Factors influencing the uptake of 2009 H1N1 influenza vaccine in a multiethnic Asian population

doi:10.1016/j.vaccine.2010.04.043

Vaccine

Volume 28, Issue 28, 17 June 2010, Pages 4499-4505

https://doi.org/10.1016/j.vaccine.2010.04.043 Get rights and content

Abstract

The study aimed to determine factors influencing the uptake of 2009 H1N1 influenza vaccine in a multiethnic Asian population. Population-based, cross-sectional survey was conducted between October and December 2009. Approximately 70% of overall participants indicated willingness to be vaccinated against the 2009 H1N1 influenza. Participants who indicated positive intention to vaccinate against 2009 H1N1 influenza were more likely to have favorable attitudes toward the 2009 H1N1 vaccine. A halal (acceptable to Muslims) vaccine was the main factor that determined Malay participants’ decision to accept vaccination, whereas safety of the vaccine was the main factor that influenced vaccination decision for Chinese and Indian participants. The study highlights the challenges in promoting the 2009 H1N1 vaccine. Ethnic-sensitive efforts are needed to maximize acceptance of H1N1 vaccines in countries with diverse ethnic communities and religious practices.

Introduction

The World Health Organization (WHO) reports that as of 28 March 2010, more than 213 countries and territories have reported cases of 2009 H1N1 influenza pandemic, with at least 17,483 deaths [1]. Like most parts of the world, Malaysia was also affected by the 2009 H1N1 influenza. The first case of 2009 H1N1 influenza in Malaysia was reported on May 15, 2009. In the following weeks, exponential increases were observed, and the first death from 2009 H1N1 influenza was reported on July 23, 2009. The number of reported deaths reached its peak in mid-August, before tailing off in late September, 2009. Between July 23, 2009 and March 27, 2010, a total of 77 reported deaths were recorded.

Early vaccination against 2009 H1N1 influenza is cost-effective and may avert deaths [2]. Public acceptance of vaccination is a crucial factor in controlling the 2009 H1N1 influenza. To increase influenza vaccination rates, it is important to understand the motivators and barriers to vaccination. Previous studies reported that the acceptance of influenza vaccination is associated with socioeconomic factors, attitudes toward vaccination, perceived seriousness of influenza, perceived health risk, vaccine cost, and recommendations from authorities [3], [4], [5]. With regard to the new 2009 H1N1 vaccine, recent studies showed that cost and perceptions concerning safety and efficacy of the new vaccine strongly influenced intention to be vaccinated [6], [7], [8].

Relatively little is known about how multiethnic, multi-religious Asian countries such as Malaysia will respond to 2009 H1N1 vaccine. Malaysia has a diverse population of 27.7 million, of which the three main ethnic groups are the majority Muslim Malays (50.8%), Chinese (23.0%), and Indian (6.9%) [9]. Seasonal influenza vaccines are not routinely available for the Malaysian public. At the time of writing (April 3, 2010), limited supplies of the 2009 H1N1 vaccine were available at no cost to high-risk groups in the public and frontline healthcare staff.

As the 2009 H1N1 influenza was previously referred to as “swine flu”, it is not known how the Muslim community would react to the 2009 H1N1 vaccine, as the name might lead to the perception that the vaccine may contain porcine components that are not ‘halal’ (acceptable for use by Muslims). The term “swine flu” has impacted the Muslim community in our country. In our recent study, nearly one-third of the study participants, of which the majority (47.8%) were Malays, erroneously believed that 2009 H1N1 influenza is transmissible through eating improperly cooked pork products [10].

Therefore, this study assessed the attitudes of a predominantly Muslim, multiethnic Malaysian sample toward the 2009 H1N1 influenza and the influenza immunization. The ultimate aim was to determine factors influencing vaccine uptake, which may help increase public acceptance of 2009 H1N1 vaccine.

Section snippets

Sample

Interviews were conducted between October 6 and December 12, 2009 using a computer-assisted telephone interview (CATI) system. The study population comprised of Malaysian adults obtained using a random sample from the latest electronic residential telephone directory (2008) of Selangor state and Federal Territory of Kuala Lumpur. The sample was stratified by ethnicity. The Chinese and Indians were slightly oversampled to assure that analyses of disparities could be conducted with sufficient

Participant's characteristics

Fig. 1 provides the flowchart of the CATI process. A total of 4314 call attempts were made, resulting in 1025 responding households. The response rate computed as the number of completed interviews divided by the number of eligible and/or contacted households (1534) was 66.8%. Table 1 shows socio-demographic characteristics of the survey participants. Participants were in the age range 18–64 years, with a mean age of 39.50 (SD ± 13.27). Approximately 17% admitted to having a long-term medical

Discussion

Responses to knowledge items suggested that the study participants have a good general knowledge about the 2009 H1N1 influenza. The misconception that the 2009 H1N1 influenza can be spread by eating pork products, although relatively lower than our previous study [10] conducted approximately 2 months ago (26% vs. 31.3%), was prevalent. Ethnic differences in knowledge suggest that more vulnerable populations may be at a particular disadvantage when it comes to prevention of H1N1 influenza

Conclusion

Findings showed that majority of the people in Malaysia would accept the new 2009 H1N1 vaccine, but the decision to be vaccinated would largely depend on the assurance that the new vaccine is safe, and for Muslims, that it is halal. Findings suggest that ethnic-sensitive efforts may be needed to reach out to and gain acceptance of H1N1 vaccine in countries with diverse ethnic communities and religious practices.

Given the low psychological impact among the general population, campaigns to

Acknowledgements

The study is funded by University of Malaya (research grant RG186/10HTM), and the Ministry of Science, Technology and Innovation, Malaysia (grant 09-05-IFN-MEB-005).

Competing interests: The authors declare that they have no competing interests.

References (13)

World Health Organization. Pandemic (H1N1) 2009 – update 94 [accessed 3 April 2010]. Available at:...
N. Khazeni et al.
Effectiveness and cost-effectiveness of vaccination against pandemic influenza (H1N1) 2009
Ann Intern Med
(2009)
G.B. Chapman et al.
Time preferences and preventive health behavior acceptance of influenza vaccine
Med Decis Making
(1999)
Z. Kaufman et al.
Compliance with influenza vaccination in Israel in two successive winters, 1998/1999 and 1999/2000
Isr Med Assoc J
(2000)
S. Shahrabani et al.
The effects of socioeconomic factors on the decision to be vaccinated: the case of flu shot vaccination
Isr Med Assoc J
(2006)
J.T. Lau et al.
Acceptability of A/H1N1 vaccination during pandemic phase of influenza A/H1N1 in Hong Kong: population based cross sectional survey
BMJ
(2009)

There are more references available in the full text version of this article.

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Factors influencing the uptake of 2009 H1N1 influenza vaccine in a multiethnic Asian population

Abstract

Introduction

Section snippets

Sample

Participant's characteristics

Discussion

Conclusion

Acknowledgements

Effectiveness and cost-effectiveness of vaccination against pandemic influenza (H1N1) 2009

Ann Intern Med

Time preferences and preventive health behavior acceptance of influenza vaccine

Med Decis Making

Compliance with influenza vaccination in Israel in two successive winters, 1998/1999 and 1999/2000

Isr Med Assoc J

The effects of socioeconomic factors on the decision to be vaccinated: the case of flu shot vaccination

Isr Med Assoc J

Acceptability of A/H1N1 vaccination during pandemic phase of influenza A/H1N1 in Hong Kong: population based cross sectional survey

BMJ