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1.  Exploring Communication, Trust in Government, and Vaccination Intention Later in the 2009 H1N1 Pandemic: Results of a National Survey 
With the growing recognition of the critical role that risk communication plays in a public health emergency, a number of articles have provided prescriptive best practices to enhance such communication. However, little empirical research has examined perceptions of the quality of communication, the impact of uncertainty on changing communication, use of information sources, and trust in specific government spokespersons. Similarly, although there is significant conceptual focus on trust and communication as important in vaccination intent and acceptance, little research has explored these relationships empirically. We conducted an online survey in late January 2010 with a nationally representative sample (N=2,079) that included Hispanic and African American oversamples. The completion rate was 56%. We found that public health officials were the most trusted spokespersons, with President Obama being the most highly trusted elected official. Demographic variables, including race, accounted for 21% of the variance in trust of the president. Perceptions of the quality of communication were high, including significant understanding of uncertainty and appreciation for officials' openness about evolving information. Other factors that contributed to vaccination acceptance were quality of communication, closely following the news, and confidence in the vaccine because of a role model effect of the Obama daughters' immunizations; these factors significantly increased trust in government actions. Because the challenges of communication often vary over the course of a pandemic, there is a consistent need to pay close attention to both communication content and delivery and prepare public health officials at all levels to be effective communicators.
Clear and consistent communication by public health and government spokespersons about vaccination during the 2009 H1N1 pandemic was important to the public's trust in government actions and increased the likelihood that people sought the vaccine. Public health officials were the most trusted spokespersons, with President Obama indicated as the most highly trusted elected official. Other factors that contributed to vaccination acceptance were the quality of the communication, closely following the news, and confidence in the vaccine because of a role model effect when President Obama had his daughters immunized.
doi:10.1089/bsp.2012.0048
PMCID: PMC3689165  PMID: 23617721
2.  The Social Ecological Model as a Framework for Determinants of 2009 H1N1 Influenza Vaccine Uptake in the US 
Research on influenza vaccine uptake has focused largely on intrapersonal determinants (perceived risk, past vaccine acceptance, perceived vaccine safety) and on physician recommendation. We utilized a social ecological framework to examine influenza vaccine uptake during the 2009 H1N1 pandemic. Surveying an adult population (n=2079) in January 2010 with significant oversamples of African Americans and Hispanics, we found that 18.4% (95% CI 15.6–21.5) had gotten the 2009 H1N1 vaccine. Variables at each level of the social ecological model were significant predictors of uptake as well as of intent to get the vaccine. The intrapersonal level explained 53%, the interpersonal explained 47%, the institutional level explained 34%, and the policy and community levels each explained 8% of the variance associated with vaccine uptake. The levels together explained 65% of the variance, suggesting that interventions targeting multiple levels of the framework would be more effective than interventions aimed at a single level.
doi:10.1177/1090198111415105
PMCID: PMC3916095  PMID: 21984692
social ecological model; vaccine; health behavior; risk communication
3.  The Vagaries Of Public Support For Government Actions In Case Of A Pandemic 
Health affairs (Project Hope)  2010;29(12):2294-2301.
Government health measures in a pandemic are effective only with strong support and compliance from the public. A survey of 1,583 US adults early in the 2009 H1N1 (swine influenza) pandemic shows surprisingly mixed support for possible government efforts to control the spread of the disease, with strong support for more extreme measures such as closing borders and weak support for more basic, and potentially more effective, policies such as encouraging sick people to stay home from work. The results highlight challenges that public health officials and policy makers must address in formulating strategies to respond to a pandemic before a more severe outbreak occurs.
doi:10.1377/hlthaff.2010.0474
PMCID: PMC3445335  PMID: 21134932
4.  Racial Disparities in Exposure, Susceptibility, and Access to Health Care in the US H1N1 Influenza Pandemic 
American journal of public health  2010;101(2):285-293.
Objectives
We conducted the first empirical examination of disparities in H1N1 exposure, susceptibility to H1N1 complications, and access to health care during the H1N1 influenza pandemic.
Methods
We conducted a nationally representative survey among a sample drawn from more than 60000 US households. We analyzed responses from 1479 adults, including significant numbers of Blacks and Hispanics. The survey asked respondents about their ability to impose social distance in response to public health recommendations, their chronic health conditions, and their access to health care.
Results
Risk of exposure to H1N1 was significantly related to race and ethnicity. Spanish-speaking Hispanics were at greatest risk of exposure but were less susceptible to complications from H1N1. Disparities in access to health care remained significant for Spanish-speaking Hispanics after controlling for other demographic factors. We used measures based on prevalence of chronic conditions to determine that Blacks were the most susceptible to complications from H1N1.
Conclusions
We found significant race/ethnicity-related disparities in potential risk from H1N1 flu. Disparities in the risks of exposure, susceptibility (particularly to severe disease), and access to health care may interact to exacerbate existing health inequalities and contribute to increased morbidity and mortality in these populations.
doi:10.2105/AJPH.2009.188029
PMCID: PMC3020202  PMID: 21164098
5.  Assessing Perceptions of and Responses to Multiple Health Risks Among the Southern Poor 
Preventing Chronic Disease  2010;8(1):A11.
Introduction
We explored perceptions of and responses to multiple health risks among people living in poverty in the southern United States.
Methods
We conducted 12 focus groups and interviewed 66 focus group participants in 3 southern US cities (Birmingham, Alabama; Jackson, Mississippi; and Columbia, South Carolina). Thematic analysis was used to identify major themes.
Results
Study participants worried most about chronic health conditions and the costs to treat those conditions. Feelings of threat were influenced by family health history and race. Barriers to health-protective behaviors included time, work, family, apathy, and low response efficacy. Physical activity and checking blood pressure were the health-protective behaviors in which participants most often engaged.
Conclusion
Our results will be useful for the development of interventions that target the southern poor. Intervention messages should address the barriers that poor people face when attempting to engage in health-protective behaviors and should help strengthen people's confidence in their ability to change their behaviors.
PMCID: PMC3044022  PMID: 21159223
6.  Public Willingness to Take a Vaccine or Drug Under Emergency Use Authorization during the 2009 H1N1 Pandemic 
On April 26, 2009, the United States declared a public health emergency in response to a growing but uncertain threat from H1N1 influenza, or swine flu. In June, the World Health Organization declared a pandemic. In the U.S., hospitalizations due to swine flu numbered 6,506 on August 6, 2009, with 436 deaths; all 50 states have reported cases. The declaration of a public health emergency, followed by the approval of multiple Emergency Use Authorizations (EUAs) by the Food and Drug Administration, allowed the distribution of unapproved drugs or the off-label use of approved drugs to the public. Thus far, there are 2 antiviral medications available to the public as EUA drugs. It is possible that an H1N1 vaccine will be initially released as an EUA in the fall in the first large-scale use of the EUA mechanism. This study explores the public's willingness to use a drug or vaccine under the conditions stipulated in the FDA's nonbinding guidance regarding EUAs. Using Knowledge Networks' panel, we conducted an internet survey with 1,543 adults from a representative sample of the U.S. population with 2 oversamples of African Americans and Spanish-speaking Hispanics. Our completion rate was 62%. We examined willingness to accept an EUA drug or an H1N1 vaccine, the extent of worry associated with taking either, the conditions under which respondents would accept an EUA drug or vaccine, and the impact of language from the EUA fact sheets on people's willingness to accept a drug for themselves or their children. We also examined the association among these variables and race/ethnicity, education level, trust in government, previous vaccine acceptance, and perceived personal consequences from H1N1 influenza. These results provide critical insights into the challenges of communicating about EUA drugs and vaccine in our current pandemic.
doi:10.1089/bsp.2009.0041
PMCID: PMC2998968  PMID: 19775200

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