey n=805,1860yearsold HongKong Avianflu Nonestated Avoidinghospitalsandeatingpoultry,takingantivirals,gettingvaccinated
Outcomes:factorsassociated Beliefthattherewassustainedspreadofavianfluandmisconceptionsaboutmode withbehaviororintention oftransmissionassociatedwithallbehaviours Lau2006b Studydesign Methods Participants Country Disease Crosssectional Telephonesurvey n=818,1860yearsold HongKong SARS
101
Psychologicaltheory Behaviour
Nonestated
Outcomes:factorsassociated Femalerespondentstobesharingfeelingsmorefrequently.Loweducationallevel withbehaviororintention associatedhighIESscore.Female,olderandlesseducatedweremorelikelythan otherstohavesuchnegative feelings Ko2006 Studydesign Methods Participants Country Disease Psychologicaltheory Behaviour Crosssectional Notclear n=1552,15yearsold Taiwan SARS Nonestated Psychosocialimpactanddepression
Outcomes:factorsassociated Impactedgrouphadhigherdepressivelevels,poorerneighborhoodrelationships, withbehaviororintention poorerselfperceivedhealth,andahighereconomicimpactthanthenonimpacted group.Thepoorerselfperceivedhealthandeconomicimpactfactorswere associatedwithdepression.Theneighborhoodrelationshipfactorwasnegatively associatedwithdepressionfortheimpactedgroup Deurenbergyap2005 Studydesign Methods Participants Country Disease Psychologicaltheory Behaviour Crosssectional Telephonesurvey n=853,1981yearsold Singapore SARS Nonestated Knowledgandtrust
Outcomes:factorsassociated Knowledgesignificantlyassociatedwithhigherpublictrust withbehaviororintention Blendon2004 Studydesign Methods Participants Country Disease Psychologicaltheory Behaviour Crosssectional Telephonesurvey n=500US;2000Canada,18yearsold USandCanada SARS Nonestated Useddisinfectant,avoidedcrowds,facemaskuse,seekingprofessionalhelp
Outcomes:factorsassociated HigherlevelofconcernaboutcontractingSARS
102
withbehaviororintention Tang2004 Studydesign Methods Participants Country Disease Psychologicaltheory Behaviour Crosssectional Telephonesurvey n=1,329,1959yearsold HongKong SARS Healthbeliefmodel Facemaskuse
Outcomes:factorsassociated Women,olderpeopleandmarriedpeople.Perceivedsusceptibility,socialnormsand withbehaviororintention perceivedefficacyoffacemaskuse Myers2011 Studydesign Methods Participants Country Disease Psychologicaltheory Behaviour Crosssectional Onlinesurvey n=362,adult UK Swineflu Extendedtheoryofplannedbehavior
Intention(assessedonascaleof17,stronglydisagreetostronglyagree)meanscore 2.9 Outcomes:factorsassociated Intentiontobevaccinatedpredictedby:having apositiveattitudetovaccination; withbehaviororintention perceivingoneselftobeincontrolofthedecisiontobevaccinated;perceivingoneself tobesusceptibletoH1N1;perceivingH1N1tobeserious;lowperceivedcostsof vaccination;highperceivedbenefitstovaccination;highanticipatedregretifnot vaccinated;intentiontohaveaseasonalfluvaccination;olderage;beingunemployed Eastwood2010 Studydesign Methods Participants Country Disease Psychologicaltheory Behaviour Crosssectional Telephonesurvey n=1155,18yearsold Australia Hypotheticpandemicflu Nonestarted Intentions67%
Outcomes:factorsassociated Intentiontobevaccinatedassociatedwith:perceptionsthatpandemicfluisserious; withbehaviororintention previousseasonalinfluenzavaccination. SteelFisher2010 Studydesign Methods Crosssectional Telephonesurvey
103
n=301,30yearsold US Swineflu Nonestarted Protectivemeasures,vaccination:14%
Outcomes:factorsassociated withbehaviororintention Maurer2010 Studydesign Methods Participants Country Disease Psychologicaltheory Behaviour Crosssectional Onlinesurvey n=3917,18yearsold US Swinefluandseasonalinfluenza Nonestated Behavior20%
Outcomes:factorsassociated Vaccinationbehaviourassociatedwith:relyingonhealthcareproviderorpublic withbehaviororintention healthdepartmentforinformation(ratherthanothersources);pastseasonal influenzavaccination. Wong2010 Studydesign Methods Participants Country Disease Psychologicaltheory Behaviour Crosssectional Telephonesurvey n=1025,1864yearsold Malaysia Swineflu Nonestated Intentions70%
Outcomes:factorsassociated Intentiontobevaccinatedassociatedwith:abeliefthatthevaccinewilloffer withbehaviororintention protection;beliefthatthevaccinedoesnothavesideeffects;beliefthatvaccineis safe.AnHalalvaccineimportantforMuslims. Eastwood2009 Studydesign Crosssectional Methods Participants Country Disease Psychologicaltheory Behaviour Telephonesurvey n=1166,18yearsold Australia Pandemicinfluenza Nonestated Intendedcompliancewithquarantineandtakingantiviraldrugs
104
Outcomes:factorsassociated Greaterknowledgeofpandemic influenza,beingfemaleassociatedwithcompliance. withbehaviororintention Employedpeoplelesslikelytocomply.Perceivedsideeffectsassociatedwithreduced Sypsa2009 Studydesign Methods Participants Country Disease Psychologicaltheory Behaviour Crosssectional Telephonesurvey n=1000,15yearsold Greece Swineflu Nonestated Intentions53%reducingto37%byendofstudy
Outcomes:factorsassociated Intentiontobevaccinatedassociatedwith:feelingatriskfrompandemicflu;believing withbehaviororintention pandemicflutobeserious;havinghadpreviousseasonalfluvaccine;beingmen; olderageIntentionsnotbevaccinatedassociatedwith:concernsaboutsafetyofthe vaccine Seale2009 Studydesign Methods Participants Country Disease Psychologicaltheory Behaviour Crosssectional Interviewfacetofaceandbyemail n=620,18yearsold Sidney Swineflu Nonestated Quarantine,vaccination
Outcomes:factorsassociated withbehaviororintention Brug2004 Studydesign Methods Participants Country Disease Psychologicaltheory Behaviour Crosssectional OnlineSurvey n=373,1978yearsold Netherlands SARS Nonstated
Hygienemeasures,facemaskuse,avoidancebehaviours,avoidanceoftravelto infectedareas(compositemeasure) Outcomes:factorsassociated HigherlevelofperceivedriskandworryaboutSARS.Womenfeltmoresusceptibleto withbehaviororintention SARSandpeoplewithlesseducationfeltmoreworried Quah2004 Studydesign Methods Crosssectional Telephonesurvey
105
n=1201,21yearsold Singapore SARS Nonestated
Precautionaryhygienemeasurespracticedinlast3days(handwashing,cough hygiene,usingutensilsmaskwearing).Eightbehavioursgiventhenacompositescore calculatedofloworhighadoptionofthem Outcomes:factorsassociated Beingfemale,older,beingmoreanxiousandhavingmorebeliefthatauthorities withbehaviororintention communicationwasopenassociatedwithbehaviour Lau2003 Studydesign Methods Participants Country Disease Psychologicaltheory Behaviour Crosssectional Telephonesurvey n=1397,1860yearsold HongKong SARS Nonestated Handwashing,homedisinfection,facemaskuse,avoidancebehaviours
Outcomes:factorsassociated Higherperceivedrisk,higherperceivedefficacyofprotectivebehaviours,beingolder, withbehaviororintention femaleandmoreeducated Leung2003 Studydesign Methods Participants Country Disease Psychologicaltheory Behaviour Crosssectional Telephonesurvey n=1115,18yearsold HongKong SARS Nonestated
PrecautionarymeasuresrecommendedbyHongKongGovernment(maintaininggood personalhygieneandahealthylifestyle;washinghandswithsoapaftersneezing, coughing,andcleaningthenose;buildingupbodyimmunitywithabalancediet, regularexercise,andadequaterest;ensuringgoodindoorventilation;wearingface masksforthosewithrespiratorytractinfectionsandtheircarers;andconsulting doctorspromptlyifthereweresymptomsofrespiratoryillnesses) Outcomes:factorsassociated Beingolder,female,moreeducated,havinghigherriskperceptions,moreanxiety, withbehaviororintention andbeingsymptomaticallassociatedwithgreaterchanceoftakingprecautionary measures(classifiedas5ormoreofthoserecommended) Tang2003 Studydesign Methods Participants Crosssectional Telephonesurveys(onebeforepromotionofcommunitypreventionactivitiesand oneduringpromotion) n=1002;n=1329,1959yearsold
106
Country Disease Psychologicaltheory Behaviour
HongKong SARS Healthbeliefmodel,TheoryofPlannedBehaviour,Socialcognitivetheory
1stsurveygovernmentrecommendedpreventivebehaviours2ndsurveymask wearing Outcomes:factorsassociated 1stsurvey:beingolder,greaterperceivedsusceptibility,greaterselfefficacy2nd withbehaviororintention survey:higherperceivedefficacyofbehavioursandpreexposuretomessagesabout preventivebehavior
Tab.2.Characteristicofexcludedstudies
Study
Brug2009 Gaygisiz2011 Gaygisiz2010 Goodwin2009 Jones2009 Hong2006 Ibuka2010 Lee2010 Liao2010
Reasonforexclusion
Editorial Samplingmethod Samplingmethod Samplingmethod Preliminaryresults Studydesign Responserate12,9% Nocrosssectionalstudy ValidationStructuralEquationModel(SEM)
Tab3.Factorsassociatedtoprotectivebehavior.
Handwashing Variable Olderpeople Women 13/14 Higheducational level Unemployed people Perceived susceptibility 5/7 2/2 12/15 1/2 3/3 2/2 4/4 8/12 8/10 ..Ns 7/7 1/1 2/2 Ns 2/2
Na7/9
Behaviour Avoidingcrowded Wearingmask places

n/N n/N
Quarantine
n/N
noassociation
Vaccination
n/N
n/N
9/10
4/4
5/6
9/13
controversial
Ns 10/12
107
Perceivedseverity Highlevel ofanxiety Peceivedefficayof behaviour Perceivedself efficacy Trust Knowledge Uptakeseasonal influenzavaccine Primarycare physicianassource ofinformationor advicefrom
3/5 5/6 4/4 3/3 4/4 5/5 Ns
3/3 2/2 2/2 Ns Ns Ns Ns
1/2 2/2 1/1 2/2 Ns Ns Ns
Ns Ns 1/1 Ns Ns 1/1 Ns
9/12 Ns Ns Ns 5/5 2/3 13/13
Ns
Ns
Ns
Ns
6/6
N=numberofstudieswheretheeffectofthevariableonthebehaviourwasinvestigated;n=numbersofstudies where apositiveassociationbetweenthevariableandthebehaviourwasobserved. Na=wheren/Nreferstoanegativeassociation;Ns=wheretheassociationbetweenthevariableandthebehaviourwas notinvestigated.
108
Appendix1.Electronicsearchstrategies
ThesearchusedinMEDLINE(startingJanuary2002)wasconductedthefollowingMedicalSubjectHeading (MeSH)terms:"InfluenzainBirds"ORavianfluORavianinfluenzaAND("Communication"(Mesh)OR"Civil Defence" (Mesh) OR "Internet"(Mesh) OR "Television"(Mesh) OR "Mass Media"(Mesh) OR "Information Dissemination"(Mesh)OR"Behaviour"(Mesh)ORmodelingORpreparednessORinformationdissemination OR communication OR internet OR media OR television OR behaviour OR behaviour OR psychological response);"InfluenzaAVirus,H1N1Subtype"(Mesh)ORH1N1ORswinefluAND("Communication"(Mesh) OR "Civil Defense"(Mesh) OR "Internet"(Mesh) OR "Television"(Mesh) OR "Mass Media"(Mesh) OR "Information Dissemination"(Mesh) OR "Behavior"(Mesh) OR modeling OR preparedness OR information dissemination OR communication OR internet OR media OR television OR behavior OR behaviour OR psychological response); "SARS Virus"(Mesh) OR severe acute respiratory syndrome OR SARS AND ("Communication"(Mesh)OR"CivilDefense"(Mesh)OR"Internet"(Mesh)OR"Television"(Mesh)OR"Mass Media"(Mesh)OR"InformationDissemination"(Mesh)OR"Behavior"(Mesh)ORmodelingORpreparedness OR information dissemination OR communication OR internet OR media OR television OR behavior OR behaviour OR psychological response); "Pandemics"(Mesh) OR pandemic OR pandemics AND ("Communication"(Mesh)OR"CivilDefense"(Mesh)OR"Internet"(Mesh)OR"Television"(Mesh)OR"Mass Media"(Mesh)OR"InformationDissemination"(Mesh)OR"Behavior"(Mesh)ORmodelingORpreparedness OR information dissemination OR communication OR internet OR media OR television OR behavior OR behaviourORpsychologicalresponse).
109

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1stReportingperiod WP1PopulationBehaviourduringepidemics ResponsiblePartner:ISS Duedateofthedeliverable:M6(July31st2012) Actualsubmissiondate:M7(August31st2012)

D1.1Systematicreviewofstudiesaddressingpopulationbehavioursduringinfectiousoutbreaksandreviewofoutbreak communicationin2009pandemic TELLMEprojectGA:278723

D1.1Systematicreviewofstudiesaddressingpopulationbehavioursduringinfectiousoutbreaksandreviewofoutbreak communicationin2009pandemic TELLMEprojectGA:278723

D1.1Systematicreviewofstudiesaddressingpopulationbehavioursduringinfectiousoutbreaksandreviewofoutbreak communicationin2009pandemic TELLMEprojectGA:278723

EXECUTIVESUMMARYI Populationbehaviouralresponsetoinfectiousdiseasesoutbreaksamonggeneral population

D1.1Systematicreviewofstudiesaddressingpopulationbehavioursduringinfectiousoutbreaksandreviewofoutbreak communicationin2009pandemic TELLMEprojectGA:278723

D1.1Systematicreviewofstudiesaddressingpopulationbehavioursduringinfectiousoutbreaksandreviewofoutbreak communicationin2009pandemic TELLMEprojectGA:278723

D1.1Systematicreviewofstudiesaddressingpopulationbehavioursduringinfectiousoutbreaksandreviewofoutbreak communicationin2009pandemic TELLMEprojectGA:278723

D1.1Systematicreviewofstudiesaddressingpopulationbehavioursduringinfectiousoutbreaksandreviewofoutbreak communicationin2009pandemic TELLMEprojectGA:278723

D1.1Systematicreviewofstudiesaddressingpopulationbehavioursduringinfectiousoutbreaksandreviewofoutbreak communicationin2009pandemic TELLMEprojectGA:278723

D1.1Systematicreviewofstudiesaddressingpopulationbehavioursduringinfectiousoutbreaksandreviewofoutbreak communicationin2009pandemic TELLMEprojectGA:278723

D1.1Systematicreviewofstudiesaddressingpopulationbehavioursduringinfectiousoutbreaksandreviewofoutbreak communicationin2009pandemic TELLMEprojectGA:278723

D1.1Systematicreviewofstudiesaddressingpopulationbehavioursduringinfectiousoutbreaksandreviewofoutbreak communicationin2009pandemic TELLMEprojectGA:278723

D1.1Systematicreviewofstudiesaddressingpopulationbehavioursduringinfectiousoutbreaksandreviewofoutbreak communicationin2009pandemic TELLMEprojectGA:278723

D1.1Systematicreviewofstudiesaddressingpopulationbehavioursduringinfectiousoutbreaksandreviewofoutbreak communicationin2009pandemic TELLMEprojectGA:278723

D1.1Systematicreviewofstudiesaddressingpopulationbehavioursduringinfectiousoutbreaksandreviewofoutbreak communicationin2009pandemic TELLMEprojectGA:278723

D1.1Systematicreviewofstudiesaddressingpopulationbehavioursduringinfectiousoutbreaksandreviewofoutbreak communicationin2009pandemic TELLMEprojectGA:278723

D1.1Systematicreviewofstudiesaddressingpopulationbehavioursduringinfectiousoutbreaksandreviewofoutbreak communicationin2009pandemic TELLMEprojectGA:278723

Perceivedseverityofthedisease Perceivedselfefficacytoadoptbehavior Trustintheauthorities Havingahighlevelofknowledge Havingahighlevelofanxiety

D1.1Systematicreviewofstudiesaddressingpopulationbehavioursduringinfectiousoutbreaksandreviewofoutbreak communicationin2009pandemic TELLMEprojectGA:278723

D1.1Systematicreviewofstudiesaddressingpopulationbehavioursduringinfectiousoutbreaksandreviewofoutbreak communicationin2009pandemic TELLMEprojectGA:278723

D1.1Systematicreviewofstudiesaddressingpopulationbehavioursduringinfectiousoutbreaksandreviewofoutbreak communicationin2009pandemic TELLMEprojectGA:278723

D1.1Systematicreviewofstudiesaddressingpopulationbehavioursduringinfectiousoutbreaksandreviewofoutbreak communicationin2009pandemic TELLMEprojectGA:278723

D1.1Systematicreviewofstudiesaddressingpopulationbehavioursduringinfectiousoutbreaksandreviewofoutbreak communicationin2009pandemic TELLMEprojectGA:278723

D1.1Systematicreviewofstudiesaddressingpopulationbehavioursduringinfectiousoutbreaksandreviewofoutbreak communicationin2009pandemic TELLMEprojectGA:278723

D1.1Systematicreviewofstudiesaddressingpopulationbehavioursduringinfectiousoutbreaksandreviewofoutbreak communicationin2009pandemic TELLMEprojectGA:278723

Otherfactorsnegativelyaffectedthevaccinationacceptance: Beingwoman Thefearthatthevaccinecouldcausediseaseorsideeffects

D1.1Systematicreviewofstudiesaddressingpopulationbehavioursduringinfectiousoutbreaksandreviewofoutbreak communicationin2009pandemic TELLMEprojectGA:278723

D1.1Systematicreviewofstudiesaddressingpopulationbehavioursduringinfectiousoutbreaksandreviewofoutbreak communicationin2009pandemic TELLMEprojectGA:278723

D1.1Systematicreviewofstudiesaddressingpopulationbehavioursduringinfectiousoutbreaksandreviewofoutbreak communicationin2009pandemic TELLMEprojectGA:278723

D1.1Systematicreviewofstudiesaddressingpopulationbehavioursduringinfectiousoutbreaksandreviewofoutbreak communicationin2009pandemic TELLMEprojectGA:278723

D1.1Systematicreviewofstudiesaddressingpopulationbehavioursduringinfectiousoutbreaksandreviewofoutbreak communicationin2009pandemic TELLMEprojectGA:278723

D1.1Systematicreviewofstudiesaddressingpopulationbehavioursduringinfectiousoutbreaksandreviewofoutbreak communicationin2009pandemic TELLMEprojectGA:278723

D1.1Systematicreviewofstudiesaddressingpopulationbehavioursduringinfectiousoutbreaksandreviewofoutbreak communicationin2009pandemic TELLMEprojectGA:278723

D1.1Systematicreviewofstudiesaddressingpopulationbehavioursduringinfectiousoutbreaksandreviewofoutbreak communicationin2009pandemic TELLMEprojectGA:278723

D1.1Systematicreviewofstudiesaddressingpopulationbehavioursduringinfectiousoutbreaksandreviewofoutbreak communicationin2009pandemic TELLMEprojectGA:278723

D1.1Systematicreviewofstudiesaddressingpopulationbehavioursduringinfectiousoutbreaksandreviewofoutbreak communicationin2009pandemic TELLMEprojectGA:278723

D1.1Systematicreviewofstudiesaddressingpopulationbehavioursduringinfectiousoutbreaksandreviewofoutbreak communicationin2009pandemic TELLMEprojectGA:278723

5 15 20 June 11 29 August September 28 15

D1.1Systematicreviewofstudiesaddressingpopulationbehavioursduringinfectiousoutbreaksandreviewofoutbreak communicationin2009pandemic TELLMEprojectGA:278723

D1.1Systematicreviewofstudiesaddressingpopulationbehavioursduringinfectiousoutbreaksandreviewofoutbreak communicationin2009pandemic TELLMEprojectGA:278723

D1.1Systematicreviewofstudiesaddressingpopulationbehavioursduringinfectiousoutbreaksandreviewofoutbreak communicationin2009pandemic TELLMEprojectGA:278723

D1.1Systematicreviewofstudiesaddressingpopulationbehavioursduringinfectiousoutbreaksandreviewofoutbreak communicationin2009pandemic TELLMEprojectGA:278723

D1.1Systematicreviewofstudiesaddressingpopulationbehavioursduringinfectiousoutbreaksandreviewofoutbreak communicationin2009pandemic TELLMEprojectGA:278723

D1.1Systematicreviewofstudiesaddressingpopulationbehavioursduringinfectiousoutbreaksandreviewofoutbreak communicationin2009pandemic TELLMEprojectGA:278723

D1.1Systematicreviewofstudiesaddressingpopulationbehavioursduringinfectiousoutbreaksandreviewofoutbreak communicationin2009pandemic TELLMEprojectGA:278723

D1.1Systematicreviewofstudiesaddressingpopulationbehavioursduringinfectiousoutbreaksandreviewofoutbreak communicationin2009pandemic TELLMEprojectGA:278723

D1.1Systematicreviewofstudiesaddressingpopulationbehavioursduringinfectiousoutbreaksandreviewofoutbreak communicationin2009pandemic TELLMEprojectGA:278723

D1.1Systematicreviewofstudiesaddressingpopulationbehavioursduringinfectiousoutbreaksandreviewofoutbreak communicationin2009pandemic TELLMEprojectGA:278723

Thefundamentaldifficultiesarethatthemessageswillbemorenumerousandmorecomplex, andtheprecisecontentofthemessagesisuncertainfornowandwilldependonthespecificsofhowthepublichealth situationunfolds ExecutiveOfficeofthePresidentoftheUnitedStates,2009

D1.1Systematicreviewofstudiesaddressingpopulationbehavioursduringinfectiousoutbreaksandreviewofoutbreak communicationin2009pandemic TELLMEprojectGA:278723

D1.1Systematicreviewofstudiesaddressingpopulationbehavioursduringinfectiousoutbreaksandreviewofoutbreak communicationin2009pandemic TELLMEprojectGA:278723

D1.1Systematicreviewofstudiesaddressingpopulationbehavioursduringinfectiousoutbreaksandreviewofoutbreak communicationin2009pandemic TELLMEprojectGA:278723

D1.1Systematicreviewofstudiesaddressingpopulationbehavioursduringinfectiousoutbreaksandreviewofoutbreak communicationin2009pandemic TELLMEprojectGA:278723

D1.1Systematicreviewofstudiesaddressingpopulationbehavioursduringinfectiousoutbreaksandreviewofoutbreak communicationin2009pandemic TELLMEprojectGA:278723

D1.1Systematicreviewofstudiesaddressingpopulationbehavioursduringinfectiousoutbreaksandreviewofoutbreak communicationin2009pandemic TELLMEprojectGA:278723

D1.1Systematicreviewofstudiesaddressingpopulationbehavioursduringinfectiousoutbreaksandreviewofoutbreak communicationin2009pandemic TELLMEprojectGA:278723

D1.1Systematicreviewofstudiesaddressingpopulationbehavioursduringinfectiousoutbreaksandreviewofoutbreak communicationin2009pandemic TELLMEprojectGA:278723

D1.1Systematicreviewofstudiesaddressingpopulationbehavioursduringinfectiousoutbreaksandreviewofoutbreak communicationin2009pandemic TELLMEprojectGA:278723

D1.1Systematicreviewofstudiesaddressingpopulationbehavioursduringinfectiousoutbreaksandreviewofoutbreak communicationin2009pandemic TELLMEprojectGA:278723

D1.1Systematicreviewofstudiesaddressingpopulationbehavioursduringinfectiousoutbreaksandreviewofoutbreak communicationin2009pandemic TELLMEprojectGA:278723

D1.1Systematicreviewofstudiesaddressingpopulationbehavioursduringinfectiousoutbreaksandreviewofoutbreak communicationin2009pandemic TELLMEprojectGA:278723

MariaLuisaMorodesignofthestrategyresearch,criticalreview. BarbaraDeMeiconceptionanddesign,workinggroupcreator. StefaniaSalmasoconceptionanddesign,workinggroupcreator.