It has been previously reported that there was a marked failure in the control effects of H1N1 to achieve increased coverage rates for pandemic influenza A (H1N1) vaccination among students and health care workers in different parts of the world [3
]. However, we have not found any report through literature search on knowledge and attitudes of University students towards the H1N1 influenza and vaccination program among Indian population and others during the post-pandemic phase. Therefore, we conducted this study to investigate student responses to H1N1 influenza and their attitudes towards vaccination during the post-pandemic phase and provide baseline data, which might be useful in response planning and management strategies.
Vaccination program was implemented by the health centre, VIT University for the students during September 2010 during the post-pandemic period. In the present study, we examined the knowledge, attitude and factors responsible for their willingness/unwillingness to accept the vaccine during the post-pandemic period (October 2010 to January 2011). This represents a good case for study and to the best of our knowledge, this is the first study to examine during the post-pandemic period and the findings will be important to formulate regulations for vaccine uptake. It was assumed that there would be a drastic outreach and knowledge on safety and side effects of the vaccine when the study was conducted. As a first step in examining the attitude, the vaccination acceptance rate was verified after the introduction in the university. The report acceptance rate of H1N1 vaccine in the survey group university students, during the four months was 12.7%. During the course of the 2009 H1N1 pandemic, a number of studies reported low coverage rates for H1N1 vaccination among Greek medical students (8%), health care workers from Spain (16.5%), Italy (18%), Scotland (49.6%), France (36.5%) and general population from China (10.8%) [9
]. It should be noted that the survey among Indian students was conducted at a post-pandemic period and still report a much lower uptake among university students. The acceptability of the H1N1 vaccine will depend upon the cost and also people have more concerns about the safety and effectiveness of the vaccine worldwide [17
]. In the present study, cost would not be a blocking factor for compliance with vaccination as it was given at an affordable price to the students in the VIT University and in India. The highest coverage for vaccination was found among females (p < 0.001) during the post pandemic phase. This is in contrast to the reported gender based differences in accepting H1N1 vaccination among health care workers in France and common people in France and Israel during the pandemic phase [15
]. The above studies were conducted during the pandemic phase of H1N1 influenza and the higher number of males intending to vaccinate in the future from our study group was surprising but comparable to the result observed among common people in France [19
]. It is interesting to note that majority of the participants who had vaccination or intending to vaccinate were from the school of Bio-sciences and Bio-technology. This is quite similar to a study which reported a significant difference in the participant's attitude to get vaccinated or deny vaccination based on the school of their study in the pandemic phase [9
]. Even the H1N1 vaccination rate was higher among the biologists when compared to health care workers in Italy during the pandemic period [9
WHO recommends good hygiene as the preventive measure in limiting the spread of H1N1 influenza but limited evidence is available regarding the impact of wearing mask, cough etiquette and hand washing [3
]. Hygienic behavior is affected by many factors such as the timing of outbreak, self-risk perception, responsibility for others and personal habits [3
]. Students in the study group believed that wearing facemask followed by vaccine treatment are the most effective preventive measures. This is in contrast to the previous study reported by Akan and co investigators conducted among university students of Turkey during the pandemic period where a majority of them believed that quarantine followed by hand washing, and facemask were very effective preventive measures against H1N1 influenza [3
]. It is interesting to note that the majority of the participants among all the three groups (vaccinated, denied vaccination and intending to vaccinate) believed that H1N1 vaccine and wearing facemask will protect from H1N1 influenza. Most of the students in the study group believed that hand washing was moderately effective or low effective in preventive measures. In a previous study, it was stated that hand washing or wearing masks will not be as effective in comparison to vaccination as a preventive measures against H1N1 [22
]. Female students in Korea washed hands more frequently during the peak pandemic period of H1N1 influenza and perceived hand washing to be more effective [23
]. These differences could result from the study population demographics, the knowledge difference and might be the period of infection.
Several causes have been proposed for the low compliance to vaccination during the pandemic period [3
]. Passiveness, distrust about the vaccine, concerns about the safety and effectiveness, belief of being not in the risk population and assessment without knowing were top key elements in the attitude of our study group towards H1N1 vaccination. These were the major reasons reported for denial of vaccination among Greek medical students, Turkey university students, Health care workers from China and common population from France during the pandemic phase [3
]. At the time of the study during the post-pandemic period, there was much coverage about H1N1 vaccination in the media and various other information resources in India [5
]. Nevertheless, the high degree of rejection could be related to the varied subjective risk perception and high belief of the students in their ability to avoid infection during the post-pandemic period. Therefore, the vaccination was probably considered as being redundant. It should be noted that the study conducted among health care workers in public hospitals of Hongkong reported no change in the potential acceptance of vaccine at different WHO pandemic alert levels (pandemic alert phase 3 and 5) [24
]. Our study further reports no improvement in the acceptance of vaccine among students during the post-pandemic phase. The main reason for refusal of Indian students was fear of side effects of the vaccine, and it would be interesting to conduct studies in different groups across different countries during the post-pandemic phase.
In the present study, the self risk perception analysis showed a gender difference significantly and also more than 50% of the study group perceived the risk as moderate. It is possible that risk perception may have changed during the post-pandemic period. However, studies conducted during the peak point of the outbreak also have shown the negative attitude of the students with low self risk perception [3
]. In another study conducted in Australia, perception of susceptibility of university students significantly declined with the decline in the laboratory confirmed cases [7
]. In our study, the reasons for non-compliance that were stated by the respondents were not different when compared to other studies conducted during the pandemic period [3
]. The self-risk perception was higher in the females consistent with the previous study, and it is known that there exist some gender differences in the perceptions of environmental health risks [3
]. A cross-sectional questionnaire survey conducted among the common public in India during July-August, 2009 had shown that the males had significantly higher knowledge of H1N1 influenza compared to females, but it was females who had the significant positive attitude response towards H1N1 influenza [12
]. This is in contrast to a recent study conducted in middle and high school teachers of rural Georgia, where H1N1 vaccine acceptance was associated more with male gender [27
]. Our study shows similar perception to a study conducted in Korean University students during the peak-pandemic period where female participants perceived their personal susceptibility to H1N1 influenza as higher [23
]. Similar gender specific differences in the attitudes were reported in Chinese general population [16
]. Female participants showed higher self-risk perception and positive attitude towards vaccination in our study, and these findings are similar in both pandemic and post-pandemic period of H1N1 influenza in many study populations at different cultural backgrounds.
Knowledge and attitudes toward a pandemic are important in vaccine acceptance, and it is interesting to note that 99% of our study group knows about the outbreak of H1N1 in India and world. The seriousness of H1N1 influenza was agreed by the majority of the participants in both the group's i.e, vaccinated and those intending to vaccinate. It should be noted that this knowledge did not reflect in their actions to accept the available vaccine, and it could be possible that they have the attitude of not to worry about the disease in the future than the short term adverse effects of vaccination if any. Analysis of their knowledge on well established facts (Question 1, 2 and 3) showed the better response in the group which was vaccinated and intending to vaccinate. Majority of the students from vaccinated, and intending to vaccinate groups disagreed that the high risk individuals would highly benefit from H1N1 vaccination. We found that many of the answers from both groups (vaccinated and intending to vaccinate) reflected similar knowledge, perception of knowledge when compared to the non-vaccinated individuals. Similar findings were observed in other studies conducted during the pandemic phase of H1N1 influenza [16
The most important source of information regarding influenza pandemics was from the mass media [3
]. In the study of Kamate and coinvestigators conducted among Indians from State of Rajasthan, the maximum number of subjects obtained information related to influenza A (H1N1) from television [12
]. In our study, the major group of respondents said that they knew the information from media. At the time of our study there was much coverage about the influenza A (H1N1). Most of them were unwilling to accept H1N1 vaccination and it is apparent that public information about safety and effectiveness of the vaccine along with knowledge of the H1N1 influenza is crucial to meet the vaccination targets. It appears that students are less willing to have the vaccination during the post-pandemic period also. The reasons for unwillingness as stated by the respondents were not different from the ones given in the pandemic period when the new vaccine was launched. Our findings show that Indians require information on vaccine safety, and authorities should provide the necessary data to ensure the public confidence through media as it was the major source of information for them.
This study is unique because it was conducted among the students during the post-pandemic period to analyze their attitude difference in accepting the new vaccine. However, we realize that there are several limitations that require consideration. All the information obtained was self reported and reporting bias always exists. Although the data was collected from the heterogeneous group, we targeted students who are willing to participate and give their answers. We cannot reach all the students, and some did not return the questionnaire for varied reasons (20%). More importantly, there can be a fear factor among the students, if any ignorance of them will be pointed out in their answers. The student's opinion also can be unstable. Any unexpected event could lead to drastic change in their opinion about the vaccination.