In the early stages of the ‘swine flu’ pandemic, less than 30% of people surveyed in the UK reported washing their hands more frequently despite a massive government campaign encouraging them to do so, say researchers this month in the British Medical Journal. But as soon as the situation begins to escalate, the public is more likely to take action on government advice, say experts. A similar study in the USA, where swine flu was more widespread and had caused more serious illness, showed a much stronger response from the public.

“Our results suggest that less than two weeks after WHO [World Health Organization] responded to the swine flu outbreak by raising its pandemic alert status to 5 and in the face of intense media coverage and a major government advertising campaign, public responses to swine flu were muted,” write James Rubin, of King’s College London, and colleagues.

In the UK, intense media coverage of the outbreak began on 25 April. Five days later, the country’s health authorities launched an advertising campaign to advise the public on how to avoid becoming infected with the virus. Adverts ran on TV, radio and print media, and information leaflets were later sent to every household in the country.

To better understand people’s perceptions of swine flu, Rubin and colleagues interviewed around 1000 British people over the telephone in mid-May. At that point in the course of the emergency, 65 people had become infected with the pandemic virus across the country. The research team asked respondents about their behaviour in relation to the outbreak, as well as questions aimed to gauge their level of anxiety, and whether they had made other behavioural changes not advised by the government.

More than 72% of the respondents said they had not been washing their hands more often, 83% did not do any more cleaning or disinfecting than usual, and 85% had not discussed with friends what they would do if they fell ill.

The researchers found that the limited changes to people’s behaviour suggest that the public did not over-react in the face of the outbreak. Instead, they noted that authorities face a more challenging task in convincing the public that the threat posed by swine flu is real.

According to Peter Sandman, a risk communication consultant based in the USA, it is difficult to persuade people to adopt a new behaviour as a precaution. It typically takes a generation for a new precaution to take hold, “[w]hether it’s seat belts or smoke alarms — or coughing into your sleeve,” he explains. This is the case even when communication campaigns are well-designed and well-funded, and when the risk to health is clearly serious, Sandman points out. This research confirms that the main problem with public perception about pandemic flu is the risk of complacency, “not the risk of panic”.

In the USA, the situation has been slightly different from that documented in the British study, says Robert Blandon, of Harvard University. The outbreak was more widespread than in the UK early on, and the country borders Mexico, where a high rate of mortality was being reported among those infected with the virus, he explains.

Blandon and colleagues carried out a similar telephone survey, contacting around 1000 members of the US public on 5 and 6 May. At that point two people had died of swine flu in the USA, and more than 1400 were infected with the virus, of which 35 had been treated in hospital. In the meantime, a communication campaign by health authorities that focused on more frequent hand washing was already underway.

More than 65% of those surveyed reported washing their hands more frequently in response to the outbreak, according to Blandon and colleagues. “Essentially… there need to be certain underlying conditions before the public will respond to even the best campaign,” says Blandon. In the USA, the increased number of cases and deaths meant communications were effective, while the British experience was different at the time, he adds.

Now, the pandemic is rapidly evolving in Britain. Earlier this week, reports revealed that several apparently healthy people died after catching the swine-flu virus. Over the past week, calls to a UK health service helpline from people with flu-like illness have soared by 50%.

“Of course scary new developments produce brief periods of widespread alarm, sometimes even excessive alarm,” says Sandman. But calling a government helpline is prudence, not panic as some journalists have described, he adds. The British public are showing an “adjustment reaction” to the pandemic as a result of the two most recent deaths in otherwise healthy people, he says, a response that is “inevitable and appropriate”.

“[G]etting people to prepare while the seriousness of the threat is still uncertain is very, very difficult,” says Sandman. “Of course a catastrophic and terrifying situation sometimes does the job virtually overnight.”