Canadian survey on pandemic flu preparations

This study has been reviewed and approved by the University of Toronto and York University Research Ethics Boards.

All original framework authors and additional investigators translated text from "Stand on Guard for Thee" into survey format. Decisions about item construction were based on investigator consensus. Once preliminary items were judged adequately conveyed via telephone interview, the survey was pilot-tested with volunteers of both sexes and all socioeconomic strata. Each pilot subject commented on item clarity and this feedback was reviewed by each investigator. Final items resulted from iterative revisions where face validity (in relation to the framework) was matched with 8th grade reading level to precisely convey content to a population varying in educational and ethnic background.

Random sampling was achieved via random digit dialing with random digits from across Canada purchased from Sampling Modeling and Research Technologies, Inc. (SMRT, Markham, Ontario). Eligible participants included adults, 18 years or older. Screening of participants was based on standardized inquiries regarding age, citizenship, provincial residency and gender. To characterize nationwide attitudes, we stratified the sample per province to obtain sub-samples equivalent to the province's contribution to national population. To maximize response rate, we administered a core of selected items to all respondents while administering additional sections (Form A and Form B) to alternate subjects. Each participant was provided the option of survey administration in English or French and all contacts with Quebec residents were initiated in French. The survey administration was conducted by a team of N = 7 graduate students (2 males, 5 females).

Descriptive results of the percentages of responses to the survey questions were tabulated. Logistic regression analyses were used to ascertain which demographic factors were significantly associated with survey outcomes. Specific factors were treated as independent (predictor) variables and key findings as dependent (outcome) variables. These analyses addressed the following factors: sex; age; educational background; employment status; residence (eastern provinces versus central provinces versus western provinces; urban versus rural area); relationship status (married or single) and family status (with children versus without children). Dichotomous variables (sex, residential community, and parity) were used in combination with continuous variables that were dichotomized as follows: age [18-50 years versus 51-93 years], martial status [married versus non-married (single, separated, divorced, widowed)], education (<college/university versus = college/university), and employment [employed (full time) versus unemployed (part time & unemployed)].

Of the 5464 calls made, 1690 calls reached answered telephones. Of the 559 individuals who answered calls and could be identified as eligible for participation, 88.5% completed the survey. The demographics of the final sample are presented in Table 1. Altogether, 501 subjects responded to common items, and 261 subjects responded to Form A items while 240 subjects responded to Form B items (Table 1). Demographics for the entire sample vary insignificantly from the demographics of the subsamples completing Form A and Form B.

Full survey results are found in Table 2 and below is a summary reflecting findings with the highest percentages of support.

About 91% of subjects agreed the most important goal of pandemic influenza preparations was saving lives, with 41% endorsing saving lives solely in Canada as the highest priority and 50% endorsing the saving of lives globally as the highest priority. Older age (aged 51 - 93 years (OR = 8.51, p < 0.05)) and current employment (as opposed to unemployment) (OR = 9.48, p < 0.05) were associated with an endorsement of saving lives globally as highest priority (Figure 1) while female gender was associated (OR = 2.74, p = 0.01) with an endorsement of the protection of human rights as an important priority. Strong majorities also favored stocking adequate protective antiviral dosages for all Canadians (92%) and, if effective, influenza vaccinations (95%).

About 90% of respondents supported the obligation of health care workers to report to work and face associated risks during an influenza pandemic unless they had a serious health condition that increased their risks. Over 84% supported the government's provision of disability insurance & death benefits at no charge for health care workers facing elevated risk. Other strong findings indicated support for health care workers who don't feel safe at work being able to file a grievance (84%) and for a plan enabling members of the public to play a volunteer role in maintaining order and offering services should first responders be overwhelmed (97%).

Majorities were found for the right of governments to conscript health care workers during a pandemic (62% agree versus 25% disagree versus 13% neutral) and for the rights of health care workers caring for children or elderly relatives to be excused from pandemic duties (57% agree versus 30% disagree versus 33% neutral). Despite these concessions, a modest majority favored loss of employment or professional license (48% agree versus 37% disagree versus 15% neutral), if health workers were absent without cause during a pandemic.

In terms of regression findings, female gender was associated with agreeing that health care workers with dependents should not have to report to work (OR = 2.07, p < 0.05) (Figure 1) and with not agreeing (OR = 2.10, p < 0.05) the government should be able to conscript health care workers during a pandemic (Figure 1). Unmarried individuals (OR = 4.64, p < 0.05) were more likely to agree that health care workers with serious health conditions should not have to work during a pandemic and younger respondents of both genders (OR = 3.99, p = 0.05), those with children (OR = 15.29, p < 0.001), and those married (OR = 4.34, p < 0.05) were more likely to disagree that the government should provide disability insurance and death benefits to health care workers during a pandemic.

Strong majorities favored governmental power to order quarantines and suspend rights (e.g. traveling, right to assemble) during outbreaks (85%), providing those quarantined had basic needs met (food, shelter, social support) (95%) and access to support services after the end of quarantine (79%). This advocacy of governmental power extended to international authorities advising against travel to outbreak areas to stop a pandemic spread, even when the consequences included serious economic loss (97%). Non-married participants were more likely to endorse (OR = 5.46, p < 0.05) the government's power to order quarantines while older subjects (OR = 4.38, p < 0.05) and those with = college education (OR = 3.38, p < 0.03) were more likely to endorse the government's responsibility to meet the basic needs of those quarantined.

Strong findings were observed for how priorities should be determined for antiviral treatments, if adequate stores were unavailable for all Canadians; and how priorities should be apportioned for hospital treatment, if adequate facilities were unavailable for all (Table 3). In both situations, the highest priorities were assigned to children and health workers infected while serving patients.

A strong majority supported hospital treatment priorities being set (72% in favor versus 28% in opposition) while only a moderate majority favored each resident having an equal chance at antiviral access (59%). Subjects with < college/university education were significantly less likely (OR = 2.25, p < 0.05) to support the government setting priorities regarding distribution of antiviral medications. Females (OR = 2.3, p < 0.05) and those with < college/university education (OR = 2.98, p < 0.01) were more likely to agree that adults with chronic illnesses should have high priority to antiviral medications. In terms of limited treatment resources during a pandemic, older participants (OR = 2.56, p < 0.05) and females (OR = 2.51, p < 0.05) were more likely to believe the sickest patients should have high priority to hospital treatment. Females (OR = 2.19, p < 0.05) were less likely to believe that patients who were most likely to recover should have high priority access to hospital treatment. Non-married participants (OR = 2.84, p = 0.05) were more likely to believe that health care workers who become infected during a pandemic should have high priority to hospital treatment. Participants living in rural communities (OR = 3.13, p < 0.05) were less likely to believe that children should have high priority to hospital treatment access. Older participants and those with ≥ college/university education were less likely to believe that adults with dependents should have high priority to hospital treatment.

Over 70% agreed that Canada should provide international assistance to poorer countries to prepare for a pandemic, even if resources for Canadians were reduced. While 92% of this group believed provision should be at least 7 to 10% of all resources generated, 43% believed the proportion should be greater than 10%. Unemployed individuals (OR = 3.14, p < 0.05) were more likely to disagree with providing international assistance and those unemployed (OR = 2.72, p < 0.05) and living in rural communities (OR = 3.00, p = 0.01) were significantly more likely to disagree with Canada donating more than 10% of total resources to poorer countries.

Strong support was found for development of a plan enabling members of the public to play volunteer roles in maintaining order and offering services if properly trained (98%). Strong support was also found for having pandemic risks communicated by radio (90%), television (97%) and by the internet (81%), with somewhat less support for telephone communication (69%). The particular risks considered most relevant included knowing where the epidemic is most active (98%) and the current risks of death (69%) and infection (78%). Strong support was also found for how severe an offense the disobeying of quarantine orders should be considered. About half (50%) of respondents equated it with a manslaughter offense and over a quarter (27%) saw it as equal to physical assault. In terms of organization of citizens during a pandemic, subjects with < college/university education (OR = 1.83, p = 0.01) and with children (OR = 1.98, p < 0.05) were less likely to submit information into a national database enabling the government to request assistance (from them) during a pandemic. In terms of preferences for communicating health risk information, older participants (OR = 2.55, p < 0.05) were more likely to want health risk information communicated via internet. Females (OR = 1.87, p < 0.05) were more likely to want health risk information communicated via telephone. Younger participants were less likely to want to know risk of death (OR = 2.02, p < 0.05) and risk of infection (OR = 2.64, p = 0.01) (Figure 1).