Parental Perceptions and Predictors of Consent for School-located Influenza Vaccination in Urban Elementary School Children in the United States

Susan Cheung; Hai-Lin Wang; Laurene Mascola; Alvin Nelson El Amin; Pia S. Pannaraj


Influenza Resp Viruses. 2015;9(5):255-262. 

In This Article

Abstract and Introduction


Background School-located influenza vaccination (SLV) programs have the potential to mass-vaccinate all enrolled children, but parental consent is required.

Objective To examine parental attitudes and determine predictors of parental consent for vaccination of schoolchildren through SLV programs.

Patients/Methods Surveys were distributed to parents of 4517 children during 2009–2010 (year 1) and 4414 children during 2010–2011 (year 2) in eight elementary schools in conjunction with a SLV program.

Results Participants included 1259 (27·9%) parents in year 1 and 1496 (33·9%) in year 2. Parental consent for 2009 H1N1, 2009 seasonal, and 2010 seasonal influenza vaccines was obtained from 738 (70·8%), 673 (64·5%), and 1151 (77·2%) respondents, respectively. During the 2009 pandemic, respondents concerned about influenza severity were twice as likely to consent for the 2009 H1N1 vaccination compared to unconcerned respondents (OR 2·04, 95% CI:1·19–3·51). During year 2, factors that predicted parental consent were the perception of high susceptibility to influenza infection (OR 2·19, 95% CI:1·50–3·19) and high benefit of vaccine (OR 2·23, 95% CI:1·47–3·40). In both years, college-educated parents were more likely to perceive vaccine risks (year 1: 83·6 versus 61·5%, P < 0·001 and year 2: 81·1% versus 60·6%, P < 0·001) and less likely to consent for seasonal influenza vaccine (year 1: OR 0·69, 95% CI:0·53–0·89 and year 2: OR 0·61, 95% CI:0·47–0·78) compared to non-college-educated parents.

Conclusions Parents who appreciate the risks of influenza and benefits of vaccination are more likely to consent for SLV. More research is needed to determine how to address heightened safety concerns among college-educated parents.


Schoolchildren, aged 5–18 years, represent the primary vector of influenza transmission in the community.[1,2] Influenza attack rates of 30–50% among schoolchildren are higher than those of adults, and children have longer periods of communicability compared to adults.[3] Societal burdens of influenza include excess medical visits, excess antibiotic use, school absenteeism, parental work absenteeism, secondary illness among family members, and mortality.[2,4–6] Improving vaccination rates among school-aged children will benefit the vaccinated children and reduce community-wide transmission of influenza.[7–10,2] Disease modeling of influenza pandemics suggests that vaccinating schoolchildren may be the most efficient approach to reduce overall numbers of infection.[11,12] For these reasons, the Center for Disease Control and Prevention (CDC)'s Advisory Committee on Immunization Practices expanded the recommendation for annual influenza vaccination to school-age children beginning in the 2008–2009 influenza season.[13] Since then, annual influenza vaccination coverage has increased yearly but still only reached 55% among children 5–17 years of age during the 2013–2014 season.[14]

School-located mass vaccination (SLV) programs have effectively increased influenza vaccination rates among children.[15–17] These programs increase access by offering vaccines during school hours and do not require parental presence during vaccine administration. However, parents play an important role in influenza prevention as they must consent for their children's vaccination. Most SLV programs in the United States vaccinate between 15% and 50% of students.[16,18] The SLV programs in Hawaii have achieved high statewide success. However, despite widespread availability, promotion and favorable media attention toward SLV programs, <50% vaccination rate has been achieved.[15]

Obtaining parental consent is a major obstacle for influenza vaccination in public schools.[19,20] Because parental perception influences their decision to allow their children to be vaccinated, it is important to understand these factors in an effort to increase consent rates. We conducted a cross-sectional survey to ascertain parental perceptions of influenza illness and influenza vaccinations and to determine predictors of consent for school-located vaccination in urban Los Angeles County schools over two influenza seasons.