Community awareness, use and preference for pandemic influenza vaccines in Pune, India

Figures & data

Table 1. Summary of sample characteristics

	Number of participants
	Focus group discussion (FGD)^a, n=28	Semi-structured interview (SSI), n=436	In-depth interview (IDI), n=12
Age^b
18–25	5	76	1
26–35	5	85	5
36–45	5	62	2
46–55	4	119	1
56–65	3	94	3
Sex
Female	13	221	10
Male	15	215	2
Site
Urban	10	215	6
Rural	18	221	6
Area
Urban middle-income	5	102	5
Urban low-resource	5	113	1
Rural more accessible	6	113	6
Rural less accessible	12	108	0

^a Five focus groups were conducted, each with 5–6 participants. Two focus groups were conducted with women, two with men and one with both men and women.

^b Specific ages for one focus group with 6 participants at the rural site were not collected. Hence, the total number of participants categorized by age for the focus groups does not add up to 28.

Table 2. Awareness, health care provider recommendation and use of pandemic influenza vaccines

	Overall (%)	Age group (%)^a			Area of residence (%)					Sex (%)
		Younger	Older	P value^b	Urban middle-income	Urban low-resource	Rural more accessible	Rural less accessible	P value^b	Female	Male	P value^b
	n = 436	n = 223	n = 213		n = 102	n = 113	n = 113	n = 108		n = 221	n = 215
Awareness of vaccines to prevent swine flu
Nasal vaccine^c	26.6	31.4	21.6	*	47.1	25.7	26.6	8.3	***	25.8	27.4
Injectable vaccine^d	23.4	26.0	20.7		28.4	26.6	17.7	21.3		21.7	25.1
Recommendation by health care provider
To take a swine flu vaccine^e	15.8	20.6	10.8	**	23.5	20.4	13.3	6.5	**	13.1	18.6
Uptake of swine flu vaccine
Personal use^f	8.3	9.4	7.0		13.7	6.2	9.7	3.7	*	5.9	10.7
Others in household^g	10.6	NA	NA		19.6	7.1	14.2	1.9	***	NA	NA

^a Younger age group: 18–45 years, Older age group: 46–65 years; NA: Not applicable.

^b Fisher's exact test was used to compare proportions across age groups, area of residence and sex: *p ≤ 0.05, **p ≤ 0.01, *** p ≤0.001.^cFrequency of affirmative responses to the question: “Are you aware of a vaccine that is sprayed into a person's nose to protect against swine flu?”^dFrequency of affirmative responses to the question: “Are you aware of a vaccine that is injected into a person's upper arm to protect against swine flu?”

^e Frequency of affirmative responses to the question: “Has your health care provider ever recommended your taking a vaccine to protect against swine flu?”

^f Frequency of affirmative responses to the question: “Have you ever taken a vaccine to prevent swine flu?”

^g Frequency of affirmative responses to the question: “Has anyone else in your household ever taken a vaccine to prevent swine flu?”

All questions were enquired in the local language, Marathi, and translations have been provided here.

Table 3. Reasons for non-use of pandemic influenza vaccines

Reasons for not taking the pandemic influenza vaccine (personally or for someone in the household)^a	Overall (%)	Area of residence (%)					Sex (%)
		Urban middle-income	Urban low-resource	Rural more accessible	Rural less accessible	P value^b	Female	Male	P value^b
	n = 436	n = 102	n = 113	n = 113	n = 108		n = 221	n = 215
Low risk attributed to influenza	55.0	46.1	57.5	60.2	55.6		49.8	60.5	*
Sufficient precautionary measures already taken	15.8	29.4	25.7	6.2	2.8	***	15.8	15.8
Access (where and how to get it)	14.7	7.8	9.7	17.7	23.1	**	11.8	17.7
Unaware of vaccine	11.7	2.0	13.3	12.4	18.5	***	12.7	10.7
Cost of vaccine	5.0	4.9	8.0	3.5	3.7		5.9	4.2

^a Response to the question: “For you or anyone in your household who did not take the vaccine for swine flu, were there any particular reasons not to take it? Can you explain why some (or all) did not take it?” were coded into categories described in the table. Multiple categories could have been mentioned and coded for each respondent. 7.3% of respondents did not provide a reason. Categories reported by less than 5% are not presented. They included: lack of encouragement by health care provider (3.9%), other miscellaneous (3.4%), vaccine shortage due to high demand (2.1%), no time to take the vaccine (1.6%), doubts about vaccine effectiveness (0.9%), and general avoidance of medication (0.9%).

^b Fisher's exact test was used to compare proportions across area of residence and sex: *p≤0.05, **p≤0.01, ***p≤0.001. No differences were observed across age groups and they have hence not been presented.

Table 4. Preference for injectable or nasal pandemic influenza vaccine

	Overall	Age group			Area of residence					Sex
		Younger	Older	p value^a	Urban-middle income	Urban low-resource	Rural more accessible	Rural less accessible	p value^a	Female	Male	p value^a
	n = 436	n = 223	n = 213		n = 102	n = 113	n = 113	n = 108		n = 221	n = 215
More powerful vaccine (%)^b
Neither	0.0	0.0	0.0		0.0	0.0	0.0	0.0		0.0	0.0
Both equal	3.0	2.7	3.3		2.9	3.5	1.8	3.7		3.6	2.3
Injection	44.3	44.4	44.1		42.2	51.3	40.7	42.6		45.2	43.3
Nasal spray	32.6	36.3	28.6		33.3	31.0	37.2	28.7		26.2	39.1	**
Cannot say	20.2	16.6	23.9		21.6	14.2	20.4	25.0		24.9	15.3	*
Safer vaccine (%)^c
Neither	0.7	0.5	0.9		0.0	0.9	0.0	1.9		0.9	0.5
Both equal	9.6	11.7	7.5		9.8	5.3	14.2	9.3		12.2	7.0
Injection	57.1	54.7	59.6		46.1	64.6	54.9	62.0	*	55.2	59.1
Nasal spray	27.5	29.6	25.4		42.2	24.8	25.7	18.5	**	25.8	29.3
Cannot say	5.0	3.6	6.6		2.0	4.4	5.3	8.3		5.9	4.2
Personal preference (%)^d
No preference	11.2	8.1	14.6	*	9.8	6.2	10.6	18.5	*	12.7	9.8
Injection	58.5	59.2	57.8		52.9	65.5	54.9	60.2		59.3	57.7
Nasal spray	30.3	32.7	27.7		37.3	34.5	28.3	21.3		28.1	32.6

^a Fisher's exact test was used to compare proportions across age groups, area of residence and sex, *p≤0.05, **p≤0.01, ***p≤0.001

^b Frequency of responses to the question: “Do you think either of these vaccines (the nasal spray or the injection) would be more powerful and better able to protect you against swine flu? … Why?”

^c Frequency of responses to the question: “Which one of these vaccines (nasal spray or injection) do you think would be safer for you? … Why?”

^d Frequency of responses to the question: “If you could choose either of these vaccines to protect yourself against swine flu, which one would you prefer, the nasal spray or the injection? … Why?”

All questions were enquired in the local language, Marathi, and translations have been provided here.

Table 5. Reasons for preferring an injectable vaccine or a nasal vaccine for pandemic influenza

A) Reasons for preferring an injectable vaccine
Theme	Illustrative quote
Perceived powerfulness of vaccine
Injectable vaccine spreads through the body from absorption in the blood	“In our village it is believed that the medicine reaches the whole body only through an injection” (29 yr, rural woman)
Injectable vaccine spreads faster in the body	“An injectable vaccine spreads all over quickly. The nasal one takes time while the injection spreads faster” (23 yr, urban man)
Injectable vaccine has longer lasting effects	“Injectable vaccine because its effect will last for long” (31 yr, rural man)
Nasal vaccine may be expelled while breathing, sneezing or in mucus	“The injectable vaccine allows the medicine to disperse internally. The medicine if administered through the nasal route will get expelled through breath. It won't go inside” (64 yr, rural man)
Nasal vaccine may not reach all parts of the body	“Injectable vaccine is better because the nasal vaccine will travel with the breath and only reach the lungs while the injectable one will circulate through the blood in the entire body” (60 yr, rural man)
Pain caused by injectable vaccine is an indication of its powerfulness	“Actually, pain at the injection site is considered as good sign” (rural woman, FGD)
Side effects or safety concerns of alternative
Fear of numerous side effects from nasal vaccine	“If given in the nose then it creates irritation in the throat, and the whole mouth becomes bitter” (46 yr, rural woman)
Familiarity and trust
Past experience and familiarity with injections	“I will prefer the injectable vaccine since we are used to taking injections. We have never taken it through the nose” (27 yr, urban man)
Implicit trust in injections	“Injection- all I can understand is that, it will be effective when we take it” (50 yr, woman)
Fear of relatively unknown nasal vaccine	“A person fears taking it through the nose. There is no fear in an injection. I fear the nasal one” (48 yr, rural woman)
B) Reasons for preferring a nasal vaccine
Theme	Illustrative quote
Perceived powerfulness of vaccine
Nasal vaccine can reach all parts of the body through breath	“[I prefer] nasal as when we breathe it reaches the whole body. Injection does not affect the body so fast” (59 years, urban woman)
Nasal vaccine has a more immediate effect	“Will take it through the nose. It will have an immediate effect” (50 yr, rural woman)
Nasal vaccine is administered through the nose where germs enter	“Nasal [is preferred] because we would have the disease through there…Its effect would be more than injectable” (21 yr, rural man)
Nasal vaccine has desirable side effects indicative of vaccine doing its job	“Nasal administration must cause tingling and stinging….You don't feel anything after taking the injectable vaccine but you can feel the medicine going inside and also the stinging caused when administered through the nose” (47 yr, rural man)
Side effects or safety concerns of alternative
Fear of needles or pain caused by injectable vaccines	“The nasal one is better. With an injection, there is inflammation or pain later” (57 yr, urban man)
Concerns regarding potential re-use of needles in injectable vaccines	“There is a risk associated with the injection because an already used syringe may be used again, unlike in case of a nasal vaccine which I think spreads in the entire body in the vapour form” (65 yr, urban man)

Table 5(A) lists main themes and illustrative quotes distilled from respondent narratives regarding why an injectable vaccine was preferred over a nasal one. Narratives from focus group discussions and open questions in semi-structured interviews were analysed thematically grouped under broad domains of perceived powerfulness (or efficacy), side effects or safety concerns and familiarity, trust. Explanations provided were either perceived advantages of the injectable vaccine or perceived disadvantages of the nasal vaccine. Similarly, in Table 5(B), explanations for preference of the nasal vaccine were due to either perceived benefits of the nasal vaccine or perceived disadvantages of the injectable vaccine.