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Vaccine 30 (2012) 4002– 4006

Contents lists available at SciVerse ScienceDirect

Vaccine

j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / v a c c i n e

orrelates of 2009 H1N1 influenza vaccination among day care-aged children, iami-Dade County

essica Gomez ∗, Fermin Leguen 1, Guoyan Zhang 1, Erin O’Connell 1

iami-Dade County Health Department, 8600 NW 17th Street, Suite 200, Miami, FL 33126 United States

r t i c l e i n f o

rticle history: eceived 5 May 2011 eceived in revised form 8 April 2012 ccepted 10 April 2012 vailable online 25 April 2012

eywords: 009 H1N1 influenza

nfluenza vaccine erception ttitude cceptance hildren

a b s t r a c t

Background: The aim of this study was to assess factors influencing 2009 H1N1 influenza vaccination among a demographically diverse group of day care-aged children. Day care children were chosen because they were an initial target group for vaccination and are at higher risk of influenza infection than children cared for at home. Methods: A cross-sectional study was conducted from March to May 2010 among parents of day care aged children in 13 day care facilities in Miami-Dade County. Data was collected by an anonymous self- administered two-page 20 question survey which consisted of demographic variables and information regarding 2009 H1N1 influenza vaccine knowledge, attitude and acceptance. Data was analyzed using SAS to conduct both bivariate and multivariate analyses. Results: There were 773 participants in the study. The response rate ranged from 42% to 72.2% among day care centers. A total of 172 parents (22.3%) and 225 (29.1%) children had received the 2009 H1N1 influenza vaccine. Non-Hispanic White and Black parents were more likely to vaccinate their children than Hispanic and Haitian parents. Primary reasons for non-vaccination included vaccine safety (36.7%) and side effects (27.1%). Among parents who spoke with a health care professional, 274 (61.4%) stated

the health care professional recommended the vaccine. Conclusion: Misperceptions about influenza vaccination among parents created a barrier to 2009 H1N1 influenza vaccination. Parents who got the vaccine, who believed the vaccine was safe and whose children had a chronic condition were more likely to immunize their children. Clear, reliable and consistent vaccine information to the public and health care providers and initiatives targeting minority groups may increase

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vaccination coverage amo

. Introduction

In July 2009, the Advisory Committee on Immunization Prac- ices (ACIP) identified five initial target groups that should receive he 2009 H1N1 influenza monovalent vaccine [1]. Persons aged

months to 24 years were among these initial target groups. In ontrast to seasonal influenza, 2009 H1N1 influenza infection dis- roportionately affects persons under 24 years of age [2]. During he 2009–2010 influenza season, children less than five years of ge had the highest incidence of hospitalization for 2009 H1N1 nfluenza [1].

On September 15, 2009, the Food and Drug Administration (FDA) pproved the distribution of four 2009 H1N1 influenza monovalent

accines in the United States. The 2009 H1N1 influenza vaccina- ion campaign in Miami-Dade County was led by the Miami-Dade ounty Health Department (MDCHD) and began on October

∗ Corresponding author. Tel.: +1 305 234 5400x2553; fax: +1 305 470 5533. E-mail address: yessica [email protected] (Y. Gomez).

1 Tel.: +1 305 234 5400x2553; fax: +1 305 470 5533.

264-410X/$ – see front matter. Published by Elsevier Ltd. ttp://dx.doi.org/10.1016/j.vaccine.2012.04.037

is population. Published by Elsevier Ltd.

19, 2009 and ended April 2010. The MDCHD serves Miami- Dade County, an area comprised of 35 municipalities in South Florida with a population of 2.4 million, of which 65.1% are His- panic, 15.4% are non-Hispanic White and 19.0% are non-Hispanic Black [3].

Research has shown that vaccination is the most effective method of preventing and reducing 2009 H1N1 influenza mor- bidity, hospitalization, and mortality [1]. However, influenza vaccination coverage among children during the previous influenza season revealed low compliance with ACIP recommendations [4]. Studies have shown parental vaccine knowledge, attitudes, and perceptions are strong predictors of vaccine acceptance [5,6,18,22]. Little is known about the factors influencing parental acceptance of a new influenza vaccine.

The aim of this study was to assess factors influencing 2009 H1N1 influenza vaccination among a demographically diverse group of day care-aged children. Day care children were chosen

because they were an initial target group for vaccination and are at higher risk of influenza infection than children cared for at home [1]. During the 2009–2010 influenza season, Miami-Dade County children under five years of age were more than twice as likely to

ine 30 (2012) 4002– 4006 4003

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Table 1 Demographic characteristics of 773 Survey Respondents, Miami-Dade County, 2010.

Characteristic N (%)

Marital status Divorced/separated 77 10.0 Married 481 62.5 Single 206 26.8 Widowed 5 0.7

Gender of parent/guardian Female 612 80.0 Male 153 20.0

Age group of child/children (years) 6 months-2 361 34.2 3–5 585 55.4 ≥6 110 10.4 Sex of child/children Female 475 45.0 Male 581 55.0

Race/ethnicity White, non-Hispanic 118 15.3 Black, non-Hispanic 82 10.6 Hispanic 490 63.4 Haitian 76 9.8 Other/unk 7 0.9

Level of education Less than high school 65 8.4 High school or equivalent 155 20.1 Some college, vocational 313 40.6 Graduate degree 238 30.9

Geographic region Northeast 221 28.6 Northwest 203 26.3 Kendall 188 24.3

Y. Gomez et al. / Vacc

e hospitalized for 2009 H1N1 influenza than persons in other age roups [7].

. Material and methods

.1. Study design

This cross-sectional study was carried out in 13-day care facili- ies in Miami-Dade County. The facilities were located in the north, outh, east, and western regions of the county. The sample was hosen from 250 large capacity day care centers (at least 100 chil- ren enrolled) out of 1434-day care centers that are registered with he Florida Department of Children and Families in Miami-Dade ounty. A stratified random sampling method was used to select 12 eographically representative facilities in the county. One-day care enter that consisted mainly of Haitian children was conveniently hosen to ensure that the sample was reflective of the main eth- ic groups residing in Miami-Dade. All 13 day care centers agreed o voluntarily participate in the study. The target population for articipation was parents of children aged 6 months-5 years.

At least one MDCHD representative visited each day care center o distribute the surveys. All surveys included a cover letter which xplained the aim of the study, the use of the data, confidentiality ssues, and the option of declining participation. Participants were nstructed to either complete the survey on site while the MDCHD epresentative was there or to take the survey and return it to the ay care administrator. Participants also had the option of faxing it irectly to the MDCHD.

.2. Questionnaire

Data was collected by an anonymous self-administered 2-page urvey. The survey was available in English, Spanish, and Creole. ll surveys were distributed, completed, and returned between arch and May 2010. The questionnaire consisted of 20 questions

egarding sex, age, race/ethnicity, level of education, knowledge f influenza, perception of risk in their community, vaccine safety oncerns, whether parents and children received the 2009 H1N1 nfluenza vaccine and reasons for refusing the vaccine. Respon- ents were also asked if they spoke with a health care professional bout getting the vaccine and whether the health care professional ecommended the vaccine. Since some parents filled out the same uestionnaire for more than one child, each questionnaire was con- idered a family unit for analysis purposes, i.e., each family only lled one questionnaire.

.3. Statistical analysis

Data was entered in Epi-Info version 3.5.1 and analyzed using AS version 9.13 (SAS institute Inc., Cary, North Carolina, USA). escriptive analysis was completed for all survey questions. The ain outcome variable was 2009 H1N1 influenza vaccination status

vaccinated vs. not vaccinated). Bivariate analysis was performed o examine the association between parents’ demographic charac- eristics, knowledge of 2009 H1N1 influenza, perception of vaccine afety and vaccination status. All variables that were significantly ssociated with vaccination status at the univariate level were ncluded in a multivariable logistic regression model to estimate djusted odds ratios and 95% confidence intervals. A p-value of less han 0.05 was considered statistically significant.

. Results

.1. Characteristics of respondents

There were 1283 parents that met the target population cri- eria for this study. Of the 1283 parents eligible to participate,

Far South 161 20.8

seven hundred and seventy three (60.2%) fully completed the ques- tionnaire. The response rate ranged from 42% to 72.2% among day care centers. The demographic characteristics of respon- dents are summarized in Table 1. Among respondents, 80% were females and 20% were males. The majority of the par- ticipants were married (62.5%) and Hispanic (63.4%). Most of the children enrolled in the study belonged to the 3–5-year- old age group (55.4%). 55% of children were male and 45% were female.

3.2. Immunization rate and intent to immunize

A total of 172 parents (22.3%) and 225 (29.1%) children had received the 2009 H1N1 influenza vaccine at the time of the sur- vey. 45% of those vaccinated received the vaccine at their private doctor’s office and 19.4% received the vaccine at their local health department clinic.

When respondents who had not vaccinated their child were asked “Will you try to get the vaccine for your child in the next few months?”, 15% of respondents stated they were planning to immu- nize their child, 60% were not planning to immunize their child, 24% responded “do not know/unsure” and 1.3% did not respond. Respondents who were not planning to vaccinate their child cited concerns about vaccine safety (36.7%) and side effects (27.1%) as the main reasons for non-vaccination.

3.3. Attitude and perception

The majority of parents felt that 2009 H1N1 influenza vaccine was either a big problem (24.9%) or a medium problem (25.8%) in their community. Although vaccination was higher among

4004 Y. Gomez et al. / Vaccine 30 (2012) 4002– 4006

Table 2 Influenza A (H1N1) 2009 vaccination coverage among day care-aged children by selected characteristics, Miami-Dade County, 2010 (n = 773).

Characteristic N % % Vaccinated % Non-vaccinated p value

Race/ethnicity 0.00 White, non-Hispanic 118 (15.4) 39.8 60.2 Black, non-Hispanic 82 (10.6) 40.2 59.8 Hispanic 490 (63.9) 25.9 74.1 Haitian 76 (10.1) 22.4 77.6

Level of education 0.13 Less than high school 65 (8.4) 38.5 61.5 High school or equivalent 155 (20.1) 33.6 66.4 Some college, vocational 313 (40.6) 26.5 73.5 Graduate degree 238 (30.9) 27.3 72.7

Geographic region 0.00 Far South 161 (20.8) 36.0 64.0 Northeast 221 (28.6) 35.3 64.7 Northwest 203 (26.3) 20.7 79.3 Kendall 188 (24.3) 25.0 75.0

Knowledge of 2009 influenza A (H1N1) 0.55 Yes 748 (97.4) 28.9 71.1 No 20 (2.6) 35.0 65.0

Perception of problem in the community 0.00 Big problem 192 (24.9) 40.1 59.9 Medium problem 199 (25.8) 28.1 71.9 Small problem 173 (22.4) 23.1 76.9 Not a problem 99 (12.8) 23.2 76.8 Do not know/unsure 109 (14.1) 26.6 73.4

Think vaccine is safe 0.00 Yes 227 (29.9) 68.7 31.3 No 276 (36.3) 3.6 96.4 Do not know/unsure 257 (33.8) 21.0 79.0

Parent got H1N1 vaccine 0.00 Yes 172 (22.3) 77.9 22.1 No 601 (77.7) 15.1 84.9

Doctor recommended vaccine 0.00 Yes 274 (61.4) 59.1 40.9 No 172 (38.6) 5.8 94.2

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Presence of chronic illness Yes 99 (13.1) No 655 (86.9)

on-Hispanic Whites, other ethnic groups that included Blacks, aitians, and Hispanics were more than three times likely to per- eive 2009 H1N1 influenza to be a big problem in their community. lack and Haitian parents were also more likely than non-Hispanic hite parents to respond feeling unsure as to whether 2009 H1N1

nfluenza was a problem in their community. Haitians were more han twice as likely as non-Hispanic Whites to feel unsure as to hether or not they would recommend the vaccine to a friend or

elative. When asked about the safety of the 2009 H1N1 influenza vac-

ine, 29% of respondents felt it was safe, 36% felt it was not safe, nd 35% did not know or were unsure. Hispanic and Haitian par- nts were less likely than non-Hispanic White parents to think the accine was safe. Of the 773 respondents, four hundred and seventy ine (62.0%) had spoken with a health care provider about the vac- ine. Among ethnic groups, Hispanics and Haitians were less likely OR = 0.53, CI: 0.33–0.86 and OR = 0.32, CI: 0.17–0.62) than non- ispanic Whites to have spoken to a health professional about the accine. Among parents who spoke with a health care professional, 74 (61.4%) stated the health care professional recommended the accine, while 38.6% stated they had not.

Among the parents who felt the 2009 H1N1 influenza vaccine as unsafe, the most cited reasons for vaccine safety concerns were

ack of sufficient information on the vaccine (33.7%) and beliefs that he vaccine had not been properly tested (24.9%). Other reasons ited were that they had heard the vaccine was unsafe and that the accine causes illness.

0.00 40.4 59.6 27.3 72.7

3.4. Factors associated with immunization

Several variables were associated in bivariate analyses with 2009 H1N1 influenza immunization as presented in Table 2. Non- Hispanic White and Black parents were more likely to vaccinate their children than Hispanic and Haitian parents. Parents who per- ceived 2009 H1N1 influenza as a big problem, that believed the vaccine was safe, whose doctor recommended the vaccine, who got the 2009 H1N1 influenza vaccine and whose children had a chronic condition were more likely to immunize their children.

When factors associated with 2009 H1N1 influenza at the bivari- ate level were entered into a multivariate analysis, only three factors were significantly associated with immunization. As shown in Table 3, parents who got H1N1 vaccine, who felt the vaccine was safe and whose child had a chronic condition were more likely to vaccinate their children.

4. Discussion

Despite the importance of 2009 H1N1 influenza immunization coverage among children, less than a third of the children in our study population received the vaccine at the time the study was conducted. Our results were consistent with Florida state esti-

mates published by the Centers for Disease Control and Prevention (CDC), which estimated 32.3% immunization coverage in children [8]. Vaccination rates among parents were lower than among their children. Children with chronic conditions were more likely to be

Y. Gomez et al. / Vaccine 30 (2012) 4002– 4006 4005

Table 3 Multivariate Analyses of factors associated with Influenza A (H1N1) non-vaccination among day care-aged children by selected characteristics, Miami-Dade County, 2010 (n = 773).

Odds ratio (95% CI)

Characteristic % Non-vaccinated Crude Adjusted p value*

Race/ethnicity White, non-Hispanic 60.2 1 1 Black, non-Hispanic 59.8 0.98 (0.55–1.75) 0.95 (0.38–2.40) 0.91 Hispanic 74.1 1.89 (1.24–2.88) 1.33 (0.69–2.56) 0.38 Haitian 77.6 2.30 (1.20–4.42) 1.82 (0.67–4.97) 0.24

Level of education Less than high school 61.5 1 1 High school or equivalent 66.4 1.23 (0.68–2.26) 0.85 (0.37–1.98) 0.71 Some college, vocational 73.5 1.73 (0.99–3.03) 1.58 (0.71–3.56) 0.27 Graduate degree 72.7 1.66(0.94–3.00) 1.92 (0.81–4.56) 0.14

Perception of problem in the community Big problem 59.9 1 1 Medium problem 71.9 1.71 (1.12–2.61) 1.54 (0.81–2.93) 0.19 Small problem 76.9 2.23 (1.41–3.51) 1.89 (0.99–3.64) 0.06 Not a problem 76.8 2.21 (1.28–3.83) 1.17 (0.52–2.62) 0.70 Do not know/unsure 73.4 1.85 (1.11–3.09) 0.82 (0.40–1.65) 0.57

Think vaccine is safe Yes 31.3 1 1 No 96.4 58.45 (29.29–116.63) 30.05 (14.01–64.47) <0.0001 Do not know/unsure 79.0 8.26 (5.48–12.46) 4.65 (2.85–7.60) <0.0001

Geographic region Far South 64.0 1 1 Northeast 64.7 1.03 (0.68–1.58) 1.02 (0.50–2.07) 0.66 Northwest 79.3 2.16 (1.35–3.45) 0.86 (0.44–1.68) 0.96 Kendall 75.0 1.69 (1.07–2.68) 1.33 (0.63–2.78) 0.46

Parent got H1N1 vaccine Yes 22.1 1 1 No 84.9 19.76 (12.94–30.19) 9.30 (5.54–15.63) <0.0001

Presence of chronic illness Yes 59.6 1 1

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* Adjusted odds ratio

accinated. This finding was not surprising given a national poll onducted at the beginning of the 2009 H1N1 influenza vaccination eriod, which found that parents of children with high-risk condi- ions were more likely to plan to get their children vaccinated for 009 H1N1 influenza [9].

Among children that had not received the vaccine, only 15% f parents intended to vaccinate their child within the next few onths. The main barriers to vaccination in our study were con-

erns about vaccine safety and side effects. Many parents felt that he vaccine had not been properly tested and not enough infor-

ation was available to ensure its safety. Similar findings were ound in several studies conducted during and after the 2009 1N1 influenza vaccination period, where parents cited reserva-

ions about safety and concerns about side effects as barriers to accination [7,10,22].

In addition to safety concerns, many parents did not have a pos- tive attitude about the vaccine. While more than half of parents cknowledged that 2009 H1N1 influenza was a problem in their ommunity, only 22% of them stated it was very likely that they ould recommend the vaccine to a friend or relative. Many par-

nts recognized 2009 H1N1 influenza as a serious problem in their ommunity prior to vaccine availability, but it seems that once he vaccine became available, concerns about safety and reliable nformation deterred them from vaccinating their children.

Hispanics and Haitian children in our study had lower vac-

ination rates than non-Hispanic White children, which is not urprising given the low vaccination rates for seasonal influenza mong minority groups [12,13,15]. However, a national poll before he vaccination campaign commenced found that more Hispanic

1.80 (1.17–2.79) 2.24 (1.20–4.20) 0.01

parents than non-Hispanic White and Black parents were plan- ning to vaccinate their children against 2009 H1N1 influenza [14]. Despite encouraging numbers, our results were consistent with low 2009 H1N1 Influenza vaccination rates across minority groups dur- ing the 2009–2010 influenza season [16]. A study of 2009 H1N1 influenza vaccination acceptance in Georgia also found low vacci- nation acceptance among minority groups [26].

Haitian parents were more likely to feel unsure about whether or not 2009 H1N1 influenza was a problem in the community and whether or not they would recommend the vaccine to a relative or friend. This carries important implications given that a study during the 2009 H1N1 influenza pandemic found that over a third of respondents had discussed the vaccine with family and friends [7]. Furthermore, Hispanics and Haitian parents were less likely than non-Hispanic Whites to think the vaccine was safe. This find- ing is consistent with a study conducted in Latin America and the Caribbean (home to many Hispanics and Haitians), which found that safety concerns and misinformation about the vaccine was a key challenge in 2009 H1N1 influenza vaccination [25]. A poll conducted in California also found that minority groups, particu- larly Blacks and Latinos were more likely to doubt the safety of the vaccine and dismiss 2009 H1N1 influenza immunization [11].

Numerous studies have shown that physician recommendation is a significant predictor of vaccination [17,20,21]. Over half of the parents in our study had spoken with a heath care provider about

getting the vaccine for their children. However, 40% of those who spoke with a health care professional stated that the health care professional did not recommend the vaccine. Many health care providers during the 2009–2010 influenza season were reluctant to

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ecommend a new vaccine to their patients. Physicians were also eluctant to get the vaccine for themselves [19,22–24]. Misinfor- ation and misperceptions about the 2009 H1N1 vaccine among

ealth care providers created a vaccination barrier among them- elves and their patients [9,19]. Additionally, lack of access to health are among minorities may have prevented them from seeking hysician advice [13]. In our study, Hispanics and Haitian parents ere less likely than White parents to have spoken to a health rofessional about the vaccine. This may be associated with dispar-

ties in access to health care among racial/ethnic groups. According o the 2010 Miami-Dade Community Health Report Card, non- ispanic Whites had greater access to health insurance and source f health care than Hispanics and non-Hispanic Blacks [27].

This study was not without limitations. First, the results are nly representative of Miami-Dade County and not generalizable to ther counties or the state of Florida. Second, face-to-face encoun- ers with parents may have potentially created interview/social esirability bias. Third, low response rates among some day ares may have impacted our findings. Lastly, other factors such s insurance coverage, income and seasonal influenza vaccina- ion coverage, which may have been associated with 2009 H1N1 nfluenza vaccination were not included in this study.

. Conclusion

Results from this study suggest a need for increased dissem- nation of influenza vaccine safety information to the public.

isperceptions about influenza vaccination among parents created barrier to 2009 H1N1 influenza vaccination. Future vaccination fforts, particularly for novel influenza viruses, should focus on roviding the public with sufficient, reliable, and clear informa- ion on the benefits and risks of vaccination. Since health care roviders play a key role in childhood vaccinations, enhanced com- unications and consistent dissemination of vaccine information

o health care providers may increase influenza vaccination cov- rage in the upcoming influenza seasons. Lastly, efforts targeting inority groups may increase vaccination coverage among this

opulation and contribute to a decrease of influenza transmission n the community.

cknowledgment

We thank Pamela Leone, Pamela Mann and Travis Murphy for heir assistance in the development and administration of the sur- ey used in this study.

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