BMC Public Health 2009, 9:258 http://www.biomedcentral.com/1471-2458/9/258 implementation of infection control behaviour and knowledge, efficacy beliefs and risk perceptions [10,12,14-19]. Perceived personal risk appears to be an important factor. During the SARS epidemic, a survey of cross-border travellers from Hong Kong to mainland China identified that reported levels of mask wearing were lower when individuals stated they wore masks mainly in order to protect others from infection than when they wore masks to protect themselves [13]. However, the role of these factors may be less influential in the context of infections such as influenza, which is seen by most people as a familiar and everyday risk [20,21]. Research also points to socio-demographic factors as influences on infection control behaviour. Men were less likely than women to engage in appropriate handwashing practices in hospitals [14] and less likely to believe that preventive behaviours for controlling SARS were effica- cious [11-13,18]. Findings with regard to age are more inconsistent, with some research identifying an inverted- U relationship [11] and some reporting that older adults are more likely to engage in certain types of preventive behaviours [12]. Practical barriers reported to impede implementation of infection control behaviour have included: high work load; time constraints; skin irritation; and availability of hand decontamination facilities [22,23]. While surveys are useful for identifying broad associations between preventive behaviour and attitudinal and socio- demographic factors, qualitative research is needed in order to develop a more detailed understanding of how these factors may affect adherence to infection control behaviours in different contexts. Qualitative research to date has focussed on the attitudes and perceptions of HCWs toward infection control behaviours [24,25] and continuing to work during a pandemic [26,27]. Whitby, McLaws, and Ross [25] found that nurses viewed hand- washing as a habitual behaviour primarily determined by the perceived risk of infection from a patient i.e. primarily motivated by self-protection. The attitudes and motiva- tions of HCWs may not be generalisable to individuals at a population level however, since they work within a health-specific context which actively promotes hand- washing behaviour. Three qualitative investigations were undertaken during the SARS epidemic examining individuals' experiences of quarantine [28,29] and the responses of older Chinese people living in Canada [30]. These studies suggest that social and emotional factors may override the influence of rational attitudes such as risk perceptions and efficacy beliefs. Older Chinese people held a perceived ethical duty to protect others, 'filial piety', which facilitated adherence to quarantine protocols [30]. However, an eth- ical duty could also act as a barrier to social isolation measures, with reports that caring for an infected loved one took priority over one's own health [28]. Research examining the handwashing behaviours of caregivers in developing countries also suggests that an immediate need to care for or "nurture" a child may undermine the implementation of adequate handwashing procedures [31]. Fears of isolation, boredom or stigmatisation were also barriers to compliance with infection control proce- dures [29]. We could only identify one qualitative study that has examined perceptions of pandemic influenza and infec- tion control behaviours. Janssen, Tardif, Landry, and Warner [32] found that existing knowledge and awareness of pandemic influenza amongst the general public in the United States was on the whole very poor, with concern about a pandemic low. Few individuals were willing to learn and implement behaviours to control a pandemic when such an event was neither present nor showed immediate signs of occurring. This highlights the impor- tance of context. Attitudes and responses at the height of a pandemic may vary considerably from responses when there is no salient threat of infection. Anticipated responses to the risk of a human-to-human H5N1 out- break were also examined in Hong Kong, where people have recent experience with SARS [17]. The likelihood of adopting infection control behaviours was associated with older age, perceptions of risk and susceptibility to infection, perceived likelihood of a local outbreak, per- ceived severity as compared to SARS, perceived efficacy of the behaviours and concern for family members. How- ever, it is unclear how far these findings can be generalised from non-western cultures such as Hong Kong and China to the UK and other western populations [11,17]. The research presented here examined perceptions of influenza and in particular the anticipated likelihood of implementing a variety of infection control behaviours in a Western culture with no recent epidemic experience. This study comprised the first empirical stage of the devel- opment of a complex intervention [33]. The purpose was to inform the development of a website-based infection control intervention to modify respiratory infection trans- mission within the home, in both non-pandemic and pandemic contexts. Following the PRECEDE-PROCEED intervention development approach [34], a medical team identified the behavioural determinants considered important to preventing virus transmission. The aim of this study was to determine the 'changeability' of these determinants, i.e. how acceptable and feasible it would be to promote each behaviour. A qualitative design was used so as to develop a detailed understanding of the interre- lated factors which might support or inhibit the adoption of each of the infection control measures. Focus groups Page 2 of 11 (page number not for citation purposes)