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Stress, adherence to preventive measures for reducing influenza transmission and influenza-like illness
  1. Vanessa Perez1,2,
  2. Monica Uddin1,2,
  3. Sandro Galea3,
  4. Arnold S Monto2,
  5. Allison E Aiello1,2
  1. 1Center for Social Epidemiology & Population Health, School of Public Health-University of Michigan, Ann Arbor, Michigan, USA
  2. 2Department of Epidemiology, School of Public Health- University of Michigan, Ann Arbor, Michigan, USA
  3. 3Department of Epidemiology, Mailman School of Public Health, Columbia University, New York City, New York, USA
  1. Correspondence to Dr Allison E Aiello, Associate Professor of Epidemiology, Department of Epidemiology, Center for Social Epidemiology & Population Health, University of Michigan-School of Public Health, SPH Tower 109 Observatory, Ann Arbor, MI 48109-2029, USA; aielloa{at}


Background Using data from a randomised intervention trial of facemask use and hand hygiene for reducing transmission of seasonal influenza among university students, we examined if levels of perceived stress were negatively associated with adherence to these preventive measures and incidence of influenza-like illness (ILI).

Methods Longitudinal analyses using generalised estimating equations were examined. Perceived stress was self-reported at baseline using a validated scale. Compliance with preventive measures was self-reported throughout the study period and reported ILI symptoms were defined as cough and one or more of fever/feverishness, chills and body aches.

Results Higher levels of perceived stress were not associated with facemask or hand hygiene compliance. However, perceived stress was significantly associated with a greater ILI incidence (HR1.25, 95% CI 1.07 to 1.45) even after controlling for demographic and behavioural risk factors.

Conclusions Among students in the university setting, higher levels of perceived stress affect ILI symptom reporting but not compliance with preventive measures for reducing transmission of influenza. Further studies are needed to examine whether psychological stress is a key mechanism explaining socio-demographic health disparities in confirmed influenza infection among healthy persons in the community setting.

  • Psychological stress
  • influenza
  • behaviour
  • schools
  • young adult
  • health behaviour
  • psychological stress
  • psychosocial influence
  • social epidemiology

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  • Competing interests None.

  • Ethics approval This study was conducted with the approval of the University of Michigan Institutional Review Board for the original study that has been published (trial registration:; identifier: NCT00490633).

  • Provenance and peer review Not commissioned; externally peer reviewed.