UK pandemic influenza strategy focused on vaccination of high risk groups, although evidence shows that school-age children have the highest infection rates. Vaccination of children might be an additional strategy. We undertook a cross-sectional study amongst 149 parents of primary school children aged 4–7 years in Birmingham, UK to quantify intention to accept pandemic influenza vaccine and identify factors affecting uptake. Ninety-one (61.1%, 95% CI 52.8, 68.9) had or would accept vaccine for their child. The most common reasons for declining vaccine were concerns about safety (58.6% reported this), side effects (55.2%), or believing their child had already had swine flu (12.1%). Parents of nonwhite ethnicity (OR 2.4 (1.1, 5.0)) and with asthmatic children (OR 6.6 (1.4, 32.1)) were significantly more likely to accept pandemic vaccine, as were those whose children had ever received seasonal vaccine and those who believed swine flu to be a serious threat (OR 4.2 (1.9, 9.1)). Parents would be more likely to accept vaccination if they received a letter of invite, if the government strongly encouraged them, if it were administered at school, and if it were more thoroughly tested. Accurate media portrayal of safety of the vaccine during future pandemics will be essential.
The swine flu (H1N1) pandemic was confirmed on June 11th, 2009 by the World Health Organisation (WHO). The WHO declared the pandemic over by August 10th, 2010 [
In order to tackle the pandemic, plans worldwide were based on a vaccination programme and education [
There are few studies reporting likely uptake rates of this strategy among school-aged children, although a Mumsnet poll [
Given the threat of future pandemics, and also the high levels of H1N1 circulating in the subsequent 2010/11 influenza season, it is important to determine factors which might affect pandemic influenza vaccine uptake in young children in order to inform future vaccination policy decisions. We present a study undertaken during the 2009/10 influenza H1N1 pandemic among parents of primary school children to determine vaccine acceptance rates and factors affecting their decision to consent or not.
We undertook a cross-sectional survey among the parents of primary school children in Birmingham, UK to establish factors affecting uptake of (and intention to receive) pandemic influenza A H1N1 vaccination in the 2009/2010 season for their children.
Parents of Key Stage 1 children (reception, years 1 and 2, i.e., ages 4–7 years inclusive) in the chosen schools who could read and understand English and were aged 18 years or over were included. 80 schools within the Birmingham Local Education Authority were randomly selected. These schools were contacted via e-mail to see if they would be interested in participating in the study. If, after 1 week, they had not responded (either favourably or not), they were called by telephone. The participating schools were sent questionnaires with cover letters, to be distributed to every child in Reception, Year 1 and Year 2. The schools were asked to give out the questionnaires, collect them back in within 1 week, and post them back to the investigators.
The questions were largely closed-ended and where possible were based on those used in similar studies previously carried out (the appendix), most importantly the paper by Zijtregtop et al. published recently in 2010, which used the Health Belief Model and the Behavioural Intention Model to derive their questions [
The main outcome was the intention to vaccinate their child or not. This was identified by asking
Statistical analyses were undertaken in STATA 10. Simple descriptive statistics were used to describe the respondents and uptake rates. Multiple logistic regression analysis was undertaken to determine independent associations between specific factors and intention to receive the vaccine (providing odds ratios and 95% confidence intervals), adjusting for age, sex, ethnicity, smoking status, asthma status of child (model 1), and additionally for receipt of seasonal influenza vaccine (model 2). Outcomes with 5-point Likert scales were collapsed to 3 categories: agree/strongly agree, neither agree or disagree, and disagree/strongly disagree.
Five schools agreed to take part in the study. 846 questionnaires were distributed to parents of children in Key Stage 1 in these schools, of which 149 were returned, giving a response rate of 17.6%. The highest response rate from a single school was 50% from school A and the lowest response rate was from school C (5.3%).
Of the 149 respondents, 118 (79.2%) were females (Table
Characteristics of respondents.
Characteristic |
|
---|---|
Number of respondents | 149 |
|
|
A | 46 (30.9%) |
B | 14 (9.4%) |
C | 5 (3.4%) |
D | 45 (30.2%) |
E | 39 (26.2%) |
|
118 (79.2%) |
|
|
<25 | 11 (7.4%) |
26–30 | 30 (20.1%) |
31–35 | 34 (22.8%) |
36–40 | 42 (28.2%) |
41+ | 32 (21.5%) |
Number of children (mean) (SD) | 2.4 (1.0) |
Smoking status | |
Never smoked | 96 (64.4%) |
Ex smoker | 29 (19.5%) |
Current smoker | 24 (16.1%) |
Ethnicity | |
White British/other | 69 (46.3%) |
Mixed | 10 (6.7%) |
Indian | 18 (12.1%) |
Pakistani | 42 (28.2%) |
Other Asian | 5 (3.4%) |
Black | 4 (2.7%) |
Not stated | 1 (0.7%) |
Education of main earner | |
No education completed | 19 (12.8%) |
Secondary | 35 (23.5%) |
College/vocational | 47 (31.5%) |
Degree or higher | 48 (32.2%) |
Long term illness | |
None | 101 (67.8%) |
Child | 14 (9.4%) |
Parent/other member | 22 (14.8%) |
Combination | 12 (8.1%) |
Long term illness of child | |
None | 126 (84.6%) |
Asthma | 16 (10.7%) |
Other | 6 (4.7%) |
Childhood routine vaccines | |
Yes | 129/149 (86.6) |
No | 15/149 (10.1) |
Partially | 5/149 (3.4) |
Child ever received seasonal flu vaccine | |
Yes | 13/149 (8.7) |
No | 136/149 (91.3) |
111 (74.5%) respondents agreed/strongly agreed that they had a full understanding of the swine flu pandemic, while 13 (8.7%) felt that they did not (Table
Knowledge and attitudes to pandemic influenza.
Agree/strongly agree | Neither agree or disagree | Disagree/strongly disagree | |
---|---|---|---|
I have a full understanding of the swine flu pandemic ( |
111 (74.5%) | 25 (16.8%) | 13 (8.7%) |
The swine flu pandemic is a serious threat to society ( |
78 (52.4%) | 48 (32.2%) | 23 (15.4%) |
I feel I am at high risk of getting swine flu ( |
27 (18.1%) | 64 (43.0%) | 58 (38.9%) |
38 (25.5%) parents stated that they had been offered vaccine for their child (Table
Pandemic swine flu vaccine acceptance among children.
| |
---|---|
Acceptance among children offered | 23/38 (60.5%) |
Intention to accept among children not offered | 68/111 (61.3%) |
Total positive intention to vaccinate child | 91/149 (61.1%) |
Future intention to vaccinate other children under 5 years of age | 59/96 (61.5%) |
Of those expressing positive intention to vaccinate, the main reasons included: “
Main reasons for intention to accept pandemic vaccine.
Reason |
|
---|---|
Worried about child catching swine flu | 21 (18.9%) |
Worried child would become severely ill if they caught swine flu | 11 (9.9%) |
Child has a long-term medical condition | 8 (7.2%) |
To prevent the child infecting other family members | 8 (7.2%) |
Followed advice from GP/school | 8 (7.2%) |
Children are more at risk than adults | 7 (6.3%) |
Prevent child having time off school | 4 (3.6%) |
Know others who have had swine flu | 3 (2.7%) |
Recommended vaccines should always be taken | 1 (1.1%) |
Of those expressing an intention to refuse the vaccine, the main reasons for not vaccinating their child included:
Main reasons for refusing pandemic vaccine.
Reason |
|
---|---|
Worried about the safety | 34 (58.6%) |
Worried about side effects | 32 (55.2%) |
Do not consider swine flu a threat | 12 (20.7%) |
Believe my child has already had swine flu | 7 (12.1%) |
Do not think the vaccine is effective | 6 (10.3%) |
Do not have time to go to the GP | 3 (5.2%) |
Against all vaccinations in general | 3 (5.2%) |
When asked which statements they agreed or strongly agreed with, 84 (56.4%) of parents stated they would be more likely to vaccinate their child if they received a letter inviting them to be vaccinated, 92 (61.7%) if the government strongly encouraged them, 72 (48.3%) if it were administered at school, and 98 (65.8%) if it were more thoroughly tested.
Table
Factors affecting intention to receive pandemic vaccine.
Factor | Positive intention |
OR (95% CI) | Model 1 |
Model 2 |
---|---|---|---|---|
Age of parent (years) | ||||
|
86 (62.3%) | 1.0 | 1.0 | 1.0 |
< 25 | 5 (45.5%) | 0.5 (0.1, 1.7) | 0.3 (0.1, 1.3) | 0.3 (0.1, 1.3) |
Sex of parent | ||||
Male | 18 (58.1%) | 1.0 | 1.0 | 1.0 |
Female | 73 (61.9%) | 1.2 (0.5, 2.6) | 1.7 (0.7, 4.0) | 1.7 (0.7, 4.1) |
Smoking status of parent | ||||
Never smoker | 57 (59.4%) | 1.0 | 1.0 | 1.0 |
Ex-smoker | 17 (58.6%) | 1.0 (0.4, 2.3) | 1.4 (0.5, 3.7) | 1.5 (0.5, 3.9) |
Current smoker | 17 (70.8%) | 1.7 (0.6, 4.4) | 2.3 (0.8, 6.5) | 2.0 (0.7, 5.8) |
Education of main earner | ||||
Primary or less | 14 (73.7%) | 1.0 | — | — |
Secondary or higher | 77 (59.2%) | 0.5 (0.2, 1.5) | — | — |
Ethnicity | ||||
White | 36 (52.2%) | 1.0 | 1.0 | 1.0 |
Non-white | 54 (68.4%) | 2.0 (1.0, 3.9) | 2.4 (1.1, 5.0) | 2.5 (1.2, 5.5) |
Parent vaccinated against swine flu | ||||
No | 74 (58.3%) | 1.0 | — | — |
Yes | 17 (77.3%) | 2.4 (0.8, 7.0) | — | — |
Child has asthma | ||||
No | 77 (57.9%) | 1.0 | 1.0 | 1.0 |
Yes | 14 (87.5%) | 5.1 (1.1, 23.3) | 6.6 (1.4, 32.1) | 4.5 (0.8, 24.7) |
Child ever received seasonal influenza vaccine | ||||
No | 79 (58.1%) | 1.0 | — | 1.0 |
Yes | 12 (92.3%) | 8.7 (1.1, 68.5) | — | 6.2 (0.7, 58.0) |
*Model adjusted for age, sex, smoking status, ethnicity, and asthma.
†Model adjusted for age, sex, smoking status, ethnicity, asthma, and receipt of seasonal influenza vaccine.
In an additional analysis adjusting for the factors above, respondents who agreed/strongly agreed that swine flu was a serious threat to society were significantly more likely to accept the vaccine (OR 4.2 (1.9, 9.1)).
We investigated the factors that would influence acceptance of the swine influenza vaccination in primary school children. An important finding was that 61.1% of our study population were prepared to accept the swine flu vaccination if it were offered to their children (aged mainly over 5 years), and a similar proportion would also accept it for their younger children aged under 5 years. After multivariate analysis, three determinants were shown to have a significant association with positive intention to vaccinate. It was found that respondents of nonwhite (mainly Asian) origin were over twice as likely to accept the swine flu vaccine for their children than those who were of white ethnicity. Parents whose children had asthma were more than 6 times more likely to accept the vaccine than those who did not, and those who had received seasonal vaccine were also more likely (although some of this effect were likely to be explained by the child having asthma). It was also found that strong encouragement from the government, sending a letter to the parents and receiving the vaccination at school, would make the parents more likely to accept the vaccine. Concern about the safety of the vaccine and fear of side effects occurring were the main reasons given by participants who would not want their child vaccinated, and a large proportion of parents felt they would be more likely to consent to the vaccine if it were more thoroughly tested. More than 20% of parents cited a key reason for not agreeing to have their child vaccinated which was because they did not think swine flu was a serious threat to society. This is reflected by the finding that those who did think that swine flu was a serious threat were more than four times as likely to accept the vaccination for their children than those who did not.
Firstly, to our knowledge, this study is unique in that it examines factors affecting pandemic influenza vaccine uptake specifically among primary school children of this age. The questionnaires used were based around previously validated questionnaires used in similar studies [
School willingness to participate may be affected by different characteristics of the schools. These characteristics may also influence positive intention. The response rate was 17.6% which is low in comparison to another postal questionnaire in Birmingham [
Compared with the general population of Birmingham, in which 70.4% of the population classified themselves as white British/Irish/Other [
Furthermore, we note that our “intention to accept rates” is consistent with other studies as discussed below, which increases the confidence in our results.
Lastly, the small sample size in this study decreases its power, which decreases the probability that the study will be able to detect significant findings. Therefore, it is possible that some factors may have affected swine influenza vaccination uptake, but this study was unable to demonstrate this due to insufficient numbers.
Although several studies have researched factors involved in uptake of the seasonal influenza vaccine, studies specific to the swine influenza pandemic have only recently been available [
We found that the belief that swine flu is a threat to society positively influenced the uptake of vaccination. This accords with O’Reilly et al.’s study into factors affecting seasonal influenza uptake in health care workers, which found that beliefs about health were important determinants in the uptake of immunization [
The main reasons for not receiving the vaccination in our study were found to be the fear of adverse reactions and worry about the safety of the vaccine. Similar findings were produced in 1976 North American studies which found that one of the principal reasons for declining vaccination was the worry that adverse reactions would occur. This may be due to the number of cases of Guillain-Barre syndrome occurring among recipients of swine flu vaccination during that time [
Low levels of anxiety towards the swine flu pandemic were shown in recent papers from the UK and Australia [
The findings of our study suggest that there is a relatively high positive intention to vaccinate if offered pandemic influenza vaccine. If this intention was followed through, then a vaccination programme among both primary school age children and under 5s would be worth carrying out in the event of future pandemics, particularly in pandemics when perceived threat was high. The way in which the swine influenza vaccination scheme is run would have a significant effect on the uptake of the vaccine. Strong government encouragement, sending a letter inviting children to be vaccinated or if the children were to receive the vaccination at school, was suggested to improve the chance that parents would accept swine flu vaccination. From these results, we would suggest that these methods are considered in the implementation of such a vaccination scheme in order to increase uptake rates. Clearly public views on the seriousness of the health risk and perceptions about the safety of the vaccine should be addressed with accurate media portrayal, particularly on television and the internet as these were found to be the main conduits of current affairs for our respondents. This season’s experience from school-located vaccination programmes in the USA might also be useful for practical issues [
Understanding the factors involved in acceptance of the swine influenza vaccination is crucial for the effective implementation of future pandemic vaccination schemes. If swine influenza vaccination in children is accepted by the government as a worthwhile activity, then methods of maximising acceptance of the vaccine must be considered. Increasing uptake rates may be tackled in part by altering people’s beliefs. Having some knowledge about who is likely to want the vaccination and why, and the reasons people may not want their children vaccinated, will allow health professionals to be prepared to answer patient’s questions and concerns and the government to design their approach. Accurate media portrayal of the health risks of the pandemic and the safety of the vaccine is essential. Individual letters to parents from the government and administration of the vaccine in school would also appear to be important.
Given the high rates and complications of pandemic influenza in subsequent years, and the emerging interest internationally of a “herd immunity” approach, this research also has relevance for interim seasonal vaccination.
Age of parent/guardian…… Sex (Please tick as appropriate)
Male □ Female □ How many children do you have living at home? (Number of children per age range)
0–4 yrs…… 5–9 yrs…… 10–14 yrs…… 15+ yrs…… What is your current living situation?
Living without partner Living without partner but with relatives Living with partner Living with partner and relatives Other Smoking status:
Current regular smoker Current occasional smoker Ex-smoker Never smoked Highest level of education of the main earner:
No education completed Secondary education completed (e.g., GCSEs or equivalent) College or Sixth form education completed (e.g., A-levels or equivalent) Vocational training Degree completed Masters completed PHD completed Where do you usually get your information on current affairs from? (Please circle most appropriate)
Broadsheet/Tabloid/TV/Internet/Magazine/None/Other Do you or any member of your household have a long-term illness? (e.g., COPD, asthma, diabetes, heart disease, liver disease, kidney disease, MS, stroke) (Please circle all that apply)
Child/Me/Other member/None Please select one box per row/statement I have a full understanding of the swine flu pandemic
Strongly Agree Agree Neither Agree or Disagree Disagree Strongly Disagree The swine flu pandemic is a serious threat to society
Strongly Agree Agree Neither Agree or Disagree Disagree Strongly Disagree I feel I am at a high risk of getting swine flu
Strongly Agree Agree Neither Agree or Disagree Disagree Strongly Disagree Do you know anyone that has had swine flu (including yourself)?
Yes/No Did you have the swine flu vaccination?
Yes/No
If you have more than one child, please answer for the child in year 1/2 that brought this questionnaire home Does your child have a long-term illness? Asthma/Other respiratory illness/Other long-term illness/None Do you consider your child to have a disability? Yes/No Has your child had all the vaccinations recommended by your GP (including MMR)? Yes/Partially/No Has your child ever had the seasonal flu vaccine? Yes/No Has your child been offered the swine flu vaccine this winter? Yes/No (If no, go to question (20)) If yes, did they have the vaccination? Yes/No (If no, go to question (21)) If your child were offered it at some point in the future, would you vaccinate them against swine flu? Yes/No (If no, go to question (21))
If you’ve answered yes to either question (19) or (20), please describe the factors contributing to this decision
If no, what factors contributed to this decision? (Please tick any that apply)
□ Do not think the vaccine is effective □ Worry about side effects of vaccine □ Worry about the safety of the vaccine □ Can’t find the time to go to the GP □ Do not consider swine flu as a threat □ I believe my child has already had swine flu □ I am against vaccinations in general □ Other (please specify) I would be more likely to vaccinate my child if:
(Please tick one option per row/statement) I received a letter inviting them to be vaccinated
□ Strongly Agree □ Agree □ Neither Agree or Disagree □ Disagree □ Strongly Disagree The government strongly encouraged children of my child’s age to have it done
□ Strongly Agree □ Agree □ Neither Agree or Disagree □ Disagree □ Strongly Disagree The vaccine was given at my child’s school
□ Strongly Agree □ Agree □ Neither Agree or Disagree □ Disagree □ Strongly Disagree The vaccine was tested more thoroughly
□ Strongly Agree □ Agree □ Neither Agree or Disagree □ Disagree □ Strongly Disagree Regarding any of your OTHER children up to the age of 5 years—if offered, would you consent to their having swine flu vaccination?
Yes/No/do not have any others of this age-group
What is your ethnic origin?
How long have you lived in the UK?
Thank you for taking the time to complete our questionnaire!
R. E. Jordan supervised this project for 3rd year medical students. The initial idea was created by R. E. Jordan but the remaining five authors designed the study, collected the data, and wrote the first draft together. M. Janks and A. Odedra undertook the first analysis and R. E. Jordan completed the analyses. R. E. Jordan supervised all aspects and redrafted the paper for submission. All authors took responsibility for the integrity of the data and accuracy of the data analysis.
R. E. Jordan is funded by the NIHR; but none of the authors have financial relationships with any organisations that might have an interest in the submitted work in the previous three years, no other relationships or activities that could appear to have influenced the submitted work.
The authors would like to thank the participating primary schools and parents and also Ms. Andrea Robinson for her help in printing the questionnaires. R. E. Jordan is funded by the National Institute for Health Research, UK. The costs of printing the questionnaire were met by the University of Birmingham College of Medical and Dental Sciences.