Risk Analysis, Vol. 31, No. 4, 2011 DOI: 10.1111/j.1539-6924.2010.01529.

A Social-Cognitive Model of Pandemic Influenza H1N1 Risk

Perception and Recommended Behaviors in Italy

Gabriele Prati,1,∗ Luca Pietrantoni,1 and Bruna Zani1

The outbreak of the pandemic influenza H1N1 2009 (swine flu) between March and April
2009 challenged the health services around the world. Indeed, misconceptions and worries
have led the public to refuse to comply with precautionary measures. Moreover, there have
been limited efforts to develop models incorporating cognitive, social-contextual, and affec-
tive factors as predictors of compliance with recommended behaviors. The aim of this study
was to apply a social-cognitive model of risk perception and individual response to pandemic
influenza H1N1 in a representative sample of Italian population. A sample of 1,010 Italians
of at least 18 years of age took part in a telephone survey. The survey included measures of
perceived preparedness of institutions, family members and friends’ levels of worry, exposure
to media campaigns (social-contextual factors), perceived coping efficacy, likelihood of infec-
tion, perceived seriousness, personal impact, and severity of illness (cognitive evaluations),
affective response and compliance with recommended behaviors. Results demonstrated that
affective response fully mediated the relationship between cognitive evaluations and social-
contextual factors (with the exception of exposure to media campaigns) and compliance with
recommended behaviors. Perceived coping efficacy and preparedness of institutions were not
related to compliance with recommended behaviors.

KEY WORDS: H1N1 pandemic flu; risk perception; social-cognition; worry, media campaigns

1. INTRODUCTION that worldwide more than 213 countries and terri-

tories or communities were affected, causing 16,713
Between March and April 2009, the Centers
deaths.(4)
for Disease Control and Prevention (CDC) identi-
The emergence and fast spread of this previ-
fied cases of human infection with a swine-origin
ously unknown variant of influenza A (H1N1) virus
influenza A (H1N1) virus in North America and
prompted health authorities to call for rapid develop-
Mexico.(1−3) In June 2009, a total of 74 countries and
ment of behavioral interventions aimed at reducing
territories had reported laboratory confirmed infec-
the spread and impact.(5) Recommended behaviors
tions and the World Health Organization (WHO)
included, for example, keeping distance from people
declared the first pandemic of the 21st century to
who show symptoms of influenza-like illness, such as
have started. As of March 7, 2010, WHO reported
coughing and sneezing (trying to maintain a distance
of about 1 m if possible), cleaning hands thoroughly
with soap and water, or cleanse them with an alcohol-
1 Department of Education, University of Bologna, Bologna, Italy.
∗ Address
based hand rub on a regular basis (especially if touch-
correspondence to Gabriele Prati, Dipartimento di
Scienze dell’Educazione, Università di Bologna, via Filippo Re,
ing surfaces that are potentially contaminated), and
6 – 40126 Bologna, Italy; tel: +39 051 2091610; fax +39 051 reducing the time spent in crowded settings if possi-
2091489; gabriele.prati@unibo.it ble.(6)

645 0272-4332/11/0100-0645$22.00/1 ⃝
C 2010 Society for Risk Analysis
646
Previous epidemiological studies have shown
that there is evidence for the effectiveness of spe-
cific behaviors related to hygiene as a measure
against SARS transmission.(7) However, misconcep-
tions and worries have led the public to refuse
to comply with precautionary measures during the
outbreak of SARS(8,9) and of pandemic influenza
H1N1.(10−14) In particular, the psychosocial factors
related to recommended behaviors against pandemic
influenza H1N1 were: knowledge,(10−14) risk percep-
tion,(10,13,14) worry,(10,13,14) perceived efficacy of var-
ious behavioral responses,(10−13) and media expo-
sure.(13) Findings from these studies may provide per-
tinent information in designing and implementing fu-
ture pandemic flu outbreak prevention programs.
One limitation of these studies was the lack of
a theoretical model to describe the processes linking
psychosocial factors to recommended behaviors. The
aim of this study is to test a model in which social,
cognitive, and affective variables predict compliance
with recommended behaviors.
Several models of health behavior recognized as
key determinants of recommended behavior cogni-
tive (e.g., risk perception) and social factors (e.g.,
social norms).(15−18) More recently, the additional
contribution of the emotional response to risk
perception in influencing behavior was acknowl-
edged.(19) Indeed, the scientific literature showed
that cognitive and affective systems interact in de-
termining response to a threat.(20−22) According to
processing theories cognitive evaluations of the threat
arise from affect,(23) whereas according to appraisal
theories cognitive evaluations influence affect.(24) A
prospective study supported appraisal theories. In a
five-month longitudinal study Kobbeltved and her
colleagues(25) followed a group (N = 129) of military
sailors during an international operation, exploring
prospectively the relations between perceived risk
and related feelings. They found greater support for
the influence of cognitive evaluations on worry than
the reverse. Moreover, a qualitative study involving
analysis of transcripts of individual and group inter-
views held across Canada (N = 73) about concerns
and decisions surrounding terrorism-related risk
found support for appraisal theories too.(26) Results
suggested that individuals’ worry or concern arising
from the threat of terrorism were influenced by cog-
nitive evaluations, such as their perceptions of threat,
uncertainty, and control. Behavioral responses to
terrorism (e.g., individual preparedness behaviors,
avoidance) appeared to stem from individuals’ cogni-
tive evaluations and affective response. In addition to
Prati, Pietrantoni, and Zani
the relationship between cognitive and affective fac-
tors, this study showed that behavioral responses to
terrorism were influenced by sociocontextual factors,
such as respondents’ opinions regarding the way in
which the threat is regulated by authorities. Based
on these studies, Lee and Lemyre(27) developed a
social-cognitive perspective of terrorism risk percep-
tion and individual response, which postulates the
mediation role of worry in the relationship between
cognitive evaluations and behavioral responses. Lee
and Lemyre tested these relationships in a represen-
tative sample of Canadians, using data collected as
part of a national survey. They found that worry and
behavioral responses were functions of cognitive and
social-contextual factors. Worry independently con-
tributed to the prediction of behavioral responses
above and beyond cognitive and social-contextual
factors, and partially mediated the relationships of
some of these factors with behavioral responses.
One question arising from these studies is
whether the model may be applicable to other risks.
The first aim of this study was to apply Lee and
Lemyre’s model(27) to behavioral responses to pan-
demic influenza H1N1. We do think that Lee and
Lemyre’s model may be applicable to pandemic in-
fluenza H1N1 because previous studies highlighted
the importance of cognitive, affective, and social-
contextual factors in predicting compliance with rec-
ommendations.(10−14) Data from 1,158 Italian people
revealed that pandemic influenza H1N1 is perceived
as low risky and dreadful, while the opposite is true
for terrorism.(28) Although there are differences in
the nature of these risks, we do not expect differ-
ences in the relationships postulated in Lee and Le-
myre’s model(27) because its theoretical premises are
derived from psychosocial theories of behavior (e.g.,
theory of reasoned action, theory of planned behav-
ior, social-cognitive model of disaster preparedness)
and the constructs are not specific to terrorism.
This study is different from Lee and Lemyre’s
research(27) for other two reasons: the test of a sin-
gle model and the inclusion of other variables in
the model: likelihood of infection, severity of ill-
ness, family members and friends’ level of worry,
and exposure to media campaigns. To our knowl-
edge the relationships postulated in Lee and Le-
myre’s model(27) were never tested in a single model.
To address these questions, we analyzed our data in
a structural equation modeling (SEM) framework,
which has a number of methodological advantages.
More specifically, SEM techniques are preferable to
regression techniques for testing mediation models
A Social-Cognitive Model of Pandemic Influenza H1N1
because they permit the modeling of both measure-
ment and structural relationships and yield overall
fit indices.(29,30) For these reasons, we aimed at test-
ing a (SEM) model in which cognitive factors and
social-contextual factors influence behaviors through
the mediation of affective response. We hypothe-
sized the influence of cognitive factors derived from
key themes of how people perceived the swine flu
outbreak. Rubin and colleagues(10) found that be-
lieving that there is currently a high risk of catching
pandemic influenza H1N1 (likelihood of infection)
and that catching it will have severe consequences
(severity of illness) were both associated with com-
pliance with official recommendations. Moreover, in
their theoretical model Lee and Lemyre(27) posit the
influence of two other cognitive dimensions, the per-
ceived seriousness of the threat (e.g., how serious
people perceive the threat) and perceived coping effi-
cacy (e.g., how people perceive themselves as able to
control or cope with the threat). For these theoretical
and empirical reasons, we hypothesized the role of
likelihood of infection, severity of illness, perceived
seriousness, and perceived coping efficacy in compli-
ance with recommended behaviors (through the me-
diation of affective response).
Among social-contextual factors, Lee and Le-
myre(27) hypothesized the role of respondents’ views
on the regulation of terrorism. The authors adopted
a “social norm” perspective to predict that individ-
uals would be most likely to adopt behavioral re-
sponses when there is the contribution of the social
context to engagement in recommended behavior, in
that case the perceived level of preparedness of in-
stitutions. That is, the engagement of authorities in
recommended behavior establishes social norms for
such behavior. Social norms are considered predic-
tors of behaviors in the theory of reasoned action(18)
and the theory of planned behavior.(17) Following
this theoretical perspective, we hypothesized the role
of perceived level of preparedness of institutions in
compliance with recommended behaviors (through
the mediation of affective response).
Given that social norms may be a function of me-
dia messages(31,32) and family members and friends’
influence,(33,34) along with levels of preparedness of
institutions we hypothesized the role of two differ-
ent sources of social influence: the information ex-
changed with the groups the individual belongs to
and the information delivered by education cam-
paigns. Mass media interventions should be con-
sidered given their small but significant impact on
647
health protection behaviors.(31) According to Snyder
and colleagues’ meta-analytic study,(32) campaigns
promoting the adoption of a new behavior or re-
placement of an old behavior (e.g., seatbelt cam-
paigns, dental care) have had the greatest success
rates, whereas campaigns aiming to cease an un-
healthy behavior people are already doing or pre-
vent initiation of a risky behavior have had the
least success. These findings are interesting because
recommended behavior against the infection of in-
fluenza A (H1N1) virus concerns mostly the adop-
tion of a new behavior or replacement of an old
behavior.
In Italy the Minister of Health and the local
public health authorities disseminated health mes-
sages on H1N1 influenza to the public and health-
care professionals through several different types of
media, TV, newspaper, radio, leaflet, and poster. It
should be mentioned that Rubin and colleagues(10)
did not find an effect of an information leaflet on
compliance with official recommendations. Since it
is likely that the leaflet had no effects because
it was assessed during a period of relatively low
H1N1 influenza transmission in the United King-
dom, we hypothesized that exposure to media cam-
paigns may be related to recommended behaviors
after a period of relatively high H1N1 influenza
transmission.
The second source of social influence refers to
the communication that takes place within the prox-
imal network. According to Scherer and Cho(33) risk
perceptions and behavior have, to a great extent,
been studied as individual cognitive mechanisms in
which “individuals collect, process, and form percep-
tions as atomized units unconnected to a social sys-
tem” (p. 262). Based on Burt’s network theory of
contagion,(34) Scherer and Cho(33) put forward a so-
cial network contagion theory of risk perception that
hypothesized the existence of risk perception net-
works, that is, relational groupings of individuals who
share, and perhaps create, similar risk perceptions.
In this way, individuals who are in frequent contact
share similar information, attitudes, emotion, and be-
havior. To test this theory, we hypothesized that fam-
ily members and friends’ level of worry may predict
individuals’ level of worry.
For these theoretical and empirical reasons, we
hypothesized the role of exposure to media cam-
paigns and family members and friends’ level of
worry in compliance with recommended behaviors
(through the mediation of affective response).
648
1.1. Study Objectives and Hypotheses
As said before, the primary objective of this
study was to test a model in which cognitive fac-
tors and social-contextual factors influence, through
the mediation of affective response, behavioral re-
sponses to pandemic influenza H1N1 in a represen-
tative sample of Italian adults. Perceptions of insti-
tutional preparedness for pandemic influenza H1N1,
family members and friends’ levels of worry, and ex-
posure to media campaigns were examined as social-
contextual factors. Public perceptions in relation to
pandemic influenza H1N1 on the dimensions of like-
lihood of infection, seriousness, severity, personal
impact, and coping efficacy were examined as specific
cognitive factors. Worry about pandemic influenza
H1N1 was included as affective response, and com-
pliance with official recommendations was included
as behavioral responses to this threat.
In line with previous research findings and based
on Lee and Lemyre’s model,(27) the hypothesis of this
study was to test a model that takes into account the
following relationships:
(i) People who perceive pandemic influenza
H1N1 as riskier (i.e., as more probable, more
severe, more serious, as having a greater per-
sonal impact) would be more likely to comply
with health-related recommendations through
partial mediation of affective response.
(ii) People who perceive themselves as able to
control or cope with pandemic influenza
H1N1 (e.g., higher perceived coping efficacy)
would be more likely to comply with health-
related recommendations through partial me-
diation of affective response.
(iii) People who have more favorable perceptions
of institutional preparedness for pandemic in-
fluenza H1N1 would be more likely to comply
with health-related recommendations through
partial mediation of affective response.
(iv) People who perceive family members and
friends as more worried about pandemic in-
fluenza H1N1 would be more likely to comply
with health-related recommendations through
mediation of affective response.
(v) People who were exposed to media campaigns
would be more likely to comply with health-
related recommendations through mediation
of affective response.
No specific hypotheses of mediation (partial vs.
full) were developed about the relationship of family
Prati, Pietrantoni, and Zani
members and friends’ levels of worry and exposure
to media campaigns to health-related recommenda-
tions through affective response, given that this is a
relatively unexplored area of research.
2. METHOD
2.1. Participants
A sample of 1,010 Italians of at least 18 years of
age took part in the survey. Male participants were
459 (45.4%). Mean age was 49.93 years (SD = 16.96)
(range: 18–89). The sample was stratified by region
(North, Center, South, and Islands) as well as age
group (18–29 years, 30–44 years, 45–54 years, 55–
64 years, 65 or over) and gender according to 2009
Istat data.
2.2. Measures
Participants were asked questions about recom-
mended behaviors, social-contextual factors, cogni-
tive factors, and affective response to pandemic in-
fluenza H1N1 2009.
2.2.1. Social-Contextual Factors
Perceived level of preparedness of institutions.
Participants were asked to respond to the following
questions: “Do you think the national authorities are
doing a good job of dealing with the Swine flu out-
break?” (item 1), “Do you think the authorities have
enough resources to cope with the Swine flu out-
break” (item 2), “How much do you think the na-
tional authorities are prepared for the Swine flu out-
break?” (item 3), “How much do you think the local
authorities are prepared for the Swine flu outbreak?”
(item 4) (1 = not at all, 10 = extremely). An index of
perceived institutional preparedness was computed
by summing over respondents’ ratings of prepared-
ness of institutions. Factor analysis revealed the pres-
ence of one factor. The scale demonstrated adequate
internal consistency (Cronbach’s alpha of .75). Vari-
able skewness and kurtosis were, respectively, −0.47
and 0.12.
Exposure to media campaigns. Participants were
asked to report if they remembered at least one in-
formative campaign about A/H1N1 virus. Permitted
responses for each question were yes or no. There
were no missing data for this variable. A total of 689
participants (68.2%) answered “yes” to this question.
A Social-Cognitive Model of Pandemic Influenza H1N1
Family members and friends’ level of worry. Par-
ticipants were asked how much they felt family mem-
bers and friends worry about A/H1N1 virus infection
(1 = not at all, 10 = extremely). Variable skewness
and kurtosis were, respectively, 0.65 and −0.56.
2.2.2. Cognitive Factors
Based on previous studies,(10,27) cognitive dimen-
sions of risk perception were assessed with the fol-
lowing five questions: “How serious do you think it
is its impact in Italy?” (perceived seriousness), “Do
you think you are at risk of catching swine flu?” (like-
lihood of infection), “Do you think that Swine Flu is
a serious condition?” (severity of illness), “Do you
think that if you catch Swine Flu it will have ma-
jor consequences for your life?” (perceived personal
impact), and “How well do you think you would be
able to cope with it?” (perceived coping efficacy).
Ratings on these cognitive factors were provided us-
ing a 10-point Likert-type scale (1 = not at all, 10 =
extremely). Skewness and kurtosis of perceived se-
riousness were, respectively, 0.06 and −0.97. Skew-
ness and kurtosis of likelihood of infection were,
respectively, 0.49 and −0.60. Skewness and kurto-
sis of severity of illness were, respectively, 0.32 and
−0.97. Skewness and kurtosis of perceived personal
impact were, respectively, 0.32 and −0.93. Skewness
and kurtosis of perceived coping efficacy were, re-
spectively, −0.46 and −0.51. Principal component
analysis (PCA) was used to examine the structure
in the data. A total of 87.12% of variance was ex-
plained by PCA. The analysis revealed the presence
of three dimensions explaining, respectively, 47.97%,
22.39%, and 13.06% of variance. The first dimension
was named “perceived severity” and included three
items: perceived seriousness, severity of illness, and
perceived personal impact. Cronbach’s alpha was ac-
ceptable (.79). The second dimension included the
item concerning perceived coping efficacy whilst the
third dimension included likelihood of infection.
2.2.3. Affective Response to Pandemic Influenza
H1N1 2009
Feelings of worry about pandemic influenza
H1N1 2009 were assessed with two questions: “To
what extent do you currently worry about influenza
H1N1?” (item 1) and “Do you feel scared about in-
fluenza H1N1?” (item 2). Ratings were provided us-
ing a 10-point Likert-type scale (1 = not at all, 10 =
extremely). The correlation between these two items
649
was high (Pearson’s r = .65, p < 0.001) and Cron-
bach’s alpha was acceptable (.75). Variable skewness
and kurtosis were, respectively, 0.55 and −0.69.
2.2.4. Recommended Behaviors
Individual behavioral responses to the threat of
pandemic influenza H1N1 2009 were assessed with
the question: “Over the past month, what have you
done to avoid A/H1N1 virus infection?” This was
followed by a list of seven behaviors recommended
by the Italian Ministry of Health: “I have increased
the amount I clean or disinfect things that I might
touch, such as door knobs or hard surfaces,” “I have
washed my hands with soap and water more often
than usual,” “I have used tissues when sneezing,” “I
have kept distance from people who show symptoms
of influenza-like illness, such as coughing and sneez-
ing,” “I have discussed with a friend or family mem-
ber what we would do to avoid A/H1N1 virus infec-
tion,” “I have discussed with my family doctor how
to avoid A/H1N1 virus infection,” “I have looked for
more information about this risk.”
Permitted responses for each question were yes
or no. A total score of recommended behavior was
obtained by summing over respondents’ ratings of
recommended behaviors (no = 0, yes = 1). Variable
skewness and kurtosis were, respectively, 0.18 and
−0.86.
2.3. Procedure
Between February 16 and 19, 2010 Demetra s.a.s
(a company specialized in collecting data) carried out
a telephone survey of Italian residents, using random
digit dialing. Data were collected using computer-
assisted telephone interviewing. Proportional quota
sampling was used to ensure that respondents were
demographically representative of the general adult
(> = 18 years old) population, with quotas based, as
indicated above, on age group, sex, and region. To
reduce selection bias, participants were initially in-
formed that the survey related to “issues currently
under debate in Italy” and were only informed that
the real issue was pandemic influenza H1N1 2009 af-
ter obtaining their verbal consent to proceed. Partic-
ipants had the opportunity to select “don’t know/no
opinion” as a response (coded as 0) if they had no
opinion or if they did not know what to answer re-
garding a specific item. Items within sections were
sequenced randomly to balance for possible order ef-
fects.
650
Of the total 5,859 phone numbers dialed, 66 were
fax machines, 48 were answer machines, 452 were
not valid, 61 were busy, 833 were unanswered, 1,070
were not eligible (e.g., company or private firm tele-
phone number or respondents were underage), 4,469
resulted in a refusal, 322 required a call-back, and
133 were addressed to individuals with demographic
characteristics of quotas already met. A total of 1,010
(17.3%) interviews completed and the response rate
2, as defined by AAPOR—American Association for
Public Opinion Research,(35) was 24.58%.
2.4. Data Analyses
There were no missing data in our data. How-
ever, “do not know” answers were coded as missing
values. None of the variable we investigated had a
percentage of “do not know” answers higher than
2.4%. Missing data estimation was employed using
maximum likelihood imputation procedure as rec-
ommended by Graham.(36) Moreover, we imputed
the missing values under a normality assumption and
then fit the structural model to the imputed data us-
ing chi-square test statistic that is robust to nonnor-
mality. This hybrid procedure is considered to be ex-
cellent in dealing with missing data.(37)
We used structural equation modeling to test
our proposed model of the role of affective response
in mediating the relationship between cognitive and
social-contextual factors and recommended behav-
ior. We employed the Yuan-Bentler χ 2 statistic,(38)
an adjustment for multivariate nonnormality applied,
in this study, to the maximum likelihood estimation
techniques of the covariance matrix. Yuan-Bentler
corrections are extensions of Satorra and Bentler(39)
corrections to incomplete data. Yuan-Bentler correc-
tions with incomplete data have been found to per-
form remarkably well.(40) Given that difference be-
tween two scaled chi-squares (e.g., Yuan-Bentler χ 2 )
for nested models is not distributed as chi-square, dif-
ference testing was done using the scaling correction
factor. We did not, however, use chi-square to assess
the adequacy of fit of our models.
To test the mediational paths we followed the
data analytic strategy outlined by Mathieu and Tay-
lor.(41) In testing for the significance of the indirect
effect, MacKinnon, Fairchild, and Fritz(42) recom-
mended resampling methods. According to Mac-
Kinnon,(30) we derived point estimates and bias
corrected bootstrap confidence intervals (BC CIs)
for indirect effects by formulating 1,000 bootstrapped
resamples. The significance of the indirect effects at
the .05 level is supported if the bias corrected and ac-
Prati, Pietrantoni, and Zani
celerated bootstrap confidence intervals for the esti-
mates exclude zero. An indirect effect is said to occur
if the confidence interval for the indirect effect does
not contain zero.
3. RESULTS
Bivariate correlations among all variables of in-
terest along with means and standard deviations are
presented in Table I. With the exclusion of sever-
ity of illness, the mean for all the cognitive eval-
uation variables were below the midpoint of five.
Lower mean values were found for family mem-
bers and friends’ worry and affective response. The
mean values for perceived coping efficacy and level
of preparedness of institutions were above the mid-
point. Since perceived coping efficacy was not re-
lated to recommended behaviors, we have therefore
excluded this measure from further analysis. More-
over, since exposure to media campaigns had no sig-
nificant relationship with indicator variables of af-
fective response to pandemic influenza H1N1 2009,
we have therefore excluded this variable from me-
diation analysis. We considered the direct influence
of exposure to media campaigns on recommended
behaviors.
Following the data analytic strategy outlined by
Mathieu and Taylor,(41) we first fit “only directs”
and “no directs” models to serve as additional bases
of comparison. Thus, we fit a model in which all
the variables of interest, with the exclusion of affec-
tive response to pandemic influenza H1N1 2009 (al-
though this variable remains as a latent variable in
the model), predicted recommended behaviors (only
direct model). The only directs model exhibited ac-
ceptable fit indices [Y-Bχ 2 (48) = 177.699, p < 0.001;
NNFI = 0.93; CFI = 0.96; RMSEA = 0.052].
The no direct effects model estimated paths
from each of the antecedents (cognitive and social-
contextual factors with the exception of exposure to
media campaigns) to affective response to pandemic
influenza H1N1 2009 (the mediator), and from the
mediator to the dependent variable (recommended
behaviors). This model exhibited slightly better fit
indices [Y-Bχ 2 (53) = 182.340, p < 0.001; NNFI =
0.94; CFI = 0.96; RMSEA = 0.049]. In this model,
the direct effect of preparedness of institutions to af-
fective response to pandemic influenza H1N1 2009
was not significant; therefore, preparedness of insti-
tutions was excluded from mediation analysis.
According to Mathieu and Taylor(41) there is a
significant full mediation effect when the addition of
the direct paths in the no direct effects model does
 Table I. Summary of Intercorrelations, Means, and Standard Deviations for Demographic, Cognitive, Social-Contextual, Affective, and Behavioral Response Variables

M SD 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

1. Gendera — .06 .18∗∗∗ .10∗∗ .14∗∗∗ .08∗ .05 −.02 −.05 .02 −.02 .06 .11∗∗ .12∗∗∗ .13∗∗∗ .11∗∗
2. Age 49.93 16.96 — .02 −.15∗∗∗ .08∗ .08∗ −.13∗∗∗ −.10∗∗ −.09∗∗ −.04 −.07∗ .00 −.03 −.02 −.01 −.02
3. Perceived 4.74 2.43 — .35∗∗∗ .61∗∗∗ .53∗∗∗ .03 .05 .11∗∗ .27∗∗∗ −.03 .10∗∗ .51∗∗∗ .55∗∗∗ .65∗∗∗ .23∗∗∗
seriousness
4. Likelihood of 4.02 2.56 — .34∗∗∗ .37∗∗∗ .19∗∗∗ .05 .07∗ .13∗∗∗ .08∗ .02 .40∗∗∗ .40∗∗∗ .45∗∗∗ .22∗∗∗
infection
5. Severity of illness 5.01 2.69 — .55∗∗∗ −.03 .04 .07∗ .23∗∗∗ −.04 .10∗∗ .48∗∗∗ .57∗∗∗ .58∗∗∗ .25∗∗∗
6. Perceived personal 4.55 2.83 — −.01 .02 .05 .15∗∗∗ −.05 .03 .60∗∗∗ .60∗∗∗ .56∗∗∗ .29∗∗∗
impact
7. Perceived coping 6.23 2.59 — .23∗∗∗ .21∗∗∗ .18∗∗∗ .43∗∗∗ −.12∗∗∗ .04 .03 −.02 −.01
efficacy
8. Level of 6.34 2.55 — .49∗∗∗ .48∗∗∗ .49∗∗∗ −.12∗∗∗ −.02 .01 .04 .02
preparedness of
institutions (item 1)
9. Level of 6.71 2.41 — .44∗∗∗ .35∗∗∗ −.10∗∗ .03 .01 .06 .04
preparedness of
A Social-Cognitive Model of Pandemic Influenza H1N1

institutions (item 2)
10. Level of 5.72 2.62 — .32∗∗∗ −.05 .12∗∗∗ .15∗∗∗ .20∗∗∗ .10∗∗
preparedness of
institutions (item 3)
11. Level of 6.11 2.49 — −.11∗∗ −.04 −.02 .00 −.01
preparedness of
institutions (item 4)
12. Exposure to media 1.32 .47 — .03 .05 .06 −.07∗
campaignsb
13. Family members 3.85 2.65 — .62∗∗∗ .60∗∗∗ .27∗∗∗
and friends’ worry
14. Affective response 3.88 2.78 — .65∗∗∗ .26∗∗∗
(item 1)
15. Affective response 3.94 2.79 — .29∗∗∗
(item 2)
16. Recommended 3.05 1.92 —
behaviors

Note: a Gender was coded as 1 for men and 2 for women. b Exposure to media campaigns was coded as 1 for exposure and 2 for nonexposure. ∗ p < 0.05, ∗∗ p < 0.01, ∗∗∗ p < 0.001.
651
652 Prati, Pietrantoni, and Zani

not significantly improve the fit of the model, and the
inclusion of the mediator turns the previously signifi-
cant direct effects into nonsignificance.
The “family members and friends, level of worry
direct” model (by adding a path from this antecedent
to the dependent) was not a significant improvement
over the no directs model ["χ 2 (1) = 0.22, p > 0.05].
The indirect effect of family members and friends’
level of worry to recommended behaviors via affec-
tive response was significant (bootstrap estimate =
0.034, BC 95% CI = 0.000 to 0.072), whereas the di-
rect effect was not significant (bootstrap estimate =
0.005, BC 95% CI = −0.085 to 0.073).
The “perceived severity direct” model was not
a significant improvement over the no directs model
["χ 2 (1) = 0.87, p > 0.05]. The indirect effect of
perceived seriousness to recommended behaviors
through affective response was significant (bootstrap
estimate = 0.116, BC 95% CI = 0.767 to 8.740),
whereas the direct effect was not significant (boot-
strap estimate = −0.519, BC 95% CI = -9.549 to
0.215).
The “likelihood of infection direct” model was
not a significant improvement over the no directs
model ["χ 2 (1) = 2.83, p > 0.05]. The indirect effect
of likelihood of infection to recommended behaviors
via affective response was significant (bootstrap esti-
mate = 0.116, BC 95% CI = 0.767 to 8.740), whereas
the direct effect was not significant (bootstrap esti-
mate = −0.519, BC 95% CI = −9.549 to 0.215).
These mediational analyses showed that adding
a path from the antecedents to the dependent vari-
able does not improve the fit of the model. There-
fore, the most parsimonious and the best fitted model
was the no direct effects model that estimated paths
from each of the antecedents (cognitive and social-
contextual factors) to affective response to pandemic
influenza H1N1 2009 (the mediator), and from the
mediator to the dependent variable (recommended
behaviors) (see Fig. 1). The R2 (explained variance)

Perceived Severity of Perceived

seriousness illness personal
impact Item 1 Item 2

1.08** 1.00*** 1.04***

1.00** 1.13**
(.77) (.75) (.79) (.82)
(.74)
Perceived severit y
0.98** Affective response to
(.82) pandemic influenza
2.25**
H1N1 2009
(.47)
0.08*(.09)
3.44** Likelihood of
(.70) infection

0.49*
(.13)
0.62** Family members and (.14) 0.32**
(.12) friends’ levels of wor ry 0.12* (.36)

0.12**
(.02) -0.03
(-.03) Recommended
-0.03 behaviors Fig. 1. The no direct effects model
Level of (.09) (N = 1,010).
preparedness of
institutions

0.83***
0.79*** 1.00*** 0.73*** -0.40*
(.58) (.78) (.64) (.72) -0.13**
(-.14) (-.10)

Exposure to media
campaignsa
Item 1 Item 2 Item 3 Item 4

Note: ∗∗ p < 0.01, ∗∗∗ p < 0.001; Y-Bχ 2 (20) = 182.340, p < 0.001; NNFI = 0.94; CFI = 0.96;
RMSEA = 0.049. a Exposure to media campaigns was coded as 1 for exposure and 2 for non-
exposure. Standardized estimates are shown in parentheses. Dropping level of preparedness
of institutions results in increase in the fit of the model, Y-Bχ 2 (54) = 79.699, p < 0.001; NNFI
= 0.95; CFI = 0.97; RMSEA = 0.054.
A Social-Cognitive Model of Pandemic Influenza H1N1
of the variables affective response and recommended
behaviors was, respectively, .95 and .14.
4. DISCUSSION
The aim of this study was to evaluate hypotheses
drawn from Lee and Lemyre’s sociocognitive model
of risk perception and individual responses(27) ap-
plied to pandemic influenza H1N1 in a representative
sample of Italian population. The key characteristic
of this model is the integration of cognitive, social-
contextual, and affective factors involved in individ-
ual responses to hazard.
Affective response to pandemic influenza H1N1
2009 predicted individual response to pandemic in-
fluenza H1N1 above and beyond cognitive and socio-
contextual factors. Moreover, affective response to
pandemic influenza H1N1 2009 fully mediated the re-
lationship of cognitive and social-contextual factors
to recommended behaviors with the exception of ex-
posure to social campaigns that had a direct effect on
this outcome. Finally, level of preparedness of insti-
tutions and perceived coping efficacy did not predict
either affective response nor recommended behav-
iors.
Our results concur with those of two studies
that found low levels of worry and anxiety toward
pandemic influenza H1N1 2009 in a cohort in Aus-
tralia(11) and in the United Kingdom.(10)
4.1. Predicting Affective Response to Pandemic
Influenza H1N1 2009
In line with the findings of previous studies sup-
porting the influence of cognitive evaluations and af-
fective response,(25−27) in this research perceived se-
riousness, likelihood of infection, personal impact of
illness, and severity of illness were all related to af-
fective response.
In this study, we did not find a relationship be-
tween perceived efficacy and affective response. Re-
search findings about perceived efficacy were incon-
sistent. On the one hand, perceived control (a vari-
able related to perceived efficacy) was associated
with higher affective response about risk.(26,43) On
the other hand, perceived efficacy was associated
with lower affective response about risk as found in
Lee and Lemyre’s study.(27) It seems likely that the
differential relationship of perceived efficacy to af-
fective response may explain this result. However, it
should be noted that we have used only one single
653
indicator for measuring coping efficacy. Thus, this re-
sult may be interpreted with caution.
In contrast with Lee and Lemyre’s model,(27)
perceived institutional preparedness did not pre-
dict affective response although bivariate correla-
tion showed a small positive association. As in Lee
and Lemyre’s study,(27) when controlling for other
variables the relationship between perceived insti-
tutional preparedness and affective response disap-
peared. It may be that the perception of institutional
preparedness does not contribute to form mental im-
ages and visceral responses that are related to antici-
patory emotions.(20) Thus, perception of institutional
preparedness may be more likely to influence cogni-
tive evaluations rather than affective response.
Another sociocontextual factor not related to af-
fective response is exposure to social campaigns. This
is probably due to the fact that social campaigns in
Italy were not characterized by fear appeals messages
that try to scare people to motivate actions.(44)
The only sociocontextual factor related to affec-
tive response is family members and friends’ levels of
worry. This variable is the strongest predictor of af-
fective response to pandemic influenza H1N1 2009.
This result is in line with Scherer and Cho’s network
contagion theory of risk perception(33) and suggests
that there is a sharing of concerns and emotions be-
tween those individuals who are most linked to each
other through interpersonal contacts.
4.2. Predicting Recommended Behaviors
In addition to affective response to pandemic in-
fluenza H1N1 2009, this study examined the predic-
tors of recommended behaviors through the medi-
ation of affective response. Affective response con-
tributed independently from cognitive and social-
contextual factors to recommended behaviors and
fully mediated the relationship between the cognitive
and social-contextual factors (with the exception of
exposure to media campaigns) to recommended be-
haviors. This result is in line with the “affect heuris-
tic” that highlights the importance of affect for risk-
related behavior.(19−21) In particular, the literature
on severe acute respiratory syndrome(45,46) and pan-
demic influenza H1N1 2009(10) suggests that worry
or anxiety may be associated with compliance with
health-related recommendations.
It is interesting to note that although the liter-
ature showed that cognitive evaluation of risk can
motivate individuals to protect themselves,(47−50) we
did not find this relationship to be direct, but rather
654
indirect through mediation of affective response. It
is possible that Italian people perceived pandemic
influenza H1N1 2009 as an intangible risk and took
precautionary measures only if this perception influ-
enced affect.
We found that family members and friends’ lev-
els of worry were related to recommended behaviors
through the full mediation of affective response to
pandemic influenza H1N1 2009. This result suggests
that Scherer and Cho’s network contagion theory
of risk perception(33) may be domain specific: fam-
ily and friends’ worry influences primarily affective
response rather than behaviors. Thus we should ex-
pect that family and friends’ compliance with health-
related recommendations will be primarily related to
individuals’ compliance with health-related recom-
mendations. Future studies should explore this hy-
pothesis.
Neither perceived coping efficacy nor perceived
institutional preparedness was associated with rec-
ommended behaviors. On the one hand, we found
that people comply with official recommendations
regardless of how well they think they are able to
cope with it. It seems that people who comply with
recommended behaviors may or may not be aware
of their effectiveness. Thus, they comply with rec-
ommended behaviors in response to emotional ac-
tivation. On the other hand, we found that peo-
ple comply with official recommendations regard-
less of how prepared the institutions are perceived.
We can argue that for some people the percep-
tion of institutional preparedness may relate to a
greater compliance with recommended behaviors be-
cause they think “if authorities are taking action, it
means that there is a danger and we should do some-
thing” (higher risk perception and establishment of
social norms).(27) For others the perception of insti-
tutional preparedness may relate to apathy because
they think “if authorities are taking action, they will
solve the problem and there is no need to do any-
thing” (diffusion of responsibility).(27) Thus, future
studies are needed to address the role of higher risk
perception, establishment of social norms, and diffu-
sion of responsibility to disentangle the effect of per-
ceived institutional preparedness.
The effect of exposure to media campaigns on
recommended behavior was not mediated by affec-
tive response. A number of mechanisms could ex-
plain this relationship. Media campaigns may con-
tribute to the establishment of social norms that are
considered determinants of behaviors in the theory
of reasoned action(18) and the theory of planned be-
Prati, Pietrantoni, and Zani
havior.(17) Alternatively, through media campaigns
people may learn what to do and once educated they
comply with recommended behaviors regardless of
their negative emotional activation. As we said be-
fore, media campaigns in Italy were not character-
ized by fear appeals messages and therefore their
effect may be mediated by other types of emotions
(e.g., positive emotions such as comfort by having
learnt something useful). For example, the major ed-
ucational campaign was started by the Ministry of
Health during winter to provide the public with in-
formation and advice. Topo Gigio, the lead charac-
ter of a children’s puppet show on Italian television
(translated as “Louie Mouse”), endorsed this cam-
paign. This campaign showed, among other things,
what individuals could do to protect themselves and
others. The tone of the campaign was positive. In
conclusion, this study showed that media campaigns
may have an influence on compliance with recom-
mended behaviors, in contrast with Rubin and col-
leagues’ study.(10) It seems likely that leaflets had no
effects in that study because it was assessed before
a period of relatively high H1N1 influenza transmis-
sion in the United Kingdom.
4.3. Limitations and Future Directions
The main limitation of this study related to its
cross-sectional design that does not permit establish-
ing a causal relationship. The major difficulty with
correlational research relates to the reciprocal na-
ture of their relationship. For example, it may be that
people more compliant with recommended behav-
iors tend to remember more easily the exposure to
media campaigns. Another example is the relation-
ship between perceived risk and behavior: the adop-
tion of precautions can determine the level of risk
perceived.(50) Although qualitative(26) and longitudi-
nal(27) studies have provided support for the causal
relationship between cognitive evaluations and affec-
tive response, this and the other hypotheses deserve
to be tested in future experimental studies.
A second limitation of this study relates to non-
response that is common in telephone surveys of
longer length.(31) Although the response rate of this
study was not very low, it raises questions about
the generalizability of findings to the overall Ital-
ian population. A third limitation of this study re-
lates to the use of single-item measures. Although
the use of single-item scales may constitute an im-
portant methodological weakness, in this study we
chose these measures to reduce the length of the
A Social-Cognitive Model of Pandemic Influenza H1N1
interview and to reduce the risk of high nonresponse
rate.
A fourth limitation of this study is related to
the explained variance of recommended behaviors.
Future study may include in the model others vari-
ables such as trust in institutions to explain more vari-
ance.(10)
4.4. Conclusion
Despite these limitations, this study provided
pertinent information on the processes linking psy-
chosocial factors to recommended behaviors facing a
risk situation. The model we tested showed the cen-
tral role of emotional responses to a specific risk in
shaping individual behaviors. With the exception of
exposure to media campaign, the effects of cognitive
evaluations of risk and family and friends’ influence
on behaviors were explained by an increase in the af-
fective response. Moreover, this study tested the va-
lidity of a social-cognitive perspective of risk percep-
tion and individual response in a new field, such as
health hazard.
Findings have significant implications in enhanc-
ing the effectiveness of prevention activities against
the global spread of future pandemic influenza. In
particular, findings suggest that risk management
strategies aimed at raising pandemic influenza risk
perception need to consider not only cognitive as-
pects but also emotional responses to elicit com-
pliance with recommendations. Risk communica-
tion effort should, therefore, use images, metaphors,
and narratives because, according to Slovic and col-
leagues,(22) this is the way our experiential system
(which represents risk as a feeling) encodes reality.
It should be noted that research findings suggested
that affect is important for successful risk communi-
cation.(51,52) Moreover, this study showed that me-
dia campaigns may have an effect on compliance
with recommendations despite the low-risk percep-
tion and emotional worry levels concerning this haz-
ard. Finally, this study is of value to the development
of risk management strategies also in terms of the
contribution of social networks in dealing with con-
troversial risk situations. More specifically, given the
influence of friendship and family members on the
risk perceptions of individuals, risk communication
efforts may be less successful without knowledge of
how the meaning of a specific risk is constructed by
groups and community networks.
655
ACKNOWLEDGMENTS
This research is part of a wider project on en-
vironmental risk perceptions and is supported by
a grant from the Italian Ministry of Health, Prot.
n.417/2009, 30.04.2009.
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