ORIGINAL ARTICLE
Factors Associated With the Ability and Willingness of Essential
Workers to Report to Duty During a Pandemic
Robyn R. M. Gershon, MHS, DrPH, Lori A. Magda, MA, Kristine A. Qureshi, DNSc, RN,
Halley E. M. Riley, BA, Eileen Scanlon, RN, MSN, Maria Torroella Carney, MD, FACP,
Reginald J. Richards, DrPH, and Martin F. Sherman, PhD
Objective: To determine essential workers’ ability and willingness to report
to duty during a serious pandemic outbreak and to identify modifiable risk
factors. Methods: Workers (N ⫽ 1103) from six essential workgroups
completed an anonymous, cross-sectional survey. Results: Although a
substantial proportion of participants reported that they would be able
(80%), fewer would be willing (65%) to report to duty. Only 49% of
participants would be both able and willing. Factors significantly associated
with ability/willingness included individual-level (eg, intentions to adhere
to respiratory protection and pandemic vaccination recommendations) and
organizational-level factors (eg, preparedness planning for respiratory pro-
tection and worker vaccination programs). Conclusions: During a serious
pandemic event, non–illness-related shortfalls among essential workers
could be substantial. Organizational preparedness efforts should focus on
worker protection programs and the development of policies that would
facilitate the attendance of healthy workers.
H istorically, during disasters or their immediate aftermath, most
medical and emergency response personnel typically report to
duty in their usual or emergency (functional) role.1,2 Yet, more than
30 years ago, Dynes and Quarantelli3 cautioned that disaster pre-
paredness planning should take into account not just how people are
expected to respond, but rather how they are likely to respond.
Recent studies on health care workers’ ability and willingness to
report during infectious disease outbreaks suggest that such caution
might well be warranted.4 Research findings indicate that when fear
of contagion with novel and/or potentially lethal agents is high,
willingness to report to duty among health care workers (HCWs) is
low, with predicted nonillness absenteeism rates for the United
States ranging from ⬃35% to 80%.5–17
Beyond fear, worker shortages might also result from personal
obligations that compete and possibly override professional obliga-
tions. Referred to as “dilemmas of loyalty” by early disaster research-
ers,18 this might result in absenteeism in otherwise healthy workers
who choose to stay home to take care of family responsibilities or other
personal matters. Nonillness absenteeism resulting from both lack of
willingness and ability (or availability) combined with illness-related
From the Department of Sociomedical Sciences (Dr Gershon, Ms Magda, Ms
Riley), Mailman School of Public Health, Columbia University, New York,
NY; School of Nursing and Dental Hygiene (Dr Qureshi), University of
Hawaii at Manoa, Honolulu, Hawaii; Nassau County Department of Health
(Ms Scanlon, Dr Carney), Long Island, NY; The School of Public Health and
Health Services (Dr Richards), George Washington University, Washington,
DC; and Department of Psychology (Dr Sherman), Loyola University Mary-
land, Baltimore, Md.
The contents of this article are solely the responsibility of the authors and do not
necessarily represent the official views of NSF, HJF, or USUHS.
Address correspondence to: Robyn R. M. Gershon, MHS, DrPH, Mailman
School of Public Health, Columbia University, 722 West 168th Street, Room
938, New York, NY 10032; E-mail: RG405@columbia.edu.
Copyright © 2010 by American College of Occupational and Environmental
Medicine
DOI: 10.1097/JOM.0b013e3181f43872
JOEM • Volume 52, Number 10, October 2010
absenteeism could lead to severe workforce shortages. This may be
especially acute in the early part of an outbreak— before effective
pharmaceutical interventions are available. The delivery of health care
services will likely be challenged by the combination of increased
patient care demands and staff shortages due to illness. Additional
shortages related to nonillness absenteeism could lead to system
failure. In other essential infrastructure sectors,19,20 such as law en-
forcement, these shortfalls not only would affect the provision of
necessary services but have implications for our national security and
functional capabilities as well.
Most of the earlier studies on ability and willingness focused
on HCWs’ response to hypothetical outbreaks involving bioterror-
ism agents (eg, smallpox) or severe acute respiratory virus. Very
few studies focused on pandemic agents and, to our knowledge,
none targeted response workers from other essential work sectors.
To address this gap and to provide information that might be useful
in both surge capacity modeling21–23 and organizational prepared-
ness planning efforts, we conducted a pandemic-related ability and
willingness study of workers from essential work sectors. The study
was completed concurrently with the World Health Organization’s
announcement that the novel H1N1 virus outbreak had developed
into the 2009 Influenza Pandemic.24
MATERIALS AND METHODS
Participants
Workers from six organizations representing essential infra-
structure sectors were recruited to participate in this study. The
organizations were all located in Nassau County, a suburb of New
York City with an estimated population of 1.34 million people.25
The work populations included hospital workers, police department
personnel, emergency medical services personnel, fire department
personnel, public health department workers, and correctional fa-
cility officers. All procedures were approved by the Columbia
University Medical Center Institutional Review Board and appli-
cable review boards of participating organizations.
Questionnaire Development and Design
A conceptual framework (see Fig. 1) with two major domains,
individual- and organizational-level factors, adapted from DeJoy’s
Behavioral-Diagnostic model, guided the development of a new study
questionnaire.26,27 To refine and validate study constructs that might
predict worker intentions, focus groups were held with representatives
from each workgroup. A draft questionnaire was constructed that
included several scales previously validated in other studies, as well as
additional items added following analysis of the focus group data. A
short scenario describing a serious pandemic event was also included
to provide context for the pandemic-related items. In addition, a
questionnaire cover sheet defining the terms “ability” (ie, physical and
mental health, personal or legal obligations, and the competing obli-
gations or circumstances that might hinder the ability to report to duty
in one’s usual capacity) and “willingness” (ie, your voluntary inten-
tions to report to duty) was also provided, as well as distributed and
discussed at focus group sessions. It should be noted that we define
995
Gershon et al
FIGURE 1. Conceptual study
framework.
“ability” as “availability to work” in contrast to the definition of
McCabe et al.28 In a recent publication describing a new preparedness
framework, referred to as “Ready, Willing, and Able,” McCabe et al.28
define “ready” as availability and they use the term “able” to denote
competency. The draft questionnaire was reviewed by a group of
public health emergency preparedness experts for content validity. The
questionnaire was then pilot tested on 15 representative participants
and revised to improve readability. The final 49-item questionnaire
was prepared at a ninth grade reading level to facilitate its rapid
completion.29 Our study questionnaire and codebook are available
from the corresponding author.
Measures
Various response formats were used, such as “yes/no,”
categorical options, Likert-type scales, and open-ended.
Individual Factors
Demographic, Job-Related, and Health Status Variables. These
included gender, age, race/ethnicity, education, marital status, and
presence of children living at home; professional licenses/certifica-
tions, job title/role, employment status (paid or volunteer), tenure at
work, retirement/turnover/exit intentions, emergency volunteer activi-
ties, past disaster response history, spouse/partner’s employment as an
essential worker (eg, first responder, health care, or law enforcement
worker), and personal health status and health problems.
Influenza Vaccination History and Pandemic Vaccination
Intentions. Past seasonal influenza vaccination history and inten-
tions to be vaccinated against a pandemic influenza strain during an
outbreak.
Respiratory Protection Perceptions of Efficacy, Current
Respiratory Protection Practices, and Pandemic-Related
Adherence Intentions. Several items addressed current use and
type of respiratory protection available at work, confidence in the
protection afforded by N95 respirators, barriers to respirator use,
and intentions to wear a respirator in the event of a pandemic.
Pandemic-Related Perception of Risk and Concern. Four
items addressed perceived risk of infection and concern regarding
contagion.
Potential Facilitators and Barriers. A 17-item checklist of
facilitators that would increase workers’ ability and willingness to
report included the following: “the availability of pandemic influenza
vaccine,” “if my family had priority for the pandemic influenza
vaccine,” “if I was assured of my protection from infection,” “if I could
stay in touch with family,” “if I had provisions for childcare,” “care for
elders or other family members,” “available pet care,” “if I could leave
work when I need to,” “if my coworkers also reported to duty,” “if I
thought no one else was going to report,” “if I felt it was my duty to
report,” “hazard duty pay,” “respirator availability,” “respirator train-
ing is available,” “if I had a steady stream of information would be
996 © 2010 American College of Occupational and Environmental Medicine
JOEM • Volume 52, Number 10, October 2010
available during the pandemic,” “if I had more knowledge about the
pandemic,” and “other.”
A five-item checklist of potential barriers to ability (ie,
“responsible for other family members (and/or pets),” “obligations
to a second employer and/or volunteer commitments,” “personal
chronic health problem,” “other personal obligations,” and “I have
no obligations or restrictions”) was also included.
Organizational Factors
Workplace Safety Climate. A four-item workplace safety
climate scale was adapted from a previous safety climate mea-
sure.30 The items included the following: “Employees are told when
they do not follow good safety and health practices,” “I feel free to
report safety or health violations where I work,” “The health and
safety of workers is a high priority with management where I
work,” and “At my workplace, all reasonable steps are taken to
minimize my risk of exposure to occupational hazards.” The four
response choices ranged from “strongly disagree” to “strongly
agree.” The internal consistency of the responses to this scale
yielded a Cronbach alpha of 0.81 (95% CI ⫽ 0.79 – 0.83).
Organizational Trust and Shared Values. A four-item scale,
adapted from two previous trust studies was used to measure trust
in one’s employer and shared values.31,32 These items were com-
bined to assess trust and shared values as one entity. Respondents
rated the extent to which they agreed with these statements (ie, “During
a pandemic, I believe my employer will be concerned about my
safety,” “During a pandemic, my employer will have the necessary
ability/expertise to make sure I am protected at work,” “During a
pandemic, I believe that my employer will be concerned about my
family’s safety,” and finally, “My employer and I share the same
values”). Four response choices ranged from “strongly disagree” to
“strongly agree.” The internal consistency of responses to this scale
yielded a Cronbach alpha of 0.89 (95% CI ⫽ 0.88 – 0.90).
Employer Pandemic Planning. A previously validated5 three-
item scale addressed respiratory protection program (RPP) ele-
ments (ie, respirator availability, prior respiratory training, and
respirator fit-testing). The three-item RPP scale had a Cronbach
alpha of 0.78 (95% CI ⫽ 0.76 – 0.80). Two additional items mea-
sured employer pandemic planning (ie, “Does your employer have
a pandemic influenza emergency plan?” with response options of
“yes/no/I don’t know,” and “Have you received training at work on
pandemic influenza over the past 12 months?” with “yes/no”
answer choices).
Outcomes
Ability and Willingness to Report to Work in the
Event of an Influenza Pandemic. Two items measured ability
and willingness: “During a pandemic, what is the maximum shift you
JOEM • Volume 52, Number 10, October 2010
would be able to work?” and “During a pandemic, what is the
maximum shift you would be willing to work?” There were four
response categories for both items: 1) “report for my usual shift,” 2)
“report for an extended shift (12 hours) everyday,” 3) “report and
remain overnight at work for up to two week stretches,” and 4) “report
for the duration of the early phase of a pandemic outbreak and remain
overnight at work.” For analysis purposes, data for the two main
outcome variables, ability and willingness to report to duty, were
dichotomized into two categories: “usual shift or more” versus “no
response.” A third outcome variable, both ability and willingness was
formed, and dichotomized as “both able and willing” versus “either
ability or willingness” or “neither ability nor willingness.”
Questionnaire Administration
From November 2008 to June 2009, we conducted an anon-
ymous, self-administered, cross-sectional survey of 1103 workers.
A multimethod recruitment strategy was used to obtain a conve-
nience sample. Methods included in-person distribution at regularly
scheduled employee meetings, distribution with paychecks, bulk
distribution by supervisors, and distribution on-site. All completed
questionnaires were returned to the study office in sealed envelopes.
Statistical Analysis
Of 1990 distributed questionnaires, 1149 were completed
and returned to the study office. Of these, 46 questionnaires were
excluded from data analysis due to incomplete or missing data,
resulting in a sample of 1103 participants. The final response rate
was 55%; response rates by workgroup ranged from a low of 42%
(hospital workers) to a high of 76% (police department workers).
After data cleaning and editing procedures, basic descriptive anal-
ysis of the data (eg, frequencies, histograms, and measures of
central tendency) was performed to characterize the sample as a
whole. The data met the assumptions required for the intended
statistical testing procedures, and level of significance was P ⬍
0.05, two-tailed. For each scale, internal consistency reliability
estimates (Cronbach alphas) were calculated and scale descriptive
statistics were performed. Pearson’s ␹2 analysis was performed to
assess relations between categorical items and outcomes. Odds
ratios (OR) and their 95% confidence intervals (CI) were calculated
where appropriate to assess the association between the indepen-
dent variables (individual and organizational) and outcome vari-
ables (ability, willingness, and both ability and willingness). Given
that we were interested in identifying risk factors applicable across
a broad range of essential workgroups, we did not conduct separate
analyses for each workgroup.
Significant predictor variables at the univariate level were
entered into logistic regression models to determine their joint
contributions to the three outcome variables, while accounting for
possible confounding variables. Demographic variables were
forced entered, and forward stepwise entry of other predictor
variables was performed for exploratory purposes. All analyses
were conducted using SPSS 16.0.1.33
RESULTS
Individual Factors
Demographic, Job-Related, and Health Status
Variables
The 1103 participants in this study included hospital workers
(n ⫽ 169, response rate ⫽ 42%), police department personnel (n ⫽
304, response rate ⫽ 76%), emergency medical services workers
(n ⫽ 191, response rate ⫽ 71%), fire department personnel (n ⫽ 93,
response rate ⫽ 47%), department of health workers (n ⫽ 158,
response rate ⫽ 49%), and correctional facility employees (n ⫽
188, response rate ⫽ 47%). A majority of the participants were
© 2010 American College of Occupational and Environmental Medicine
Essential Workers’ Ability and Willingness to Report to Duty
male (63%), Caucasian (77%), and married/with partner (66%). Of
these, 24% reported that their spouse/partner was an essential
worker. One half of the respondents had children younger than 18
years living at home. The average age was 41 years (standard
deviation ⫽ 11.4 years; range ⫽ 18 –75 years). Demographic
profiles for each workgroup were similar to those of the participat-
ing workgroups. One third worked in a second job or held a
volunteer position, and in these secondary positions, 57% were
expected to report to duty during an emergency. Forty-one percent
of the sample had prior experience responding to an actual disaster
(natural or manmade). Thirty-five percent had one or more chronic
health problems. Demographic and job-related information is fur-
ther detailed in Table 1.
Influenza Vaccination History and Intentions
Approximately half of the sample (45%) reported seasonal
influenza vaccination in the previous 12 months, with almost twice
as many participants (84%) reporting that they would be “likely” to
“extremely likely” to take a safe and an effective pandemic influ-
enza vaccine during an outbreak.
Respiratory Protection Attitudes, Practices, and
Intentions
Only 7% of the sample was very confident in the protection
provided by N95-type respirators. Half of the sample (49%) was
“somewhat confident” and 21% were “not at all confident.” When
respiratory protection was needed on the job, only 10% of essential
workers reported that they actually complied; however, 80% re-
ported they intended to wear a respirator all of the time at work
during a pandemic. Reasons for noncompliance with respirator
protection, even during a pandemic, included the following: “un-
comfortable to wear” (22%), “hard to breathe while wearing one”
(21%), and, “gets in the way” (14%).
Pandemic-Related Perception of Risk and Concern
Most essential workers (79%) reported that they were either
“somewhat” or “very concerned” that a pandemic might occur
within the next 5 to 10 years. During an outbreak, most participants
were concerned that they might be exposed to pandemic influenza
at work (74%) or within the community (70%), with about half
concerned about exposure at home (53%).
Fifty-nine percent of participants evaluated their coworkers’
(workers who perform jobs similar to theirs) risk of inflection as
“high risk” or “extremely high risk,” whereas 47% rated their own
risk at similar levels. Twelve percent reported that they intended to
either prematurely retire or quit their job in the event of a pandemic
outbreak.
Potential Facilitator and Barriers
The most common facilitators to ability to report to duty
during a pandemic outbreak included being able to leave work if
necessary (69%), the availability of elder care or care for other
family members (33%), childcare (32%), and pet care (32%).
Family-related responsibilities (61%) were the most common
barrier to ability to report to duty, followed by “obligations to a
second employer and/or volunteer position” (14%). Respondents
who reported one or more potential barriers to their ability
(versus no barriers) were more likely to have children at home
younger than 18 years (OR ⫽ 5.04; 95% CI ⫽ 3.63–7.01; P ⬍
0.001) and be married/with partner (OR ⫽ 2.83; 95% CI ⫽
2.11–3.79; P ⬍ 0.001).
Factors that facilitated willingness were related to personal
and family safety. For example, 78% of essential workers would be
willing to report if they knew they would be safe from infection and
77% would be willing if their family had priority to receive the
pandemic influenza vaccine. Other common facilitators of willing-
ness included the ability to communicate with family members
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Gershon et al JOEM • Volume 52, Number 10, October 2010

TABLE 1. Description of the Essential Workers Sample Characteristics n (% Reporting)*

(N ⫽ 1103) Required to respond to disasters in secondary
Characteristics n (% Reporting)* position
Yes 380 (37.1)
Gender
No, N/A 644 (62.9)
Male 692 (63.0)
Prior disaster response experience
Female 406 (37.0)
Yes 451 (41.1)
Age (mean ⫾ SD), yr 41.3 ⫾ 11.4
No 645 (58.9)
Race
Volunteer
White 837 (76.9)
Yes 347 (33.7)
Non-white 252 (23.1)
No 692 (67.1)
Highest educational degree
Did not graduate from high school 6 (0.5) *Column numbers may not add to 1103 due to missing values.
High school diploma or general educational 188 (17.1) †Participants were able to select more than one health condition.
development degree
Associates degree or some college 409 (37.2)
Bachelor’s degree 312 (28.4)
Postgraduate/professional degree 184 (16.7) while at work (77%) and availability of a constant, steady stream of
Marital status
information at work (62%).
Married/partner 721 (65.5)
Unmarried/no partner 379 (34.5) Organizational Factors
Spouse/partner is an essential worker Workplace Safety Climate and Organizational Trust
Yes 193 (18.0) A large proportion of the sample favorably assessed their
No, N/A 876 (82.0) organization’s safety climate. Most agreed with the following
Have children at home statements: “I feel free to report safety or health violations where I
Yes 547 (49.9) work” (84%); “Employees are told when they do not follow good
No 549 (50.1) safety and health practices” (73%); “At my workplace, all reason-
Self-reported health status
able steps are taken to minimize my risk of exposure to occupa-
tional hazards” (71%); and “The health and safety of workers is a
Excellent or very good 729 (66.5)
high priority with management where I work” (71%). The mean
Good 325 (29.7) score for the four-item workplace safety climate scale was 2.99
Fair, poor, or very poor 42 (3.8) (max ⫽ 4.0), with a standard deviation of 1.38.
Personal health problems† In terms of organizational trust and shared values, most
High blood pressure 179 (16.2) respondents (74%) agreed with the statement “During a pandemic,
Arthritis/joint pain 134 (12.2) I believe my employer will be concerned about my safety.” How-
Respiratory problems, heart disease, or diabetes 138 (12.5) ever, a lower percentage, 58%, agreed that their employer would be
Other chronic problems 84 (7.6) concerned for the employee’s family, and a similar percentage
Mental health 15 (1.4) (58%) thought that employers and workers shared the same worker
Pay status of primary position
safety values. More than half of the respondents (64%) agreed that
their employer had the necessary ability/expertise to protect em-
Paid 924 (85.5)
ployees from a pandemic. The mean score among responses on the
Volunteer 117 (10.8) four-item organizational trust and shared values scale was 2.54
Paid and volunteer 40 (3.7) (max ⫽ 4.0), with a standard deviation of 1.66.
Length of tenure at primary position, yr
0–5 368 (33.8) Employer Pandemic Planning
6–10 153 (14.0) Roughly two-thirds of respondents (62%) reported that their
workplace provided some form of respiratory protection (eg, sur-
11–15 182 (16.7)
gical masks, N95-type respirators, and/or SCBA), with 41% report-
16–20 146 (13.4) ing that N95-type respirators were available. Surgical masks and
⬎21 363 (33.8) SCBAs were available to 39% and 21% of respondents, respec-
Years until retirement from primary position, yr tively. Approximately 13% of the sample stated that respiratory
0–5 151 (14.1) protection was not available, and 25% said they were not sure.
6–10 213 (19.8) More than half of the sample (60%) received prior respiratory
11–15 197 (18.3) protection training, and a similar proportion (55%) had been fit-
16–20 151 (14.0) tested for a respirator.
⬎21 363 (33.8) Forty-two percent of respondents reported having all three
Second job or regular volunteer position
elements of a RPP available to them (ie, respirator availability,
prior respiratory training, and respirator fit-testing), 34% reported
Yes 362 (33.0)
the availability of only one or two elements, and 25% reported none
No 734 (67.0) of the three RPP elements were available. The mean score for the
three-item RPP scale was 1.75 (max ⫽ 3.0), with a standard
deviation of 1.23.
In terms of employer pandemic planning, only a small
proportion of the sample (9%) reported that they were aware of

998 © 2010 American College of Occupational and Environmental Medicine

JOEM • Volume 52, Number 10, October 2010 Essential Workers’ Ability and Willingness to Report to Duty

their employer’s pandemic plans. Similarly, few (15%) had ever

received pandemic influenza training at work. TABLE 3. Factors Significantly Associated With Essential
Workers’ Willingness to Report to Duty During a Pandemic
Outcomes vs. Not Willing to Report to Duty
Ability and Willingness to Report to Work in the Factor OR 95% CI P
Event of an Influenza Pandemic Intention to wear respiratory 2.47 1.07–5.68 ⬍0.05
One quarter of participants reported that the maximum shift protection during a pandemic*
they would be able (ie, available) to work during an influenza pan- Provision of organizational 1.64 1.23–2.19 ⬍0.001
demic was their usual shift, 30% were able to work their regular plus facilitators to increase ability
extended shifts, and 25% reported that they would be able to work for Provision of facilitators to 1.57 1.23–2.02 ⬍0.001
the duration of a pandemic event. Twenty percent of the sample increase willingness
reported that they would not be able to work any shift—including their Availability of one or more 1.56 1.16–2.09 ⬍0.01
regular shift. By workgroup, ability of workers to report for at least elements of a RPP at work
their usual shift ranged from a high of 85% (police officers) to a low Intention to receive a pandemic 1.53 1.10–2.13 ⬍0.05
of 75% (corrections workers) (see Table 2). influenza vaccine during an
Factors associated with ability to report to duty during a outbreak
pandemic included provision of organizational factors to increase No intention to either 1.51 1.10–2.07 ⬍0.01
ability (OR ⫽ 2.29; 95% CI ⫽ 1.66 –3.17; P ⬍ 0.001), intention to prematurely retire or quit their
receive a pandemic influenza vaccine during an outbreak (OR ⫽ job in the event of a
1.97; 95% CI ⫽ 1.37–2.85; P ⬍ 0.001), more than 12 years of pandemic outbreak
education (OR ⫽ 1.53; 95% CI ⫽ 1.07–2.19; P ⬍ 0.01), and High level of trust in employer 1.50 1.08–2.09 ⬍0.01
married/have partner (OR ⫽ 1.39; 95% CI ⫽ 1.03–1.88; P ⬍ 0.05). Prior training on respirator 1.48 1.18–1.92 ⬍0.01
In terms of willingness, 10% of participants reported that the protection
maximum shift they would be willing to work during an influenza Spouse/partner is not an 1.46 1.06–2.00 ⬍0.05
pandemic was their usual shift, 31% were willing to work their regular essential worker (or n/a)
plus extended shifts, and 24% reported that they would be willing to Less concern that a pandemic 1.43 1.04–1.98 ⬍0.05
work for the duration of a pandemic event. Thirty-five percent of the might occur within the next
sample reported that they would not be willing to work any shift— 5–10 yr
including their regular shift. Willingness, by workgroup, ranged from Prior disaster response 1.39 1.08–1.79 ⬍0.05
a high of 74% (public health workers) to a low of 56% (corrections experience
workers). The proportion willing to report to duty for their usual shift Workplace has two or more 1.34 1.05–1.72 ⬍0.05
or more, by workgroup, is shown in Table 2. pandemic preparedness
There were several factors significantly associated with will- elements†
ingness to report to duty during a pandemic (versus not willing), Provision of one or more forms 1.31 1.02–1.70 ⬍0.05
including intention to wear respiratory protection, provision of of respiratory protection at
work
organizational facilitators to increase ability, availability of RPP
elements, intention to receive a pandemic influenza vaccine, no *At least some of the time (vs. never).
intention to prematurely retire or quit, organizational trust/shared †Two or more of the following elements: respirator training, respirator fit-testing,
values, spouse/partner’s occupation as an essential worker [-], less pandemic influenza training, and workplace has established pandemic plans.
concern that a pandemic might occur within the next 5 to 10 years,
prior disaster response experience, and two or more workplace
pandemic preparedness elements (ie, respirator training, respirator department of health workers (59%), and the group least able and
fit-testing, pandemic influenza training, and workplace has estab- willing was the corrections workers (37%). In terms of being both
lished pandemic plans). The ORs of all factors significantly asso- able and willing to report to duty, factors significantly associated
ciated with willingness are shown in Table 3. with this outcome are presented in Table 4.
During a pandemic, 51% of participants were both not able To determine the unique contributions of variables that were
and not willing to report to duty, not even for their usual shift (see significantly related to the major outcomes (ability to report to duty,
Table 2). The group most likely to be both able and willing was the willingness to report to duty, and ability and willingness to report

TABLE 2. Rates of Ability, Willingness, and Ability and Willingness to Report to Duty
During a Pandemic Outbreak for Their Usual Shift or More, by Work Group
Both Able
Population N Able Willing and Willing*
Department of health 158 129 (81.6) 117 (74.1) 93 (58.9)
Police 304 258 (84.9) 199 (78.3) 161 (53.0)
Fire 93 71 (76.3) 65 (69.9) 49 (52.7)
Emergency medical services 191 145 (75.9) 130 (68.1) 95 (49.7)
Hospital 169 138 (81.7) 96 (56.8) 73 (43.2)
Corrections 188 140 (74.5) 106 (56.4) 70 (37.2)
Total Sample 1,103 881 (79.9) 713 (64.6) 541 (49.0)

Values are represented as n (%).

*Work groups listed in descending frequency.

© 2010 American College of Occupational and Environmental Medicine 999

Gershon et al JOEM • Volume 52, Number 10, October 2010

to duty), three logistic multiple regression analyses were conducted.

TABLE 4. Factors Significantly Associated With Essential
Workers’ Ability and Willingness to Report to Duty During a
Pandemic vs. Not Able and Willing to Report to Duty
Factor OR
Intention to wear respiratory 10.64
protection during a pandemic*
Intention to receive a pandemic 2.17
influenza vaccine during an
outbreak
Provision of organizational 2.10
facilitators to increase ability
No intention to either prematurely 1.96
retire or quit their job in the event
of a pandemic outbreak
Provision of facilitators to increase 1.73
willingness
More than 12 yr of education 1.51
Prior training on respirator 1.47
protection
Availability of one or more elements 1.45
of a RPP at work
Less concern that a pandemic might 1.40
occur within the next 5–10 yr
Spouse/partner is not an essential 1.40
worker (or n/a)
History of seasonal influenza 1.35
vaccination in prior 12 mo
Provision of one or more forms of 1.34
respiratory protection at work
*At least some of the time (vs. never).
Demographic variables significantly related to the outcome variable
in the bivariate analyses were controlled for in step one of each
model. Forward entry was used to enter the other predictor vari-
95% CI P ables significant in the bivariate analyses.
2.48–45.45 ⬍0.001 For the ability outcome (able to report to duty for usual or
longer shift versus not able), two demographic variables, education
1.53–3.05 ⬍0.001 and marital status were entered in step one as control variables
because of their significant univariate relations to the ability vari-
able. They were, however, not significantly related to ability in the
1.56–2.82 ⬍0.001 final equation (shown in Table 5). The final step of this model,
which forward entered five previously significant factors, revealed
1.33–2.89 ⬍0.001 that only two of these factors entered the regression equation
(provision of organizational facilitators to ability and intention to
receive a pandemic influenza vaccine). The factor that carried the
1.36–2.20 ⬍0.001 most “impact” in predicting ability, as determined by effect size (ie,
adjusted odds ratio), was the provision of one or more organiza-
1.10–2.07 ⬍0.01 tional facilitators to increase ability.
1.15–1.88 ⬍0.01 In regards to willingness (willing to report to duty for usual or
longer shift versus not willing), occupation of spouse and disaster
1.09–1.93 ⬍0.05 response experience were entered in step one as control variables, with
prior disaster response significantly related to willingness in this step.
1.02–1.94 ⬍0.05 However, prior disaster response was not a significant predictor of
willingness in the final step of the model (shown in Table 5). Forward
1.02–1.91 ⬍0.05 entry of 12 factors significant in the bivariate analyses resulted in three
factors entering the model (prior respirator training, trust in employer,
1.06–1.71 ⬍0.05 and no intention to prematurely retire or quit). No other factors entered
the model after this step.
1.04–1.71 ⬍0.05 For the ability and willingness outcome variable (both able
and willing to report to duty versus either or neither), two demo-
graphic variables (education and occupation of spouse) entered in
step one. More than 12 years of education was a significant
predictor of ability and willingness in this first step; however, it was
not significant in the final model (shown in Table 5). The final step
of the model (step six) revealed that 6 of 11 factors were significant
predictors of ability and willingness. Intention to wear a respirator
during a pandemic (at least some of the time versus never) carried

TABLE 5. Significant Logistic Regression Results for Reporting to Duty During a Pandemic Outbreak
Able and Willing
Able vs. Willing vs. vs. Only Able/Only
Not Able Not Willing Willing/Neither
(n ⴝ 954) (n ⴝ 901) (n ⴝ 901)
OR 95% CI OR 95% CI OR 95% CI
More than 12 yr of education 1.36 0.91–2.05 1.25 0.86–1.79
Married/partner 1.29 0.92–1.80
Intention to receive a pandemic influenza vaccine during an outbreak 1.79** 1.17–2.66 2.22*** 1.48–3.35
Provision of facilitators to increase ability 2.11*** 1.48–3.02 1.81** 1.28–2.56
Spouse/partner is not an essential worker (or n/a) 1.39 0.96–2.00 1.42 0.99–2.03
Prior disaster response experience 1.24 0.92–1.67
Prior training on respirator protection 1.41* 1.05–1.90 1.59** 1.20–2.10
High level of trust in employer 1.48* 1.01–2.15
No intention to either prematurely retire or quit their job in the event of a 1.73** 1.15–2.60 1.65* 1.08–2.52
pandemic outbreak
Low level of concern for infection with pandemic influenza during an 1.38* 1.04–1.83
outbreak in general
Intention to wear respiratory protection during a pandemica 6.89* 1.55–30.74
Constant 0.16*** 0.24*** 0.46***
Nagelkerke RStep 2 ⫽ 0.05 Nagelkerke RStep 3 ⫽ 0.04 Nagelkerke RStep 6 ⫽ 0.09

*P ⬍ 0.05; **P ⬍ 0.01; ***P ⬍ 0.001.

a
At least some of the time (vs. never).

1000 © 2010 American College of Occupational and Environmental Medicine

JOEM • Volume 52, Number 10, October 2010
the greatest “impact” in predicting those who were both able and
willing to report to duty.
DISCUSSION
In this study, a high proportion of participants (80%) indi-
cated that they would be able to report to duty during a serious
pandemic, although fewer (65%) would be willing. When we
combined the portion of those both able and willing, more than half
of the essential workers in our study might be absent from the
workplace because of non–illness-related factors. These rates are
similar to rates previously published with respect to hypothetical
pandemic events, although most of these earlier studies targeted
health care workers and methodological design and instruments
varied greatly across studies.5– 8,34 –37 Therefore, we must use
caution when comparing the rates from this study with other
published rates.
Comparison of the rate of intentions in our study with the
actual response to the 2009 H1N1 Pandemic is also problematic.
First, the magnitude of the event scenario we presented in our
questionnaire was more in line with the 1918 Pandemic, whereas
the 2009 Pandemic was milder than expected, and second, infor-
mation on worker response and absenteeism rates during the H1N1
Pandemic is very limited. In one recently published study by Santos
et al.,38 mean sick hours for HCWs employed by a major New York
City medical system increased by nearly 24% (P ⬍ 0.001) com-
paring June 2009 to June 2008 rates. Certain departments (eg, adult
and pediatric emergency departments and intensive care units)
experienced very high increases in sick hours—these departments
also had the greatest surge of patients with influenza-like symp-
toms. Most of the sick employees were tested for laboratory
confirmation of infection, and these were almost always positive,
except for one group, comprised of social workers and counselors.
The authors reported that although they found that social workers
had the highest increase in sick hours (40%) compared with other
workgroups, such as physicians and nurses, they actually had the
lowest infection rate. The data available to the authors did not allow
them to determine the reason for this, although they speculated that
this might have been due to non–illness-related reasons.
There are numerous anecdotal reports of patient surges
during the 2009 H1N1 Pandemic leading to stressed health care
facilities and exhausted workers, especially in emergency medicine
and intensive care departments. Nevertheless, the available evi-
dence suggests that essential work sectors, including health care,
were able to continue to provide services and effectively meet their
staff-related surge capacity needs.36 Therefore, it seems apparent
that staff shortages during the H1N1 Pandemic were not exacer-
bated by non–illness-related absenteeism. Nonillness shortfalls
might also have been minimized by the limited school closings and
continued operation of mass transit systems.
Certain key findings from our study merit discussion. First,
although most participants had little confidence in respiratory
protection, most reported that they intended to wear respirators “all
the time” (at work) during a pandemic. It seems that participants are
willing to wear these devices, perhaps for extended periods and
although they deem them both unreliable and uncomfortable, in
order to protect their health. Because the intended use of respirators
was a highly significant factor related to ability/willingness, essen-
tial work organizations should determine the advisability of devel-
oping and implementing an appropriate RPP for their at-risk em-
ployees. This might be especially critical in the early phase of a
pandemic, before a vaccine is available and in the event that other
pharmaceuticals are in short supply. Guidance on RPPs is readily
available.39 – 43 Where feasible, employers should include input
from workers expected to wear the devices, as many respiratory
© 2010 American College of Occupational and Environmental Medicine
Essential Workers’ Ability and Willingness to Report to Duty
protection compliance barriers reported in our study and others
were related to comfort, fit, and other wearability issues.34
Second, it is evident that workers’ sense of safety will
similarly be enhanced by vaccination against pandemic influenza.
Although the Centers for Disease Control and Prevention reported
that the H1N1 vaccination rate among US HCWs was only 37%,44
in our sample, 84% of participants reported that they intended to be
vaccinated. Early and sporadic vaccine shortages and the lessening
of concern as our worst fears regarding the virulence of H1N1 were
not realized probably influenced the actual vaccination rates. In
support of vaccination recommendations, many health care facili-
ties in the US launched worker vaccination programs. Going
forward, there are now excellent program models that can be
readily adopted by other essential work organizations in close
consultation with local health departments.45– 47
Third, because organizational policies and programs that
would help workers meet their personal obligations (eg, childcare in
case of widespread school closures) during a pandemic is also
related to increased willingness, it would be helpful for essential
sector employers to identify the needs of their workforce and to
develop strategies to implement these. Although it may be infeasi-
ble for many employers to organize and coordinate family care
plans that would allow employees to work additional shifts, a
reasonable alternative is to request that employees prepare and
update family (and pet) care back-up plans. Good examples of
personal emergency plans are available.48 –50
All of these initiatives are part of an overall comprehensive
pandemic preparedness plan. Useful pandemic guidelines and
checklists for the workplace have been published.51–55 One impor-
tant aspect of preparedness includes pandemic-related human re-
sources policies. These might include workplace policies regarding
quarantine, since in our focus groups, some workers reported that
they were fearful of the imposition of mandatory quarantine. Other
workers were worried about compensation and “return to work”
policies. In our survey, we found that willingness to report would
be increased if workers could stay in touch with their families and
leave work when needed. These types of concerns should be
addressed in policies and then clearly communicated to employees.
Sample human resources policies on pay and sick leave flexibilities
during a pandemic are available from the US Office of Personnel
Management.56 Additional policy guidance is available from the
US Department of Labor, which is currently reviewing the Family
and Medical Leave Act with respect to pandemic influenza.57
Another helpful document, “HHS Pandemic Influenza Plan Sup-
plement 11 Workforce Support: Psychosocial Considerations and
Information Needs,” provides guidance on supporting worker’s
psychological well-being during disasters.58
Communicating pandemic preparedness planning and expec-
tations to workers will also serve to build organizational trust. A
very low percentage of study participants (15%) ever received prior
pandemic training at work, although training materials were made
readily available by the Centers for Disease Control and Prevention
prior to the first reported case. Our results underscore the need for
periodic pandemic training and communication with essential
workers. Workers’ willingness to report to duty under potentially
risky conditions is reasonably tied to the degree of protection they
feel that their employers can provide. Thus, it is important that the
planned risk reduction measures be clearly communicated to work-
ers. A recent study on mitigating absenteeism of hospital workers
during a pandemic by Garrett et al.4 similarly supports our recom-
mendation that essential sector employers take measurable steps to
safeguard workers’ safety and to clearly communicate these steps.
Finally, one other interesting finding that, to our knowledge,
has not been previously reported, was that in response to a pan-
demic event, 12% of study participants would consider early
1001
Gershon et al
retirement or job exit rather than report to duty. This is a concern
given the rapidly aging US workforce and the fact that many
essential workers are also public service workers, many of whom
are already eligible to retire. The development of strategies to retain
these most experienced workers during public health emergencies
remains an area for future exploration.
Our study findings also suggest some avenues for other
additional research. For example, although organizational pan-
demic planning and communication strategies to safeguard work-
ers’ health is extremely important, evidence-based research on best
practices for essential sectors is lacking and should be the subject of
future investigations.
Limitations
Our study was conducted in a “high risk” area in terms of
disaster exposure, response, and readiness; many of the participants
in this study responded to the World Trade Center attack. Like
many other responders to this disaster, they are highly motivated
and altruistic. Essential workers from other geographic areas might
not be as responsive. However, a similar study was replicated in
Honolulu, Hawaii (K. Qureshi, Principal Investigator), and the
ability and willingness rates of workers deemed essential in each
setting were similar (results under submission, personal correspon-
dence with corresponding author, K. Qureshi). Formal statistical
comparisons are planned between the two samples.
Given the anonymous nature of our study, extensive and
individualized follow-up could not be conducted, and thus another
potential limitation was the response rate, which was suboptimal.
The ability and willingness of nonresponders to this study could be
quite different from that of the responders. Nevertheless, this is a
large sample, with an adequate number of respondents to analyze
relationships between outcomes and factors associated with these
outcomes. In addition, because of the cross-sectional study design,
causality cannot be ascertained. Furthermore, workers’ intentions
may not be predictive of their actual behaviors. Clearly further
studies, with randomized sampling, of other essential workgroups
are needed. Other geographic areas, work settings, and additional
essential workgroups (eg, telecommunications, transportation, and
commerce) should also be studied.
CONCLUSIONS
There is an absence of definitive intervention and implemen-
tation research on best practices for safely supporting the atten-
dance of essential workers.59 However, our results suggest, as
noted, a number of relatively simple strategies that employers can
implement to support employees’ response during infectious dis-
ease outbreaks. These include developing and communicating or-
ganizational pandemic plans and policies that address: distribution
of vaccines and other pharmaceuticals to workers and their family
members; respiratory protection; workers’ competing family obli-
gations; and nonillness absenteeism and disciplinary actions (or
lack thereof) related to this.
The 2009 Pandemic stressed several of the essential sectors,
most notably health care, but did not overwhelm any one sector.
Future pandemics may prove otherwise, regardless of our staffing
expectations given past performances. The shortfalls as predicted in
this study could have a profound impact on the delivery of essential
services. Therefore, mathematical models that predict staffing re-
quirements during a pandemic should consider nonillness shortages
to improve their accuracy. Essential work sector employers might
want to consider assessing the ability and willingness of their own
work populations to help inform their planning efforts. Willingness
might best be determined using a simple anonymous survey, and
the barriers to ability can be identified using focus groups com-
prised representative workers. Going forward, a concerted effort is
1002 © 2010 American College of Occupational and Environmental Medicine
JOEM • Volume 52, Number 10, October 2010
merited to identify and implement effective strategies to reduce
non–illness-related absenteeism in essential work sectors during a
pandemic event.
ACKNOWLEDGMENTS
The authors gratefully acknowledge Drs. Ted Scharf, Dori
Reissman, and Kathleen Kowalski-Trakofler and Ms. Kellie Pierson
of the National Institute for Occupational Safety & Health for their
advice and help with this project. The support of Nassau County
agency leadership and the enthusiastic participation of workers
essential to the conduct of this study were greatly appreciated.
This work was supported by a grant from the National
Science Foundation (NSF) #0653493 and a subaward agreement
#193419 from the Henry M. Jackson Foundation for the Advance-
ment of Military Medicine, Inc. (HJF)—part of a primary award
#HU0001-08-1-0004 from the Uniformed Services University of the
Health Sciences (USUHS).
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