Healthcare Workers' Willingness to Work During an Influenza Pandemic

A Systematic Review and Meta-analysis

Yumiko Aoyagi; Charles R. Beck; Robert Dingwall; Jonathan S. Nguyen-Van-Tam


Influenza Resp Viruses. 2015;9(3):120-130. 

In This Article

Abstract and Introduction


To estimate the proportion of healthcare workers (HCWs) willing to work during an influenza pandemic and identify associated risk factors, we undertook a systematic review and meta-analysis compliant with PRISMA guidance. Databases and grey literature were searched to April 2013, and records were screened against protocol eligibility criteria. Data extraction and risk of bias assessments were undertaken using a piloted form. Random-effects meta-analyses estimated (i) pooled proportion of HCWs willing to work and (ii) pooled odds ratios of risk factors associated with willingness to work. Heterogeneity was quantified using the I 2 statistic, and publication bias was assessed using funnel plots and Egger's test. Data were synthesized narratively where meta-analyses were not possible. Forty-three studies met our inclusion criteria. Meta-analysis of the proportion of HCWs willing to work was abandoned due to excessive heterogeneity (I 2 = 99·2%). Narrative synthesis showed study estimates ranged from 23·1% to 95·8% willingness to work, depending on context. Meta-analyses of specific factors showed that male HCWs, physicians and nurses, full-time employment, perceived personal safety, awareness of pandemic risk and clinical knowledge of influenza pandemics, role-specific knowledge, pandemic response training, and confidence in personal skills were statistically significantly associated with increased willingness. Childcare obligations were significantly associated with decreased willingness. HCWs' willingness to work during an influenza pandemic was moderately high, albeit highly variable. Numerous risk factors showed a statistically significant association with willingness to work despite significant heterogeneity between studies. None of the included studies were based on appropriate theoretical constructs of population behaviour.


Although variable in severity,[1,2] one consistent feature of pandemic influenza is a surge in demand for health care.[3,4] Hospitalization due to influenza A(H1N1)pdm09 in the USA was estimated at approximately 274 000 cases between April 2009 and April 2010[5] contrasting with 95 000 annual influenza-associated primary hospitalizations from 1979 to 2001.[6] In 2009–10, the availability of intensive care unit beds came under pressure in most national health systems.[1,7] Healthcare workers (HCWs) play key roles during an influenza pandemic, but a serious shortage of personnel may occur at peak times or in severe pandemics because of absenteeism due to illness, caring for family members who are ill, or refusal to work.[8] Effective preparation for the next pandemic requires estimates of HCWs' willingness to work and an understanding of influencing factors.

The available data are highly variable. One Nigerian study found only one quarter of HCWs stating they would be willing to work in a unit treating patients with influenza A(H1N1)pdm09,[9] whilst an Australian qualitative study of family physicians found 100% of participants willing to work.[10] Chaffee[11] first reviewed willingness to work during disasters and reported that the following factors would be influential: type of disaster, concern for close family, friends and pets, responsibility for dependants, the perceived value of one's response, belief in a duty of care, access to personal protective equipment (PPE), provision of basic needs (water, food, rest, shelter and communication tools) and prolonged working hours. Three published reviews reported that similar factors would be associated with willingness to work during an influenza pandemic,[12–14] but the data were not summarized quantitatively.

We addressed this evidence gap by conducting a systematic review and meta-analysis in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) statement. The review questions sought to elucidate the proportion of HCWs willing to work during an influenza pandemic, and to identify risk factors associated with willingness to work. Our findings are interpreted with reference to sociological understandings of population behaviour, which have to date largely been absent from the peer-reviewed literature, but are highly relevant to the development of appropriate interventions to minimize refusal to work.