Interview conducted by April Cashin-Garbutt, BA Hons (Cantab)
Your recent research looked at people’s protective behaviors during the 2009 H1N1 ‘swine flu’ pandemic. Please could you give a brief introduction to this type of flu?
In 2009, a new strain of influenza, or flu, virus emerged and spread rapidly to many countries around the world. It was declared a pandemic by the World Health Organization (WHO) in June 2009. A pandemic flu strain is different than a seasonal flu strain because it is a new strain to which few people have immunity and so it spreads easily from person to person. Depending on how severe the resulting illness is, a pandemic flu can have devastating effects. Most famously, the pandemic flu of 1918-19 was estimated to sicken 20-40% of the global population and kill 50 million people. Fortunately, H1N1 did not have as high a mortality rate, although recent estimates suggest that it ultimately killed between 151,700 and 575,400 people worldwide.
(Statistics from: http://www.flu.gov/pandemic/about/index.html and http://www.cdc.gov/flu/spotlights/pandemic-global-estimates.htm)
What exactly is protective behavior with regards to H1N1?
In simple terms, protective behaviors are the things people can do to reduce their risk of getting sick with the H1N1 virus, and they are often a critical part of the public health response to influenza. These behaviors include pharmaceutical approaches, such as vaccination, and non-pharmaceutical interventions (NPIs). In turn, NPIs include personal protective measures like hand-washing as well as social distancing measures like staying away from shopping malls or sporting events where there may be infected individuals. These behaviors can slow the spread of illness and reduce the total infection rates, and they may be supported with interrelated government policies – as when the government closes schools or funds vaccination programs or promotes hand-washing through communication campaigns.
How did your research into this topic originate?
The Harvard Opinion Research Program (HORP) focuses on understanding the public’s response to major public health problems in order to improve related public policy. During the H1N1 pandemic, we worked with the Centers for Disease Control and Prevention and the National Public Health Information Coalition to track the United States (US) public’s response to the H1N1 pandemic over time. Specifically, we looked at the public’s understanding of the disease and its causes, their concerns and assessment of the illness, their awareness of various communications about H1N1, their views of government policy, and their adoption of a range of protective behaviors. At the close of the pandemic, we wanted to conduct additional research that we thought might inform policy that could better protect and engage the public in future pandemics. For this reason, we wanted to draw larger lessons about public response to government policies and practices in a wider range of situations than existed in just the United States. And so we looked at a number of countries around the world to learn about key patterns in behavior adoption, including the range of behavior adoption rates, the range of behavior adoption rankings (i.e. which are more or less frequently adopted relative to each other and apart from the absolute rates) and the relationship between behaviors adopted. Specifically, we wanted to know whether there was a relationship between adopting NPIs and getting vaccinated.
What did your research involve?
At the close of the pandemic (Nov-Dec 2010), we conducted simultaneous polls – much like those used in elections – among the public in five countries: Argentina, Japan, Mexico, the United Kingdom and the United States. We asked a random sample of approximately 900 people in each country about the behaviors they adopted in response to H1N1 over the whole course of the pandemic. The questionnaires were parallel across countries, as they had the same questions but were revised to be appropriate culturally in each setting.
What did your research find?
The study had three key findings. First, although each of the countries had a sizable number of infections, the public in each country reacted quite differently in terms of their rates of behavior adoption. For example, nearly 90% of people in Argentina and Mexico said they more frequently washed their hands or used hand sanitizer, while approximately three quarters of people in the US and Japan and just half of those in the United Kingdom (UK) said the same.
Second, although the rates were quite variable across countries, some behaviors were more popular than others across countries. In general, people around the world were more likely to adopt individually-oriented behaviors, like hand-washing and sneezing or coughing etiquette practices, than to adopt many social distancing measures, like staying away from places with large groups of people. And increased hand-washing, for example, was the most commonly adopted practice.
Third, people who adopted NPIs were no less likely to get vaccinated than those who did not adopt NPIs. This was true for all behaviors in all countries, which suggests quite a robust relationship.
Why do you think there were wide variations between countries?
The differences between behavior adoption in countries is a fascinating and important area to explore further. Studies suggest that, at the population level, driving factors may include 1) the disease itself – the pattern of illness and the seriousness of the illness; 2) the response – including government policy and the cost/availability of interventions like vaccination; 3) the culture – including past norms around illness in general and influenza specifically; and 4) the media’s portrayal of these. Moreover, all of these factors are re-interpreted by the public itself during the outbreak. So, ultimately, public perception shapes the public’s willingness to adopt measures, and we must pay attention to public views in order to develop appropriate policy responses.
Do you think your research was limited by having to rely on respondents answering the poll truthfully?
Polls offer an important opportunity to hear about people’s reactions and views from their perspective. In this case, it gives us an important tool to track behaviors that would be extremely difficult to measure otherwise – things like covering sneezes and coughs, hand-washing, avoiding other people who seem sick. These things are done frequently and in private and, in some cases, are defined by intent. That is, even if we could observe people’s behaviors to the necessary degree, we would need to ask them why they are, say, cleaning their house or why they decided not to go to the mall in order to know whether they are doing something to protect themselves from illness or for some other reason. Observation clearly would be difficult and there are no alternative records of such data.
For these reasons, polls provide a critical piece of data that we can’t find elsewhere. All that said, there is the risk that people will not answer truthfully – for example, they may be more likely to say they did things that are socially desirable. Because of these and other threats to validity, there is a long history and science to developing question techniques and wording in a way that will allow us to gather more accurate information. For example, we use techniques in the poll to allow people to admit they did not do something without losing face. Even so, results may show slightly higher estimates of public cooperation than truly existed for socially desirable behaviors. This means that if the rates of adoption for a beneficial behavior are low in your poll, there is an even more pressing need to understand the public’s reasoning and perception in order to better motivate them in the future.
What impact do you think your research will have?
We hope the results of this research will help inform global and individual government policies related to public health preparedness for pandemic influenza. First, results are a reminder that a one-size-fits-all approach to policy will not have as great an impact as a customized approach that accounts for differences in public perceptions. Second, policies should nonetheless build on any commonalities across countries, such as being aware of the greater adoption rate of individual, personal protective behaviors as compared to social distancing measures. And third, we have no evidence that policy approach need to hold back on promoting NPIs for fear of suppressing public demand for vaccine. This, policies will do best to combine both pharmaceutical and non-pharmaceutical approaches.
Do you have any plans for further research into this area?
Understanding the public’s needs and perceptions of public health emergencies is an on-going passion for me. I certainly see the need for additional comparative international research in order to help improve policies. Further, I think there is a greater need to understand the response of subsets of the public that may have particular needs and concerns, including racial/ethnic minorities.
Would you like to make any further comments?
I would like to reiterate the importance of understanding public health issues from the perspective of the public. If we understand the public’s needs and views, we can develop more effective policies going forward.
Where can readers find more information?
The study can be found at the Lancet Infectious Diseases website: http://www.thelancet.com/journals/laninf/issue/current
Information about the Harvard Opinion Research Program can be found at:
More information about H1N1 and other pandemic influenzas can be found at the Centers for Disease Control and Prevention website dedicated to this topic:
About Dr Gillian SteelFisher
Gillian SteelFisher is the Assistant Director of the Harvard Opinion Research Program (HORP) and a Research Scientist at the Harvard School of Public Health. She directs HORP’s program on biological security and the public, which involves a series of surveys at state, national and international levels to understand the public response to the threats of public health emergencies, including terrorism / bioterrorism and emerging infectious diseases. In this capacity, Dr. SteelFisher was the director of a 14-poll project focused on the public’s response to H1N1 during the course of the pandemic.