Seasonal and 2009 H1N1 influenza vaccine uptake, predictors of vaccination, and self-reported barriers to vaccination among secondary school teachers and staff

Abstract

Objective: Teachers, like healthcare workers, may be a strategic target for influenza immunization programs. Influenza vaccination is critical to protect both teachers and the students they come into contact with. This study assessed factors associated with seasonal and H1N1 influenza vaccine uptake among middle- and high-school teachers. Methods: Participants were recruited from two counties in rural Georgia. Data were collected from surveys in September 2009 and May 2010. Multivariate logistic regression was used to assess the association between teachers’ attitudes toward seasonal and H1N1 influenza vaccination and vaccine uptake. Results: Seventy-eight percent of teachers who planned to receive seasonal influenza vaccine and 36% of those who planned to receive H1N1 influenza vaccine at baseline reported that they did so. Seasonal vaccine uptake was significantly associated with perceived severity (odds ratio [OR] 1.57, P=0.05) and self-efficacy (OR 4.46, P=0.006). H1N1 vaccine uptake was associated with perceived barriers (OR 0.7, P=0.014) and social norms (OR 1.39, P=0.05). The number one reason for both seasonal and H1N1 influenza vaccine uptake was to avoid getting seasonal/H1N1 influenza disease. The number one reason for seasonal influenza vaccine refusal was a concern it would make them sick and for H1N1 influenza vaccine refusal was concern about vaccine side effects. Conclusions: There is a strong association between the intention to be vaccinated against influenza (seasonal or 2009 H1N1) and actual vaccination uptake. Understanding and addressing factors associated with teachers’ influenza vaccine uptake may enhance future influenza immunization efforts.

Introduction

In the US, both seasonal and 2009 H1N1 influenza vaccination coverage are low. On average, 36,000 people a year die of influenza disease.1 Even though school children have not been considered at high risk of influenza mortality, annual morbidity is still high, with illness attack rates in school children exceeding 10% in most years.2 In February 2010, the Centers for Disease Control and Prevention's (CDC) Advisory Committee on Immunization Practices (ACIP) recommended universal annual influenza vaccination to continue to expand protection against influenza to more people and to decrease transmission.3 Despite well-documented evidence regarding effectiveness and safety, uptake of seasonal influenza vaccine among adults in the US falls far short of targeted rates. During the 2009–2010 influenza season, only 28% of non-high risk adults received the seasonal influenza vaccine.4

On June 11, 2009, the World Health Organization declared the outbreak of a novel influenza A (H1N1) a pandemic.5 In the US 2009 H1N1-related mortality disproportionately affected children (0–17 years), who accounted for approximately 1,270 deaths and approximately 86,000 hospitalizations.6 Similar to seasonal influenza, school-aged children also played a key role in 2009 H1N1 influenza virus transmission.7 Approximately 55 million students and 7 million staff attend more than 130,000 public and private schools in the US. Schools therefore have the potential to become explosive, centrifugal outbreak centers due to their large population, high levels of close social contact and permeable boundaries. Vaccination of these groups could help protect one-fifth of the country's population from influenza.8 However, as with seasonal influenza, 2009 H1N1 influenza vaccination coverage was low. A recent study stated that only 37% of children aged 6 months to 17 years and 34% of adults ages 19–64 years reported receiving the 2009 H1N1 influenza vaccine.9

Attitudes concerning influenza vaccine likely play a role in vaccine acceptance and uptake. One recent study assessing whether adults who intended to get a seasonal influenza vaccine actually got one reported that perceived lack of need, lack of belief in influenza vaccine, and “not getting around to it”, were reasons for non-uptake of seasonal influenza vaccine.10 Several studies have looked at the predictors of seasonal influenza vaccination among healthcare workers. These studies may be particularly relevant because teachers, like healthcare workers, work in an environment conducive to disease spread, placing them at high risk for infection and subsequent spread to others. In these studies, the most common reasons for intent to receive seasonal influenza vaccine include protection of self, protection of family and protection of patients.11–13 Similar to healthcare workers, teachers may also have a vested interest in protecting their contacts, family, friends and/or students against influenza.

Uptake of 2009 H1N1 influenza vaccine was lower than reported estimates of intent to receive the vaccine, which were approximately 50%, with some studies showing acceptance as high as 65%.14–17 Several studies have assessed attitudes predicting intent to receive a 2009 H1N1 influenza vaccine among adults. These studies found that perceived risk, perceived safety and receipt of previous seasonal influenza vaccine were all predictors of 2009 H1N1 influenza vaccine acceptance.15,18,19 Similar to seasonal influenza vaccine, studies assessing 2009 H1N1 influenza vaccine acceptance among healthcare workers have found significant associations with a desire to protect contacts and receipt of seasonal influenza vaccine. Concerns with safety and efficacy were also factors in acceptance of 2009 H1N1 influenza vaccine among healthcare workers.20–22

Limited data are available for adults, including healthcare workers, on correlates for intent to receive an influenza (seasonal or 2009 H1N1) vaccine. No study, to date, has assessed influenza vaccine (seasonal or 2009 H1N1) uptake among teachers and staff, despite the fact that they have the potential to be a target group for immunization programs against influenza infection.

The purpose of this study was to investigate factors associated with seasonal and 2009 H1N1 influenza vaccine uptake among middle- and high-school teachers in a rural, low-income setting during the 2009–2010 influenza season. Specifically, this study assessed: (1) the association between baseline intention to receive a seasonal or 2009 H1N1 influenza vaccine with self-reported vaccine uptake; (2) correlates of seasonal and 2009 H1N1 vaccine uptake; and (3) reasons for vaccination or non-vaccination against seasonal and 2009 H1N1 influenza.

Results

Response rates and participant characteristics.

The follow-up survey was completed by 66 out of 161 school staff members (41%). Of the 66 follow-up participants, 57 (86%) also completed a baseline survey. Follow-up respondents ranged in age from 24–68 years, with a mean age of 46.1 years (SD = 11.7). The majority of participants were female (n = 50, 76%) and white (n = 51, 77%). Minority participants identified as black (n = 12, 18%), Hispanic (n = 2, 3%) and other (n = 1, 2%). Minority categories were combined for analyses. Most participants were teachers (n = 58, 88%). Other participants included administrative staff, counselors and media specialists.

Baseline vaccination intention and uptake.

Of the 57 participants who completed both baseline and follow-up surveys, 37 (65%) planned to get a seasonal influenza vaccination at baseline. Of the 37 participants who planned to get a seasonal influenza vaccination, 29 (78%) reported receiving an influenza vaccination at follow-up (Chi-square = 12.8, p < 0.001). Twenty-eight participants planned to get a 2009 H1N1 influenza vaccination at baseline, if it was available. Of those, 10 (36%) reported receiving a 2009 H1N1 influenza vaccination at follow-up (Chi-square = 6.5, p = 0.012).

Correlates of seasonal influenza vaccination.

The items comprising each psychosocial measure, scale ranges and Cronbach's alphas are detailed in Table 1. Correlates of seasonal influenza vaccination among teachers and staff members are presented in Table 2. Forty-one (62%) participants reported receiving a seasonal influenza vaccination in the past year. In bivariate analyses, correlates of seasonal influenza vaccine uptake included: perceived severity of seasonal influenza, perceived benefits of seasonal influenza vaccination, perceived barriers to seasonal influenza vaccination, self-efficacy for seasonal influenza vaccination and social norms regarding seasonal influenza vaccination. Demographic variables and perceived susceptibility to seasonal influenza were not significant, and were therefore excluded from multivariate analyses. In multivariate analyses, only two variables remained significantly associated with receipt of a seasonal influenza vaccination. Participants with higher perceived severity of seasonal influenza and increased self-efficacy for seasonal influenza vaccination demonstrated increased odds of receiving a seasonal influenza vaccination (OR = 1.57, p = 0.05 and OR = 4.47, p = 0.006, respectively).

Correlates of 2009 H1N1 influenza vaccination.

Correlates of 2009 H1N1 influenza vaccination among teachers and staff members are also presented in Table 2. Only 14 (21%) participants reported receiving a 2009 H1N1 influenza vaccination in the past year. In bivariate analyses, correlates of H1N1 influenza vaccine uptake included: perceived severity of 2009 H1N1 influenza, perceived benefits of 2009 H1N1 influenza vaccination, perceived barriers to 2009 H1N1 influenza vaccination, self-efficacy for 2009 H1N1 influenza vaccination and social norms regarding 2009 H1N1 influenza vaccination. Demographic variables and perceived susceptibility to 2009 H1N1 influenza were not significant, and were therefore excluded from multivariate analyses. In multivariate analyses, only two variables remained significantly associated with receipt of a 2009 H1N1 influenza vaccination. Participants with more perceived barriers to 2009 H1N1 influenza vaccination demonstrated a decrease in the odds of getting a 2009 H1N1 influenza vaccination (OR = 0.70, p = 0.014), while participants with more positive social norms regarding 2009 H1N1 influenza vaccination demonstrated an increase in the odds of receiving a 2009 H1N1 influenza vaccination (OR = 1.39, p = 0.05).

Reasons for vaccination and non-vaccination against seasonal influenza.

Reasons for vaccination and non-vaccination against seasonal influenza and H1N1 influenza vaccination are presented in Table 3. Among participants who received a seasonal influenza vaccination (n = 41), the most commonly reported reasons were: (1) wanting to avoid getting seasonal influenza (93%), (2) knowing someone who got sick from seasonal influenza (81%) and (3) hearing about seasonal influenza on the news (78%). Among participants who did not receive a seasonal influenza vaccination (n = 25), the most commonly reported reasons were: (1) concern the seasonal influenza vaccine would make them sick (64%), (2) the belief that they did not need the seasonal influenza vaccine (56%) and (3) concern about side effects from the seasonal influenza vaccine (52%).

Reasons for vaccination and non-vaccination against H1N1 influenza.

Reasons for vaccination and non-vaccination against seasonal influenza and 2009 H1N1 influenza vaccination are also presented in Table 3. Among participants who received a 2009 H1N1 influenza vaccination (n = 14), the most commonly reported reasons were: (1) wanting to avoid getting H1N1 influenza (100%), (2) to protect other family members against H1N1 influenza (93%) and (3) hearing about 2009 H1N1 influenza on the news (93%). Among participants who did not receive a 2009 H1N1 influenza vaccination (n = 52), the most commonly reported reasons were: (1) concern about side effects from the 2009 H1N1 influenza vaccine (58%), (2) concern the seasonal influenza vaccine would make them sick (58%) and (3) did not want a new vaccine (52%).

Discussion

The objectives of this study were to (1) compare intention to receive influenza (seasonal or 2009 H1N1) vaccine with self-reported receipt, (2) assess correlates of seasonal and H1N1 influenza vaccine uptake and (3) examine reasons for vaccination or non-vaccination against seasonal and H1N1 influenza. Among all participants, 62% reported receiving a seasonal influenza vaccine and 21% reported receiving a 2009 H1N1 influenza vaccine. This study contributes to the literature by examining intent to receive an influenza vaccine and subsequent vaccine uptake as well as factors associated with vaccination. Among participants who completed both baseline and follow-up surveys, 78% of teachers who intended to get a seasonal influenza vaccine received one, while 36% of teachers who intended to get the 2009 H1N1 influenza vaccine received one. These data demonstrate a strong association between the intention to be vaccinated against influenza (seasonal or 2009 H1N1) and actual vaccination uptake. This finding may lead to further studies on interventions that target adults who have expressed intent to receive vaccination but may be at risk for not following through. This is also the first study focusing on middle- and high-school teachers and staff, a potentially important population for vaccination education, as vaccinating this population against influenza is critical to protecting not only themselves but also adolescents they come into contact with in the classroom.

Teachers and school staff, like healthcare workers, play a vital role in the community. Also, similar to healthcare workers, working in an environment conducive to disease spread places teachers at risk for infection and subsequent transmission to others. Seasonal influenza vaccination coverage among healthcare workers historically has been below 50%, with vaccination coverage for 2009 H1N1 influenza being even lower at 22%.30 This study showed that influenza vaccine (seasonal or 2009 H1N1) uptake among teachers is similar to that of healthcare workers.

We found that perceived severity and self-efficacy for vaccination were significant predictors of seasonal influenza vaccination. The acceptance of and adherence to public health measures by the population depends largely on the way people perceive a threat.31 While our study assessed vaccine uptake, this result is similar to studies of intent to receive a seasonal influenza vaccine among healthcare workers which also found that lack of perceived personal need or a belief of not being at risk were factors in not accepting seasonal influenza vaccine.11–13 The lack of perceived severity may be overcome through educational campaigns emphasizing how teachers themselves are a potential source of infections for their students. Campaigns should also have a convincing message about other purposes of influenza vaccine, such as stopping transmission and protection of others through herd immunity.

In multivariate analyses, correlates of 2009 H1N1 influenza vaccine uptake were perceived barriers and social norms regarding vaccination. Perceived barriers included believing that the vaccine would make participants sick and that the vaccine does not prevent influenza. These are similar barriers expressed by healthcare workers regarding whether they will accept a 2009 H1N1 influenza vaccine.20,21 For all of these factors, ongoing education about the importance of infection control, especially when anxiety rates and risk perceptions maybe low, and education on effectiveness of influenza vaccine may improve actual vaccine uptake, not just intention or acceptance of vaccine. Social norms, a measurement of the participant's belief that their medical provider, family and others would approve of their receiving the 2009 H1N1 vaccine, was also significantly associated with vaccine receipt. These findings are consistent with other studies demonstrating that social norms predict both intention to be vaccinated and vaccination.32–35 The importance of the normative beliefs in our study population suggests that campaigns for influenza vaccination may be most successful if they include information about endorsement of influenza vaccination by physicians and trusted individuals and focus on vaccination as a social norm. Interestingly, perceived susceptibility was not a significant predictor of uptake for either seasonal or 2009 H1N1 influenza vaccine, despite the fact that teachers and staff come into close contact with adolescents, who are major transmitters of influenza.

Reasons for vaccination or non-vaccination were similar for both seasonal and 2009 H1N1 influenza. The most important reason for acceptance of both vaccines was desire to avoid getting sick with seasonal or 2009 H1N1 influenza viruses. Hearing about seasonal or 2009 H1N1 influenza on the news was also an important reason for vaccine acceptance, highlighting the importance of public health communications as the media has undoubtedly played a key role in public perceptions of the vaccine and disease severity, and should be engaged from the earliest stage as informed advocates of vaccination. Reasons for non-vaccination against seasonal influenza included safety concerns, but also feeling that the vaccine was not needed. Similarly, the top reasons for non-vaccination against 2009 H1N1 influenza vaccine revolved around feelings of apprehension around safety and not wanting a new vaccine. This is consistent with other studies of acceptance of 2009 H1N1 influenza vaccine.15,18,19 This finding suggests that the public has to be convinced about vaccine safety and efficacy of the vaccine, and that many have a lack of understanding about the process of developing influenza vaccine. Public acceptance of new vaccines is a crucial factor in controlling diseases. To increase vaccination rates of existing vaccines and facilitate acceptance of new vaccines, such as the 2009 H1N1 influenza vaccine this past year, it is important to understand the motivators for and barriers to vaccination. The findings in this report are subject to several limitations. First, the survey sample size was small and reduced the power of our analysis and the precision of our effect estimates. Second, the response rate was relatively low, indicating the possibility of response bias among teachers who were more interested in influenza vaccination. The results are representative only of the populations of two small counties in rural Georgia. Those who participated in the follow-up study may differ from those who did not participate; however, there were no baseline characteristics that differed in the two groups. We did not assess health insurance status among the participants, which could be a potential confounding factor.

Methods

Participants.

Participants were recruited from middle- and high-schools in two rural counties participating in an ongoing school-based seasonal influenza vaccination intervention aimed at students. Data were collected from surveys distributed to middle- and high-school teachers and staff members at pre- and post-intervention time points. All teachers and staff members were asked to participate in the survey. Both counties comprised rural, high minority, low-income populations. Data from the 2008–2009 academic year indicated that students in participating counties ranged from 38% African-American in one county to 95% African-American in the second county. Eligibility for free or reduced-cost meals ranged from 61% in one county to 88% in the other. Eligibility criteria for participation for the current study included: (1) being a teacher or staff member in a participating middle- or high-school; and (2) providing written informed consent to participate in the study. All procedures were approved by the Institutional Review Board of Emory University.

Procedures.

At baseline, packets containing consent forms and survey instruments were distributed on September 11, 2009, prior to implementing the intervention to increase vaccination against seasonal influenza among students. At that time, the 2009 H1N1 influenza vaccine was in production but had not yet been approved for release by the Food and Drug Administration. At follow up, packets were delivered and returned in May 2010, before the end of the school year. Packets were similar at both time points. The first page of the packet contained an informed consent form, which was separated upon receipt of the completed survey and stored separately from completed questionnaires. The survey instrument was a self-administered, paper-and-pencil questionnaire, distributed to participants via school mailboxes. Participants were not required to complete the baseline survey in order to complete the follow-up survey. At both time points, participants received a $30 gift card as compensation for their time.

Instrument.

The survey instrument was designed to assess demographic, behavioral and psychosocial factors associated with seasonal and 2009 H1N1 influenza vaccinations. Psychosocial survey items were guided by the Health Belief Model (HBM)24 and the Integrated Behavioral Model (IBM).25 Questions were adapted from existing surveys assessing related concepts because previous questionnaires did not assess attitudes and beliefs toward 2009 H1N1 influenza.26–29

Measures.

Vaccination uptake. Influenza vaccination was assessed by asking the following questions: “Did you receive the seasonal flu vaccine this fall or winter?” and “Did you receive the H1N1 flu vaccine this fall or winter?”

Baseline vaccination intention. In the baseline survey, vaccination intention was assessed by asking: “Do you plan to get the regular seasonal flu vaccine this fall or winter?” and “Do you plan to get a swine flu vaccine this fall or winter, if it is available?”

Demographic variables. Participants reported their age, race, gender, grade taught/primary job at the school, and seasonal influenza immunization history.

Psychosocial variables. Six psychosocial variables were assessed to determine participants' attitudes and beliefs regarding seasonal and H1N1 influenza vaccinations. The items comprising each psychosocial measure, scale ranges and Cronbach's alphas are detailed in Table 1. All psychosocial constructs were measured by questions based on five-point Likert scales ranging from 1 (strongly disagree) to 5 (strongly agree). The range for each construct represents the addition of the responses to each item within that measure. For example, “perceived benefits” includes three questions, meaning responses could range from 3 (an answer of 1 to each question) to 15 (an answer of 5 to each question).

Psychosocial measures guided by the HBM included: (1) perceived severity of seasonal/H1N1 influenza infection, (2) perceived susceptibility to seasonal/H1N1 influenza infection, (3) perceived benefits of seasonal/H1N1 influenza vaccination, (4) perceived barriers to seasonal/H1N1 influenza vaccination and (5) perceived self-efficacy to get vaccinated against seasonal/H1N1 influenza. An additional variable, social norms, was guided by the IBM.

Reasons for vaccine acceptance or refusal. Participants who reported receipt of a seasonal/H1N1 influenza vaccination were provided with a list of potential reasons for vaccination. Participants were asked to identify whether each reason was a factor (y/n) in determining why they got the vaccine. Participants who did not receive a seasonal/H1N1 influenza vaccination were provided with a list of potential reasons for non-vaccination. Participants were asked to identify whether each reason was a factor (y/n) in determining why they did not get vaccinated. Response options were not mutually exclusive. All assessed reasons for vaccination and non-vaccination are listed in Table 3.

Data analysis.

Data management and analysis was conducted using SPSS/PASW Statistics version 17. First, questions assessing psychosocial constructs were combined into scales, and Cronbach's alphas were calculated for each scale to assess internal consistency (Table 1). Univariate descriptive analyses were performed to assess demographic, behavioral and psychosocial variables relating to seasonal and H1N1 influenza vaccinations. Next, among participants who completed both baseline and follow-up surveys, chi-square analyses were conducted to assess the association between baseline intention to receive a seasonal/H1N1 influenza vaccination and self-reported vaccination uptake at follow-up. Among teachers and staff members who completed the follow-up survey, bivariate analyses were conducted to assess demographic and psychosocial correlates of seasonal and H1N1 influenza vaccine uptake. Variables that were significant at the p = 0.10 level in bivariate analyses were then entered into multivariate logistic regression analyses to assess correlates of seasonal and H1N1 influenza vaccine uptake, controlling for potential confounding variables. Finally, frequency analysis was conducted to assess reasons for vaccination (among participants who reported receiving a seasonal/H1N1 influenza vaccination at follow-up) and non-vaccination (among participants who reported not receiving a seasonal/H1N1 influenza vaccination at follow-up).

Conclusions

Teachers are critical for a functioning school system and, like healthcare workers, may be a strategic target for influenza immunization programs. Teachers have a heightened risk of both contracting and spreading influenza to others, which can place their students and families at risk. Our study is, to our knowledge, the first to assess factors associated with seasonal and 2009 H1N1 influenza vaccination uptake among teachers. Efforts to promote vaccination programs should take into account psychosocial factors, particularly perceived barriers, to the pandemic vaccine. Specifically, influenza vaccination programs which focus on safety, risk and social norms may have more of an impact on vaccine uptake. Data presented in this study may assist in planning educational programs to improve vaccine uptake for seasonal influenza as well as pre-pandemic planning.

Abbreviations

OR	=	odds ratio
CDC	=	Centers for Disease Control and Prevention
ACIP	=	Advisory Committee on Immunization Practices
HBM	=	health belief model
IBM	=	integrated behavioral model

Figures and Tables

Table 1 Survey items and measurement characteristics for psychosocial variables

Variable	Range	Seasonal influenza alpha	2009 H1N1 influenza alpha
Perceived severity	2–10	0.896	0.822
Flu is a serious disease
Flu is a serious disease in adults my age
Perceived susceptibility	2–10	0.832	0.822
I am very likely to get the flu
Compared to my friends, I am more likely to get the flu
Perceived benefits	3–15	0.817	0.717
Flu vaccine will prevent me from getting sick with the flu
If I get the flu vaccine, it will help me protect my friends and family from getting the flu
Flu vaccine will prevent me from missing work because of the flu
Perceived barriers	5–25	0.676	0.779
Flu vaccine will make me sick
Flu vaccine does not prevent the flu
Getting a flu vaccine costs too much money
Getting the flu vaccine is painful or uncomfortable
I would feel sore the day after a flu vaccine
Self-efficacy	1–5	-	-
I feel comfortable getting the flu vaccine
Social norms	5–25	0.691	0.757
Most people important to me think I should get a flu vaccine
My doctor thinks I should get a flu vaccine
My coworkers think I should get a flu vaccine
I know other people my age who got the flu vaccine
Most of my coworkers got the flu vaccine

Table 2 Correlates of seasonal and 2009 H1N1 influenza vaccine uptake among middle- and high-school staff members in rural georgia

	Seasonal influenza vaccination				2009 H1N1 influenza vaccination
Variable	Bivariate/Unadjusted OR (95% CI)	p-value	Multivariate/Adjusted OR (95% CI)	p-value	Bivariate/Unadjusted OR (95% CI)	p-value	Multivariate/Adjusted OR (95% CI)	p-value
Demographic variables
Age	1.03 (0.99, 1.08)	0.141	-		1.00 (0.97, 1.02)	0.747	-
Race
White	-		-				-
Minority	0.44 (0.14, 1.41)	0.166	-		0.53 (0.10, 2.70)	0.443	-
Gender
Male	-		-		-		-
Female	0.46 (0.13, 1.63)	0.229	-		0.51 (0.14, 1.83)	0.300	-
Psychosocial variables
Perceived severity	1.87 (1.25, 2.78)	0.002**	1.57 (1.00, 2.48)	0.050*	2.04 (1.12, 3.69)	0.019*	1.83 (0.91, 3.66)	0.089
Perceived susceptibility	1.15 (0.88, 1.50)	0.300	-		1.36 (0.94, 1.97)	0.108	-
Perceived benefits	1.24 (1.00, 1.54)	0.048*	0.98 (0.72, 1.35)	0.917	1.38 (1.04, 1.85)	0.0277*	0.96 (0.56, 1.63)	0.869
Perceived barriers	0.80 (0.65, 0.98)	0.033*	0.950 (0.71, 1.28)	0.733	0.70 (0.54, 0.90)	0.005**	0.70 (0.52, 0.93)	0.0146*
Self-efficacy	4.59 (2.09, 10.0)	<0.001***	4.46 (1.54, 12.9)	0.006**	2.92 (1.38, 6.19)	0.005**	1.62 (0.44, 5.93)	0.464
Social norms	1.45 (1.13, 1.88)	0.004**	1.38 (0.95, 2.00)	0.087	1.43 (1.12, 1.82)	0.004**	1.39 (1.00, 1.94)	0.050*

* p . 0.05

** p . 0.01

*** p < 0.001.

Table 3 Reasons for acceptance or refusal of seasonal and 2009 H1N1 influenza vaccinations

	Seasonal influenza vaccination N(%)	2009 H1N1 influenza vaccination N (%)
Reasons for acceptance	(n = 41)	(n = 14)
To protect other family members	27 (65.9)	13 (92.9)2
Wanted to avoid getting the seasonal flu/H1N1	38 (92.7)1	14 (100.0)1
Had a good experience with the seasonal flu vaccine in the past	31 (75.6)	9 (64.3)
Know someone who got sick from the seasonal flu/H1N1	33 (80.5)2	4 (28.6)
Heard about it on the news	32 (78.0)3	13 (92.9)3
Recommended by a friend/family member	26 (63.4)	8 (57.1)
Recommended by family doctor	26 (63.4)	10 (71.4)
Family has had good experiences with the seasonal flu vaccine in the past	28 (68.3)	-
Got very sick from seasonal flu in the past	10 (24.4)	-
Reasons for refusal	(n = 25)	(n = 52)
Did not know I was eligible for the seasonal flu/H1N1 vaccine	2 (8.0)	14 (26.9)
Concerned about side effects from the vaccine	13 (52.0)3	30 (57.7)1
Did not need it	14 (56.0)2	13 (25.0)
The vaccine was not available when I went to get it	3 (21.0)	7 (13.5)
Was not recommended to me	5 (20.0)	17 (32.7)
Hard to get the flu vaccine	1 (4.0)	9 (17.3)
Hard to find time to fit it in	7 (28.0)	11 (21.1)
Vaccine costs too much	2 (8.0)	5 (9.6)
Concerned it would make me sick	16 (64.0)1	30 (57.7)2
No appointment times were available	2 (8.0)	1 (1.9)
The seasonal flu/H1N1 vaccine does not prevent the flu	5 (20.0)	12 (23.1)
Allergic to eggs	2 (8.0)	2 (3.8)
Did not want a new vaccine	-	27 (51.9)3

1–3 Superscript numbers indicate the top three reasons for vaccine acceptance or refusal.

Acknowledgements

We thank the superintendents, principals, teachers and staff at our participating counties for their participation and support. We are also grateful to Dr. Ketty M. Gonzalez, District Health Director at the East Central Health District, for her support of the study. This work was supported by the Centers for Disease Control and Prevention [R18 IP000166].