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Healthcare workers attitudes to working during pandemic influenza: A qualitative study

Centre for Biomedical Ethics, The University of Birmingham, Birmingham, UK.
BMC Public Health (Impact Factor: 2.26). 03/2009; 9(1):56. DOI: 10.1186/1471-2458-9-56
Source: PubMed


Healthcare workers (HCWs) will play a key role in any response to pandemic influenza, and the UK healthcare system's ability to cope during an influenza pandemic will depend, to a large extent, on the number of HCWs who are able and willing to work through the crisis. UK emergency planning will be improved if planners have a better understanding of the reasons UK HCWs may have for their absenteeism, and what might motivate them to work during an influenza pandemic.This paper reports the results of a qualitative study that explored UK HCWs' views (n = 64) about working during an influenza pandemic, in order to identify factors that might influence their willingness and ability to work and to identify potential sources of any perceived duty on HCWs to work.
A qualitative study, using focus groups (n = 9) and interviews (n = 5).
HCWs across a range of roles and grades tended to feel motivated by a sense of obligation to work through an influenza pandemic. A number of significant barriers that may prevent them from doing so were also identified. Perceived barriers to the ability to work included being ill oneself, transport difficulties, and childcare responsibilities. Perceived barriers to the willingness to work included: prioritising the wellbeing of family members; a lack of trust in, and goodwill towards, the NHS; a lack of information about the risks and what is expected of them during the crisis; fear of litigation; and the feeling that employers do not take the needs of staff seriously. Barriers to ability and barriers to willingness, however, are difficult to separate out.
Although our participants tended to feel a general obligation to work during an influenza pandemic, there are barriers to working, which, if generalisable, may significantly reduce the NHS workforce during a pandemic. The barriers identified are both barriers to willingness and to ability. This suggests that pandemic planning needs to take into account the possibility that staff may be absent for reasons beyond those currently anticipated in UK planning documents. In particular, staff who are physically able to attend work may nonetheless be unwilling to do so. Although there are some barriers that cannot be mitigated by employers (such as illness, transport infrastructure etc.), there are a number of remedial steps that can be taken to lesson the impact of others (providing accommodation, building reciprocity, provision of information and guidance etc). We suggest that barriers to working lie along an ability/willingness continuum, and that absenteeism may be reduced by taking steps to prevent barriers to willingness becoming perceived barriers to ability.

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BMC Public Health
Open Access
Research article
Healthcare workers' attitudes to working during pandemic
influenza: a qualitative study
Jonathan Ives
, Sheila Greenfield
, Jayne M Parry
, Heather Draper*
Christine Gratus
, Judith I Petts
, Tom Sorell
and Sue Wilson
Centre for Biomedical Ethics, The University of Birmingham, Birmingham, UK,
Primary Care Clinical Sciences, The University of
Birmingham, Birmingham, UK,
Department of Public Health, Epidemiology & Biostatistics, The University of Birmingham, Birmingham, UK,
Geography, Earth and Environmental Sciences, The University of Birmingham, Birmingham, UK and
Centre for the Study of Global Ethics,
Edgbaston, Birmingham, UK
Email: Jonathan Ives -; Sheila Greenfield -; Jayne M Parry -;
Heather Draper* -; Christine Gratus -; Judith I Petts -;
Tom Sorell -; Sue Wilson -
* Corresponding author
Background: Healthcare workers (HCWs) will play a key role in any response to pandemic influenza, and the UK healthcare
system's ability to cope during an influenza pandemic will depend, to a large extent, on the number of HCWs who are able and
willing to work through the crisis. UK emergency planning will be improved if planners have a better understanding of the
reasons UK HCWs may have for their absenteeism, and what might motivate them to work during an influenza pandemic.
This paper reports the results of a qualitative study that explored UK HCWs' views (n = 64) about working during an influenza
pandemic, in order to identify factors that might influence their willingness and ability to work and to identify potential sources
of any perceived duty on HCWs to work.
Methods: A qualitative study, using focus groups (n = 9) and interviews (n = 5).
Results: HCWs across a range of roles and grades tended to feel motivated by a sense of obligation to work through an
influenza pandemic. A number of significant barriers that may prevent them from doing so were also identified. Perceived
barriers to the ability to work included being ill oneself, transport difficulties, and childcare responsibilities. Perceived barriers
to the willingness to work included: prioritising the wellbeing of family members; a lack of trust in, and goodwill towards, the
NHS; a lack of information about the risks and what is expected of them during the crisis; fear of litigation; and the feeling that
employers do not take the needs of staff seriously. Barriers to ability and barriers to willingness, however, are difficult to
separate out.
Conclusion: Although our participants tended to feel a general obligation to work during an influenza pandemic, there are
barriers to working, which, if generalisable, may significantly reduce the NHS workforce during a pandemic. The barriers
identified are both barriers to willingness and to ability. This suggests that pandemic planning needs to take into account the
possibility that staff may be absent for reasons beyond those currently anticipated in UK planning documents. In particular, staff
who are physically able to attend work may nonetheless be unwilling to do so. Although there are some barriers that cannot
be mitigated by employers (such as illness, transport infrastructure etc.), there are a number of remedial steps that can be taken
to lesson the impact of others (providing accommodation, building reciprocity, provision of information and guidance etc). We
suggest that barriers to working lie along an ability/willingness continuum, and that absenteeism may be reduced by taking steps
to prevent barriers to willingness becoming perceived barriers to ability.
Published: 12 February 2009
BMC Public Health 2009, 9:56 doi:10.1186/1471-2458-9-56
Received: 29 October 2008
Accepted: 12 February 2009
This article is available from:
© 2009 Ives et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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The World Health Organisation describes an influenza
pandemic as an event in which "a new influenza virus
appears against which the human population has no
immunity, resulting in several, simultaneous epidemics
worldwide with enormous numbers of deaths and illness"
[1]. In the United Kingdom (UK) the Department of
Health (DH) is forecasting that up to half of the popula-
tion could become infected with up to 750,000 deaths
under the reasonable worst case scenario [2]. These
assumptions work on the basis of cumulative clinical
attack rates of up to 50%; 4% of symptomatic patients
requiring hospital admission; and a case fatality rate of 0.2
– 2.5% [2]. Even at the lower end of these estimates, an
influenza pandemic will place the National Health Service
(NHS) under severe strain, and it is clear from the recent
National Risk Register [3] that it is regarded as a signifi-
cant threat to national security in the UK.
Healthcare workers (HCWs) will play a key role in any
response to pandemic influenza, and will be in the front-
line of exposure to infection. UK planning assumes that
once a pandemic is confirmed, the NHS will "care for
large numbers of cases, and will only provide essential
care" for other patients [2]. Recent guidance, based on an
(unreferenced) survey tool, suggests that up to 50% of the
workforce may be absent from work at the peak of the
pandemic because of caring responsibilities [4]. A model-
ling summary submitted to the DH by the Scientific Pan-
demic Influenza Advisory Committee Subgroup on
Modelling estimates staff absenteeism at between 30–
35% at the peak, taking into account the cumulative effect
of staff illness, the need to look after ill children, and pos-
sible school closures [5].
It may not, however, be reasonable to assume that HCWs
will be willing to work even if they are able to do so. For
instance, during the early years of the Human Immunode-
ficiency Virus (HIV) epidemic doctors debated whether it
was ethically permissible to refuse to treat those with HIV
[6-10]; and during the 2003 Severe Acute Respiratory Syn-
drome (SARS) outbreak some HCWs were not willing to
treat SARS patients [11-13]. HIV and SARS provide rea-
sonable comparators to pandemic influenza, and it is not
unreasonable, therefore, to assume that the response to
pandemic influenza may be similar.
The limited data on factors influencing HCWs' willingness
to work highlight a sense of professional obligation, esti-
mated risk to oneself and ones' family and inclusion in
preparedness planning [14-16] Ehrenstein and colleagues
[17] found 28% of German HCWs (physicians, final year
medical students, nurses and administrators) may aban-
don work in favour of protecting themselves and family.
Qureshi and colleagues [18] found the most significant
barrier to US HCWs' willingness to work was fear for their
own and their family's health. A survey of clinical and
non-clinical HCWs in the US estimated that up to 50%
would be unwilling to work, with clinical staff more likely
to attend than non-clinical [19]. Research from Singapore
suggests that the risks posed to self and to family would be
significant concerns for primary care physicians [20], and
a similar Australian study of general practitioners high-
lights a strong sense of obligation to work coexisting with
concerns about being provided with protective equipment
and the welfare of dependants [16]. It cannot be taken for
granted that these studies can be applied to workers from
other health services nor that the results of these studies
can be used to inform their attempts to modify attitudes
ahead of a pandemic. Different countries have different
health care systems and different healthcare cultures.
Given that healthcare culture is likely to have an impact
upon the willingness of HCWs to work, it is important
that culture specific research is conducted.
UK emergency planning, and consequently patient care,
will be improved if it is possible to establish the factors
associated with UK HCWs' willingness to work, and iden-
tify the motivations HCWs have for continuing to work.
This study, therefore, aimed to explore UK NHS HCWs'
views about working during an influenza pandemic, in
order to identify factors that might influence their willing-
ness and ability to work and potential sources of any per-
ceived duty to work. The majority of work in this area to
date has utilised survey tools, and whilst large scale sur-
veys can provide important and generalisable information
about people's views and the frequency of those views, it
is also important that qualitative research is conducted to
begin to build a picture of why those views are held. Given
the aim of research on the attitudes of HCWs towards
working during pandemic influenza is to enable us to pre-
dict and modify behaviour, it is important to have data
that will help us understand the 'why?' as well as the
'what?' and 'how many?'.
Participants were recruited from three NHS Trusts in the
West Midlands, one acute teaching, one rural district gen-
eral, and one Primary Care Trust.
Ethical Approval
NRES approval for this project was granted by Notting-
ham Research Ethics Committee 2 (Ref: 07/H0408/120),
and R&D approval was gained from each participating
Recruitment took place using advertisements via internal
e-mail, through managers and snowballing (using key
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participants to recruit others). All participants approached
by managers were made aware that participation was vol-
untary, and managers would not be told who had eventu-
ally participated. All potential participants who contacted
the research team, regardless of how they had heard about
the study, were sent an information sheet, and those who
were willing to participate were entered on a database.
Participants for focus groups were purposively selected
from this database according to job category with a view
to getting as wide a range of HCW roles as possible,
including a mix of age, gender and seniority. Signed
informed consent was gained from all participants prior
to participation.
Ten focus groups were planned with volunteer HCWs
(grouped according to homogeneity of role: ×2 ancillary
and clerical (A1 & A2), ×2 nurses (N1 & N2), professions
allied to medicine (P), junior doctors (below consultant –
JD), consultants (C), general practitioners (GP), managers
(M) and community based HCWs (CH). Failure to iden-
tify a suitable time for a consultant doctor group led to
interviews (n = 5) being undertaken with this category.
Both focus groups and interviews followed a standardised
topic guide, developed over a series of meetings of the
authors and of the study steering committee. Open ques-
tions were used, enabling the content of the discussions,
but not the form, to be participant led. The topic guide
started by asking what participants knew about pandemic
influenza, followed by questions about training and the
effect they anticipated pandemic influenza to have on
their work. Participants were asked if they felt they would
be able to carry on 'business as usual as far as possible' [2]
in their professional life; how likely they were to report to
work if fit and well; whether they thought HCWs had a
duty to work, why, and how far this duty extended. The
discussions ended by asking participants to discuss the
things that would worry them about working during an
influenza pandemic, and what things they thought their
employers, the Government, or professional bodies and
unions could do to make it easier for them to work.
Focus groups are a recognised qualitative tool, suitable for
research that aims to explore how people think and feel,
where the emphasis is on exploring people's opinions,
experiences, wishes and concerns [21,22] The dynamic,
interactive, nature of focus groups means that participants
are continually interacting with one another, exchanging
views and perspectives, and this level of interaction ena-
bles the researcher to examine meanings, reasons and
motivations "with a degree of complexity that is not typi-
cally available with other methods" (p16) [23] and to
access the rich texture of normative influences on people's
attitudes and behaviours [24]. The aim of a focus group is
not to gather data that is statistically significant or gener-
alisable to the wider population, but to gather informa-
tion that can help us begin to understand why people may
choose to act and behave in the way they do. For this rea-
son, the results are not presented numerically, as in this
context frequency has little meaning and detracts from the
qualitative presentation style.
Data analysis
All focus groups/interviews were transcribed verbatim, and
were formally reviewed by three of the authors (SG/JI/
JMP). Transcripts were initially free-coded by JI on ATLAS-
ti software according to content [25], and then organised
into thematic units that were continually re-visited and
revised. Analysis and data collection occurred simultane-
ously, with a constant comparative method [26] utilised
to ensure an iterative approach to the interpretive project.
Analytic induction [25] was also employed, with themes
being identified, hypotheses generated and fed into subse-
quent groups/interviews and then revised in the light of
new data.
Given the nature of qualitative enquiry, the analysis was
not conducted numerically. 'Significance' in qualitative
research, and particularly in a focus group, cannot be
determined by the frequency with which a view or opin-
ion is raised, but rather in the manner in which it is raised,
discussed, and negotiated by the group. What is important
in a focus group analysis is not how many people stated a
particular view, but rather what general themes emerged
out of the discussion [27]. Bowling [28] points out that "
[q]ualitative research describes in words rather than num-
bers" (p352), and as such, we have presented our results
by describing themes that tended to arise out of the group
process, rather than counting the number of individuals
who expressed a particular view. This is justified, first,
because the number of participants (n = 64) is insufficient
to find any statistical significance. Second, our analysis
focussed on what was said (the quality of views) rather
than how often it was said (the quantity of views). What
general frequency indicators are provided are given solely
to give the reader an impression of whether the views
under discussion were majority or minority views, and we
have indicated in which groups the themes under discus-
sion arose.
A different kind of study is needed to determine the prev-
alence of the views reported, and the qualitative data
reported in this article have been used to develop a large
scale survey tool, the work for which is ongoing [29]. This
article only discusses our qualitative data, and focuses on
the variety of views and perspectives present in our
research population.
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Of n = 64 participants, n = 32 were male, n = 31 female,
and n = 1 undisclosed. N = 14 were aged 21–30, n = 12
were aged 31–50, n = 23 were aged 41–50, and n = 14
were aged 51 and over. N = 48 classified themselves as
being White British, n = 3 as White Irish, n = 1 as White
Scottish, n = 3 as Asian, n = 1 as Black African, n = 3 as
Indian, n = 4 as other, and n = 1 undisclosed. N = 5 par-
ticipants were junior hospital doctors; n = 5 were consult-
ants; n = 12 were nurses; n = 6 worked in professions
allied to medicine; n = 16 were ancillary workers; n = 10
were general practitioners, n = 5 were community health-
care workers; and n = 5 were managers. The demographic
and professional spread of participants was not sought to
be representative of NHS workers in the UK, but sought to
access a wide range of views and perspective across a wide
range of HCWs working in different areas of the NHS.
The overall themes that emerged are summarised in Figure
1. The network depicted expresses the relationships
between the key themes that arose across all focus groups
and interviews. Themes interact in one of four ways: (1)
Impacting upon (a change in one may cause a change in
the other); (2) Motivation (3) Association; (4) Solution.
In this paper we discuss key issues that relate to the 'duty
to work' and 'barriers to working'. Eight main themes
emerged relating to these two issues. Selected quotations
are used to illustrate each of these eight themes.
The Duty to Work
Overall, participants seemed to feel a strong sense of duty
to work regardless of the circumstances and displayed a
general willingness to work during an influenza pan-
demic. This sense of duty was found across all categories
Barriers to willingness and ability: associations and solutionsFigure 1
Barriers to willingness and ability: associations and solutions.
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of workers, but was justified in a variety of ways that can
be brought under three headings:
• a professional ethic
• a duty to help
• a work ethic and confederate loyalty
A professional ethic (prominent in 4/9 focus groups and 5/
5 interviews)
Some participants felt the duty to work is a professional
duty that entails an obligation to work even in difficult
and dangerous circumstances, because that is what they
signed up for when they joined their profession. This kind
of view was expressed most forcefully by hospital doctors
and GPs, some of whom felt that this duty, which was
developed during their training, was one owed both to
their profession and to their patients. There were mixed
views among participants about how far this obligation
extended across different healthcare roles. Some doctors,
for example, felt that the professional obligation did not
apply so much to ancillary staff or nurses, though others
felt that it applied to everyone, (see below).
Sense of duty developed during training
JI: So...what would you see as a source of this obligation
to work, why would you personally feel that obligation to
carry on? [long pause] It's a very tough question, I know.
C4: I suspect it must be something to do with the training,
inherent to how it is being imparted. Now that's what I
feel, I don't know what drives it to come to work, I sup-
pose if I can come to work when I'm fit and well without
a pandemic around, I expect that if I'm fit and well and
I'm expected to work, then if it's a pandemic I'll have to
come and work.
Duty confined to doctors
JI: There's various ways of looking at healthcare workers
duties and some people will argue that health workers
have a duty to tend to the sick and do their job no matter
what. Some people will extend that to just doctors, some
to doctors and nurses, and some would extend to anybody
including admin and secretarial staff. Would you feel that
that kind of duty does exist and how far do you think it
GP10: Doctors yes, nurses probably, reception staff
GP8: No.
GP10: That depends on the people you've got. I think
most of ours would turn up.
JI: What's the difference?
GP10: I just think it's the ethic. I mean you get into this job
basically to look after people and, rather than man a
phone for eight hours a day...
Duty to work extends to all roles
JD2: I think it's an obligation for doctors, I think that's set
out by the GMC isn't it? It's the duty of a doctor.
JD5: It should be extended, I don't know, it's just my own
opinion, it should be extended to everybody who comes
in contact with the patient. Not only doctors, nurses as
JD2: Well the hospital wouldn't function if it was just the
doctors putting in the extra hours because you need sup-
port from the nursing staff, even down to the cleaning.
A duty to help (prominent in 8/9 focus groups and 2/5
Some participants across a range of jobs spoke about an
obligation arising from a general 'duty to help'. Some, for
example, claimed that being in a position to help another
person was a sufficient motivator for helping them. Oth-
ers expressed the view that if a person or a society is in
need, that need gives everyone a moral incentive to take
steps to meet that need. Notions of a duty to help were
sometimes accompanied by references to the "Blitz/Dun-
kirk' spirit" of wartime Britain in the 1940s, and the belief
that in the event of a social crisis we all have to pull
together and do what we can for the common good. Here,
the duty to help was constructed both as an individual
and a social requirement to contribute to the common
good, applying to us as persons and not only as HCWs.
One key source of the duty to help for some HCWs was
that they had specific skills that would make them partic-
ularly useful, and this seemed to make them feel they had
a special responsibility where others might not, see below.
If you can help, you should help/The obligation to help those in need
A1/9: I am agency staff but I don't feel any different. If I'm
of use then there's no point me sitting around redun-
dant...when I can actually do something, It'd be more
frustrating for me to be sat at home because I can't work
even though I can contribute, it would just feel counter
A1/2: I kind of feel about it the same way as if I saw some-
body get knocked over by a car, I'd go and help if I could.
A1/6: Yes, its human nature I think a lot of it.
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A1/2: Yeah, that's the sort of way I feel about it. If there's
something I could do, I would do it, you know. I think, I
don't, I can't explain any more than that really, it's just
that, you know
A1/5: And if you were in that situation you'd hope some-
body would help you, you know
A1/2: Well exactly and I think it's the good of human kind
really, that you wanna help if you can
Blitz/Dunkirk spirit
N1/5: We're British, Dunkirk spirit.
N1/3: Absolutely.
N1/5: And that has, bizarrely enough, that has been ban-
died around. You know that there are a lot of people that
will just adopt this, well
N1/3: Spirit of the Blitz.
N1/5: Yeah, get on with it
Specific skills
CH4: I think it would depend on what help was required.
If it was to administer medicines or injections, it's obvious
which one would be needed more. If it was to sit there and
just chat, support, wash then the nursing skills perhaps
might be in use somewhere else so it's a really hard ques-
tion to answer. I don't think you could just split it like that
'cause you'd need to know more wouldn't you? [everyone
A simple work ethic and confederate loyalty (prominent in
6/9 focus groups and 3/5 interviews)
Many participants, in a variety of roles, felt that absentee-
ism if one was able to work (whatever one's employment,
in or out of the health service) was generally wrong and
not just wrong during a pandemic.
This simple work ethic (see below) may be related to or
reinforced by, a complex sense of loyalty and obligation
to workplace confederates, in this case colleagues and
patients. This account tended to emerge from a belief that,
as both colleagues and patients depend upon you doing
your job, by refusing to work (when you are physically
able) you are letting both your patients and your col-
leagues down in way that is morally unacceptable, for
Work ethic
A2/8: I mean personally, it don't matter what job I've got,
whatever job I sign up for I look into that field and carry
it on and I get, try to get personal satisfaction out of it and
part of this becomes a dedication of where I want to be
and what I want to do and it's like I'm now, I'm in domes-
tics now and that gets some of my attention so therefore
it's spread into that. So I'd come in anyway if I was all
right, I would come in and that just ends it. Like if you had
to do it anywhere else, you know you tend to go in
because you think, 'Well someone else might be ill'.
JI: If you were fit and well during an Influenza pandemic,
how likely do you think it is that you would work as nor-
C3: Yeah sure, it's part of the role.
JI: Yeah, so I mean can you expand on that by 'part of the
C3: Well that is part of what you do isn't it? You don't just
work when the sun's shining.
HC3: You're not a nurse just when everything's okay, do
you know what I mean? You're a nurse when things are
not okay.
Not wanting to let patients or colleagues down
P4: I feel like that really I would be letting those patients
down if I didn't come in because they're my raison d'être,
that's why I'm here.
P1: It's not just your patients. It's your colleagues as well.
P5: Yeah.
P1: You're letting your team down as well as the patients.
P4: That's right.
N2/4: I think that's the other thing. It's camaraderie. You
get like a good little team on a ward and half the time if
you do feel a little bit sort of a little bit sick you think 'oh
well I've got to go in because they'll struggle without me'.
Barriers to working
Although all participants tended to feel they have a duty
to work during an influenza pandemic, there were none-
theless a number of perceived barriers to so doing. These
tended to fall into one of two categories:
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• perceived barriers to ability (prominent in 9/9 focus groups
and 5/5 interviews)
• perceived barriers to willingness (prominent in 9/9 focus
groups and 5/5 interviews)
These categories, however, were not clear cut in all cases,
and the lines were most blurred when it came to concerns
about childcare and family obligation. Some participants
who had children regarded staying at home to look after
them as a necessity that affected their ability to work,
rather than a choice (see below). Childcare is not, how-
ever, obviously distinguishable from a barrier to willing-
ness; for instance, where parents choose to look after their
children themselves rather than rely on available others to
do so for them. Choice, of course, is itself a nebulous con-
cept. Where there is no externally available or accessible
childcare, and where children are too young to care for
themselves, there is a barrier to ability. However, what
counts as 'accessible' or 'too young' and whether the avail-
able childcare is regarded as an adequate or acceptable
alternative may owe as much to personal choice or prefer-
ence as to inescapable circumstance.
It seems likely that the 'childcare' barrier is age and gender
related. Women with young children tended to regard it as
an insurmountable obstacle, with men raising the issue
less often. Whether this gender difference was due to the
participants' need to present themselves to their peers as
participating in typical gender roles is unclear, although
the discrepancy observed is predictable, and consistent
with what we might expect. The group in which it was
least prominent was the GP group, which was comprised
largely of older men. The discussion was most prominent
in the nursing groups, where women with young children
were in the majority. The apparent lack of concern about
this issue in the GP group may reflect gendered norms in
the home, the age of the participants which meant that
they were unlikely to have young children, or that GPs
were better placed to afford reliable, private childcare.
Similarly, the junior doctors did not discuss this issue: it
was raised in passing only once. When they were ques-
tioned about why it had not been discussed, the answer
was simply that they did not have children so it was not
an issue.
For some, the duty to family was expressed as the simple
claim that 'family comes first' which was taken for granted
as an unassailable moral premise. If a child or a family
member needed them they would not come into work
pandemic or no pandemic: duties to families were more
important than any duty to work. This was not so much a
matter of weighing up competing obligations (to work
and to family) but rather represented a pre-defined moral
hierarchy acting as a barrier to ability (see below). For oth-
ers, childcare functioned as a barrier to willingness, where
a choice puts family before work.
Some barriers to ability were fairly concrete like being ill
oneself and problems with transport (including lack of
fuel). Participants recognised that they could not work if
incapacitated by illness, and also anticipated that in the
event of an influenza pandemic transport infrastructures
might be affected, making it difficult to travel to work.
Some participants thought that during an influenza pan-
demic people might be reluctant to use public transport
for fear of becoming infected, leading to more people trav-
elling to work in private cars. These same participants
anticipated that Trusts would not have the parking space
to accommodate additional demand, creating a further
barrier for people who would otherwise be willing and
able to work (see below). Insurmountable barriers to abil-
ity, however, exist at the extreme end of a continuum; for
example where a person is literally too ill to get out of bed
or function safely, where the person is infectious and
poses a demonstrable risk to others, or where there is no
fuel at all and the distance to work is too great to cover on
foot or cycle. Further along this continuum, HCWs will be
exercising choice about how to prioritise the different
demands on their time and resources, and the greater the
scope for preference or choice to be exercised, the more
like a barrier to willingness the perceived obstacle
Child-care as a barrier to ability
N2/1: Well I've got two small children, small children are
probably more likely to get these things so, the ones at
school, if the schools are closed there's no way I'd be able
to come in because you can't [Laughs] You can't just leave
your kids. They're obviously a priority.
A1/5: you'd have other outside influences wouldn't you?
If you had children, if the schools were closed down and
you'd got no-one to look after your children you... what,
what options would you have then? You know your first
duty is to their care so you would have to think about
them before you could come in. If you'd got nobody to
look after your children or equally your elderly parents if
all that starts.
P2: I was gonna say where, in my case there's one adult to
look after a number of children at home and I'm their sole
means of support. And so to me they need that support
every day you know whether the hospital needs mine or
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not, I'm not. You know that's the kind of a theoretical
benefit to the hospital. You know 'cause I work in prevent-
ative health. So it's easy for me to say my kids need me
every day, and it's gonna be a different decision for every-
body isn't it?
Family comes first
N2/1: But it's not just people with children, it's people
with old parents or you know it's home situations isn't it?
It's family situations and family comes before anything.
Concrete barriers to ability
A1/2: I think there's a Government issue as well like, you
know for example if I come on, I come to work on the
train, if the trains were all down because there's no staff to
run them or whatever and I have to come to work in my
car, um where do I park, um, and then you, I mean the
icing on the cake would be if you parked up, they just said
park anywhere and then get a bloomin' ticket from Q-park
JI: What kind of effect do you think that Pandemic Influ-
enza would have your work place and on your job?
C1: I think I would see it in two ways, one is if I'm person-
ally myself infected, and affected then it would have an
implication from the point of view of my ability to work,
and if it's going to be infectious then clearly there's going
to be the issue of isolation. So if I'm infected and if I'm iso-
lated then I wouldn't be able to work. If I'm not infected
and I need to come to work it would pose a question in
my mind whether I'm going to get infected if I come to
Negotiating risk and duty (prominent in 9/9 focus groups
and 4/5 interviews)
Other individuals saw the duty to their family as one of
many competing claims. Concern about taking the virus
home and infecting one's family, for example, was not
perceived as a barrier to ability when participants believed
that they were in a position to negate or mitigate the risk
by employing infection control measures, or minimising
direct contact with family members by staying at the
workplace or sleeping in the spare room. Some groups,
however, particularly consultants and managers, felt that
anyone who thought that absenteeism would reduce the
risk to their family had failed to appreciate that 'pan-
demic' meant that the virus was endemic in the commu-
nity (see below).
Negotiating risk and duty
GP5: So if it is that there is a substantial risk that you your-
self may succumb which sort of people might not be too
concerned about their own mortality but the young chil-
dren and dependents might be more of a concern. Then
you'd want to make sure that if you're gonna put yourself
in the front line then it's something worth doing. So
there's no point, there's no point and if you're gonna be
there you ought to be very well co-ordinated nationally
and so you know what you're doing. Get as much protec-
tion as you can.
JI: Would that, do you think, be a requirement of your
going into work, or would you go in anyway?
GP5: I think most of us would go in, even me who's rais-
ing all these concerns, I think most of us would go in, but
there's a little bit of me that says that I'd tell you on the
GP3: I think if it was gonna kill you, you know sort of peo-
ple, you know sort of healthy people or you know in their
sort of thirties or whatever like me supposedly, yeah it
would be nice to think you were gonna have some sort of
protection, some sort of pull them down type fancy mask
and yeah I might sort of sleep in the shed rather than give
it to my daughter, but yeah.
Understanding 'pandemic'
JI: So people have said 'Well it's not me I'm worried about,
it's taking it home to my children'. I think given what
you've said, that's not going to be a concern for you?
C2: Well I mean that seems ridiculous to me, I mean I just
think the whole point about a pandemic is it affects the
whole herd, the whole tribe and why should I worry about
taking it home when they're more likely to catch it from
school or shopping or, and I don't know whether that's
right but that's the way I've always looked at it really...I
think it's probably a false assumption that you're gonna
keep them safe by not going to work.
The risk to self (prominent in 9/9 focus groups and 2/5
Despite disagreement on what the risk was and how it
could be managed, the risk to family members of working
was important to everyone whereas the risk to self seemed
to be of less concern. Even when one GP broke the con-
sensus that seemed to be emerging from her group by sug-
gesting that if the risk was great she would not work, she
made only passing reference to her own safety and quickly
justified her position with reference to the safety of her
family (see below). However, participants' apparent
ambivalence to personal risk was to some extent belied by
regular discussion of personal protective equipment
(PPE). Whilst participants were reluctant to say outright
that personal risk concerned them, many stressed the
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importance of being provided with effective PPE (for
example see below).
Risk to self
GP2: Okay, can I be honest? If there was an outbreak I
don't think I'd come in...If I put my life and my family's
life at risk it's easier to say you would come in but then
when you see your colleagues dying I think it's a different
thing if you're taking it back to your family because you
love them don't you, and I don't think if there was an out-
break and I saw my colleagues really sick on death's door
that I'd want to be coming into work and putting my hus-
band and my family at risk. I just don't think I could do it.
The need for PPE
N2/4: I think as well being aware of um showing, you
know, how they use those paper masks in theatre whether
that would be an effective barrier against it or whether
you'd need something sort of
N2/3: The proper equipment, rather than a cheaper alter-
native which they tend to do don't they as well? Proper
equipment would be best
N2/6: Yeah, what protection are the staff that's coming to
work going to have against catching it from the patients?
Reciprocity (prominent in 8/9 focus groups and 1/5
The belief that the relationship between HCW and
employer is not reciprocal was one of the most significant
barriers to willingness. Specifically, participants did not
believe that the efforts of HCWs would be reciprocated or
rewarded. This was expressed in a variety of different ways,
including an expectation that HCWs would get no thanks
or recognition for their efforts, the worry that any PPE pro-
vided would be the 'cheaper alternative' (see above) and
concern that workers would receive little guidance or deci-
sion-making support (e.g. with respect to how resources
should be allocated, how treatment should be allocated,
or whether decisions made would receive the backing of
the Trust).
The majority of participants said they had been given nei-
ther information about pandemic influenza, nor been
made aware of what would be expected of them during
such a crisis, and this gave many the impression that their
employing Trust did not care about them or take their
needs seriously. Lack of information was a key theme
across all groups, with the majority finding the lack of
information and engagement a demotivator to work,
while clear information, guidance and support seemed to
be important motivators (see below). The obvious excep-
tion was the management group, which included public
health doctors, who were concerned about giving staff too
much information, as they did not know if current infor-
mation was accurate. They reasoned that as it was so diffi-
cult to get information through to the workforce, it was a
waste of resources to attempt to do so, and possibly coun-
ter-productive, if the information given turned out to be
inaccurate. Their preference was to disseminate informa-
tion if, when and as it was needed (for example below).
This was in direct contrast to the views expressed by the
majority of other groups, who wanted information imme-
diately and to be involved in the planning effort. The GPs
were most similar to the managers; most seemed confi-
dent that they could cope with the pandemic if and when
it occurred, and believed that the necessary information
and guidance would be sent to them as and when appro-
priate, and that their role was one of implementation.
The need for information
N1/1: It's giving people information as well, if you're
more informed about something you're more likely to do
it than if you get up and you're not told anything, why
should I put myself at risk if I don't have all of the infor-
The dangers of giving information
M6: I think one of the difficulties is that there was a lot of
changes initially in the national guidance on what could
be expected, and there was a reluctance to pass that infor-
mation down and then have to review it, and you know
that affects the creditability of the information they're
M3: but it's still very difficult given that we don't know
when or what to give information. And if you think about
giving information down to that level, it so rarely gets
down there that if you got it down there now and it was
wrong you'd have very great difficulty changing it when
you need it to be right. So it's not about keeping ignorant,
it's about informing people when you know. And it would
be, I think it would be very wrong to give detailed guid-
ance when we don't know what we're or what, you know,
what the dangers are. But we've got to have a system in
place to give guidance in an authoritative manner when
the time comes.
Both clinical and non-clinical participants were worried
about being asked to perform a role they had not been
trained for, and had concerns both about being a danger
to patients and being subject to litigation if something
went wrong. Participants tended to feel they would need
more support than usual from their managers (to help
them to make decisions, to fight their corner, and to give
hands-on assistance). There was also a belief, however,
that there would be less support during a pandemic. It was
clear that many participants would be reluctant to take on
extended roles without some assurance that they would
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be protected from litigation and without explicit guidance
on how to negotiate the ethical dilemmas that the pan-
demic was likely to produce (see below).
Litigation worries
A2/8: One thing that crossed my mind, is if I'm called in
to help, clinical-wise and I make a gaffe, and the relatives
take me to court who's gonna protect me? And it'll make
me decide whether I was gonna help or not really.
N1/5: There isn't enough, from what the Critical Care
Community, are saying coming out of the Department of
Health to reassure them and there's a big fear amongst
medical staff that you know, two years down the line
they'll be litigated against because they rationed and
denied services to people because there weren't enough
beds or because they chose one patient over another. And
these are genuine concerns that are being expressed by
nursing staff alone.
Apprehension about ethical dilemmas
CH1: Well who would get the vaccination, how would
you choose?
CH5: I guess the consultant makes the decision who gets
it and who doesn't.
CH3: So selection, like Auschwitz isn't it?
CH1: I wouldn't like to be...
CH?: That would be awful wouldn't it
CH5: I wouldn't like to think they'd think it would be left
up to an administrator...
CH4: Who you prioritise and deny people as well
CH5: I would be very reluctant to go anywhere without
proper guidelines, because that would stay on your con-
science forever wouldn't it.
Need for reciprocal support
P6: It is, it is a different decision for everybody but I think,
personally I would be... I'd feel obliged to come in anyway
professionally but I would like to know that the Trust
doesn't – how shall I put this? – I would like to know that
the Trust can rely on me but at the same time I can rely on
the Trust to make sure of my safety...Because I'd feel
obliged to come in and I will come in but they've got to
make sure that they go the full mile as well.
A further, connected, issue was that of the general erosion
of morale and goodwill in the NHS as a whole. This was
connected to the previously mentioned expectation that
the HCWs' role during a pandemic would not be appreci-
ated, recognised or rewarded. Some participants believed
that NHS staff generally felt so under-valued and under-
appreciated that some would be unlikely to report for
work if they thought they were at personal risk. The major-
ity seemed to feel that, in a crisis, their sense of obligation
to their patients or colleagues would overcome their gen-
erally low morale, but anticipated that many of their col-
leagues would not feel the same way (see below).
Wanting to feel appreciated
A1/8: If they just show they're grateful for what you did.
Say if a patient says to me, 'Oh you've kept my room spot-
less while I've been in here', it gives me a boost to think
I've done something, but when you don't get no credit,
then that's a knock back to you. That's when morale goes
A1/5: Is it a matter of esteem as well isn't it, you know?
A1/1: Come the end of the pandemic you've kept your
bone marrow transplant ward isolated, clean and none of
the patients have come down with the flu or whatever it
is, and everything goes in the paper and you don't get a
single mention that's gonna be soul destroying
Erosion of goodwill/morale
N2/4: I think for years now a lot of the NHS has run on
goodwill of nurses and I think that bit by bit, especially
the Trust where I come from...that's why I left there, the
goodwill was eroded...
N2/1: They beat it out of you don't they? ...You're right.
They do! They badger you and badger you until...I mean
it's a caring profession. It's not a job you do for the money.
It's a job you do because you want to do it but there is a
Some people will not work
CH5: I mean I could probably split my staff in two camps,
of the administration camp there's those I know would be
there and they'd give their time and those that would say
'Sorry, no'. And that's just because of the people that they
are and then the other obligations that they have.
The NHS staff in our study, across all roles and profes-
sions, tended to believe that they should, and would,
work through an influenza pandemic. There was a wide-
spread belief that they had a duty to work, and that in not
continuing to work they would be doing something mor-
ally wrong. The basis for this sense of duty varied from
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group to group. Some were motivated by a sense of pro-
fessional obligation; some by a general duty to help those
in need; and others by a work ethic or feelings of confed-
erate loyalty
Despite this, there were also barriers to working that
impacted on this sense of duty, prominent amongst which
were the need to care for/protect dependents and lack of
information, guidance and support. These can be either
barriers to ability or barriers to willingness, although the
two are not always readily distinguishable. Most barriers
seem to form a continuum with preference at one end and
insurmountable circumstance at the other with increas-
ingly difficult choices in the middle. The harder the
choice, the more likely it is to be perceived as a barrier to
ability; for instance, choosing to walk into work will be
easier if it takes half an hour and if one is relatively used
to exercise than if it takes an hour and a half and one is
not. In the latter case, the absence of motorised transpor-
tation is more likely to be perceived as a barrier to ability.
Equally, it would be wrong to assume, however, that it is
always possible in practice to make a choice that is present
in principle; a position that fails to appreciate the impact
of inflexible external constraints and social circumstances.
A decision to work (or not to work) is likely to be the
result of a combination of motivations and beliefs, which
interact with both genuine and constructed barriers to
ability. For some, this combination may result in a genu-
ine barrier to ability or a barrier to willingness that is gen-
uinely perceived as a barrier to ability, and for others
simply a barrier to willingness.
Which of these motivations, and which of these barriers,
proves to be the most significant in the event of an influ-
enza pandemic is something that can only be known and
understood after the event. The barriers to, and motiva-
tions for, working, however, that we have identified may
suggest forms of remedial action if these barriers and
motivations are found to be prevalent in the workforce.
The key to the efficacy of this remedial action may be to
effect changes that prevent barriers to willingness from
becoming insurmountable barriers to ability. If HCWs are
concerned about infecting their families then steps might
be taken to minimise this risk. Similarly, if transport is a
likely issue steps might be taken to facilitate transport to
and from work. Ensuring that staff are protected from lit-
igation, and ensuring that they know they are protected,
may also remove a barrier to taking on extended roles.
This seems to be in line with DH guidance that staff
should be provided with appropriate indemnity [30],
although the definition of negligence found in the DH
Human Resources guidance implies that no special pro-
tections will be given to staff working in extended roles in
an emergency situation [4]. If we are correct in hypothe-
sising that many barriers to working lie along an ability/
willingness continuum, the key to effective mitigation is
likely to be taking steps to tip the scale so that more barri-
ers than not are experienced as barriers to willingness –
which are more negotiable than barriers to ability. This
will at least ensure that more HCWs than not feel they are
in a position where working is an option for them.
One concern prominant in all groups (with the exception
of the doctors and managers – who seemed to feel they
knew what they supposed to do) was that participants felt
they were not being told what was expected of them. If
this is a widespread problem, one effective strategy (and
one already indicated in DH planning guidance [30]) may
be to have a policy of education and communicating
emergency plans to staff, outlining what is known, what is
not known, and what is expected of them. If Trusts are
concerned about disseminating information before all the
facts are known, then a policy of 'explicit uncertainty'
might be adopted. The key point is that HCWs may not
necessarily expect to be told all the answers, but they want
to be kept in the loop and to be reassured that when infor-
mation becomes available it will be communicated to
them. Simply ensuring that systems are in place for the
dissemination of information when it becomes available
is not enough. The existence of these systems may have to
be more effectively communicated to encourage the feel-
ing that the needs of workers are being acknowledged.
Our data suggests that giving workers evidence in the pre-
pandemic phase that goodwill expended by them during
a pandemic will be reciprocated by employers will
encourage that expenditure. Reciprocity was identified as
a key factor in the ethical guidance published by the DH
[31], and this study reinforces its significance – suggesting
that reciprocity is not just an ethical concern, but also a
very practical one. Building goodwill amongst staff and
encouraging confederate loyalty is likely to be an effective
strategy to increase the motivation to work amongst
HCWs. This is, however, no small task and it is unlikely
that simply telling staff they are needed and are appreci-
ated will be effective. A more promising avenue may be to
encourage team cohesion in small units. It has been
observed that soldiers on active duty may be motivated
more by feelings of in-group loyalty than by a commit-
ment to abstract ideals [32] (although a causal link
between team cohesion and effectiveness/performance
has been challenged [33]). It seems likely that similar
team motivations may be at work with HCWs. Feelings of
team cohesion may not enhance an HCW's effectiveness,
but it may deter absenteeism.
A significant strength of this study is that participants were
sampled from three different NHS settings across a wide
variety of roles, and yet the overarching themes were con-
sistent across groups. The findings also concord with pre-
vious work conducted overseas, showing some resonance
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with the findings of both Qureshi et al [18] and Ehren-
stein et al [17] insofar as the perceived risks to family and
children were very prominent. As one reviewer of this arti-
cle pointed out, this suggests that barriers to working may
be similar across some nations, and indicates there may
be some benefit to the international sharing of strategies
for dealing with HCW absenteeism.
An obvious limitation to these findings is responder bias.
Participants in a focus group or interview may be the type
of people who are already motivated and interested, or
feel strongly about the topic area. Since it is likely that
such individuals would be more willing to work during an
influenza pandemic, our results may overstate HCWs'
willingness to work. Another limitation to this study is the
responder bias towards people identifying themselves as
'white British'. Further work, focussing on minority
groups, may be required if there is reason to think that the
views of white British people are likely to be different to
those of other ethnic groups. However, a specific analysis
looking at the views of our non-'white British' participants
showed that no such difference was visible within our
focus groups.
This study attempted neither to provide estimates of the
proportion of NHS staff who may work in the event on an
influenza pandemic nor to predict the characteristics of
such staff, though this work is ongoing [29]. It does, how-
ever, suggest that although UK HCWs may feel a general
obligation to work during an influenza pandemic, there
are a number of possible barriers to working that may sig-
nificantly reduce the workforce of the NHS at such a time.
Some of these barriers may be insurmountable but others
may not. Relatively simple steps could be taken that might
increase the likelihood of HCWs being willing and able to
continue to work.
Current UK planning [4] assumes that up to 50% of the
NHS workforce may require time off at the peak of a pan-
demic. Given that this level of absenteeism is likely to
cause significant problems for a health service already in
crisis, it is important that every means of encouraging
HCWs to work if they are able are identified. The data pre-
sented in this article suggests a number of factors that may
affect HCW's willingness to work. Further, if, as we sug-
gest, factors affecting ability and willingness lie along a
continuum, it will be important to take measures to pre-
vent barriers to willingness becoming perceived barriers to
ability. Where barriers to working are based on deeply
held moral values – such as that of putting family or more
specifically children first – such barriers may prove as
insurmountable as being too ill to work. More effective
might be efforts to ensure that wherever HCWs feel that a
choice to work or not is necessary or possible they are
inclined to choose in favour of working. They are more
likely to be so inclined if they continue to perceive what-
ever barrier gave rise to the choice as one of willingness
rather than ability. Based on our focus groups with UK
HCWs, we have suggested a number of possible measures
that may achieve this which include providing transport,
accommodation and useful and timely information to
staff as well as demonstrating to them that they are needed
and valued. These, or similar, measures may encourage
the view that choosing to work is a realistic and acceptable
option. If people feel they have no choice but to stay away,
they will stay away. If people find that there are no con-
crete barriers that effectively prevent them from being able
to work, they have to make the choice for themselves, and
where this choice is available other factors such as percep-
tions of duty (however conceived), peer pressure, or the
knowledge that they will be supported and thanked may
provide the motivation to make the choice in favour of
HCW(s): Health Care Worker(s); DH: Department of
Health; WHO: World Health Organisation; NRES:
National Research Ethics Service; NHS: National Health
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
All authors were involved in the design of the project. HD
was Principle Investigator, with the SG and JMP acting as
qualitative supervisors (and SW as quantitative supervi-
sor). Focus groups and interviews were organised and
conducted by JI, with assistance from HD, TS and JMP.
Primary analysis was conducted by JI, and formally
reviewed by SG, JMP and JIP, with additional input from
HD and CG. The first draft of this manuscript was pro-
duced by JI, which was then reviewed and revised by all
authors. All authors read and approved the final manu-
This paper presents independent research commissioned by the National
Institute for Health Research (NIHR). The views expressed are those of the
author and not necessarily those of the NHS, the NIHR or the Department
of Health.
This study was funded by the National Institute for Health Research,
through the Research for Patient Benefit Programme.
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Pre-publication history
The pre-publication history for this paper can be accessed
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    • "First, vaccination could be framed as part of their professional role and not simply as a personal decision [34]; indeed, research on Turkish HCWs' acceptance of A/H1N1 vaccination revealed that this was linked to their belief that vaccination was a professional responsibility [25]. Moreover, the organizational culture in the workplace should include norms and habits for influenza vaccination in non-pandemic contexts, whereby vaccination could be framed as a valued behaviour to be incentivized or rewarded [35], and should highlight the negative consequences of HCWs' illness from influenza, such as work absenteeism and increased burden on work colleagues [36]. Practice managers and senior GP partners should be encouraged to get vaccinated to provide positive role models as 'flu champions' [37] to reassure colleagues of the safety of new vaccines [38]. "
    [Show abstract] [Hide abstract] ABSTRACT: Healthcare workers (HCWs) are encouraged to get vaccinated during influenza pandemics to reduce their own, and patients', risk of infection, and to encourage their patients to get immunised. Despite extensive research on HCWs' receipt of vaccination, little is known about how HCWs articulate pandemic influenza vaccination advice to patients. To explore HCWs' uptake of the A/H1N1 vaccine during the pandemic of 2009-2010, their recommendations to patients at the time, and their anticipated choices around influenza vaccination under different pandemic scenarios. We conducted semi-structured interviews and focus groups with eight vaccinated and seventeen non-vaccinated HCWs from primary care practices in England. The data was analysed using thematic analysis. The HCWs constructed their receipt of vaccination as a personal choice informed by personal health history and perceptions of vaccine safety, while they viewed patients' vaccination as choices made following informed consent and medical guidelines. Some HCWs received the A/H1N1 vaccine under the influence of their local practice organizational norms and values. While non-vaccinated HCWs regarded patients' vaccination as patients' choice, some vaccinated HCWs saw it also as a public health issue. The non-vaccinated HCWs emphasised that they would not allow their personal choices to influence the advice they gave to patients, whereas some vaccinated HCWs believed that by getting vaccinated themselves they could provide a reassuring example to patients, particularly those who have concerns about influenza vaccination. All HCWs indicated they would accept vaccination under a severe pandemic scenario. However, most non-vaccinated HCWs expressed reticence to vaccinate under the mild pandemic scenario. Providing evidence-based arguments about the safety of new vaccines and the priority of public health over personal choice, and creating strong social norms for influenza vaccination as part of the organizational culture, should increase uptake of influenza vaccination among primary care HCWs and their patients. Copyright © 2015 Elsevier Ltd. All rights reserved.
    Full-text · Article · Mar 2015 · Vaccine
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    • "A qualitative study in the United Kingdom found that most physicians felt an obligation to work during a pandemic, though there were barriers to their willingness and ability to work [11]. Fear of infecting their families was a common concern, as well as barriers to finding childcare in order to continue working [11,12] . Barriers to obtaining personal protective equipment (PPE) [12] , and concerns about contracting influenza caused some reluctance [13]. "
    [Show abstract] [Hide abstract] ABSTRACT: Effective pandemic responses rely on frontline healthcare workers continuing to work despite increased risk to themselves. Our objective was to investigate Alberta family physicians willingness to work during an influenza pandemic. Design: Cross-sectional survey. Setting: Alberta prior to the fall wave of the H1N1 epidemic. Participants: 192 participants from a random sample of 1000 Alberta family physicians stratified by region. Main Outcome Measures: Willingness to work through difficult scenarios created by an influenza epidemic. The corrected response rate was 22%. The most physicians who responded were willing to continue working through some scenarios caused by a pandemic, but in other circumstances less than 50% would continue. Men were more willing to continue working than women. In some situations South African and British trained physicians were more willing to continue working than other groups. Although many physicians intend to maintain their practices in the event of a pandemic, in some circumstances fewer are willing to work. Pandemic preparation requires ensuring a workforce is available. Healthcare systems must provide frontline healthcare workers with the support and resources they need to enable them to continue providing care.
    Full-text · Article · Jun 2013 · Asia Pacific Family Medicine
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    • "An intervention study to look at the feasibility to promote safe precautionary practices, especially among high-risk groups, is essential [1,22]. It would also be useful to explore the prevailing challenges for prevention and preparedness among high-risk groups (poultry workers and butchers) by using qualitative techniques [29-31]. "
    [Show abstract] [Hide abstract] ABSTRACT: Avian influenza (AI) is a global public health threat. Understanding the knowledge that butchers have about it and the precautionary practices they take against it is crucial for designing future preparedness programs. This study aimed to identify the social determinants of knowledge and precautionary measures of AI among butchers in the Kathmandu district in Nepal. The study was based on a cross-sectional study design using structured interview questionnaires and checklists to observe social determinants and the precautionary measures of 120 butchers aged 15 years and above from the Kathmandu district. The majority of the respondents were male (69.2%) and more than half (53.3%) were from the age group of 25-39 years (mean: 31.08, SD: ±9.82). Nearly two-thirds (61.3%) of the respondents had a 'poor knowledge', and the remaining had 'some knowledge', about AI. More than half (55.4%) of the respondents were in the category of displaying 'poor practice' towards AI and the remaining half were in the 'satisfactory practice' category. None of the respondents had 'adequate knowledge' or displayed 'good practice'. The respondents in the >25 years of age group were less likely [OR 0.169; 95% CI (0.056-0.512)] compared to those in the <25 years age group to have a poor knowledge about AI; and the respondents with 'primary education' were more likely [OR 3.265; 95% CI (1.326-8.189)] to have a poor knowledge about AI as compared to those who had a secondary or above level of education. Respondents who did not know the correct definition of AI were more likely to follow poor practices [OR 4.265; 95% CI (1.193-15.242)]; and the respondents who did not know the risk groups associated with AI were also more likely to follow poor practices [OR 3.103; 95% CI (1.191-8.083)]. This study points out the need to address butchers to improve their knowledge of, and more importantly their compliance with, the precautionary measures to prevent avian influenza.
    Full-text · Article · Jun 2013 · Infectious Diseases of Poverty
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