Intended for healthcare professionals


Public perceptions, anxiety, and behaviour change in relation to the swine flu outbreak: cross sectional telephone survey

BMJ 2009; 339 doi: (Published 02 July 2009) Cite this as: BMJ 2009;339:b2651
  1. G James Rubin, senior research fellow1,
  2. Richard Amlôt, research fellow2,
  3. Lisa Page, clinical lecturer1,
  4. Simon Wessely, professor of epidemiological and liaison psychiatry1
  1. 1King’s College London, Institute of Psychiatry, Department of Psychological Medicine, Weston Education Centre, London SE5 9RJ
  2. 2Health Protection Agency, Emergency Response Department, Porton Down, Wiltshire
  1. Correspondence to: G James Rubin g.rubin{at}
  • Accepted 23 June 2009


Objective To assess whether perceptions of the swine flu outbreak predicted changes in behaviour among members of the public in England, Scotland, and Wales.

Design Cross sectional telephone survey using random digit dialling.

Setting Interviews by telephone between 8 and 12 May.

Participants 997 adults aged 18 or more who had heard of swine flu and spoke English.

Main outcome measures Recommended change in behaviour (increases in handwashing and surface cleaning or plans made with a “flu friend”) and avoidance behaviours (engaged in one or more of six behaviours such as avoiding large crowds or public transport).

Results 37.8% of participants (n=377) reported performing any recommended behaviour change “over the past four days . . . because of swine flu.” 4.9% (n=49) had carried out any avoidance behaviour. Controlling for personal details and anxiety, recommended changes were associated with perceptions that swine flu is severe, that the risk of catching it is high risk, that the outbreak will continue for a long time, that the authorities can be trusted, that good information has been provided, that people can control their risk of catching swine flu, and that specific behaviours are effective in reducing the risk. Being uncertain about the outbreak and believing that the outbreak had been exaggerated were associated with a lower likelihood of change. The strongest predictor of behaviour change was ethnicity, with participants from ethnic minority groups being more likely to make recommended changes (odds ratio 3.2, 95% confidence interval 2.0 to 5.3) and carry out avoidance behaviours (4.1, 2.0 to 8.4).

Conclusions The results support efforts to inform the public about specific actions that can reduce the risks from swine flu and to communicate about the government’s plans and resources. Tackling the perception that the outbreak has been “over-hyped” may be difficult but worthwhile. Additional research is required into differing reactions to the outbreak among ethnic groups.


  • We thank Julia Clark, Michele Corrado, and Meghann Jones (Ipsos MORI); Sandro Galea (University of Michigan); John Simpson, John Stephenson, Virginia Murray, Iain Mallett, and Helen Maguire (Health Protection Agency); the participants of the UK’s Scientific Pandemic Influenza Committee’s Behavioural and Communications Group; and many others for their timely and useful advice on wording of the questions and the survey design. Data collection was done by interviewers working for Ipsos MORI.

  • Contributors: GJR had the original idea for the study and developed the study design with RA, LP, and SW. GJR carried out the analyses and wrote the first draft of the paper. All authors contributed to further drafts and had full access to all the data. SW is guarantor.

  • Funding: This study was supported by the National Institute for Health Research, as part of a career development research training fellowship awarded to GJR. RA is supported as a full time employee of the Health Protection Agency. SW is funded by the NIHR Biomedical Research Centre for Mental Health, the South London and Maudsley NHS Foundation Trust, and the Institute of Psychiatry, King’s College London. The funders played no part in the study design; the collection, analysis, or interpretation of the data; the writing of the report; or the decision to submit the manuscript for publication. The views expressed in this publication are those of the authors and not necessarily those of their funders or employers.

  • Competing interests: None declared.

  • Ethical approval: This study was approved by King’s College London’s Psychiatry, Nursing and Midwifery Research Ethics Committee (PNM/08/09-102).

  • Data sharing: Full top line results for the survey are available from GJR at g.rubin{at}

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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