Preparedness and response to potential large-scale health hazards constitutes one the biggest challenges for policy makers. This challenge is intensified as the certitude about the events and about the outcomes decreases. The accepted practice in many of such cases is to rely on the precautionary principle . This principle establishes an obligation for action; even when the absence of scientific certainty makes it difficult to predict the likelihood of harm occurring, or the level of harm should it occur. In most cases this obligation has to be translated into “institutional” actions such as budget allocation, organization, and active preparedness of the relevant institutions. In certain cases the collaboration of the general public is required as exemplified by the two cases examined here: preparedness against pandemic flu and against a chemical warfare attack. This adds to the complexity of the preparedness challenge, since success is dependent on the compliance of the public.
The willingness of the public to take part in the preparedness efforts depends on the trust that the population has in authorities [14, 15], on the way the public perceives the risk and the proposed countermeasures, and finally on the self-efficiency  of individuals, which determines their readiness to perform the active procedure of compliance. As a consequence, several modes of interrelationships between the public and the authorities can be expected.
On one hand, the public may exhibit distrust in authorities, reject expert recommendations altogether and as a consequence decide not to comply. Surprisingly, this was a rare phenomenon in the response to the two campaigns: 2.2% for mask-acquisition and 1.1% for H1N1 vaccination. On the other hand, the public may exhibit confidence in authorities, accept unconditionally the evaluations of formal experts, and exhibit high levels of compliance with governmental recommendations. This combination was manifested by a large number of individuals in their response to the mask acquisition campaign (35.6% of respondents) but was not common in the response to H1N1 vaccination (8.8%).
Our study reveals that the interrelationship between authorities and the public in the response to preparedness programs is more complex. In the case of mask-acquisition, a substantial fraction of the population (17.2%) believes in the credibility of the authorities, believes in the use of gas masks as a countermeasure, but nevertheless fail to actually comply with the recommendation. This discrepancy between beliefs and compliance with gas mask acquisition was found to be linked with low self-efficacy and passivity, an attitude often observed in the reaction to various health recommendations .
Contrary to this, low compliance with H1N1 vaccination is mainly related to a divergent evaluation of the situation, rather than passivity. Many respondents (34.8%) trusted the credibility of authorities, believed that one should accept vaccination under certain conditions, yet decide not to comply with vaccination.
Taken together, these observations suggest a major difference in the response towards the recommendation to acquire gas masks and that to get vaccinated against H1V1. The dominant response to the first recommendation can be defined as “trusting-non reflective-compliance”, whereas the dominant response to the second recommendation was “trusting-reflective-noncompliance”. This difference can be linked in the apparent difference in the attitude of the public to the two recommendations. The attitude towards H1N1 vaccination is characterized by reasoned assessment of the risks involved in failure to get vaccinated. Many people believe that not everyone needs to be vaccinated and that compliance should be left to personal decision. Moreover, when non-compliers were asked to explain their lack of compliance, about half of the respondents provided reasoned argumentation, based on their personal evaluation of risks related to disease and vaccine.
Contrary to this, the response to the gas mask campaign appears to lack sophistication. Only a small number of respondents believed that mask-acquisition is a matter of personal choice (perhaps in part because, as opposed to situation with vaccinations, mask use by one person has no bearing on other individuals). Surprisingly, respondents did not appreciate the relativity of risk (geographic distribution) as a factor in mask-acquisition. This is in contrast to the perception of risk-relativity, which was exhibited by the extensive self-evacuation of the population from Tel-Aviv to Jerusalem during the First Gulf War [18, 19].
The marked difference in the response to H1N1 vaccination and gas mask acquisition can be explained in several ways. The difference can be attributed, in part, to the nature of the recommended intervention: In contrast to acquiring masks, which is merely a procedural event (getting to the distribution center or ordering the mask by phone), vaccination involves a non-pleasant physical intervention, entailing certain risks. Nevertheless, this difference in itself is not a sufficient explanation, since perception of real risk does not deter Israelis from accepting routine, well-established vaccination programs such as childhood vaccination [20, 21]. Another explanation could be a differential attitude towards policies related directly to health and those elated to military defense . Our results suggest, however, that the credibility of the MOH did not differ from the credibility of the HFC. It should be noted that the rejection of vaccination by the public, in general, is a well-recognized phenomenon that accompanies the history of vaccination and is prevalent in many different societies. The rejection of H1N1 vaccine, in particular, was identified in most industrialized countries and the controversy was propagated by popular media worldwide. Interestingly, the controversy over H1N1 vaccination was also manifested by the attitude of health care workers who often refused to get vaccinated. In contrast, the gas mask acquisition campaign was not associated with any notable controversy and was not criticized by the relevant experts.
One possible explanation for the difference in the attitudes towards H1N1 vaccines and gas-mask campaigns could be related to the time-dimensions framing the events. A potential chemical attack is remote and uncertain, and therefore individuals were not faced with the need to make an immediate decision or invest “intellectual efforts” in such a decision. On the other hand, the H1N1 epidemic was an evolving event [23, 24], with new information accumulating every day, much uncertainty about future development, continuous debates among experts, and intense exposure by the media. This could lead to a high level of involvement of lay individuals and pressure to personally confront the vaccination dilemma. All this is reflected in the high awareness, high degree of reasoning, and a reflexive attitude towards the recommendation to comply with vaccination.
Several limitations can be identified in this study: (a) The study was based on a telephone survey and a time when 15% of the population did not have land-line phones; the response rate was 62%. (b) The divergence between the actual compliance of the Israeli population and declared compliance of the survey group is considerable, which could be attributed to social desirability or a sampling bias. This should be taken into consideration in the analysis of data. One should note, however, that this study suggests conformism in the public’s response towards mask-acquisition as opposed to non-conformism towards H1N1 vaccination. The potential biases described suggest that non-conformist approaches may actually be more prevalent among the full population than they were among our sample. Accordingly, this point actually strengthens the case for our contention that non-conformism plays a major role in the public response to governmental preparedness policies. (c) There are no analyses to determine if any of the responses to the survey questions differ by demographic variables. In our previous studies, we thoroughly examined the effect of demographic variants on attitudes towards vaccination [7, 20], and demonstrated that non-conformism was associated with younger age and with the Jewish population. In this study, where compliance was juxtaposed to attitude and to trust, the large number of response variables (see Tables 6 and 7) would prohibit a coherent analysis of the effect of demography.
It should be stated that the attitude of the public to vaccination in general, and to H1N1 vaccination in particular has been the subject of many studies [22, 23, 25–29], using a variety of models and identifying a broad range of correlates of compliance. Those correlates include the extent to which H1N1 influenza is perceived to be risky, the extent to which the vaccination is perceived to be risky, and the degree of trust in government. We chose to analyze our data using a model that focuses on the role of reflexivity in the public’s response to risk [20, 24, 30, 31]. Thus, the survey did not cover items related to compliance with other vaccines (seasonal influenza vaccines) or to exposure to information provided by formal authorities, nor did it examine in-depth the perception of risks related to vaccination or to diseases.
In the future, it would be useful to develop an integrated model of the public’s response to governmental preparedness policies that incorporates both the new factors identified in this article and the more widely recognized factors emphasized in the professional literature to date. It will also be useful to apply such an integrated model in empirical studies of public responses in various types of large-scale health hazards. This could be used to assess how the relative strengths of the possible explanatory factors vary across different types of hazards and societal contexts.
Notwithstanding all these limitations, the major contribution of this study is the identification of a unique interrelationship between trust in authorities, attitudes towards acceptance, and actual compliance with vaccination, which could be defined as a “trusting-reflective-noncompliance” response. The interrelationship between trust and compliance has been the subject of previous studies [25, 26, 32] and the interrelationship between a reflective attitude and compliance with vaccination has been analyzed in the past by us [7, 20, 24] and by others [27–29]. However, to the best of our knowledge, the analysis of the three-way interaction between trust, attitude, and compliance is new.
The newly identified “trusting-reflexive-noncompliance” response profile appears to be an outcome of the shift in responsibility from the State to the individual, which characterizes the era of the so called “reflexive modernity” [30, 31]. In the case of preparedness against forthcoming epidemics, this transitional state is reflected in the observation that people accept the role of the State as a responsible authority but in parallel try to formulate their personal opinion on upcoming risks. Another outcome of this study is the realization that the public distinguishes trust related to belief in the objectivity of authorities (“good will” and lack of bias) and trust related to confidence in the competence of authorities . A large number of respondents believed that the H1N1 vaccination campaign was grounded in honesty and good will, yet the actual behavior during the epidemic suggests that the public did not accept the judgment of the expert authorities.
The emergence of a vaccination-reflexive population, which is also manifested in the changing attitudes of the public to MMR vaccination, HPV vaccination, and childhood vaccination protocols [20, 24], deserves careful consideration. Reasoned-assessment and reflexivity towards vaccination are by no means identical to making the right decisions. In the first paper in this series  we have clearly stated that in many cases (about 30%) reasoned non-compliance with swine-flu vaccination was based on wrong assumptions (for example, “I am eating a healthy diet and therefore I am protected against flu”).
The trends identified in this study may, therefore, have dangerous implications for the cause of public health. Reflexive assessment of vaccination programs by lay individuals rely, in most cases, on personal perceptions of risks and is most likely based on self-interests. Lay individuals are less likely to take into consideration group-interests related to vaccines, and are less receptive to concepts such as vaccination for the sake of the more vulnerable or vaccination aimed at achieving herd immunity. In addition, assessment of vaccination programs and most specifically new vaccination programs requires high degrees of knowledge and understanding that are in many cases beyond the capability of even the most sophisticated lay individuals. In addition, a judgmental public is more likely to reject a “new vaccine”. This is precisely the scenario where the stakes are highest – an emerging infection for which there is no effective treatment other than a newly developed vaccine.
In spite of the anticipated dangers, vaccination-reflexivity can be harnessed to enhance the benefits from vaccination. “Vaccination-reflexivity” should be distinguished from “Anti-vaccination”. Recent studies suggest that only 2-8% of the population in developed countries can be defined as “hard anti-vaccinators”, whereas the number of individuals that exhibit reflexive attitudes is on the rise [20, 24]. Anti-vaccination movements, which have accompanied vaccination from its very beginning, are mostly based on ideologies, beliefs, and emotional approaches that magnify dangers, and therefore are less amenable to change. Reflexive-vaccination, on the other hand, is based on assessment and evaluation and could be targeted by appropriate communication programs.
Our findings, which indicate that the reflexive public did not lose its trust in the genuine motivation of authorities, and did appreciate the difficulty faced by authorities in dealing with high uncertainties, suggest that the public could be receptive to risk-communication messages. Nevertheless, these messages should take into consideration the fact that the public does not accept recommendations in a non-conditional way.