Title: Evaluating and improving communication with the public during a pandemic, using rapid turn around telephone surveys
Funder: Department of Health and Social Care

Abstract: DESIGN: The project has four stages. The first three occur prior to the pandemic, the fourth during the pandemic. Stage 1 consists of meetings with stakeholders and a re-review of existing literature. This will allow us to generate items for a new telephone survey that will assess uptake and predictors of protective behaviours among the general public during a pandemic. Stage 2 consists of three rounds of cognitive interviews which we will use to refine the wording of our new questions. Stage 3 consists of a cross-sectional telephone survey of a randomly selected, demographically representative sample of the British population during a normal flu season, with a one week follow-up of the same sample. Stage 4 consists of weekly telephone surveys conducted during the pandemic, with follow-up of specific samples as required. SETTING: Stages 1 and 2 will take place within King's College London. Telephone surveys in Stages 3 and 4 will recruit representative samples of the general public within Britain. TARGET POPULATION: Members of the general British public, aged 16 or over. HEALTH TECHNOLOGIES BEING ASSESSED: We will assess an improved version of the telephone survey used by the Department of Health to assess uptake and predictors of recommended behaviours among the public during the 2009/10 pandemic. MEASUREMENT OF OUTCOMES: The selection of outcome variables to be measured in our Stage 3 and 4 surveys will be determined as part of our project. We will ask stakeholders from the Department of Health and Health Protection Agency what protective behaviours they are most likely to recommended to members of the public in the next pandemic. Initial consultation suggests that these behaviours are likely to include respiratory and hand hygiene, vaccine uptake (intended and actual) and use of healthcare resources (actual and intended). Secondary outcomes will include the presence of self-reported influenza-like illness among the population. If data concerning these outcomes are to inform policy in real-time during a pandemic, the must pragmatic and robust option is to use a series of telephone surveys to obtain self-report data on performance of these behaviours among the public. SAMPLE SIZE: A total sample size of 30 participants for each round of interviews in Stage Two will allow sufficient opportunity for any obvious difficulties with question wording to emerge. Sample sizes of 1,067 participants for the surveys in Stages Three and Four will provide us with a sample error of plus or minus three percentage points for our prevalence rates. PROJECT TIMETABLE: Our pre-pandemic work will take seven months. Stage 1 will begin on 1 August 2012, Stage 2 on 1 October 2012 and Stage 3 on 1 December 2013 (the first available flu season for this study). We will submit our interim report detailing our new survey template on 1 March 2013. In Stage 4, we propose running surveys for the first six months of the pandemic.

Lay abstract: During the 2009/10 influenza pandemic, the Department of Health used an extensive multimedia campaign to inform the public about the nature of 'swine flu' and to provide advice on various protective behaviours. In particular, people were advised to wash their hands regularly with soap and water, to use tissues appropriately, to use a telephone helpline to get advice if suffering from flu-like symptoms and to have the swine flu vaccine if in an 'at-risk' group. Although these behaviours would have reduced the spread of the virus, uptake of each of them was disappointingly low. If we are to encourage people to engage in these type of protective behaviours in a future pandemic, it is important that we monitor what the level of uptake is in the community, that we identify if the Department of Health's communications campaign is having any effect on that uptake, and that we understand why the campaign is having an effect. During the 2009/10 pandemic, this type of monitoring was achieved by running a series of rapid turn-around telephone surveys of the general population of Britain. Using standard opinion poll methods, 39 surveys were run at a rate of roughly one a week. In each survey, around 1050 randomly chosen members of the public were interviewed about their behaviours, their perceptions about swine flu, and where they were getting their information from about the pandemic. As part of a previous grant from the NIHR, our team analysed these data and provided feedback to the Department of Health. For example, we observed that people who had been exposed to the Government's advertising campaign were more likely to use recommended behaviours than those who had not, and that this seemed to be because the adverts were convincing people that those recommended behaviours were effective in preventing illness. Unfortunately, because the surveys had to be designed and put into use very quickly, we also identified several problems with them which limited the amount of feedback we were able to give. In this study, we will spend seven months prior to the next pandemic designing, testing and refining a new set of survey questions, so that these can then be used immediately and with confidence as soon as the next pandemic begins. During the pre-pandemic part of our work, we will first work with the Department of Health, the Health Protection Agency and other stakeholders to make sure we understand what types of behaviour they will be asking the general public to do in the next pandemic. We will then examine the existing academic literature to identify the main psychological drivers of those behaviours. We will also use a well-established psychological theory called Protection Motivation Theory to make sure that we cover all of the relevant psychological drivers. Having established what the key behaviours and their psychological predictors are, we will produce a list of potential survey questions that can be used to measure those variables. We will then use three rounds of one-to-one interviews, interviewing thirty people in each round, to make sure that our questions are clear and make sense to people. We will perform a test for the full survey during a normal influenza season, asking a market research company to call 1,067 people to test out our new questions. These people will be asked to take part in the survey twice, answering identical questions one week apart. Having designed our new survey, we will put the research on-hold until a pandemic begins. As soon as this happens, we will be able to use our survey to obtain a snap shot of behaviours, perceptions and concerns in the general population. By repeating the survey weekly, we will be able to see how behaviours and perceptions change over time, and to explore what seems to be driving these changes (e.g. the volume of media reporting, or the number of deaths that have been reported). By analysing the data in real-time, we will also be able to give feedback to the Department of Health communications team and other stakeholders about the impact of their communications strategy and about ways of improving the strategy by targeting those psychological variables that predict whether someone will or will not adopt a given behaviour. We will be able to judge the success of our research by assessing whether changes to the Department of Health communications strategy that result from our advice have any effect on levels of behaviour, as seen in our survey data. Our multidisciplinary team are ideally placed to conduct this research because we have experience in analysing the Department of Health's swine flu survey data and also because we have extensive experience in running our own 'rapid reaction' surveys during public health crises such as the London bombings, the Litvinenko affair, and the early stages of the swine flu outbreak. In terms of ethical issues, it is possible that some of the people who are invited to take part in our research during the pandemic will be upset by being asked to talk about the pandemic. This is a particular risk if the person has recently been bereaved as a result of the pandemic, or if a friend or relative is seriously ill. Our interviewers will be told that they should tactfully terminate an interview if anyone becomes obviously upset and will be able to provide advice on the sources of support that are available to people who have been affected in this way. Telephone surveys are expensive to run, but are now rightly seen as an important component of the response to any major public health crisis. As such, numerous surveys are almost certain to be used in any future pandemic. We believe that investing money in our research proposal is a sensible way of ensuring that we get the best possible data from these surveys, providing the Department of Health and Health Protection Agency with a fully rounded understanding of how the public are reacting during an outbreak, why, and how best to communicate with them.

Research activity codes: 7.4 RESOURCES AND INFRASTRUCTURE (DISEASE MANAGEMENT);8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: INFECTION