To learn more about racial and ethnic disparities in influenza vaccination during the 2009-H1N1 pandemic, we examined nationally representative survey data of US adults. We found disparities in 2009-H1N1 vaccine uptake between Blacks and Whites (13.8% vs 20.4%); Whites and Hispanics had similar 2009-H1N1 vaccination rates. Physician offices were the dominant location for 2009-H1N1 and seasonal influenza vaccinations, especially among minorities. Our results highlight the need for a better understanding of how communication methods and vaccine distribution strategies affect vaccine uptake within minority communities.

Epidemiological data collected over the past century suggest that racial and ethnic minorities are at greater risk of contracting seasonal and pandemic influenza—and of experiencing more negative consequences as a result—compared with Whites.13 Despite this heightened risk, minorities in the United States have historically been vaccinated for influenza at rates as much as 15 to 18 percentage points lower than the rates for Whites, reflecting access barriers, negative attitudes toward vaccination, distrust of the medical system, and perceived risk of side effects.37

To minimize disparities in vaccine uptake during the 2009-H1N1 pandemic, local public health authorities adopted specifically targeted outreach efforts to encourage 2009-H1N1 vaccination among minorities. These outreach efforts included the use of alternative vaccination sites, such as retail clinics and school-located clinics; engagement of faith-based organizations; and communication in multiple languages and through ethnic media.810 Furthermore, the federal government made 2009-H1N1 vaccine available free of charge, to remove cost-related barriers to uptake. However, local public health officials reported disparities in uptake of 2009-H1N1 vaccine.11 To our knowledge, the only comparable, published national data on this topic measured uptake through the first few weeks of the vaccination campaign.12 To assess whether targeted outreach to minority populations during the 2009-H1N1 pandemic succeeded in narrowing historical disparities in influenza vaccination, we used national, cross-sectional survey data measuring influenza vaccination of adults to estimate uptake of seasonal and 2009-H1N1 influenza vaccination, vaccination location, and attitudes toward influenza vaccination by race and ethnicity.

From March 5 to March 24, 2010, we used an online research panel operated by Knowledge Networks to field a nationally representative survey of US adults aged 18 years and older (n = 4040). Knowledge Networks recruits panelists through a probability-based sampling method that includes both online and offline households.13 To ensure diversity, we oversampled older panelists, Blacks, and Hispanics (Table 1). The completion rate among sampled panelists was 73%. Respondents self-identified their race/ethnicity as White (non-Hispanic), Black (non-Hispanic), Hispanic, other, or multiracial. Respondents who self-identified as other or multiracial (n = 503) were excluded from the analysis, for a final sample of 3537. We used questions about age, chronic health conditions, work as a health care professional, and personal contact with high-risk individuals to determine whether a respondent was recommended for seasonal vaccination or 2009-H1N1 influenza vaccination by the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices.14

Table

TABLE 1 Sample Description: Knowledge Networks Panelists, United States, 2010

TABLE 1 Sample Description: Knowledge Networks Panelists, United States, 2010

White (n = 1808)
Black (n = 1141)
Hispanic (n = 588)
CharacteristicsUnweighted No.Unweighted %Weighted %aUnweighted No.Unweighted %Weighted %aUnweighted No.Unweighted %Weighted %a
Age, y
    18–49434245327324641903275
    50–64668372756850242564417
    ≥ 6570639203002612142248
Gender
    Women882494971963552995147
    Men926515142237452894953
High-risk statusb
    Recommended for seasonal vaccine16239078103190745168874
    Recommended for H1N1 vaccine582323748743472253848
Educationc
    High school graduate508283125322341522634
    College graduate594333136032191612714
    Medical insurance
    Uninsured1559131711526991734
    Currently insured1642918796485744838366
Employmentc
    Currently working680385147141372524346
    Retired641351931227191382314
Household income, $c
    < 25 000334181831528441021724
     > 75 000593333328525171953319

aPoststratification weights are computed using data from the Current Population Survey and are adjusted for known sampling probabilities, sample stratification, and nonresponse to panel recruitment and panel attrition.

bAdults recommended by the Advisory Committee for Immunization Practices for seasonal influenza vaccine were adults with certain chronic health conditions, adults aged > 50 years, pregnant women, health care workers, and adults in contact with high-risk individuals. Adults recommended for 2009-H1N1 vaccine were all adults aged 18–24 years, adults aged 18–64 years with certain chronic health conditions, health care workers, pregnant women, and adults in contact with high-risk individuals.

cColumns do not add up to 100% within this category because we did not include all subcategorical responses in the table.

To determine vaccination status, we asked survey respondents: “Have you received a H1N1/swine [seasonal] flu vaccine this flu season?” We report estimates of 2009-H1N1 and seasonal influenza vaccination, location at which vaccination took place, and attitudes toward influenza vaccination. All data were weighted to produce nationally representative estimates adjusted for known selection probabilities, sample stratification, nonresponse, and Internet use before recruitment into the panel.15 Pearson's χ2 test was used to calculate P values. We assessed the robustness of our bivariate results by estimating logistic regression models of influenza vaccination and vaccination location, controlling for household income, insurance status, age, gender, employment status, and recommendation status. We used Stata version 11 (StataCorp LP, College Station, TX) to generate all statistics.

Whites were significantly more likely than were Blacks to receive a 2009-H1N1 vaccination (20.4% vs 13.8%; P = .02) and a seasonal influenza vaccination (42.6% vs 32.2%; P = .004) during the 2009–2010 vaccination season (Table 2). Although Whites were also more likely than were Hispanics to receive a seasonal influenza vaccination (42.6% vs 29.5%; P = .002), we found no significant differences with respect to 2009-H1N1 vaccination between Whites and Hispanics (20.4% vs 18.6%; P = .62). The statistical significance of the uptake of 2009-H1N1 vaccination between Blacks and Whites persisted when controlling for the aforementioned covariates (odds ratio = 0.67; P = .05).

Table

TABLE 2 Comparison of Influenza Vaccine Uptake, Location of Vaccination, and Vaccination Attitudes: Knowledge Networks Panelists, United States, 2009–2010

TABLE 2 Comparison of Influenza Vaccine Uptake, Location of Vaccination, and Vaccination Attitudes: Knowledge Networks Panelists, United States, 2009–2010

White, % (95% CI)Black, % (95% CI)PaHispanic, % (95% CI)Pb
2009-H1N1 vaccination
    Received 2009-H1N1 vaccine20.4 (17.7, 23.0)13.8 (9.3, 18.2).0218.6 (12.3, 24.8).62
    Received provider recommendation for 2009-H1N1 vaccine21.5 (18.8, 24.2)23.9 (18.6, 29.1).4322.2 (15.3, 29.2).85
Location of 2009-H1N1 vaccinationc
    Workplace18.8 (13.1, 24.5)11.5 (5.5, 17.5).16.2 (1.0, 11.9).01
    Physician's office23.5 (18.1, 29.0)39.0 (20.9, 57.0).0742.0 (22.6, 61.4).04
    Medical clinic/health center12.1 (7.4, 16.8)18.7 (8.9, 28.5).1912.3 (0, 26).97
    Retail setting12.4 (7.6, 17.2)2.9 (0.4, 5.3).0017.8 (1.3, 14.2).3
    Health department flu clinic22.1 (15.8, 28.4)7.7 (2.6, 12.7).00219.8 (5.4, 34.2).76
Seasonal vaccination
    Received seasonal vaccine42.6 (39.2, 45.9)32.2 (26.3, 38.1).00429.5 (22.3, 36.6).002
    Received provider recommendation for seasonal vaccine33.0 (28.9, 36.1)35.2 (29.5, 40.9).4926.2 (19.7, 32.8).08
Location of seasonal vaccinationc
    Workplace21.4 (16.8, 25.9)17.0 (9.0, 25.1).5710.5 (4.4, 17.0).03
    Physician's office35.1 (30.6, 39.6)42.1 (31.2, 52.9).3141.8 (28.6, 55.3).41
    Medical clinic/health center9.6 (6.7, 12.5)10.8 (6.5, 15.0).6514.1 (2.7, 25.4).39
    Retail setting17.6 (14.1, 21.2)3.7 (1.4, 21.2)< .00113.0 (5.0, 21.0).54
    Health department flu clinic5.7 (3.7, 7.6)8.4 (2.2, 14.6).3412.1 (0, 2.5).19
Attitudes regarding vaccinationd
    Being vaccinated against seasonal flu is safe60.9 (57.4, 64.4)52.2 (45.9, 58.6).0254.3 (46.1, 62.5).14
    Being vaccinated against H1N1/swine flu is safe44.7 (41.2, 48.1)40.6 (34.2, 47.0).2839.6 (31.6, 47.5).25
    Flu vaccines can cause people to get the flu30.3 (27.0, 33.6)38.3 (32.1, 44.6).0240.5 (32.5, 48.5).02
    Vaccines are safe in general65.6 (62.1, 68.9)51.6 (45.2, 57.9)< .00155.2 (47.0, 63.5).02

Note. CI = confidence interval.

aComparing Whites and non-Hispanic Blacks.

bComparing Whites and Hispanics.

cSubsample of vaccinated adults.

dStatistics correspond to percentage of adults who strongly agree or agree with the listed statements.

For vaccinated adults of all races, physician offices were the dominant site of 2009-H1N1 and seasonal influenza vaccination. Blacks were less likely than were Whites to be vaccinated in retail clinics for both 2009-H1N1 (2.9% vs 12.4%; P = .001) and seasonal influenza (3.7% vs 17.6%; P < .001). The statistical significance of these differences remained when controlling for covariates in multivariate models (results available from authors upon request). Hispanics were less likely than were Whites to be vaccinated for 2009-H1N1 (6.2% vs 18.8%; P = .01) and seasonal influenza in the workplace (10.5% vs 21.4%; P = .03), although these differences were not statistically significant in multivariate models.

Attitudes toward influenza vaccination differed by race and ethnicity. Both Blacks and Hispanics were less likely than were Whites to agree that vaccines are “safe in general” (P < .001), and Blacks and Hispanics were more likely to agree that influenza vaccines can cause people to get the flu (P = .02).

Our analysis showed that historic racial and ethnic disparities in influenza vaccination persisted during the 2009-H1N1 pandemic, although their magnitudes varied across groups and types of vaccination. Most notably, we found that Hispanics and Whites had similar vaccination rates for 2009-H1N1. Because the virus originated in Mexico, this finding may in part be attributable to heightened awareness of 2009-H1N1 within the Hispanic community. This finding, however, is also consistent with previous research suggesting that Hispanics face cost-related barriers to vaccination, which may have been addressed by offering the 2009-H1N1 vaccine free of charge in community settings.4

The lower vaccination rates for both seasonal and 2009-H1N1 vaccine among Blacks, on the other hand, may suggest that attitudinal barriers such as historic distrust (often mentioned by unvaccinated Black adults)4 were not as easily overcome though targeted outreach and making vaccinations available free of charge. This conjecture is supported by literature showing that Blacks are less likely to have positive attitudes toward vaccination and to get vaccinated, even when vaccination is specifically recommended.5 Furthermore, our results indicated that physician offices were the dominant vaccination site for seasonal and 2009-H1N1 vaccine among all races, but Whites were more likely to also use complementary vaccination locations, such as health department clinics and retail settings. Previous research has demonstrated that retail clinics serve communities with fewer Black residents and thus may not be effective at alleviating vaccination-related disparities.16,17 Research has also suggested that offering mass vaccination clinics of the type used in the 2009-H1N1 response, in which several thousand people received vaccine at a school or health department on a given date, may exacerbate disparities because they require individuals to actively seek vaccine.2

Although no comparable public data exist on influenza vaccination uptake by race for the 2009–2010 influenza season, our results for seasonal and 2009-H1N1 vaccination uptake for all adults tracks closely (within 1 to 3 percentage points) with results from the Behavioral Risk Factor Surveillance System and the National 2009 H1N1 Flu Survey.18,19 A validation study conducted using data from 2004 through 2008 suggested that in the past, our approach has yielded estimates of influenza vaccination among racial and ethnic minorities that were moderately higher than were those derived from the National Health Interview Survey.20 Thus, our results should be interpreted as a conservative measure of disparities in influenza vaccination. As such, the substantial disparities in influenza vaccination rates we reported highlight the need for a better understanding of how various methods of communication and vaccine distribution affect vaccine uptake within minority communities.

Acknowledgments

This study was supported by the National Institute of Allergy and Infectious Diseases (grant R03AI095084).

Note. The survey data used in this study were collected under contract with GlaxoSmithKline. GlaxoSmithKline had no role in the design, management, analysis, or interpretation of these data, and had no role in the preparation, review, or approval of the article. The opinions expressed here are solely those of the authors and do not represent those of RAND, GlaxoSmithKline, or the National Institute of Allergy and Infectious Diseases.

Human Participant Protection

This study protocol was approved by the institutional review board of RAND.

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Lori Uscher-Pines, PhD, Jurgen Maurer, PhD, and Katherine M. Harris, PhDLori Uscher-Pines, Jurgen Maurer, and Katherine M. Harris are with RAND Corporation, Arlington, VA. “Racial and Ethnic Disparities in Uptake and Location of Vaccination for 2009-H1N1 and Seasonal Influenza”, American Journal of Public Health 101, no. 7 (July 1, 2011): pp. 1252-1255.

https://doi.org/10.2105/AJPH.2011.300133

PMID: 21566026