University life and pandemic influenza: Attitudes and intended behaviour of staff and students towards pandemic (H1N1) 2009

The CDC recommends that institutions of higher education balance the goals to minimize morbidity and mortality from pandemic influenza with the goal of minimising educational and social disruption [5]. Between April 30^th and September 30^th 2009, ten broadcast emails were sent out by the Director of the University Health Service to staff and students. Contained in the emails was information on the: (1) H1N1 situation; (2) modes of spread and common symptoms; (3) recommended health advice consistent with both the WHO and national recommendations; and (4) contact information for the relevant health departments [6]. Posters developed by the Commonwealth Department of Health and Ageing and UNSW were placed in high traffic areas and focused on: (1) encouraging faculty, staff and students to stay at home if symptomatic (i.e. with a fever, cough, and runny nose) and to protect each other; (2) cough/sneeze etiquette (i.e. "cover your mouth and nose when you cough and sneeze" and "dispose of used tissues in the bin) and (3) hand hygiene (i.e. "Wash your hands properly and regularly").

Data was collected from the 29 June - 30 September, coinciding with the peak of the pandemic in Australia. An anonymous online survey was designed to assess the knowledge, attitudes and perceptions of pandemic (H1N1) 2009, which was referred to by its vernacular alternative, "swine flu". The survey was piloted on June 11th with three students and three staff, representative of the members of the study population, and modified accordingly. The final version assessed: (1) demographic characteristics; (2) awareness, perceived personal risk and anxiety; (3) recent influenza-related behaviours changes; (4) intended behaviour in the event of various scenarios at UNSW and (5) compliance with different community interventions. In regards to the behaviour changes, we included four changes (cancelling social plans, avoiding busy public places, cancelling/postponing travel plans and not using public transport) that were related to avoidance behaviour and not recommended by the government and five changes (buying hygiene products, receiving the seasonal influenza vaccine, using online resources for teaching and learning and stockpiling necessities) that were related to recommended behaviours. The recommended behaviours questions were adapted with permission from a study undertaken by Rubin et al [7].

The sample comprised of both academic and non-academic staff (i.e. administration, IT and other support staff) and students at UNSW in Sydney, Australia. Participants accessed the final questionnaire via a link on an online newsletter available to all UNSW staff and students, and via an online information gateway. Emails were also sent to the heads of each Faculty, informing them of the survey. Consent was implied upon completion and submission of the questionnaire. Submitted surveys were collated in a directory and de-identified prior to analysis. Participants were offered the chance to win a $500 cash prize upon completing the survey. Ethics approval was granted by the University of New South Wales Human Research Ethics Committee.

The quantitative data on the completed survey was collected in Microsoft Excel. OpenEpi (version 2.3) was used to calculate [8], proportions, 95% confidence intervals and χ² tests for significance. Alpha was set at the 5% level. We used logistic regression to compute odds ratios to evaluate the association of demographic variables and attitudes and beliefs.

A total of 2882 UNSW staff and students aged ≥18 years completed the online survey between the 29 June and 30 September 2009. The overall response rate was 5.7% (2882/50847) and most respondents were young (18-34 years, 73.9%, 2129/2882) and born in Australia (51.8%, 1492/2882) (Table 1). Academic and general staff members were both overrepresented in our sample (12.5%, 360/2882, X² = 311.3, p < 0.001; 22.4%, 646/2882, X² = 1313, p < 0.001 respectively) compared to the actual proportions employed at UNSW (4.9%, 2497/50847 and 5.5%, 2779/50847 respectively). Students were underrepresented (65.1%, 1876/2882, X² = 1279, p < 0.001) compared to the proportion of internal students at UNSW (88.2%, 44833/50847).

Most respondents (99.6%, 2870/2882) reported that they had heard about the Australian pandemic situation. Whilst 60.4% (1742/2882) believed that it was serious, 40.4% (1165/2882) said that they were "not anxious" (Figure 1) and a further 23.8% (686/2882) reported "disinterest". Of the respondents who felt they were likely to contract pandemic influenza (42.2%, 1217/2882), 90.7% (1104/1217) believed the infection would adversely affect their health. Towards the end of the survey period and the end of winter, the percentage reporting "no anxiety" increased and the proportion of respondents who believed that the pandemic was "serious" significantly decreased (OR, 0.25 [95% CI, 0.17-6.38); p < 0.001) (Figure 2). Perceptions of susceptibility significantly decreased with the decline of laboratory-confirmed cases in Australia (OR, 0.72 [95% CI, 0.57-0.92]; p = 0.003). Asian-born respondents were significantly more likely to believe that the pandemic was serious (OR, 3.79 [95% CI, 3.16-4.55]; p < 0.001) and feel anxious (OR, 4.85 [95% CI, 2.94-8.13]; p < 0.001) compared with respondents from all other regions. Females were significantly more likely than males to think their health would be adversely affected (OR, 1.78 [95% CI, 1.37-2.33]; p < 0.001), and that the current situation is serious (OR, 1.21 [95% CI, 1.04-1.40]; p = 0.01). Respondents aged over 55 were most likely to be anxious (OR, 2.28 [95% CI, 1.00-4.68]; p = 0.02) and younger respondents aged 20-34 were the least likely group to believe that they were susceptible to infection (43.7%, 930/2129, p = 0.04).

Overall, most respondents (75.9%, 2188/2882) had not made any lifestyle changes, and 61.8% (1781/2882) had not undertaken any specific health behaviours due to the pandemic (Table 2). The most commonly reported change was the purchase of hygiene products such as face masks or hand hygiene products (20.8%, 600/2882). Asian-born respondents were significantly more likely than Australian-born respondents to indicate that they had made a lifestyle change (OR, 2.78 [CI, 2.26-3.39]; p < 0.01), although this likelihood decreased with time spent in Australia. Uptake of avoidant behaviour was significantly related to being a student (32.1%, 603/1876, X² = 44.14, p < 0.001) and belief that infection would have adverse health effects (OR, 2.22 [CI, 1.07-5.24]; p = 0.02). Those who had made at least one recommended behaviour change were significantly more likely to be anxious about the pandemic (OR, 4.27 [CI, 1.61-11.10]; p = 0.002), and were female (OR, 1.46 [CI, 1.15-1.84]; p = 0.001).

60.2% (1736/2882, p < 0.001) of respondents were willing to comply with all five public health measures if requested by authorities (Table 3). Asian-born respondents again had the highest rates (70.6%, 531/752, X² = 45.73, p < 0.001). Willingness to receive the pandemic vaccine (despite it being unavailable at the time of survey) was associated with seasonal influenza vaccination uptake over the previous 3 years, compared with those who had no vaccination history (99.1% v 85.7%, X² = 32.11, p < 0.001). The use of face masks in public was met with most resistance (16.8%, 484/2882), especially amongst respondents aged 18-24 years (19.5%, 290/1487, p < 0.001).

Just over half (51.1%, 1472/2882), were very willing to continue University schooling online however, academic staff were significantly more reluctant than students to deliver teaching by this method (OR, 0.56 [CI, 0.30-0.97]; p = 0.02). 78.5% (2282/2882) of respondents would not come to university if they were experiencing influenza-like illness (ILI) (Table 4). Students were the most likely to attend University if unwell (75%, 1407/1876, p < 0.001) and were the only group where over half would present if they had an assessment or deadline due and were unwell (66.5%, 1248/1876). However respondents who had made a lifestyle change as a result of pandemic (H1N1) were significantly more likely to absent themselves even if an exam or deadline was due (X² = 50.45, p < 0.001).