Outbreaks of seasonal influenza amongst student and university populations have been previously reported [12, 13]. These outbreaks have resulted in increased absenteeism, impaired school performance, and increased health care utilization [14]. The first reported university outbreak of 2009 pandemic H1N1 occurred at the University of Delaware (UD), affecting an estimated 10 % of the student population. It spread rapidly through the University of Delaware community with a surge in illness over a 2-week period. Although severe illness was rare in this instance, the authors documented that the outbreak caused a substantial burden and challenge to the university health care system [15]. In Japan, Uchida et al. reported that the infection rate among university students they surveyed ranged from 4.3 % to 15.5 % during the 2009 pandemic [16]. The authors suggested that continued exposure to sick individuals and disease transmission occurred during the pandemic, mainly through university club activities.
While our participants were knowledgeable about the modes of transmission of influenza, very few were able to accurately describe what ‘pandemic influenza’ actually meant. The participants had heard of ‘swine flu’, however only a few demonstrated a high level of knowledge around how it originated. There was a lot of confusion around the role that animals play in regard to ‘pandemics’. Unconfirmed beliefs and misconceptions regarding pandemic influenza H1N1 2009 have been previously documented [17, 18].
In accordance with most of the pre- and post pandemic general public studies conducted worldwide [1, 2, 8, 19, 20], our participants held a common belief that they were not at risk of acquiring the disease. Amongst our participants, it was felt that they were protected against the infection because they were ‘fit and young’. This sense of non-vulnerability has also been previously documented in our previous university study [10] and amongst dormitory housed university students (aged18-23 years) in the USA [21]. However, given the low level of comprehension about pandemic influenza, the general public may be over or underestimating their level of risk towards acquiring the disease and the health consequences if infected (serious illness, need for hospitalization, mortality risk).
As highlighted through the interviews, our students believed in the classic picture of morbidity attributable to the flu, such that only the very young, the elderly, those with co-morbidities and those with weakened immunity are at risk. This result is consistent with the risk groups identified by participants in previous studies [4]. Given this low level of anxiety towards the pandemic, it is perhaps not surprising that the students did not undertake any behavioural changes in response to the H1N1 pandemic, as highlighted here and in our previous study [10].
During the 2009 H1N1 pandemic, posters developed by the Commonwealth Department of Health and Ageing and UNSW were placed in high traffic areas. They 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) (3) hand hygiene (i.e. “Wash your hands properly and regularly”). Our participants considered regular hand washing, cough etiquette (covering mouth and nose when coughing or sneezing), and avoiding the sick as good strategies to prevent infection. During the early and peak pandemic periods, hand washing was found to be the most accepted intervention among university students in Hong Kong [22], Korea [23], United States [24] and Australia [10]. Young people such as our university students may be more amenable to hand hygiene as a strategy because of a number of reasons. Firstly, these practices are community learnt and represent actions that the person has been encouraged to carry out from a young age. Secondly, hygiene-based measures pose minimal disruptions to daily routine. However, this is just a hypothesis and was not explored in depth in the study.
Amongst our participants, mask use, as an infection control strategy was extremely unpopular. In many western settings, where medical mask/respirator use is generally restricted to the hospital setting, it is not unanticipated that people would associate embarrassment and social stigma with the use of these products. At the University, it is extremely rare to see a student wearing a medical mask. This maybe because students believe that masks are uncomfortable, inconvenient and unnecessary. Habit is an important influence on routine behaviour [25], including hygiene behaviour [26], such that despite their best intentions people may find it difficult to implement new hygiene measures during a pandemic if they have not previously made these a habit.
The implementation of infection control behaviours appears to depend on a number of environmental (e.g. time, energy, availability of facilities, social norms), and motivational (e.g. social responsibility, social relationships, selfishness) factors. In the future however, the level of adoption of measures such as masks will fluctuate with changes in perceptions of risks and the perceived infectiousness and severity of the disease.
The use of voluntary home quarantine, social distancing, and school dismissal to prevent the transmission of pandemic influenza is a standard inclusion in most countries pandemic plans [27–29]. However, lower acceptance of isolation and social distancing, which can disrupt routine and enjoyable activities, has been observed in prior studies [30, 31]. When participants were asked to comment on how they felt about the use of these interventions they stated that they were not in favour of adopting these actions and would find them extremely difficult to comply with. During an outbreak of pandemic H1N1 virus infection at a large public university in April 2009, Mitchell et al. undertook an online survey of students, faculty, and staff to assess knowledge of and adherence to university recommended non-pharmaceutical interventions [24]. They found that amongst the students with an acute respiratory infection (ARI), 44 % reported leaving campus for >1 day while sick, 35 % had visitors and only 34 % reported missing days of class. Most students attended class or work, went out in public, and participated in purely social activities (including having visitors) while having an ARI. Aside from not wanting to miss these important events, it could be suggested that low risk perceptions and mixed messages about the severity of the 2009 influenza H1N1 pandemic and about the actual need for isolation and social distancing would probably have contributed to a low acceptance rate.
There are a number of logistical issues that universities and other institutions need to contend with instigating measures such as isolation. For example, universities may have large numbers of students living on or around the campus. While some of these facilities are self-contained, others have large common dining, entertainment and study rooms. The difficulty of introducing home quarantine in this setting is that many of these students (especially international and interstate students) may be unable to leave the campus facilities and would end up having to care and cater for themselves. Given the inevitability of future disease outbreaks or pandemic, universities must undertake efforts ensure that the needs of the students are catered for in these situations. Students, their parents, and other members of the university community must be involved with planning for these events so that feasible action plans are developed. These plans must ensure that there is continuity for the student.
A strength of this study was using interviews that allowed to uncover in greater depth the attitudes and perceptions of the students. However, there are several limitations in this study. These include: (1) over reporting: as the study was conducted through face-to-face interviews with our interviewer, it may have resulted in an over-reporting of infection control behaviours to avoid embarrassment or judgement; (2) recall bias: some questions in the interview guide required participants to recall their past experiences during the 2009 H1N1 pandemic, therefore recalling errors may have occurred; (3) representation: as the study was undertaken one year after the pandemic, the responses received may not represent the attitudes that participants held during the pandemic; (4) participation rate was low.
Communicating to students effectively about the spread of influenza and the need to adopt preventative measures on a large campus presents a challenge. University officers need to find a balance between promoting and educating, while trying not to incite unnecessary fear. In the event of prolonged public health threats, such as infectious disease disasters, online messaging and regularly updated web sites have been shown to be timely and effective in providing risk communication and health messages [32]. However, it has also been demonstrated that pandemic influenza-specific web sites are among the least accessible and most difficult to understand compared with web sites addressing other types of disasters [33]. Poor accessibility can significantly undermine the effectiveness of university pandemic preparedness efforts and limit the ability of individuals to make well informed decisions during pandemics [34]. Other mediums favoured by young adults such as popular internet sites (Facebook or twitter) should be considered as a possible means of information provision to this susceptible cohort and in increasing uptake of preventative health advice. Education campaigns targeting young adults could also utilise the university networks and information gateways, or distribute information through university-wide emails and newsletters.
