Marloes Bults’s research while affiliated with Erasmus University Rotterdam and other places

The public plays an important role in controlling the spread of a virus by adopting preventive measures. This systematic literature review aimed to gain insight into public perceptions and behavioral responses to the 2009 influenza A (H1N1) pandemic, with a focus on trends over time and regional differences. We screened 5498 articles and identified 70 eligible studies from PubMed, Embase, and PsychINFO. Public misconceptions were apparent regarding modes of transmission and preventive measures. Perceptions and behaviors evolved during the pandemic. In most countries, perceived vulnerability increased, but perceived severity, anxiety, self-efficacy, and vaccination intention decreased. Improved hygienic practices and social distancing were practiced most commonly. However, vaccination acceptance remained low. Marked regional differences were noted. To prevent misconceptions, it is important that health authorities provide up-to-date information about the virus and possible preventive measures during future outbreaks. Health authorities should continuously monitor public perceptions and misconceptions. Because public perceptions and behaviors varied between countries during the pandemic, risk communication should be tailored to the specific circumstances of each country. Finally, the use of health behavior theories in studies of public perceptions and behaviors during outbreaks would greatly facilitate the development of effective public health interventions that counter the effect of an outbreak. ( Disaster Med Public Health Preparedness. 2015;9:207-219)

Over the past years, Q fever has become a major public health problem in the Netherlands, with a peak of 2,357 human cases in 2009. In the first instance, Q fever was mainly a local problem of one province with a high density of large dairy goat farms, but in 2009 an alarming increase of Q fever cases was observed in adjacent provinces. The aim of this study was to identify trends over time and regional differences in public perceptions and behaviors, as well as predictors of preventive behavior regarding Q fever. One cross-sectional survey (2009) and two follow-up surveys (2010, 2012) were performed. Adults, aged >=18 years, that participated in a representative internet panel were invited (survey 1, n = 1347; survey 2, n = 1249; survey 3, n = 1030). Overall, public perceptions and behaviors regarding Q fever were consistent with the trends over time in the numbers of new human Q fever cases in different epidemiological regions and the amount of media attention focused on Q fever in the Netherlands. However, there were remarkably low levels of perceived vulnerability and perceived anxiety, particularly in the region of highest incidence, where three-quarters of the total cases occurred in 2009. Predictors of preventive behavior were being female, older aged, having Q fever themselves or someone in their household, more knowledge, and higher levels of perceived severity, anxiety and (self-) efficacy. During future outbreaks of (zoonotic) infectious diseases, it will be important to instil a realistic sense of vulnerability by providing the public with accurate information on the risk of becoming infected. This should be given in addition to information about the severity of the disease, the efficacy of measures, and instructions for minimising infection risk with appropriate, feasible preventative measures. Furthermore, public information should be adapted to regional circumstances.

Background Lyme disease (LD) is the most common tick-borne disease in the United States and in Europe. The aim of this study was to examine knowledge, perceived risk, feelings of anxiety, and behavioral responses of the general public in relation to tick bites and LD in the Netherlands. Methods From a representative Internet panel a random sample was drawn of 550 panel members aged 18 years and older (8-15 November 2010) who were invited to complete an online questionnaire. Results Response rate (362/550, 66%). This study demonstrates that knowledge, level of concern, and perceived efficacy are the main determinants of preventive behavior. 35% (n = 125/362) of the respondents reported a good general knowledge of LD. While 95% (n = 344/362) perceived LD as severe or very severe, the minority (n = 130/362, 36%) perceived their risk of LD to be low. Respondents were more likely to check their skin after being outdoors and remove ticks if necessary, than to wear protective clothing and/or use insect repellent skin products. The percentage of respondents taking preventive measures ranged from 6% for using insect repellent skin products, to 37% for wearing protective clothing. History of tick bites, higher levels of knowledge and moderate/high levels of worry were significant predictors of checking the skin. Significant predictors of wearing protective clothing were being unemployed/retired, higher knowledge levels, higher levels of worry about LD and higher levels of perceived efficacy of wearing protective clothing. Conclusions Prevention programs targeting tick bites and LD should aim at influencing people’s perceptions and increasing their knowledge and perceived efficacy of protective behavior. This can be done by strengthening motivators (e.g. knowledge, concern about LD, perceived efficacy of wearing protective clothing) and removing barriers (e.g. low perceived personal risk, not knowing how to recognize a tick). The challenge is to take our study findings and translate them into appropriate prevention strategies.

This study examines patient's reasons for accepting Q fever vaccination, including risk perception, feelings of doubt, social influence, information-seeking behavior, preventive measures taken, and perceptions regarding received information and governmental action. Data was obtained from exit interviews conducted after Q fever vaccination, between January and April 2011. A total of 413 patients with specific cardiovascular conditions in the Netherlands participated in exit interviews; 70% were older than 60 years. Most reported reasons for accepting Q fever vaccination were: "I am at an increased risk for developing (chronic) Q fever" (69%) and "my general practitioner recommends Q fever vaccination for me" (34%). The majority (86%) reported a high perceived severity of Q fever, and only 6% felt vulnerable to Q fever after vaccination. One-third had doubts about getting vaccinated, primarily related to fears of side effects and practical barriers. Fifty-two percent solicited advice from their social networks; of these, 67% reported influence on their vaccination decision. General practitioners and family were the most reported sources of advice. Thirty percent actively sought information about Q fever vaccination. Twenty-two percent of all respondents had taken other preventive measures, such as avoiding contact with goats and sheep (74%), and cancelling or postponing visits to Q fever-affected areas (36%). Almost one-half of all respondents reported negative feelings regarding governmental action to control Q fever. Significant differences were observed regarding feelings of doubt, information-seeking behavior, perceived vulnerability, preventive measures taken, and perceptions regarding received information and governmental action regarding gender, age, educational level, and/or employment status. Vaccination decision-making may differ among socio-demographic subgroups. When preparing future vaccination campaigns, it is important to obtain greater insight into these differences and take these aspects into account in risk communication strategies by tailoring information to specific target groups.

During the 2009 influenza A (H1N1) pandemic, parents in the Netherlands were recommended to vaccinate healthy children between six months and five years of age. The aim of this study was to examine reasons for (non-)acceptance, risk perception, feelings of doubt and regret, influence of the social network, and information-seeking behavior of parents who accepted or declined H1N1 vaccination. Data on accepters were collected via exit interviews following the second-dose vaccination round in December 2009 (n=1227). Data on decliners were gathered in June and July 2010 with questionnaires (n=1900); 25 parents participated in in-depth interviews. The most reported reasons for parental acceptance of H1N1 vaccination were "I don't want my child to become sick" (43%), "Mexican flu can be severe" (10%), "the government advises it, so I do it" (6%), and "if I don't do it, I will regret it" (6%). The most reported reasons declining the vaccination were "fear of side effects/harmful consequences" (51%), "just having a bad feeling about it" (46%), and "the vaccine was not thoroughly tested" (39%). More decliners than accepters experienced feelings of doubt about the vaccination decision (decliners 63% versus accepters 51%, p<0.001), and decliners reported more often information-seeking behavior (decliners 76% versus accepters 56%, p<0.001). Decliners more frequently solicited advice from their social network than accepters (decliners 72% versus accepters 61%, p<0.001). Furthermore, accepters more often reported social influence on their vaccination decision (accepters 58% versus decliners 38%, p<0.001) and experienced more negative feelings after their vaccination decision (accepters 8% versus decliners 2%, p<0.001). Immigrant accepters and decliners more often had feelings of doubt and regret about the vaccination decision, solicited advice more often from their social network, and were more often influenced by this advice compared to native Dutch parents. To optimize response rates in future vaccination campaigns, health authorities should provide more information on vaccine benefits and possible risks, tailoring this information to specific risk groups. Health authorities should also invest in the development and implementation of effective vaccine risk/benefit communication tools.

Survey questions 'Risk perception and behavioural responses of the general public during the Influenza A (H1N1) pandemic in the Netherlands'. This questionnaire was used across the three survey rounds.

Research into risk perception and behavioural responses in case of emerging infectious diseases is still relatively new. The aim of this study was to examine perceptions and behaviours of the general public during the early phase of the Influenza A (H1N1) pandemic in the Netherlands. Two cross-sectional and one follow-up online survey (survey 1, 30 April-4 May; survey 2, 15-19 June; survey 3, 11-20 August 2009). Adults aged 18 years and above participating in a representative Internet panel were invited (survey 1, n = 456; survey 2, n = 478; follow-up survey 3, n = 934). Main outcome measures were 1) time trends in risk perception, feelings of anxiety, and behavioural responses (survey 1-3) and 2) factors associated with taking preventive measures and strong intention to comply with government-advised preventive measures in the future (survey 3). Between May and August 2009, the level of knowledge regarding Influenza A (H1N1) increased, while perceived severity of the new flu, perceived self-efficacy, and intention to comply with preventive measures decreased. The perceived reliability of information from the government decreased from May to August (62% versus 45%). Feelings of anxiety decreased from May to June, and remained stable afterwards. From June to August 2009, perceived vulnerability increased and more respondents took preventive measures (14% versus 38%). Taking preventive measures was associated with no children in the household, high anxiety, high self-efficacy, more agreement with statements on avoidance, and paying much attention to media information regarding Influenza A (H1N1). Having a strong intention to comply with government-advised preventive measures in the future was associated with higher age, high perceived severity, high anxiety, high perceived efficacy of measures, high self-efficacy, and finding governmental information to be reliable. Decreasing trends over time in perceived severity and anxiety are consistent with the reality: the clinical picture of influenza turned out to be mild in course of time. Although (inter)national health authorities initially overestimated the case fatality rate, the public stayed calm and remained to have a relatively high intention to comply with preventive measures.

To gain insight into how the Dutch general public viewed the risk during the course of the recent pandemic, into how many and which people took precautionary measures, and into the extent to which people trust the information provided by the government. Online survey, cross-sectional (the first two measurements) and follow-up investigations (the last two measurements). Between 10 and 17 November 2009, 754 people completed the online questionnaire. Earlier survey rounds were held in May (n = 572), June (n = 620) and August (n = 934). In November 2009, 38% of respondents considered the Mexican flu a serious disease and 36% viewed themselves as vulnerable to this flu. Feelings of anxiety had decreased versus earlier survey rounds. Of the respondents, 73% took precautionary measures against the disease. This concerned mainly hygiene measures, which were most frequently taken by people who were anxious, found hygiene measures effective, paid considerable attention to the media information on flu, and found information from the government reliable and those without children living at home. More than fifty percent (58%) of respondents indicated that they would be willing to have the vaccination if they would be eligible for this. Of the other 315 respondents, 40% indicated that they feared serious side effects, 35% that they doubted the effectiveness of the vaccine and 33% that they considered the vaccine to be insufficiently tested. Almost half of the respondents had read the information leaflet 'Fight the flu', which was sent to every home in the country. One third had seen the television campaign. Governmental institutions, notably the Ministry of Health, Welfare and Sport and the National Institute for Public Health and the Environment, were the most important sources of information and more than half of the respondents trusted this information. During the course of the 2009 influenza A (H1N1) pandemic, anxiety among the Dutch general public decreased progressively, while people increasingly considered themselves more vulnerable to the flu. The public therefore had a realistic view of the situation. Three quarters of the general public had taken precautionary measures against the flu. More than fifty percent would be willing to have the vaccination if they would be eligible for this. The most important reason for not wanting the vaccination was fear of serious side effects and doubts about the effectiveness of the vaccine. This is a point of attention for the development of public information campaigns about vaccinations in the future.

Objective: To determine the reaction of the general public on the information regarding the Mexican flu. Design: Online panel interview. Method: From April 30 to May 4 2009, 572 people filled out an online questionnaire. Results and conclusion: 88% of the respondents had sufficient general knowledge about the Mexican flu. This information was mostly acquired by watching television (69%). More information was desired regarding the symptoms of the flu and those personal measures that could be taken to avoid infection.