Initial psychological responses to Influenza A, H1N1 ("Swine flu")

Medical interest in Influenza A, H1N1 has been considerable [1]. However, despite dramatic warnings in the media, little is known about behavioural responses to pandemic threats. 'Common sense', lay beliefs about those most likely to be at risk, and the appropriate behaviours to adopt to avoid infection, are often not taken into account by medical practitioners. Such beliefs have been shown to influence adherence and self-care behaviours [2]. During the SARS and Ebola outbreaks, association of the viruses with Chinese or African 'others' permitted Europeans to feel relatively safe from infection [3], and contributed to the victimisation of some Chinese in Toronto [4]. Stockpiling by the worried well can rapidly lead to shortages; cancellations of travel and closure of businesses can rapidly have profound economic consequences [5, 6]. Faced with concerns about their mortality, individuals may turn to others for reassurance, but these social networks, by sharing their uncertainties, may sometimes contribute to greater stress [7].

The international threat posed by H1N1 calls for a necessary pooling of international data, both by medical teams and by social scientists. Particular concern has been expressed about the pandemic spreading to Asia, and the potential for mixing with other variants, such as avian influenza [8]. Our team in the UK, Portugal and Malaysia sought to explore initial responses to the pandemic influenza threat. Responses to a new pandemic can be very time specific, with public reactions liable to change almost daily with media coverage [9]. Particularly important may be the gathering of data during the escalating responses that accompany a WHO pandemic alert phase 4 and 5 [10]. The WHO raised their flu alert to level 5 on 29^th April [11], a mass media information campaign began in the UK on 5^th May 2009. We collected data from 30th April 2009 (at which time there had been 9 deaths and 212 confirmed cases worldwide) until 6th May 2009 (31 confirmed deaths, 1569 cases). By 6^th May there had been 27 confirmed cases in Europe, but none in Asia.

Our study sought to gather a snapshot of the attitudinal and behavioural responses during the early stages of a pandemic, knowledge about the differences between seasonal and pandemic flu, and those groups seen as most 'at risk' from infection. Understanding such attitudes and levels of knowledge may have important public health implications for information campaigns aimed at encouraging appropriate precautions against infection, while comprehending risk perceptions can help identify those groups most likely to be at risk of stereotyping and prejudice during a pandemic.

At present, it is unclear as to whether the outbreak of Influenza A, H1N1 will prove to be a "false alarm", or whether the virus will mutate and spread in a new, more dangerous form, perhaps this Autumn [16]. Our data collection in the early stages of the pandemic/pandemic of Spring 2009 suggests that respondents felt they had some control over potential infection. Respondents identified 'washing hands', avoidance of infected people, avoidance of crowded areas and mask wearing as strategies for avoiding infection, reflecting generally approved public health measures [17]. Malaysians were particularly anxious about a pandemic, despite the lack of cases of this influenza in Malaysia during our research period, probably reflecting the recent avian influenza alert in this country [8]. As with previous health alerts, personal anxieties can feed behavioural changes [18], with many Malaysians contemplating significant changes in their use of transport, and anticipating the purchasing of goods, particularly masks, in preparation. European respondents were particularly likely to have discussed the pandemic with their friends, while a quarter of respondents overall had discussed the pandemic thereat with their family. Our correlational data suggests that such conversations may reinforce existing levels of anxiety. Practitioners need to be aware that rumours spread fast during times of pandemic threat, with significant risks of emotional as well as physical 'contagion' between populations [19]. Any increase in anxiety can lead to rapid behavioural changes that can soon lead to shortages, and enhance the desire for medication available at home.

An unrealistically optimistic belief that others are at greater risk than ourselves can reduce our willingness to enact healthy behaviours [20]. During pandemics, particular 'out-groups' may be vulnerable to discrimination [21]. Although respondents correctly identified groups such as the immunocompromised as at greater risk [22], half our respondents saw the sexually active as at greater risk, almost a third of Malaysians suggested homosexuals were at more risk of infection. This may reflect a popular belief in Malaysia that homosexuals are likely to be already immunocompromised through infection with HIV/AIDS. The homeless were also perceived as at greater risk in both Malaysia and Europe. Political and health authorities need to be wary of increased stereotyping and prejudice towards particular societal groups during an influenza pandemic. Our Europe-only data suggested that individuals underestimate the threat of regular seasonal flu, while a quarter of our respondents incorrectly believed seasonal flu and swine flu symptoms were different, and that seasonal flu vaccination could help immunise against swine flu. Despite major media and governmental campaigns across Europe, there is obviously still a need for greater information with respect to symptom logy and immunisation against infection.

Our study was a rapid, cross-sectional analysis in response to a particular outbreak, and as such suffers from a number of limitations. Although this research was unique in tracing initial behavioural responses to this pandemic, our respondents were not true random samples in either continent, and we assessed only a small range of potential behaviours. Our Malaysian sample was drawn from one large city - Kuala Lumpur - and may therefore not be representative of other, more rural populations in that country. Similarly, our European data was drawn primarily from the UK and therefore cannot be seen as representative of the whole continent. Self-report biases in questionnaire completion may mean that our respondents were unwilling to provide openly prejudicial responses, whilst our study in Europe was further limited by including only those who had access to the Internet. To fully model likely behavioural changes, and their consequences for public health services, larger, more representative longitudinal studies are now needed to track public anxieties and health behaviours in the continuing battle against pandemic influenzas.

Numerous studies have identified behavioural interventions valuable in prevention of epidemic/pandemic influenza, but we know little about individuals' own perceptions of risk at the beginning of a pandemic, which groups in society they believe most at risk of infection and how they have changed and intend to change their behaviours as a pandemic develops. Our findings suggest culture and individual anxiety are important predictors of behavioural responses to pandemic influenza, with higher levels of anxiety about swine flu in Malaysia compared to Europe, and with greater levels of behavioural change in Malaysia. Particular 'out-groups' (e.g. prostitutes, homosexuals) were judged to be at relatively high risk of infection, with Malaysian respondents particularly likely to emphasise the infection risk in these groups. Such judgements of risk may have important implications for the equitable treatment of socially marginalised group, particularly as the pandemic continues to accelerate worldwide.