Nearly every respondent in this study reported they would comply with a doctor's advice to stay home for seven days if they were diagnosed with pandemic (H1N1) 2009 influenza, and the same level of compliance could be expected in the setting of avian influenza. These findings are similar to those that have been previously reported; our study adds data in the context of an actual, rather than hypothetical, pandemic.
Prior to the current pandemic, Eastwood et al read a brief description of a pandemic influenza outbreak analogous to the 1918 Spanish flu to Australian telephone survey participants, and found 97.5% of respondents would stay home for seven to ten days if they were told they might have had contact with the disease . Similarly, Barr et al reported 85% of Australians would be at least moderately willing to isolate themselves from others during an influenza pandemic. Blendon et al reported 94% of Americans would comply if they contracted a pandemic influenza and public health officials recommended they stay at home for seven to ten days. In a more recent survey from June of 2009, Blendon et al identified 236 respondents who reported that they themselves or someone in their household had experienced flu-like symptoms, and 75% of those with symptoms had stayed home. Other studies have also found support for explicit government action to contain pandemic influenza, including "encouraging" people to work from home, and quarantining infected individuals [5, 12]. Interestingly, DiGiovanni et al reported that compliance with quarantine measures during the 2003 severe acute respiratory syndrome (SARS) outbreak in Toronto, Canada was affected more by compliance monitoring, fighting boredom and stress, and minimizing stigmatization than with any actual threat of enforcement.
From a public health planning perspective, the more useful data from this study may be that regarding the level of compliance with stay at home advice that can be anticipated for seasonal influenza, and the relative lack of compliance that can be expected for the common cold. Seasonal influenza is a more common disease, each year leading to approximately 18,000 hospitalizations and costing around $115 million in Australia; the burden in the United States is much greater with the direct costs of influenza-related medical care exceeding $10 billion . Yet, these data confirm that people do not view seasonal influenza with the same level of concern as pandemic strains of influenza. While it is encouraging that respondents appear to differentiate between seasonal influenza and the common cold, the questions in this survey presumed a physician diagnosis. Large numbers of people do not seek medical care for mild to moderate respiratory illness, and it is not practical to expect lay people to reliably differentiate between a common cold and influenza. Public health efforts to encourage people to self-isolate for influenza-related illnesses may be more successful if they target symptoms (i.e., "cough and fever") rather than specific diagnoses.
This study did find some significant associations between demographic characteristics and likelihood to comply with stay at home advice for seasonal influenza that might be useful for targeting public health efforts to increase compliance. Males were less likely to report anticipated compliance with stay home advice for both a common cold and seasonal influenza, and this is consistent with other studies from Australia [7, 9]. Males have also previously been reported to feel less susceptible than females do to pandemic influenza, although this study found no differences between males and females for anticipated compliance in the setting of pandemic (H1N1) 2009 or avian influenza.
Increasing age was associated with increased anticipated compliance with stay at home advice for both the common cold and seasonal influenza, while increasing education and income were associated with decreased anticipated compliance for both diseases. Although the associations for education and income did not withstand multivariate analysis, the finding is consistent with previous work and both variables were retained as potential confounders in the final logistic regression model. Like males, wealthier and better educated people tend to view themselves as less susceptible to influenza, while older people tend to view themselves as more susceptible . Many influenza-related public health campaigns target older populations; targeting stay at home messages to wealthier and better educated populations might be a novel but worthwhile effort for containing seasonal influenza.
Employed respondents were less likely than unemployed respondents to report anticipated compliance with stay home advice for both a common cold and seasonal influenza. This association, also, did not withstand multivariate analysis, but it is an intuitive finding. Even in the setting of pandemic influenza, many people would have to forgo income in order to stay home . For example, a survey of key decision makers at U.S. businesses found 74% of the businesses provided for paid employee sick leave, but 15% of businesses did not provide for any employee sick leave, whether paid or unpaid . Still, this study found no difference in anticipated compliance rates in the setting of pandemic (H1N1) 2009 or avian influenza. This is consistent with the findings of Barr et al who reported similar rates of "willingness to comply with health protective behaviours" between employed (69.5%, 95%CI: 65.5%-73.5%) and unemployed (71.8%, 95%CI: 67.7%-76.0%) survey respondents in the setting of pandemic influenza. Eastwood et al, however, reported the contrary, finding that employed people who were unable to work from home would be less likely to self-isolate in the setting of pandemic influenza. How closely the level of actual compliance approaches the level of self-reported anticipated compliance may well be affected by issues related to income, financial security, and employer leave policies.
A particularly novel and important finding of this study was that more than one-quarter of health and community service workers reported they would not comply with a physician's advice to stay home if they had seasonal influenza. This may represent a misplaced sense of duty. Previous research has demonstrated that most healthcare workers (HCWs) would not abandon their responsibilities during an influenza pandemic,[16, 17] but isolating one's self when one has symptoms or a diagnosis of disease is a different proposition than simply refusing to work. Despite evidence of the efficacy of vaccinating HCWs, [18–23] influenza vaccination rates among HCWs are low, which presents a risk of HCW-to-HCW as well as HCW-to-patient transmission if infected HCWs report to work. Notably, as the 2003 SARS outbreak subsided and precautions were relaxed, a second wave of the disease including 90 cases of nosocomial infections emerged; 42.5% of those nosocomial infections were associated with exposure to an infected HCW. Seventeen nurses contracted SARS, and 12 (70.6%) had worked with a symptomatic co-worker within 10 days of developing symptoms. Indeed, having worked with a symptomatic co-worker was associated with increased risk (RR = 1.88) of an HCW developing the disease . We are not aware of any previous reports measuring anticipated self-isolation among HCWs with influenza. Public health officials and health facility supervisors must impress upon health workers the clinical and ethical importance of protecting both patients and other staff from exposure to employee-borne influenza, including seasonal influenza .
This study was limited in that it relied upon a telephone survey to collect data, but telephone surveys have been previously used to gather information regarding public perceptions of risk and willingness to comply with containment strategies for influenza,[5, 7, 9–12] and even to assess for the prevalence of influenza . The response rate for this survey was 41.5%; while this may indicate some response bias the sample was fairly representative of the general population, and the overall survey was not specific to influenza. That is, there is no reason to suspect that any potential respondent's decision about whether to participate in the survey would be related to their anticipated compliance with a physician's advice to stay home. A more important limitation of the study is that it measured self-reported anticipated behaviour in the context of a physician diagnosis of disease. Actual behaviour may differ, particularly since many individuals with mild to moderate viral respiratory syndromes do not seek physician care. Also, other factors including perceived severity of illness, social norms, and financial considerations could affect compliance. Thus, the rates of anticipated compliance reported by respondents to this survey must be viewed as a best-case scenario, and actual compliance might be lower. Still the results, both in terms of anticipated compliance and associations with demographic factors, are consistent with those of other studies [5, 7, 9–12]. Finally, early in the Australian pandemic (H1N1) 2009 experience there was a perceived association between international travel and increased risk, but QSS 2009 did not inquire as to respondents' individual travel history or exposure to international travellers.