H1N1 vaccination uptake among African American college students.
Abstract: Little effort has been made to develop communication messages that influence African American young adults to obtain H1N1 immunization. To better understand the communication sources that are most influential in their decision making, this cross-sectional study was undertaken among 540 students attending Delaware State University. Findings indicate students who had been immunized were more likely to check for health information online and received H1N1 information from healthcare professionals including doctors), physicians and parents compared to students who did not receive the H1N1 vaccination. Findings provide information that may inform intervention methodologies for colleges and health practitioners.
Article Type: Survey
Subject: Medical personnel (Reports)
Medical personnel (Health aspects)
African Americans (Reports)
African Americans (Health aspects)
African American universities and colleges (Reports)
African American universities and colleges (Health aspects)
Medical research (Reports)
Medical research (Health aspects)
Medicine, Experimental (Reports)
Medicine, Experimental (Health aspects)
College students (Reports)
College students (Health aspects)
Influenza (Research)
Influenza (Reports)
Influenza (Health aspects)
Vaccination (Reports)
Vaccination (Health aspects)
Authors: Ford, Kentya H.
Meshack, Angela
Roberts, Mandy
Amos, Charles
Rhodes, Warren
Barkley, Lisa
Peters, Ronald J.
Pub Date: 06/22/2012
Publication: Name: American Journal of Health Studies Publisher: American Journal of Health Studies Audience: Professional Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2012 American Journal of Health Studies ISSN: 1090-0500
Issue: Date: Summer, 2012 Source Volume: 27 Source Issue: 3
Topic: Event Code: 310 Science & research
Product: Product Code: 8010000 Medical Personnel; 8000200 Medical Research; 9105220 Health Research Programs; 8000240 Epilepsy & Muscle Disease R&D; E197500 Students, College; 8000146 Vaccination & Immunization NAICS Code: 62 Health Care and Social Assistance; 54171 Research and Development in the Physical, Engineering, and Life Sciences; 92312 Administration of Public Health Programs; 621999 All Other Miscellaneous Ambulatory Health Care Services
Accession Number: 308741521

Influenza may have a significant impact on the health of college students (American College Health Association, 2010; Merrill et al., 2010). A recent study found that 28% of college and university students develop influenza-like illnesses during a given influenza season (Nichol, D'Heilly, & Ehlinger, 2005). Nearly 19% of college and university students report that influenza-like (cold/ flu/sore throat) symptoms are major factors affecting their academic performance(American College Health Association, 2009) and additionally, are associated with significant effects on health, work performance, leisure time activities, and health-care use (Nichol, D'Heilly, & Ehlinger, 2008). College and university students were not traditionally among the high-priority groups for routine influenza vaccination in the United States (Harper, Fukuda, Uyeki, & Cox, 2004). However, since many students often reside in close living arrangements such as dormitories, use communal restrooms, engage in lengthy study groups, and/or participate in numerous social groups and intramural activities (Fiore et al., 2008), they are now considered a high-priority population for vaccination uptake (American College Health Association, 2010).

In 2009, the H1N1 flu (also known as swine flu) spread rapidly on college campuses and universities and reports indicated that young adults were especially impacted in terms of severity of illness (American College Health Association, 2010). Compared to other college students, those attending historically black colleges and universities (HBCUs) may be at increased risk of developing H1N1 or other influenza viruses as studies have shown that African Americans have reported barriers to health care access, such as lack of insurance and transportation and exist in a culture of mistrust of the health care system (Armstrong, Berlin, Schwartz, Propert, & Ubel, 2001; Blue & Valley, 2002; Chen, Fox, Cantrell, Stockdale, & Kagawa-Singer, 2007; Fiscella, Franks, Gold, & Clancy, 2000; Freimuth et al., 2001; Hennesey-Fiske, 2010; Jones, 2009). Recent reports have indicated that the 2008-2009 seasonal influenza vaccination coverage was generally low among young adults. Compared to other adult age stratifications (50-64 years--41%; 65 plus years--67.1%), persons aged 18-49 years had the lowest rate of influenza vaccination uptake (22.4%) (Centers for Disease Control and Prevention, 2010). Studies have also found racial disparities between those who receive influenza vaccines, with non-Hispanic blacks being less likely than non-Hispanic whites to receive influenza vaccination (Centers for Disease Control and Prevention, 2009; Chen, et al., 2007). Although the single best way to protect from influenza is to get vaccinated each year (Harper, et al., 2004; Nichol & Treanor, 2006), African Americans consistently report lower rates of vaccination compared to their other race counterparts.

Previous studies of factors relating to vaccination uptake have largely focused on elderly (Li & Mukamel, 2010; Thompson et al., 2004) and working populations (Blue & Valley, 2002; Nichol, D'Heilly, & Ehlinger, 2006; Shahrabani, Benzion, & Yom Din, 2009). Most studies conducted among college/ university populations have clarified the benefits of influenza vaccination in predominately white populations or in studies with no description of the population of interest (Merrill, et al., 2010; Nichol, et al., 2005; Nichol, et al., 2008), thus limiting the generalizability of findings. Despite the importance of this issue in minority populations, little is known about how to motivate African American college students to participate in immunization programs. Given recent findings regarding how H1N1 flu causes life-threatening illness (e.g., consistent pattern of oxygen deprivation in the blood of critically ill patients, incidents of shock, organ failure and death) (White, Webster, Govorkova, & Uyeki, 2009), it is important to understand factors predictive of influenza vaccination in African American populations. The purpose of this study was to assess which communication sources are most predictive of African American college students' vaccination against H1N1. To date, no study has been published on motivational influences of H1N1 vaccination among African American college students. The ongoing accrual of this kind of information will prove invaluable for the development of future H1N1 influenza interventions, as well as for other influenza-like viruses.



This study presents an analysis of data collected through the "Exploring H1N1 at Historically Black Colleges and Universities" study (H1N1-HBCU) between January 2010 and April 2010 to examine indirect and/direct messages and H1N1 vaccine uptake. H1N1-HBCU was a cross-sectional H1N1 vaccination uptake exploratory study conducted at a HBCU located in Dover, Delaware. Baseline data collection included a cross-sectional survey to 540 African American students.


The Delaware State University Committee for the Protection of Human Subjects approved the student survey and the consent procedure. Students were asked to return a signed consent form to a designated member of the H1N1-HBCU research group indicating if their willingness or lack of to participate in the study. Students under 18 years of age were not eligible to participate.

The survey was administered in freshmen orientation classes. Research staff who was trained data collectors administered the survey following standardized instructions. The importance of the study and the procedures in place to assure confidentiality were explained to students. Students who did not wish to participate were permitted to leave the classroom (n<10). The duration of survey administration was approximately 45 minutes). To obtain the maximum number of student responses, reasonable efforts via email and phone call (at least two attempts within a two-week period of the original study date) were exerted to locate and survey students who were absent during scheduled freshman orientation days.


The survey instrument was developed to include previously reliable and validated scales, including the one used for this study, and scales specifically tailored to measure changes of H1N1 uptake (Montano, 1986). The survey included questions about demographic characteristics (age, gender, university classification) and asked students to identify their H1N1 vaccination status). Students were also asked to identify the communication sources that would most influence their decision to have the H1N1 influenza vaccination. Specifically, students were asked: "What are some reasons that would motivate you to get the H1N1 vaccine?" Response categories included the following indirect communication sources: "information online", "news stories", "campus postings", and "campus brochure". Direct communication sources included "healthcare providers", "family members and friends", "friends getting vaccinated", "doctor recommended", and "parents recommended". In addition, students were asked their current H1N1 vaccination status. Specifically, they were asked "Have you been vaccinated against the H1N1 virus?" Response categories were "yes" or "no". The survey instrument was developed to include previously reliable and validated scales, including the one used for this study, and scales specifically tailored to measure changes of H1N1 uptake (Montano, 1986).


Study participants' gender, age, classification, and vaccination status were characterized using standard summary statistics. A comparison of H1N1 influenza vaccination status and influence of communication sources (indirect or direct) were observed using chi-squared statistics. Logistic regressions were then utilized to identify the communication sources significantly associated with students who received the H1N1 influenza vaccination. Specifically, the analysis examined the relationship between indirect communication sources such as exposure to information online, news stories, campus postings, H1N1 brochures as well as direct communication sources such as H1N1 discussions with healthcare providers, family members, friends, doctors, and parents on students' having previously obtained the H1N1 influenza vaccine. All data analyses were analyzed using SPSS for Windows 12.0 (SPSS, 2003).



A total of 540 students from freshmen orientation classes completed the survey. As shown in Table 1, most of the students self-identified as being female (66%). The majority of the students were 18 (49%) or 19 (34%) years old, and most classified themselves as freshmen (77%). A majority (83%) reported that they had not received the H1N1 flu vaccination.


Information online was the sole indirect cue to which students who had been vaccinated against H1N1 flu reported higher exposure compared to students who had not been vaccinated (35.2% vs. 24.2%, respectively, p<.05). The prevalence of exposure to indirect communication sources such as news stories (65.9% vs. 62.8%), campus postings (40.7% vs. 42.4%), and H1N1 brochures (36.3% vs. 28.2%) did not statistically differ by vaccination status.

Students who had received the H1N1 vaccine were significantly more likely to report greater exposure to several direct sources of communication: healthcare providers (46.2% vs. 17.2%, p<.05), doctors (50.5% vs. 34.5%, p<.05), and parents (44% vs. 30.2% p<.05). However, direct communication with family (30% vs. 29.8%) and friends (30% vs. 29.8%) did not differ significantly.


Logistic regression (Table 3) was used to model communication sources predictive of H1N1 flu vaccination uptake. It was used to adjust for selected covariates including age, gender, and university classification. When adjusted for these covariates, students who had been vaccinated were more likely to report checking for information online (OR = 1.7, 95%CI = (1.0, 2.8), p < .05). Other indirect communication sources were not significantly associated with vaccination uptake. Students who had been vaccinated against H1N1 were more likely to report direct communication sources with a healthcare provider (OR = 5.2, 95%CI = (3.0, 8.9), p < .05), to have had a doctor's recommendation (OR = 2.1, 95%CI = (1.3, 3.5), p < .05), or to have a parental recommendation (OR = 2.0, 95%CI = (1.2, 3.3), p < .05). These results are displayed in Table 3.


In the current study, we explored direct and indirect communication sources and their influence on H1N1 vaccination uptake by African American college students. Among vaccinated participants, direct recommendation and communication with parents, doctors and healthcare providers were significantly associated with vaccination uptake. Existing literature denotes that African Americans are more motivated to participate in uptake of preventative health vaccines based on direct communication sources, including community engagement (Newman et al., 2007), family support (Kakinami, Newman, Lee, & Duan, 2008; Newman, Duan, Rudy, Roberts, & Swendeman, 2004), if doctors recommended (Brewer & Fazekas, 2007; Wray et al., 2007), and if their spouse and/or significant other would support them in their decision (Kakinami, et al., 2008; Newman, et al., 2004). The results in this study are similar to previous literature as communication with parents and healthcare providers were significantly associated with vaccination uptake, suggesting that they trusted medical providers' and parents' guidance. These findings support the suggestions raised by Shade (1982) that African Americans place heavy emphasis on source and message style to determine the credibility of the intervention strategy, and more attentive to communications that entail direct, personal stimuli.

Interestingly in our study, we found only one statistically significant association with an indirect motivational factor, that is, online H1N1 information. Other forms of media, including reading news stories, campus postings and reading brochures or pamphlets were not associated with vaccination uptake. In a study investigating news media coverage of medical research in articles and volunteerism in health-related research, Mans (2006) found that African Americans were affected by news coverage, both in terms of volume and content. However, negative media coverage may have deterred African Americans from volunteering. These findings are in keeping with studies that have highlighted distrust in the healthcare system and medical research (Blue & Valley, 2002; Fiscella, et al., 2000; Freimuth, et al., 2001) among African Americans, and it is possible in our study that negative information related to H1N1 vaccine eroded trust which played a role in most forms of indirect communication sources being ineffective for vaccination uptake. It is also possible that indirect, non-interactive media-type messages (e.g., news stories and brochures) may not have resonated well with our population. Research has consistently found that culturally specific and interactive media messages in prevention efforts result in greater acceptance among minority populations (Green et al., 2009).

This analysis provides a glimpse of how various methods of communication sources can influence vaccination uptake. Future studies should seek to determine the most important channels for communicating health-related information among African Americans college students. Our finding that participants were motivated to get the H1N1 vaccine at the advice of healthcare providers and parents highlights the importance of choosing these channels for preventative health media messages. However, information about public health pandemics must be fully conveyed, as attempts to hide negative information may trigger memories of well published distrust of medical system, and again reduce trust (Mans & Stream, 2006; Quinn, Kumar, Freimuth, Kidwell, & Musa, 2009). Also, it is important to understand the effects of potential community-based counter-messaging (Plough, Bristow, Fielding, Caldwell, & Khan, 2011), as they can influence decision making regarding H1N1 vaccine, even if participants trust the advice of doctors and parents.

The delivery of health promotion messages via the internet can be effective in promoting healthy behaviors (Hanauer, Dibble, Fortin, & Col, 2004). Chiauzzi and others (Chiauzzi, Green, Lord, Thum, & Goldstein, 2005) reported that a university-based drinking prevention website for heavy drinking was effective in reaching an important sub-group, at-risk binge drinkers. Given the ever growing popularity of the internet among young-adults, it is not surprising that most would select information online as a reason to motivate to get the H1N1 vaccine. Researchers should seek to expand the use of internet-based programs for preventive health behaviors. Although we did not probe specifically on personal digital devices and text messages, it is also possible that these may be viable approaches to influence decision making with regard to immunizations as well as other health risk behaviors.

There are three limitations to the current study. First, because the data are cross-sectional, we were unable to evaluate directionality of effect. Consequently, we do not know the temporal relationship between vaccination status and perceived exposure to indirect and direct communication sources. That limitation aside, this paper highlights the need for larger cohort studies on young adults to examine the exact nature of the causal relationship. Secondly, the data evaluating media-type message exposure was obtained by self-reports; therefore, we cannot exclude the likelihood that self-report bias also influenced study findings. According to Randolph & Viswanath (Randolph & Viswanath, 2004), self-report measures are consistently used to assess media messages and are sufficient in determining health outcomes. Thirdly, the students in the current study were taken from one historically black university in Delaware. Larger studies can accurately estimate the relationship of perceived exposure to indirect and direct H1N1 vaccination communication sources.

In summary, given the substantial disparities among racial and ethnic minorities with regard to influenza vaccination, more research should address approaches that influence the decision-making process for vaccination uptake. This need is especially important as little is known about the adoption and prevalence of health risk behaviors among AA college students, particularly those attending minority institutions (Fennell, 1997; Ford & Goode, 1994; Hale & Branch-Vital, 2010). The information garnered from this research may provide strategic guidance in developing communication messages that influence H1N1 vaccination uptake, as well as other types of immunizations among African American college students. It is recommended that future studies explore ways to present health messages via indirect communication sources. Since college students are vastly exposed to modalities such as campus postings, newsletters and flyers, researchers conducting education initiatives should further explore how these indirect communication sources relate to motivation and behavior with regard to preventive health outcomes. Nevertheless, our findings may provide a first step in developing and implementing culturally appropriate immunization uptake interventions for African-American college students.


The authors thank Busuyi Olotu, B.Pharm, MS, for assistance in formatting the final manuscript.


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Kentya H. Ford, DrPH, CHES

Angela Meshack, DrPH

Mandy Roberts, MPH, DrPH

Charles Amos, DrPH

Warren Rhodes, PhD

Lisa Barkley, MD

Ronald J. Peters, DrPH

Kentya H. Ford, DrPH, CHES, is affiliated with the University of Texas at Austin, College of Pharmacy, Austin, TX. Angela Meshack, DrPH, is affiliated with the Texas Southern University, Health and Kinesiology, Houston, TX. Mandy Roberts, MPH, DrPH, is affiliated with the University of Texas Health, Medical School, Emergency Medicine, Houston, TX. Charles Amos, DrPH, is affiliated with the University of Texas, School of Public Health, Institutional Research & Effectiveness. Warren Rhodes, PhD, is affiliated with the Delaware State University, Health and Public Policy, Dover, Delaware. Lisa Barkley, MD, is affiliated with the Delaware State University, Health and Public Policy, Dover, Delaware. Ronald J. Peters, DrPH, is affiliated with the University of Texas, School of Public Health, Health Promotion and Behavioral Sciences, Houston, TX. Corresponding Author: The University of Texas at Austin, Department of Health Outcomes and Pharmacy Practice, 1 University Station A1930, 2409 University Ave, PHR 3.210C, Phone (512.471.5604), Fax (512.471.8762), Email: kentya.ford@austin.utexas.edu.
Table 1: Demographic and Sample
Statistics (N=540)

Gender                N (%)

  Male               184 (34)
  Female             356 (66)

Age (in years)

  18                 265 (49)
  19                 182 (34)
  20                  38 (7)
  21                  25 (5)
  22                  7 (1)
  23                  5 (1)
  24 and over         17 (3)


  Freshman           415 (77)
  Sophomore          85 (16)
  Junior              29 (5)
  Senior              11 (2)

Vaccination Status

  Yes                91 (17)
  No                 443 (83)

Table 2: Prevalence of exposure to direct and indirect motivating
factors by past H1N1 vaccination status

                                          Yes (%)      No (%)

Indirect (Indirect influences)

  Information online  **                 32 (35.2)   107 (24.2)
  News stories                           60 (65.9)   278 (62.8)
  Campus postings                        37 (40.7)   188 (42.4)
  H1NI brochures                         33 (36.3)   125 (28.2)

Direct (Direct influences)

  Healthcare providers **                42 (46.2)   76 (17.2)
  Family members and friends             30 (33.0)   132 (29.8)
  Friends are getting vaccinated (12a)   11 (12.1)   12.1 (30.7)
  Doctors **                             46 (50.5)   153 (34.5)
  Parents  **                            40 (44.0)   134 (30.2)

** p < .05

Table 3: Logistic Regression of Indirect and Direct Communication
Sources for H1N1 Vaccination Uptake #

                                Odds      95% C.I.    p-value


  Information online            1.725   1.040-2.861   0.035 *
  News stories                  1.238   0.753-2.033   0.400
  Campus postings               1.202   0.734-1.967   0.465
  H1NI brochures                1.569   0.950-2.591   0.079


  Healthcare providers          5.227   3.063-8.922   0.001 *
  Family members and friends    1.260   0.757-2.098   0.374
  Friends are getting           1.752   0.828-3.706   0.143
    vaccinated (12a)
  Doctors                       2.198   1.366-3.528   0.001 *
  Parents                       2.058   1.269-3.339   0.003 *

* Significant at p < .05
# Adjusted for age, gender, and university classification
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