The school district is a comprehensive preschool through 12th grade school district in the suburbs of a large city in Ohio. The district has 5 elementary schools, 1 middle school, and 2 high schools and serves nearly 7800 students. The study population for this evaluation consisted of all 841 paid full-time and part-time employees, including educational, administrative, and operational staff.

For the 2012–2013 influenza season, the influenza vaccine was offered by the school district in injection form to all employees. The vaccine was provided 1 afternoon in October 2012 at the central district office. Employees covered under the school district’s health insurance plan obtained the vaccine free of charge. Employees not covered under this plan obtained the vaccine for $25.99. The district’s insurance plan also covered influenza vaccination at physicians’ offices and many of the major retail pharmacy chains in the area.

Using a cross-sectional study design, we invited all employees in the school district to complete a Web-based survey. We used the survey tool in the EpiInfo™ 7 Publish Form to Web Service (Epi Info™, Atlanta, GA). The survey was available over a 3-week period from March 5–26, 2013. The survey link was sent to all school district employees at their work e-mail address by the district’s director of human resources with multiple reminders given over the 3 weeks.

The anonymous survey covered personal and work characteristics, pertinent medical history, and receipt of the 2012–2013 influenza vaccine. Demographic questions from the Behavioral Risk Factor Surveillance System Survey Questionnaire¹² and influenza vaccine practices questions adapted from the National 2009 H1N1 Flu Survey Questionnaire were included.¹³

We used the Theory of Planned Behavior, a widely accepted theory for predicting social and health behavior, in developing the survey.^14,15 The Theory of Planned Behavior states that a person’s attitude (positive or negative feelings toward a behavior), perception of subjective norms (the perception that there is social pressure to perform or not perform the behavior), and perceived behavioral control (the perception of choice and availability of resources necessary to perform or not perform the behavior) influence a person’s intention to perform the behavior.¹⁶

We designed questions drawing from the 3 domains of the Theory of Planned Behavior to assess knowledge about and attitudes toward the vaccine.¹⁶ Knowledge and attitudes questions were examined by extent of agreement with statements about the vaccine, using a 4-point Likert scale (ie, disagree, somewhat disagree, somewhat agree, and agree). Additional attitudes questions were examined using a 4-point scale with bipolar adjectives (eg, very good, somewhat good, somewhat bad, very bad).

Survey results were analyzed by using descriptive statistical methods such as frequencies, proportions, means, and standard deviations, as appropriate. Responses that used a Likert scale were categorized as “expressed agreement” if respondents marked “agree” or “somewhat agree,” and as “expressed disagreement” if respondents marked “disagree” or “somewhat disagree.” Internal consistency for the attitudes, subjective norms, and perceived behavioral control variables was analyzed using Cronbach’s coefficient (α) after adjusting for the directionality of items, when necessary. We created composite scores for variables within the attitudes, subjective norms, and perceived behavioral control domains where α > 0.6 by calculating the mean of the individual scores for each respondent.

Characteristics of school employees who reported receipt of the influenza vaccine were compared to those who denied receipt of the vaccine. Responses to the knowledge and attitudes questions were compared among each group. Bivariate analyses used the Student’s t-test, chi-square test, or Fisher’s exact test. We used logistic regression for the bivariate analyses of the composite scores for the attitudes, subjective norms, and perceived behavioral control domains. All tests were 2-tailed, and statistical significance was set at p < .05. We then used a multiple logistic regression model to identify factors independently associated with receipt of the vaccine. All analyses were conducted using CDC EpiInfo 7.1.1.0 with the exception of calculation of the Cronbach’s α, which used SPSS version 18.0 (SPSS Inc., Chicago, IL).

A total of 412 (49%) of 841 employees completed a survey. The median age of the respondents was 46 years, with a range of 22–71 years. Most (82%) of respondents were women. The median number of years worked in any school district was 15 years, with a range of 0–44 years. The median number of years worked in the current school district was 7 years, with a range of 0–41 years. Table 1 shows the demographic and work characteristics of survey respondents.

Of 394 respondents, 345 (88%) denied having medical conditions placing them at higher risk for influenza complications. Others reported asthma (5%), another lung disease (1%), diabetes mellitus (3%), heart disease (2%), and a weakened immune system caused by active cancer, a chronic illness, or by medicines taken for a chronic illness (4%).

We used self-reported height and weight of participants to calculate their body mass index. Of 386 respondents, 73 (19%) were classified as obese, which was defined as a body mass index ≥30. Regarding current mental health conditions, 28 (7%) reported having depression and 41 (10%) reported having anxiety. In total, 342 (86%) of 398 respondents indicated that they did not have either condition.

A total of 238 (58%) of 410 respondents reported getting the 2012–2013 influenza vaccine. A total of 245 (60%) of 411 respondents reported getting the 2011–2012 influenza vaccine the previous season; 212 (89%) of the 238 respondents getting the 2012–2013 influenza vaccine also reported getting the 2011–2012 vaccine. Of the respondents who received the 2012–2013 influenza vaccine, 68% received it by November 30, 2012. The most common place where respondents received the influenza vaccine was the school central district office (58%). Respondents also reported receiving the vaccine at a doctor’s office (15%), a pharmacy or drug store (15%), and other locations such as a hospital, other clinic, supermarket, or other nonmedical place (12%).

Vaccination coverage for the 2 largest occupational groups was 55% for teachers and 64% for aides/paraprofessionals. Vaccination rates for the other occupational groups ranged from 25% to 83% and are shown in Figure 1. In addition, 60% of respondents who reported an underlying high-risk medical condition and 59% of respondents classified as obese reported having received the influenza vaccine.

Of the 238 respondents who reported receiving the influenza vaccine, the most common main reason for receiving it was to protect oneself or one’s family (87%). Other reasons are shown in Table 2. Of the 172 respondents who had not received the influenza vaccine, the most common reason cited for not receiving it was “I don’t think I need the vaccine” (32%). Other reasons are shown in Table 3.

Most respondents had positive attitudes toward the vaccine, as most believed the vaccine to be “beneficial” (91%), “good” (92%), and “wise” (92%) versus “harmful,” “bad,” and “unwise.” The 3 attitude items had a Cronbach’s (or internal consistency) coefficient of α = 0.83. Thus, for subsequent analyses, we created an attitudes composite score by calculating the mean of the scores for the 3 items, with higher scores indicating positive attitudes.

Respondents’ beliefs about the influenza vaccine are shown in Table 4. Respondents’ agreement with subjective norm and perceived behavioral control statements about the vaccine is also shown in Table 3. These 7 subjective norms items (Table 4) had a Cronbach’s coefficient of α = 0.72. Thus, for subsequent analyses, we created 1 subjective norms composite score by calculating the mean of the scores for the 7 items, with higher scores indicating a greater perception of social pressure to get the vaccine. The latter 3 perceived behavioral control items (Table 4) had a Cronbach’s coefficient of α = 0.64. Thus, for subsequent analyses, we created 1 perceived behavioral control composite score for each vaccine by calculating the mean of the scores for the 3 items, with higher scores indicating a greater sense of perceived control.

We found no statistically significant associations between sex, race, ethnicity, highest education level, or annual household income and reporting receipt of the 2012–2013 influenza vaccine. However, respondents aged ≥50 years were more likely to have received the influenza vaccine than those aged <50 years (68% versus 51%, p = .001). Pregnancy, obesity, and having an underlying high-risk medical condition, anxiety, or depression were not significantly associated with receipt of the vaccine.

The mean number of years worked in the school district or in any school district was not significantly associated with receipt of the vaccine. Also, occupation and full-time status were not significantly associated with receipt of the vaccine. However, respondents with a primary workplace at the central district office, where the vaccine was administered, were more likely to have received the influenza vaccine than those who worked at other locations (81% versus 57%, p = .04).

Respondents who reported receiving the 2011–2012 influenza vaccine were more likely to have received the 2012–2013 influenza vaccine compared to those who did not (87% versus 16%, p < .001). Respondents who believed in the efficacy of the influenza vaccine were more likely to have received the vaccine than those who did not believe in its efficacy (69% versus 29%, p < .001). Respondents who believed that the vaccine could make them sick were less likely to have received the vaccine than those who did not (45% versus 77%, p < .001). Expressing agreement with the other belief statements in Table 4 was not significantly associated with receipt of the influenza vaccine.

Respondents with a higher (ie, more positive) attitudes composite score for the influenza vaccine were more likely to have received the vaccine (p < .001). Respondents with a higher subjective norms composite score for the influenza vaccine, or those who felt greater external pressure from others to get the vaccine, were times more likely to have received the vaccine (p < .001). In addition, respondents with a higher perceived behavioral control composite score for the influenza vaccine, or those who felt greater personal control over whether or not to get the vaccine, were more likely to have received the vaccine (p < .001).

Variables with p < .05 that were associated with receipt of the 2012–2013 influenza vaccine (except for receipt of the 2011–2012 influenza vaccine) were entered into a multiple logistic regression model to determine which ones were independently associated with receipt of the vaccine. Factors independently associated with receipt of the 2012–2013 influenza vaccine included having positive attitudes toward the vaccine (p < .001), feeling external pressure to get it (p < .001), and feeling personal control over whether or not to get it (p < .001). Believing that the vaccine could make them sick was independently associated with not receiving the vaccine (p = .03).

Our evaluation was subject to some limitations. First, respondents self-reported their receipt of the vaccine, and this may have been subject to recall errors. Vaccination was not validated by medical records. Second, our evaluation focused on employees of 1 suburban school district in Ohio, and our results may not be generalizable to employees in districts in urban and rural settings and in districts with more racial diversity. Third, our participation rate was 49%, despite multiple e-mail reminders from employer and teachers’ association representatives. We believe several factors may have contributed to this response rate. Because of initial technical difficulties, the Web survey was inaccessible over periods of time. Also, we did not have direct contact with all employees but relied on employer and teachers’ association representatives to disseminate the survey for us. This response rate raises the possibility that our results are not representative of all district employees, especially the operational employees, whose response rates (12–22%) were lower than those of the educational employees (55–61%). The response rate to our survey is higher than those seen in other electronic surveys (mean response rates between 19 and 40%), and lower rates are seen in larger surveys, workplace surveys, and surveys not offering incentives.^29–34 Nevertheless, it is possible that our survey was subject to selection bias, and that we may have overestimated or underestimated the influenza vaccination rate among district employees.

Influenza vaccination coverage among the responding school district employees was 58%. Beliefs that the vaccine was not effective or was not needed and the perception of not having enough time to get it were the most common reasons cited for not getting it. Factors independently associated with vaccine receipt were having positive attitudes toward the vaccine, feeling external pressure to get vaccinated, and feeling personal control over whether or not to get the vaccine. Our findings highlight the need to emphasize the benefits, safety, and effectiveness of vaccination and to make the vaccine more available at the workplace.

As a public health response, per the guidelines of United States Title 45 Code of Federal Regulations Part 46, this evaluation was determined to not require review by an institutional review board.