Knowledge, Attitudes, 

and Practices Regarding 

Influenza Vaccination 

Among Employees at Child 

Care Centers — Ohio

Marie A. de Perio, MD

Douglas M. Wiegand, PhD

Stefanie M. Evans, MA

Health Hazard Evaluation Report

HETA 2010-0025-3121

February 2011

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Disease Control and Prevention

Workplace

Safety and Health

 National Institute for Occupational 

Safety and Health

This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific 

facility evaluated and may not be universally applicable. Any recommendations made are not to be 

considered as final statements of NIOSH policy or of any agency or individual involved. Additional HHE 

reports are available at http://www.cdc.gov/niosh/hhe/
The employer shall post a copy of this report 

for a period of 30 calendar days at or near 

the workplace(s) of affected employees. The 

employer shall take steps to insure that the 

posted determinations are not altered, defaced, 

or covered by other material during such 

period. [37 FR 23640, November 7, 1972, as 

amended at 45 FR 2653, January 14, 1980].
Health Hazard Evaluation Report 2010-0025-3121 Page i

Report Abbreviations.......................................................................ii

Highlights of the NIOSH Health Hazard Evaluation............ iii

Summary .............................................................................v

Introduction..........................................................................1

Assessment.........................................................................7

Results.................................................................................9

Discussion .........................................................................25

Conclusions.......................................................................30

Recommendations.............................................................30

References ........................................................................36

Contents

Acknowledgments Acknowledgments and Availability of Report.....................43
Page ii Health Hazard Evaluation Report 2010-0025-3121

ACIP Advisory Committee on Immunization Practices

CDC Centers for Disease Control and Prevention

FDA Food and Drug Administration

GEE Generalized estimating equations

NAICS North American Industry Classification System

NAEYC National Association for the Education of Young Children

NIOSH National Institute for Occupational Safety and Health

pH1N1 2009 pandemic influenza A (H1N1)

VAERS Vaccine Adverse Event Reporting System

VSD Vaccine Safety Datalink

Abbreviations
Health Hazard Evaluation Report 2010-0025-3121 Page iii

What NIOSH Did

● We surveyed 384 employees at 32 licensed child care centers.

● We asked employees what they knew and thought about 

the two vaccines. We also asked whether they had gotten or 

planned to get the vaccines.

What NIOSH Found

● We found low rates of pH1N1 (12%) and seasonal influenza 

(25%) vaccination among child care center employees.

● The most common reasons for not getting either vaccine 

were beliefs that employees did not need the vaccine, that the 

vaccine did not work, and that the vaccine was not safe.

● People who had positive opinions about the vaccine or felt 

pressure from others to get the vaccine were more likely to 

have been vaccinated.

What Employers and Directors Can Do

● Work with the county health department or local healthcare 

providers to offer the vaccine at no cost at child care centers.

● Educate employees about the flu. Focus on employees’ risk 

of infection, the efficacy and safety of the vaccine, and their 

responsibility to get vaccinated.

● Consider requiring employees to get the flu vaccine as part 

of a comprehensive flu prevention program. If this is not 

feasible, encourage employees to get vaccinated.

What Employees Can Do

● Get the seasonal flu vaccine every year. Vaccination is the 

most effective way to avoid getting the flu, which can cause 

lost time from work, serious illness, and death.

● Stay informed. Get information about the flu and the flu 

vaccine from reliable sources.

In November 2009, the 

National Institute for 

Occupational Safety 

and Health (NIOSH) 

received a technical 

assistance request from 

the Department of Jobs 

and Family Services 

at an Ohio county. The 

request asked for NIOSH 

assistance in examining 

rates of 2009 pandemic 

influenza A (H1N1) 

(pH1N1) and seasonal 

influenza (also known as 

the flu) vaccination among 

employees at licensed 

child care centers in the 

county. The request also 

asked for assistance in 

assessing knowledge of 

and attitudes towards 

these two vaccines.

Highlights of the

NIOSH Health

Hazard Evaluation
Page iv Health Hazard Evaluation Report 2010-0025-3121

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Health Hazard Evaluation Report 2010-0025-3121 Page v

In November 2009, NIOSH received a technical assistance request 

from the Department of Jobs and Family Services at an Ohio 

county. The request asked for NIOSH assistance in examining rates 

of pH1N1 and seasonal influenza vaccination and in assessing 

knowledge of and attitudes towards these two vaccines among 

employees at licensed child care centers in the county.

We performed a cross-sectional survey among employees of 32 

randomly selected licensed child care centers. From January 30–

March 1, 2010, we surveyed employees about personal and work 

characteristics, pertinent medical history, receipt of or intention to 

receive the pH1N1 and seasonal influenza vaccines, and knowledge 

about and attitudes towards each vaccine.

Of 403 invited child care employees, 384 (95%) completed a 

survey. Forty-five (12%) respondents reported having received the 

pH1N1 vaccine. Eighty-five (22%) respondents reported having 

received the seasonal influenza vaccine. The most common reason 

for receiving either vaccine was to protect oneself or one’s family.

For both vaccines, among unvaccinated respondents, 19% reported 

that they intended to get the vaccine, and 81% reported that they 

did not intend to do so. The most common reasons cited for not 

intending to receive either vaccine were “I don’t think the vaccine 

will keep me from getting the flu” and “I don’t think I need the 

vaccine.”

Respondents who cared for toddlers or children 13 months–3 

years, had some college or higher as the highest level of education, 

had positive attitudes towards the vaccine, felt external pressure 

from others to get the vaccine, and felt personal control over 

whether or not to get the vaccine were more likely to have 

received the pH1N1 vaccine than those who did not have these 

characteristics. Respondents who believed in the efficacy of the 

vaccine, had positive attitudes towards the vaccine, felt external 

pressure from others to get the vaccine, and felt personal control 

over whether or not to get the vaccine were more likely to have 

received the seasonal influenza vaccine than those who did not 

have these characteristics.

We found that employees at child care centers in the county 

had low rates of pH1N1 and seasonal influenza vaccination. 

Misconceptions about the need for the vaccines and the efficacy 

and safety of the vaccines were the most common reasons cited for 

not receiving either vaccine.

NIOSH investigators 

examined the knowledge, 

attitudes, and receipt of 

seasonal influenza and 

pH1N1 influenza vaccines 

among child care center 

employees. We found 

low rates of pH1N1 

and seasonal influenza 

vaccination. The most 

common reasons for not 

receiving either vaccine 

included believing that 

employees did not need 

the vaccine, that the 

vaccine did not work, and 

that the vaccine was not 

safe.

Summary
Page vi Health Hazard Evaluation Report 2010-0025-3121

Summary (continued) Vaccination remains the most effective method to prevent 

influenza, which can cause lost work time, serious illness, and 

death. Annual influenza vaccination of all persons aged ≥ 6 

months is now recommended for the 2010–2011 influenza 

season. We recommend that efforts to improve vaccination 

rates among child care providers include notification of 

vaccination campaigns through media and public health messages 

addressing the most frequent antivaccination ideas. Educational 

interventions in the form of training that focuses on child care 

providers’ risk for infection, the efficacy and safety profile of the 

vaccine, and providers’ responsibility to get vaccinated should 

also be considered for this group. Employers should consider 

requiring influenza vaccination for their employees as part of a 

comprehensive influenza prevention program. If this is not feasible, 

then employers should encourage employees to get the vaccine.

Keywords: NAICS 624410 (Child Day Care Services), influenza, 

vaccination, child care, H1N1, pandemic, infection 
Health Hazard Evaluation Report 2010-0025-3121 Page 1

Introduction

On November 9, 2009, NIOSH received a technical assistance 

request from the Department of Jobs and Family Services at 

an Ohio county. The request asked for NIOSH assistance in 

examining rates of pH1N1 and seasonal influenza vaccination and 

in assessing knowledge of and attitudes towards these two vaccines 

among employees at licensed child care centers in the county.

Background on Licensed Child Care 

Centers in the County

The county is located in southwestern Ohio and covers 407 square 

miles. It contains a major metropolitan area, and its population 

was estimated to be 855,062 in 2009 [U.S. Census Bureau 2010]. 

In 2009, 4,332 child care facilities, including centers and homes, 

were licensed in Ohio and served 279,674 children. Approximately 

28,525 individuals are employed in these licensed facilities [ODJFS 

2009]. The Bureau of Child Care and Development in the 

Ohio Department of Jobs and Family Services is responsible for 

inspecting, licensing, certifying, and regulating child care facilities 

in the state.

As of January 2010, the county had 362 licensed child care centers 

with thousands of employees. Of these 362 centers, 135 served 

infants younger than 18 months. The Department of Jobs and 

Family Services at the county administers federal, state, and local 

programs in the areas of child support, children’s services, family 

and adult assistance, child care, adult protection, and workforce 

development. It contracts with more than 1,500 home providers 

and centers to cover part of the cost of child care for eligible lowand moderate-income families.

Child care centers in Ohio may participate in at least two voluntary 

quality control programs. NAEYC, an organization that focuses 

on the quality of education and developmental services for all 

children from birth through age 8, operates a national, voluntary 

accreditation program that has set professional standards for 

early childhood education programs since 1985. In the county, 

22 licensed child care centers participated in this accreditation 

program. Step Up To Quality is another voluntary quality rating 

system for Ohio Department of Jobs and Family Services-licensed 

child care programs. It recognizes early care and education 

programs that exceed quality benchmarks over and above Ohio’s 

licensing standards. In 2009, 880 early childhood programs in 
Page 2 Health Hazard Evaluation Report 2010-0025-3121

Introduction 

(continued) Ohio participated in the Step Up to Quality program. In the 

county, 64 licensed child care centers participated in this program 

in 2009.

Background on Influenza 

Influenza, commonly known as the flu, is a contagious respiratory 

illness caused by influenza viruses. Influenza viruses are thought 

to be spread mainly by droplets made when people with influenza 

cough, sneeze, or talk. Less often, a person might also get influenza 

by touching a surface or object that has influenza virus on it and 

then touching their own mouth, eyes, or nose [Wright and Webster 

2001]. Evidence for airborne transmission (or aerosolization of 

small particles that may remain suspended in air for long periods) 

also exists [Bridges et al. 2003; Blachere et al. 2009; Lindsley et al. 

2010a,b]. Influenza can cause mild to severe illness and can lead 

to death. Symptoms of influenza include fever, chills, cough, sore 

throat, runny or stuffy nose, muscle or body aches, headaches, 

fatigue, vomiting, and diarrhea [Nicholson 1992].

Complications of influenza include bacterial pneumonia, ear 

infections, sinus infections, dehydration, and worsening of chronic 

medical conditions [CDC 2010e]. Individuals at higher risk for 

developing influenza-related complications include children 

younger than 5 years (especially children younger than 2 years), 

adults 65 years of age and older, pregnant women, and people 

with chronic medical conditions (asthma; chronic lung disease; 

neurological conditions; heart disease; blood, endocrine, kidney, 

liver, and metabolic disorders; weakened immune system due 

to human immunodeficiency virus, cancer, or medication; and 

morbid obesity) [CDC 2010e]. In the United States, more than 

200,000 people each year are hospitalized for influenza-related 

illnesses [Thompson et al. 2004]. CDC estimates that from 1976 to 

2007, influenza-associated deaths ranged from a low of about 3,000 

to a high of about 49,000 people per year in the United States 

[CDC 2010a].

The pH1N1 virus, also referred to as “swine flu,” was first detected 

in humans in the United States in April 2009. On June 11, 2009, 

the World Health Organization signaled that a pandemic of 

pH1N1 was underway. The CDC estimated that, between April 

2009 and April 2010, 43–89 million cases of pH1N1, 195,000–

403,000 pH1N1-related hospitalizations, and 8,870–18,300 

pH1N1-related deaths occurred [CDC 2010i].
Health Hazard Evaluation Report 2010-0025-3121 Page 3

Introduction (continued) Spread of the pH1N1 virus is thought to occur in the same way 

that seasonal influenza spreads [CDC 2009a]. The symptoms of 

pH1N1 infection include fever, cough, sore throat, runny or stuffy 

nose, body aches, headache, chills, and fatigue. Some patients have 

vomiting and diarrhea; some patients have respiratory symptoms 

without a fever. Illness with the pH1N1 virus has ranged from 

mild to severe. While most people who have been sick have 

recovered without needing medical treatment, hospitalizations and 

deaths from infection with this virus have occurred. Many people 

hospitalized with the pH1N1 virus have had one or more medical 

conditions previously recognized as placing people at “high risk” 

of serious seasonal influenza-related complications, including 

pregnancy, diabetes, heart disease, asthma, and kidney disease 

[CDC 2009a]. In contrast to seasonal influenza, nearly 90% of 

deaths related to pH1N1 occurred among people younger than 65 

years of age [CDC 2010e].

Background on Influenza Vaccines 

Vaccination is the most effective method to prevent influenza 

and to prevent serious illness and death from influenza infection 

[Cox and Subbarao 1999; Nichol and Treanor 2006]. The FDA 

licensed the first pH1N1 vaccine in September 2009 [FDA 2009]. 

Since then, the FDA approved four pH1N1 vaccines produced 

by four manufacturers [FDA 2009]. All of these vaccines used the 

same licensure and manufacturing processes as those used for the 

production of the seasonal influenza vaccines. The 2009 pH1N1 

vaccine became available in the United States starting October 

2009. The pH1N1 vaccine was available as a live, attenuated 

monovalent vaccine for intranasal administration and as a 

monovalent, inactivated, split-virus or subunit vaccine for injection 

[CDC 2009f].

In July 2009, the ACIP recommended that certain groups of the 

general population receive the 2009 pH1N1 vaccine first [CDC 

2009b]. These target groups included:

● Pregnant women

● People who lived with or cared for children younger than 6 

months of age

● Healthcare and emergency medical services personnel

● Persons between the ages of 6 months and 24 years old
Page 4 Health Hazard Evaluation Report 2010-0025-3121

Introduction 

(continued) ● People aged 25–64 years who were at higher risk for 2009 

pH1N1 because of chronic health disorders or compromised 

immune systems

The ACIP recommended that children aged 6 months–9 years 

receive two doses separated by approximately 4 weeks, while 

persons aged ≥ 10 years should receive one dose [CDC 2009g]. 

The live attenuated influenza nasal vaccine was recommended for 

use in healthy, nonpregnant persons aged 2–49 years. It was not 

recommended for use in children aged < 2 years, adults > 49 years, 

pregnant women, or persons with underlying medical conditions 

that confer a higher risk for influenza complications [CDC 2009g].

In two large randomized clinical trials of the immune response 

to the pH1N1 vaccine in 410 children and 724 adults in the 

United States, researchers demonstrated the efficacy of the 

pH1N1 vaccine. After one vaccination, 92%–100% of adults 

were considered to be immune [Plennevaux et al. 2010]. Studies 

in the United Kingdom, Australia, China, and Hungary also 

demonstrated the efficacy of the pH1N1 vaccine [Clark et al. 2009; 

Greenburg et al. 2009; Liang et al. 2010; Vajo et al. 2010].

Studies in the United States found that no deaths or vaccinerelated serious adverse events occurred. Injection-site reactions 

(including pain, tenderness, and swelling) and systemic reactions 

(including fever, headache, and muscle aches) were reported, 

but no differences between vaccine and placebo groups occurred 

[Plennevaux et al. 2010].

In one published report, CDC reviewed vaccine safety results for 

the pH1N1 vaccines from two reports received through the U.S. 

VAERS and electronic data from the VSD, a large populationbased database. As of November 24, 2009, VAERS data revealed 

82 adverse event reports per 1 million pH1N1 vaccine doses 

distributed compared with 47 reports per 1 million seasonal 

influenza vaccine doses distributed [CDC 2009f]. No differences 

between pH1N1 and seasonal influenza vaccines were found 

in the types or proportion of serious reported adverse events. 

Thirteen deaths after receipt of the pH1N1 vaccine were reported. 

Significant underlying illness was reported in nine of these 

deaths, one death resulted from a motor vehicle accident, and the 

remaining three deaths are awaiting final review. Twelve reports of 

Guillain-Barre syndrome, an uncommon peripheral neuropathy 
Health Hazard Evaluation Report 2010-0025-3121 Page 5

Introduction (continued) that can cause paralysis and, in severe cases, respiratory failure 

and death, were identified by VAERS. Four of the reported cases 

met the official criteria for Guillain-Barre syndrome, four did not 

meet the criteria, and four are under review. The reported number 

of cases as of November 2009 was substantially smaller than the 

expected number for the general population. The VSD data 

showed no increase in monitored health events above background 

rates among recipients of the pH1N1 vaccine [CDC 2009f].

In another report, CDC reviewed data through March 31, 2010, 

from the Emerging Infections Program, which conducted active 

surveillance to assess the risk for Guillain-Barre syndrome after 

pH1N1 vaccination. These data showed that the rate of GuillainBarre syndrome following receipt of the pH1N1 vaccine was 

less than one excess Guillain-Barre syndrome case per 1 million 

vaccinations. This is similar to the rate following the receipt of 

some formulations of seasonal influenza vaccines [CDC 2010f].

The 2009–2010 seasonal influenza vaccine became available in 

August 2009. The seasonal influenza vaccines were also available 

as a live, attenuated vaccine for intranasal administration and as 

a trivalent, inactivated vaccine for injection [CDC 2009e]. This 

vaccine contained three strains: A/Brisbane/59/2007 (H1N1)-like, 

A/Brisbane/10/2007 (H3N2)-like, and B/Brisbane 60/2008-like 

antigens [CDC 2009e].

In July 2009, the ACIP updated its longstanding recommendations 

for seasonal influenza vaccination [CDC 2009e]. The groups 

targeted to receive the vaccine were similar to those for the 

2009 H1N1 vaccine but also included persons aged ≥ 50 years, 

residents of nursing homes and other long-term care facilities, and 

household contacts and caregivers of children aged < 5 years and 

adults aged ≥ 50 years, with particular emphasis on vaccinating 

contacts of children aged < 6 months. Target groups for both 

influenza vaccines included out-of-home child care providers.

The inactivated influenza injection vaccine can be used for any 

person aged ≥ 6 months, including those with high-risk conditions 

such as asthma, pregnancy, or immunosuppressive disorder. This 

vaccine is contraindicated and should not be administered to 

persons known to have anaphylactic hypersensitivity to eggs or 

to other components of the influenza vaccine [CDC 2010g]. The 

live attenuated influenza nasal vaccine may be used for healthy, 

nonpregnant persons aged 2–49 years [CDC 2009e].
Page 6 Health Hazard Evaluation Report 2010-0025-3121

Introduction 

(continued) The efficacy of influenza vaccines in adults has been shown to be 

70%–90% against confirmed influenza when the vaccine strains 

match the circulating strains [Fukuda et al. 2004]. Influenza 

vaccination has also been shown to reduce the rates of influenzalike illness, lost workdays, and physician visits in healthy, working 

adults when the vaccine and circulating viruses are similar [Nichol 

et al. 1995; Bridges et al. 2000].

The inactivated influenza injection vaccine contains inactivated 

viruses and cannot cause influenza in vaccine recipients [CDC 

2010g]. The most common side effect of seasonal influenza 

injection vaccines reported in adults is soreness at the injection 

site [Vellozzi et al. 2009]. Muscle pain, discomfort or weakness, 

and fever rarely occur. The live attenuated influenza nasal vaccine 

contains a weakened virus and cannot cause influenza in vaccine 

recipients. However, it can cause mild signs or symptoms including 

runny nose, nasal congestion, fever, or sore throat. These side 

effects are mild and short-lasting, especially when compared to the 

symptoms of seasonal influenza infection [CDC 2010g].

Child care providers are at risk of acquiring and transmitting 

influenza through their daily duties. Influenza can be spread 

quickly among children and providers in child care settings because 

children younger than 5 years of age are particularly vulnerable; 

they are constantly in close contact with one another and their 

providers; toys and other objects are often shared; and young 

children may not be able to wash their hands well or cover their 

mouth and nose when they cough or sneeze.

One study demonstrated the presence of influenza A virus on 

23%–53% of surfaces at 14 different day care centers tested over 

a 6-month influenza season in 2003 [Boone and Gerba 2004]. 

Although incidence of influenza and other respiratory infections 

among child care providers is unknown, several studies have 

demonstrated that children attending day care are at high risk for 

respiratory infections [Doyle 1976; Strangert 1976; Fleming et al. 

1987; Wald et al. 1988; Bell et al. 1989; Hurwitz et al. 1991].

Healthy People 2010, a national health promotion and disease 

prevention initiative, set the target seasonal influenza vaccination 

coverage rate for noninstitutionalized high-risk adults aged 18 to 64 

years at 60% [US DHHS 2000]. Data regarding seasonal influenza 

vaccination rates among child care providers is limited. In one 
Health Hazard Evaluation Report 2010-0025-3121 Page 7

Introduction (continued)

Assessment

of two published studies on this topic, researchers found that 

annual seasonal influenza vaccination rates ranged from 26%–51% 

among child care providers at one Pennsylvania child care center 

between 2002 and 2007 [Lee et al. 2008]. The authors attributed 

an increase in vaccination rates during this study to offering free 

on-site vaccination. In the other study, researchers found that 

providing an education program increased immunization rates 

among child care staff at five centers from 30% in 2002 to 60% in 

2003 [Hayney and Bartell 2005]. Review of the published medical 

literature has shown that information on knowledge of and 

attitudes towards influenza vaccination in this group is lacking.

Cross-Sectional Study 

We completed a cross-sectional survey of child care center 

employees to examine their knowledge, attitudes, and receipt of 

seasonal influenza and pH1N1 influenza vaccines. We also sought 

to determine factors that predict the likelihood of getting the 

vaccines.

We used the Theory of Planned Behavior [Ajzen 1991; Armitage 

and Conner 2001], a widely applied theory in predicting social and 

health behavior, in developing the questionnaire for our survey. 

A central factor in the Theory of Planned Behavior is that the 

individual’s intention to perform a given behavior is predictive 

of actual behavior [Azjen 1991]. The Theory of Planned Behavior 

states that a person’s attitude (positive or negative feelings towards 

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 the person’s intention to perform the 

behavior. When a person has a positive attitude towards a behavior 

and feels that others encourage the behavior and he or she has the 

choice and resources to perform the behavior, then intention to 

perform the behavior will typically be positive. Survey items were 

created to measure attitudes towards the vaccines, subjective norms 

regarding receiving the vaccines, and perceived behavioral control 

in receiving the vaccines to explore these relationships.
Page 8 Health Hazard Evaluation Report 2010-0025-3121

Assessment (continued) The questionnaire covered personal and work characteristics, 

pertinent medical history, and receipt of or intention to receive 

the pH1N1 and seasonal influenza vaccines. Demographic 

questions from the Behavioral Risk Factor Surveillance System 

Survey Questionnaire [CDC 2008] and influenza vaccine practices 

questions from the National 2009 H1N1 Flu Survey Questionnaire 

were used [CDC 2009d]. Questions drawing from the three 

variables of the Theory of Planned Behavior were also included 

to assess knowledge about and attitudes towards each vaccine 

[Francis et al. 2004]. Some knowledge and attitudes questions 

were examined by extent of agreement with statements about each 

vaccine, using a four-point Likert scale (i.e., disagree, somewhat 

disagree, somewhat agree, and agree). Other attitudes questions 

were examined using a four-point scale with bipolar adjectives 

(e.g. very good, somewhat good, somewhat bad, very bad). The 

questionnaire was anonymous and did not include any directly 

personal identifying information such as names or dates of birth.

The study population for this evaluation consisted of all employees 

working at randomly selected licensed child care centers in the 

county. All part-time and full-time employees ≥ 18 years old 

working at the facility on the date of our visit to the center were 

invited to participate. Thirty centers were selected randomly from a 

list of 135 licensed centers providing care to infants. An additional 

nine centers were selected 2 weeks later because five of the initial 

centers declined to participate. We contacted center directors via 

telephone, explained the objectives and methods of the evaluation, 

and invited the selected centers to participate. We set up one 

survey date for each center that agreed to participate.

Prior to the visit, each center director was sent an informational 

sheet by e-mail, fax, or mail to be distributed to employees. The 

informational sheet identified the purpose of the survey and when 

it would take place. We visited all participating child care centers 

from January 30– March 1, 2010. At the directors’ preference, visits 

were made during center nap hours or during staff meetings to 

ensure that participation did not interfere with child care.

During and after survey administration, information about center 

characteristics, including center type and number of employees 

were collected from center directors. Additional information about 

center characteristics, including Step Up to Quality rating, NAEYC 

accreditation, and child capacity was obtained from the Ohio 

Department of Jobs and Family Services website [ODJFS 2010].
Health Hazard Evaluation Report 2010-0025-3121 Page 9

Assessment (continued) Data Analysis 

Survey results were analyzed using descriptive statistical methods. 

Responses using 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 

measured using Cronbach’s coefficient (α) after adjusting for 

directionality. We created composite scores for variables within 

the attitudes, subjective norms, and perceived behavioral control 

domains where α > 0.7 by calculating the mean of the individual 

scores for each respondent.

Characteristics of child care center employees who reported receipt 

of each vaccine were compared to those who denied receipt of the 

respective vaccine. Among those employees who denied receipt of 

each vaccine, characteristics of employees who reported intention 

to receive each vaccine were compared to those who reported 

no intention to receive the respective vaccine. Responses to the 

knowledge and attitudes questions were also compared among each 

group. We conducted most bivariate analyses using the Student’s 

t-test, χ2test, 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. 

Bivariate analyses were conducted using SPSS (SPSS Inc., Chicago, 

Illinois). All tests were two-tailed, and statistical significance was 

set at P < 0.05. We then used a stepwise backward elimination 

multiple logistic regression model to identify factors independently 

associated with receipt of each vaccine. The reduced stepwise 

logistic regression model was then analyzed using a GEE model 

to account for the random effect of center with SAS 9.2 (SAS 

Institute, Cary, North Carolina).

Characteristics of Participating Child 

Care Centers 

Thirty-two (84%) of 38 invited licensed child care centers agreed 

to participate in the survey. One center had closed in December 

2009 although its name still appeared on the list of licensed centers 

in operation in January 2010. The six declining centers cited lack 

Results
Page 10 Health Hazard Evaluation Report 2010-0025-3121

Results (continued)

Demographic and Health Characteristics 

of Survey Respondents 

We visited all 32 participating child care centers and 384 (95%) 

of 403 employees ≥ 18 years old working on the day of the visits 

completed a survey. The median age of respondents was 30 years, 

with a range of 18–81 years. Most (97%) respondents were female, 

and 16 (4%) of responding females were pregnant at the time of 

the survey. The two racial groups most commonly represented 

were whites (52%) and blacks or African Americans (42%). Other 

demographic characteristics of survey respondents are shown in 

Table 2.

Regarding underlying medical conditions, 45 (12%) respondents 

reported having asthma or another chronic lung disease, 16 (4%) 

reported having heart disease (excluding high blood pressure), and 

14 (4%) reported having diabetes. In total, 315 (82%) respondents 

denied having an underlying medical condition that would put 

them at high risk for influenza-related complications. These 

conditions also included kidney disease, liver disease, current 

diagnosis of cancer, any immunosuppressive disease, and taking 

immunosuppressive therapy.

of interest and/or lack of time as reasons for not participating. 

Participating and declining centers had similar characteristics 

(Table 1). Most participating centers were for-profit (69%) and were 

independent or religiously-affiliated centers (75%). Four (12%) of 

centers were NAEYC accredited, and 12 (38%) of centers had a 

Step Up to Quality rating.

Table 1. Characteristics of participating and declining child care centers

Center Characteristic No. Participating Centers (%) 

n = 32

No. Declining Centers (%) 

n = 6

For profit 22 (69) 5 (83)

Center type

 Independent or religious affiliation 24 (75) 6 (100)

 Chain or corporate or university affiliation 8 (25) 0 (0)

Number of children capacity ≥ 100 15 (47) 2 (33)

Total number of employees ≥ 15 16 (50) 3 (50)

NAEYC accredited 4 (12) 0 (0)

Has Step Up to Quality rating 12 (38) 0 (0)
Health Hazard Evaluation Report 2010-0025-3121 Page 11

Results (continued)

Work Characteristics of Survey 

Respondents 

Most (85%) respondents were employed full time by their center. 

Most (62%) respondents reported caring for toddlers or children 

13 months–3 years old; 25% reported caring for young infants 0–5 

months; and 30% reported caring for older infants 6–12 months 

old. Fifty-one (13%) respondents reported not providing direct care 

to children. Other work characteristics are shown in Table 3.

Table 2. Demographic characteristics of survey respondents

Demographic Characteristic No. Respondents (%)

n = 363–384*

Female 371 (97)

Pregnant at the time of survey completion 16 (4)

Race

 Black or African American 161 (42)

 White 197 (52)

 Other† 23 (6)

Hispanic or Latino ethnicity 13 (4)

Household included: 

 One or more adults ≥ 18 years old‡ 306 (80)

 One or more children ≤ 5 years old 16 (4)

 One or more children 5–17 years old 204 (53)

Highest year of school completed

 High school graduate or GED or less 122 (32)

 Some college or technical school or higher 262 (68)

Annual household income

 < $35,000 233 (63)

 ≥ $35,000 135 (37)

*Sample sizes ranged from 363–384 because of missing values.

†Other race includes those respondents who selected American Indian or Alaska Native, Asian, Native 

Hawaiian or Pacific Islander, or “other” for race.

‡Respondents were asked to exclude themselves when answering this question.
Page 12 Health Hazard Evaluation Report 2010-0025-3121

Results (continued)

pH1N1 and Seasonal Influenza Vaccine 

Receipt, Beliefs, and Attitudes 

Forty-five (12%) respondents reported having received the pH1N1 

vaccine since October 2009. Rates of pH1N1 vaccination among 

respondents ranged from 0%–83% by child care center. Thirteen 

(41%) of the 32 centers had 0% pH1N1 vaccination rates among 

responding employees. The percentage of respondents receiving 

the pH1N1 vaccine by month is shown by the solid black line in 

Figure 1. Sixty percent of respondents who received the pH1N1 

vaccine received it by November 2009. Most (96%) respondents 

reported receiving the pH1N1 injection vaccine rather than the 

nasal spray. The most common places where respondents received 

the pH1N1 vaccine were a doctor’s office (35%) and the workplace 

(24%). Other places where respondents received the pH1N1 

vaccine are shown in Figure 2.

Table 3. Work characteristics of survey respondents

Work Characteristic No. Respondents (%)

n = 384

Full-time employment 325 (85)

Median years worked in child care (range) 6 (0–50)

Median years worked at center (range) 2 (0–38)

Ages of children cared for in job*

 0–5 months 95 (25)

 6–12 months 116 (30)

 13 months–3 years 237 (62)

 4 years and older 142 (37)

Did not provide direct care to children 51 (13)

Work at for-profit center 269 (70)

Type of center worked at 

 Independent or religiously-affiliated center 252 (66)

 Chain, corporate or university-affiliated center 132 (34)

Work at NAEYC accredited center 65 (17)

Work at center with Step Up to Quality rating 146 (38)

*Respondents could select more than one age group.
Health Hazard Evaluation Report 2010-0025-3121 Page 13

Results (continued)

Figure 1. Month when pH1N1 and seasonal influenza vaccines were received by respondents.

Figure 2. Pie chart displaying the locations where respondents received the pH1N1 vaccine by percentage.
Page 14 Health Hazard Evaluation Report 2010-0025-3121

Results (continued) Ninety-four (25%) respondents reported having received the 

seasonal influenza vaccine the previous year between October 2008 

and April 2009. Eighty-five (22%) respondents reported having 

received the 2009-2010 seasonal influenza vaccine since August 

2009. Rates of seasonal influenza vaccination among respondents 

ranged 0%–57% by child care center. Four (12%) of the 32 centers 

had seasonal influenza vaccination rates of 0% among responding 

employees. The percentage of respondents receiving the seasonal 

influenza vaccine by month is shown by the dashed black line in 

Figure 1. The majority of respondents (92%) who received the 

seasonal influenza vaccine received it by November 2009. Most 

respondents (98%) who received the seasonal influenza vaccine 

reported receiving the injection rather than the nasal spray. The 

most common places where respondents received the seasonal 

influenza vaccine were at a doctor’s office (45%) and a pharmacy 

or drug store (27%). Other places where respondents received the 

seasonal influenza vaccine are shown in Figure 3.

Figure 3. Pie chart displaying the locations where respondents received the seasonal influenza vaccine by 

percentage.

The most common reason for receiving the pH1N1 vaccine cited 

by respondents was protection of oneself or one’s family (54%). 

Other reasons cited are shown in Table 4. pH1N1 vaccination 

rates were 14% for respondents who cared for young infants (0–5 

months), 13% for those who cared for older infants (6–12 months 

old), 16% for those who cared for toddlers (13 months–3 years), 

and 11% for those who cared for children ≥ 4 years old.
Health Hazard Evaluation Report 2010-0025-3121 Page 15

Results (continued)

Twenty-five (7%) respondents reported receiving both the pH1N1 

and the seasonal influenza vaccines, 20 (5%) respondents reported 

receiving the pH1N1 but not the seasonal influenza vaccine, and 

60 (16%) respondents reported receiving the seasonal influenza but 

not the pH1N1 vaccine. A total of 278 (72%) respondents reported 

receiving neither influenza vaccine.

Of the 339 respondents who had not received the pH1N1 

influenza vaccine, 65 (19%) reported they would definitely 

(n = 15) or probably (n = 50) get one. In contrast, 274 (81%) 

reported they would definitely not (n = 127) or probably not

(n = 147) get one. Of the 298 respondents who had not received 

the seasonal influenza vaccine, 56 (19%) reported they would 

definitely (n = 13) or probably (n = 43) get one. In contrast, 

242 (81%) reported they would definitely not (n = 127) or probably 

not (n = 115) get one. One respondent did not answer this 

question. The most common reason cited for intending to receive 

either vaccine was to protect oneself or one’s family. Other reasons 

cited are shown in Table 5. The most common reasons cited for 

The most common reason for receiving the seasonal influenza 

vaccine cited by respondents was to protect oneself or one’s 

family (65%). Other reasons cited are shown in Table 4. Seasonal 

influenza vaccination rates were 17% for respondents who cared 

for young infants, 22% for those who cared for older infants, 28% 

for those who cared for toddlers, and 23% for those who cared for 

children ≥ 4 years old.

Table 4. Main reasons cited by respondents who received the pH1N1 or seasonal influenza vaccines

Main Reason Cited*

No. Respondents Who Received 

the pH1N1 Vaccine (%) 

n = 43†

No. Respondents Who Received 

the Seasonal Influenza Vaccine (%) 

n = 79‡

To protect myself/my family 23 (54) 51 (65)

My doctor recommended that I 

 receive the vaccine

 7 (16) 16 (20)

To protect the children I care for 6 (14) 5 (6)

My manager ecommended that I 

 receive the vaccine

 1 (2) 2 (3)

Other 6 (14) 5 (6)

*Respondents were asked to choose one main reason.

†Two respondents were excluded because they selected multiple reasons.

‡Six respondents were excluded because they selected multiple reasons or failed to select a reason. 
Page 16 Health Hazard Evaluation Report 2010-0025-3121

Results (continued) not intending to receive either vaccine were “I don’t think the 

vaccine will keep me from getting the flu” and “I don’t think I 

need the vaccine.” Other reasons cited are shown in Table 6.

Table 5. Reasons cited by respondents who intend to receive the pH1N1 or seasonal influenza vaccines

Reason Cited*

No. Respondents Who Intended 

to Receive the pH1N1 Vaccine (%) 

n = 65

No. Respondents Who 

Intended to Receive the 

Seasonal Influenza Vaccine (%) 

n = 55†

To protect myself/my family 50 (77) 38 (69)

To protect the children I care for 8 (12) 9 (16)

My doctor recommended that I 

 receive the vaccine

 3 (5) 5 (9)

My manager recommended that I

 receive the vaccine

 0 (0) 0 (0)

Other 4 (6) 3 (6)

*Respondents were asked to choose one main reason.

†One respondent did not answer this question.

Table 6. Main reasons cited by respondents for not receiving the pH1N1 and seasonal influenza vaccines

Main Reason Cited*

No. Respondents Who 

Did Not Intend to Receive 

the pH1N1 Vaccine (%)

n = 270†

No. Respondents 

Who Did Not Intend to 

Receive the Seasonal 

Influenza Vaccine (%)

n = 235‡

I don’t think I need the vaccine 67 (25) 73 (31)

I don’t think the vaccine will keep me from getting 

 the flu

43 (16) 69 (29)

The vaccine is not safe 42 (16) 13 (6)

I haven’t had time to get the vaccine 16 (6) 12 (5)

It costs too much to get the vaccine 8 (3) 6 (3)

I have already had the flu 4 (2) 5 (2)

I tried to get the vaccine but could not get it 4 (2) 2 (1)

I am allergic to the vaccine 3 (1) 2 (1)

I don’t know where to get the vaccine 3 (1) 2 (1)

Other 65 (24)§ 43 (18)¶

*Respondents were asked to choose one main reason. 

†Four respondents were excluded because they selected multiple reasons or failed to select a reason. 

‡Seven respondents were excluded because they selected multiple reasons or failed to select a reason. 

§The most common “other” reasons cited for not intending to receive the pH1N1 vaccine included “I don’t know 

enough about or have enough information on the vaccine,” “the vaccine is too new or was created too fast,” and 

“I just didn’t want it.” 

¶The most common “other” reasons cited for not intending to receive the seasonal influenza vaccine included “I 

just didn’t want it” and “the vaccine makes me sick or gives me the flu.”
Health Hazard Evaluation Report 2010-0025-3121 Page 17

Results (continued) Most respondents had positive attitudes towards both vaccines, 

as most believed both vaccines to be “beneficial,” “good,” and 

“wise” (Table 7) versus “harmful,” “bad,” and “unwise.” These 

first three measures of attitudes towards the pH1N1 vaccine had a 

high Cronbach’s (or internal consistency) coefficient of α = 0.879. 

Likewise, the same measures of attitudes towards the seasonal 

influenza vaccine had a high Cronbach’s coefficient of α = 0.865. 

Thus, for subsequent analyses, we created one positive attitudes 

composite score for each vaccine by calculating the mean of the 

scores for the three items.

Table 7. Attitudes of respondents towards the pH1N1 and seasonal influenza vaccines

Quality

No. Respondents who stated 

that the pH1N1 vaccine is... (%) 

n = 374–376*

No. Respondents that 

stated that the seasonal 

influenza vaccine is... (%) 

n = 373–374*

Beneficial 258 (69) 304 (82)

Good 267 (71) 301 (80)

Wise 254 (68) 297 (79)

*Samples sizes varied because of missing values.

Beliefs about the pH1N1 and seasonal influenza vaccines of all 

respondents who answered the respective questions are shown 

in Table 8. Most respondents believed that transmission of both 

pH1N1 and seasonal influenza could occur between children and 

child care providers and that both types of influenza were serious 

infections. However, most respondents had negative beliefs about 

both vaccines, including that they would make them sick and that 

they would not prevent them from getting influenza.

Table 8. Beliefs of respondents about the pH1N1 and seasonal influenza vaccines

Belief Statement

No. Respondents Who 

Expressed Agreement 

with Statement 

Regarding pH1N1 (%) 

n = 378–383*

No. Respondents 

Who Expressed 

Agreement with 

Statement Regarding 

Seasonal Influenza (%) 

n = 381–382*

Child care providers can spread __ flu to children 344 (90) 359 (94)

Children can spread __ flu to child care providers 361 (95) 360 (94)

__ flu is a serious infection 345 (91) 322 (85)

The __ vaccine could make me sick 322 (84) 319 (84)

The __ vaccine will prevent me from getting the __ flu 221 (58) 213 (56)

*Sample sizes varied because of missing values.
Page 18 Health Hazard Evaluation Report 2010-0025-3121

Results (continued) Respondents’ agreement with subjective norm statements about 

both vaccines is shown in Table 9. Some respondents chose not 

to answer specific questions; these were treated as missing values. 

Only one third of respondents believed that it was their duty to get 

either vaccine for their job. Less than half of respondents reported 

that their manager, doctor, or family and friends wanted them 

to get the vaccine, and fewer felt “social pressure” to get either 

vaccine. These seven subjective norms items regarding the pH1N1 

vaccine had a high Cronbach’s coefficient of α = 0.835. Similarly, 

these seven items regarding the seasonal influenza vaccine had a 

high Cronbach’s coefficient of α = 0.839. Thus, for subsequent 

analyses, we created one subjective norms composite score for each 

vaccine by calculating the mean of the scores for the seven items.

Respondents’ agreement with the perceived behavioral control 

statements about both vaccines is shown in Table 10. Most 

respondents felt that it was their decision whether or not to get 

each vaccine and were confident that they could get the vaccine if 

desired. Less than one third of respondents felt that they did not 

have the time or money to get the vaccine, and less than one fourth 

of respondents felt that getting the vaccine required a lot of effort. 

The latter three perceived behavioral control items regarding the 

pH1N1 vaccine had a high Cronbach’s coefficient of α = 0.733. 

Similarly, the latter three items regarding the seasonal influenza 

vaccine had a high Cronbach’s coefficient of α = 0.784. Thus, for 

Table 9. Agreement with subjective norm statements about the pH1N1 and seasonal influenza vaccines

Subjective Norm Statement

No. Respondents Who 

Expressed Agreement 

with Statement 

Regarding pH1N1 (%)

n = 364–383* 

No. Respondents 

Who Expressed 

Agreement 

with Statement 

Regarding Seasonal 

Influenza (%)

n = 364–381*

It is/was my duty to get the __ vaccine for my job 116 (30) 115 (30)

A majority of my coworkers have gotten or plan to get the 

 __ vaccine

 95 (26) 128 (35)

People who are important to me want(ed) me to get the

 __ vaccine 

115 (30) 125 (33)

My manager/employer wants(ed) me to get the __ 

 vaccine

 91 (24) 85 (23)

My doctor recommends(ed) that I get the __ vaccine 133 (35) 161 (43)

My family/friends want(ed) me to get the __ vaccine 106 (28) 121 (32)

I feel/felt social pressure to get the __ vaccine 83 (22) 63 (17)

*Sample sizes varied because of missing values.
Health Hazard Evaluation Report 2010-0025-3121 Page 19

Results (continued)

Factors Associated with Influenza 

Vaccine Receipt 

We found no statistically significant associations between age, sex, 

or race and reporting receipt of either the pH1N1 vaccine or the 

seasonal influenza vaccine. However, respondents of Hispanic 

or Latino ethnicity were more likely to have received the pH1N1 

vaccine than those not of Hispanic or Latino ethnicity (46% vs. 

10%, P < 0.01). Hispanic or Latino ethnicity was not significantly 

associated with receipt of the seasonal influenza vaccine.

Annual household income and whether or not a respondent’s 

household included adults and children ≤ 5 years old were not 

significantly associated with receipt of either vaccine. Respondents 

with children 6–17 years old in their household were more likely 

to get the seasonal influenza vaccine than those who did not have 

children 6–17 years old (29% vs. 16%, P < 0.01). Respondents 

whose highest level of education was some college or technical 

school or higher were more likely to have received the pH1N1 

vaccine than those whose highest level of education was high 

school graduate or less (15% vs. 5%, P < 0.01). Highest level of 

education was not significantly associated with receipt of the 

seasonal influenza vaccine.

subsequent analyses, we created one perceived behavioral control 

composite score for each vaccine by calculating the mean of the 

scores for the three items.

Table 10. Agreement with perceived behavioral control statements regarding the pH1N1 and seasonal influenza 

vaccines

Perceived Behavioral Control Statement

No. Respondents Who 

Expressed Agreement 

with Statement 

Regarding pH1N1 (%) 

n = 377–384*

No. Respondents Who 

Expressed Agreement 

with Statement 

Regarding Seasonal 

Influenza (%) 

n = 379–380*

It is/was my decision whether or not to get the __ vaccine 362 (94) 369 (97)

I am/was confident I could get the __ vaccine if I wanted 347 (91) 358 (94)

I do/did not have the time to get the __ vaccine 111 (29) 109 (29)

I do/did not have the money to get the __ vaccine 118 (31) 104 (27)

Getting the __ vaccine requires(ed) a lot of effort on my

 part

 98 (26) 95 (25)

*Sample sizes varied because of missing values.
Page 20 Health Hazard Evaluation Report 2010-0025-3121

Results (continued) Respondents who were pregnant at the time of survey 

administration were more likely to have received the pH1N1 

vaccine than those who were not (38% and 10%, P < 0.01). 

However, pregnancy was not associated with receipt of the seasonal 

influenza vaccine. Having an underlying medical condition, 

which includes diabetes, asthma, kidney disease, heart disease, 

liver disease, cancer, an immunosuppressive condition, and taking 

immunosuppressive therapy was not significantly associated with 

receipt of either vaccine.

The mean number of years worked in child care or at a particular 

center and whether or not a respondent provided direct care to 

children were not significantly associated with receipt of either 

vaccine. Respondents who worked part-time were more likely to 

have received the pH1N1 vaccine than those who worked full-time 

(24% vs. 10%, P < 0.01). Respondents who cared for toddlers (aged 

13 months–3 years) were also more likely to have received the 

pH1N1 vaccine than those who did not (16% vs. 5%, P < 0.01). 

Respondents who cared for young infants (aged 0–5 months) were 

less likely to have received the seasonal influenza vaccine than 

those who did not (14% vs. 25%, P < 0.01). The other age groups 

of children cared for among respondents were not significantly 

associated with receipt of either vaccine.

Respondents who worked at corporate or university-affiliated 

or chain child care centers were more likely to have received the 

pH1N1 vaccine (22% vs. 6%, P <0.01) and the seasonal influenza 

vaccine (29% vs. 19%, P = 0.02) compared to those who worked 

at independent or religiously-affiliated centers. Respondents 

who worked at NAEYC-accredited centers were more likely to 

have received the pH1N1 vaccine than those who worked at 

nonaccredited centers (28% vs. 8%, P <0.01). The other center 

characteristics, including nonprofit status, total children and 

employees, and Step Up to Quality rating, were not significantly 

associated with reporting receipt of either vaccine.

Respondents who believed in the efficacy of the pH1N1 vaccine 

were more likely to have received the vaccine than those who did 

not believe (17% vs. 4%, P < 0.01). Expressing agreement with the 

other belief statements in Table 8 was not significantly associated 

with receipt of the pH1N1 vaccine. Respondents who believed in 

the efficacy of the seasonal influenza vaccine were more likely to 

have received the vaccine than those who did not believe (33% vs. 

8%, P < 0.01) in its efficacy. Respondents who believed that the 
Health Hazard Evaluation Report 2010-0025-3121 Page 21

Results (continued) seasonal influenza vaccine could make them sick were also less 

likely to have received the vaccine than those who did not (20% 

vs. 34%, P = 0.01). Expressing agreement with the other belief 

statements in Table 8 was not significantly associated with receipt 

of the seasonal influenza vaccine.

Respondents with a higher positive attitudes composite score 

for the pH1N1 and seasonal influenza vaccines, or those who 

had more positive attitudes towards the vaccines were more 

likely to have received that vaccine (P < 0.01 for both vaccines). 

Respondents with a higher subjective norms composite score for 

the pH1N1 vaccine and the seasonal influenza vaccine, or those 

who felt external pressure from others to receive the vaccine 

were more likely to have received that vaccine (P < 0.01 for both 

vaccines). In addition, respondents with a higher perceived 

behavioral control composite score for the pH1N1 vaccine and the 

seasonal influenza vaccine, or those who felt personal control over 

whether or not to get the vaccine were more likely to have received 

that vaccine (P = 0.04 for the pH1N1 vaccine and P = 0.02 for the 

seasonal influenza vaccine).

Variables with P < 0.05 that were associated with receipt of the 

pH1N1 vaccine were selected and entered into a stepwise backward 

elimination multiple logistic regression model and then a GEE 

model to determine which ones were independently associated 

with receipt of the vaccine (Table 11). Factors independently 

associated with receipt of the pH1N1 vaccine included having 

some college or technical school or higher be the highest level of 

education (P < 0.01), caring for toddlers (P = 0.03), having positive 

attitudes towards the vaccine (P < 0.01), feeling external pressure 

to get the vaccine (P < 0.01), and feeling personal control over 

whether or not to get the vaccine (P = 0.04).
Page 22 Health Hazard Evaluation Report 2010-0025-3121

Results (continued)

Variables with P < 0.05 that were associated with receipt of 

the seasonal influenza vaccine were selected and entered into 

a stepwise backward elimination multiple logistic regression 

model and then a GEE model to determine which ones were 

independently associated with receipt of the vaccine (Table 12). 

Factors independently associated with receipt of the seasonal 

influenza vaccine included believing in the efficacy of the seasonal 

influenza vaccine (P < 0.01), having positive attitudes towards 

the vaccine (P < 0.01), feeling external pressure to get the vaccine 

(P < 0.01), and feeling personal control over whether or not to get 

the vaccine (P = 0.03). Caring for young infants (P = 0.02) and 

having children 6–17 years old in the household (P < 0.01) were 

independently associated with not receiving the vaccine.

Table 11. Variables associated with receipt of the pH1N1 vaccine entered into stepwise logistic regression 

model

Variable P value

Some college or higher as highest level of education <0.01

Full-time employment Not significant

Caring for children 13 months–3 months (toddlers) 0.03

Working at a chain, corporate or university-affiliated center Not significant

Believing in the efficacy of the pH1N1 vaccine Not significant

Positive attitudes composite score (i.e., having positive attitudes towards the 

pH1N1 vaccine)

<0.01

Subjective norms composite score (i.e., feeling external pressure to get the pH1N1 

vaccine)

<0.01

Perceived behavioral control composite score (i.e., feeling personal control over 

whether or not to get the pH1N1 vaccine)

0.04
Health Hazard Evaluation Report 2010-0025-3121 Page 23

Results (continued)

Factors Associated with Intention to 

Receive the Influenza Vaccines 

Among those respondents who reported they had not received 

the pH1N1 vaccine (n = 339), those who reported Hispanic or 

Latino ethnicity (57% vs. 18%, P < 0.01) and caring for toddlers 

aged 13 months–3 years (23% vs. 14%, P = 0.03) were more likely 

to report intention to receive the vaccine that those without these 

characteristics. In addition, those who reported believing that 

pH1N1 infection is a serious infection (21% vs. 0%, P < 0.01), 

believing in the efficacy of the vaccine (26% vs. 11%, P <0.01), 

and believing that the pH1N1 vaccine could make them sick (33% 

vs. 17%, P <0.01) were more likely to report intention to receive 

the vaccine than those without these beliefs. Similar to those that 

received the pH1N1 vaccine, those who reported having positive 

attitudes towards the vaccine (P < 0.01), feeling external pressure 

to get the vaccine (P < 0.01), and feeling personal control over 

whether or not to get the vaccine (P < 0.01) were more likely to 

have reported intention to receive the pH1N1 vaccine than those 

not reporting this.

Variables with P < 0.05 that were associated with intention 

to receive the pH1N1 vaccine were selected and entered into 

a stepwise backward elimination multiple logistic regression 

model and then a GEE model to determine which ones were 

Table 12. Variables associated with receipt of the seasonal influenza vaccine entered into stepwise logistic 

regression model

Variable P value

Not having children 6–17 years in the household <0.01

Not caring for children 0–5 months (young infants) 0.02

Working at a chain, corporate or university-affiliated center Not significant

Believing in the efficacy of the seasonal influenza vaccine <0.01

Believing that the seasonal influenza vaccine could make them sick Not significant

Positive attitudes composite score (i.e., having positive attitudes towards the seasonal 

influenza vaccine)

<0.01

Subjective norms composite score (i.e., feeling external pressure to get the seasonal 

influenza vaccine)

<0.01

Perceived behavioral control composite score (i.e., feeling personal control over 

whether or not to get the seasonal influenza vaccine)

0.03
Page 24 Health Hazard Evaluation Report 2010-0025-3121

Results (continued) independently associated with intention to receive the vaccine 

(Table 13). Factors independently associated with intention to 

receive the pH1N1 vaccine included caring for toddlers (P = 0.02), 

having positive attitudes towards the vaccine (P < 0.01), and feeling 

external pressure to get the vaccine (P < 0.01).

Table 13. Variables associated with intention to receive the pH1N1 vaccine entered into stepwise logistic 

regression model

Variable P value

Caring for children 13 months–3 months (toddlers) 0.02

Believing that pH1N1 is a serious infection Not significant

Believing in the efficacy of the pH1N1 vaccine Not significant

Believing that the pH1N1 vaccine could make them sick Not significant

Positive attitudes composite score (i.e., having positive attitudes towards the pH1N1 

vaccine)

<0.01

Subjective norms composite score (i.e., feeling external pressure to get the pH1N1 

vaccine)

<0.01

Perceived behavioral control composite score (i.e., feeling personal control over 

whether or not to get the pH1N1 vaccine)

Not significant

Among those who reported they had not received the seasonal 

influenza vaccine (n = 297), those who reported Hispanic or 

Latino ethnicity (62% vs. 17%, P < 0.01) and an annual household 

income of less than $35,000 (23% vs. 10%, P < 0.01) were more 

likely to have reported intention to receive the seasonal influenza 

vaccine than those without these characteristics. In addition, those 

who reported believing in the efficacy of the seasonal influenza 

vaccine (28% vs. 10%, P < 0.01), having positive attitudes towards 

the vaccine (P < 0.01), and feeling external pressure from other to 

receive the vaccine (P < 0.01) were more likely to have reported 

intention to receive the seasonal influenza vaccine than those 

without these beliefs and attitudes.

Variables with P < 0.05 that were associated with intention to 

receive the seasonal influenza vaccine were selected and entered 

into a stepwise backward elimination multiple logistic regression 

model and then a GEE model to determine which ones were 

independently associated with intention to receive the vaccine 

(Table 14). Factors independently associated with intention to 

receive the seasonal influenza vaccine included having an annual 

household income < $35,000 (P < 0.01), having positive attitudes 

towards the vaccine (P < 0.01), and feeling external pressure to get 

the vaccine (P < 0.01).
Health Hazard Evaluation Report 2010-0025-3121 Page 25

Results (continued)

Only 12% of responding child care center employees reported 

having received the pH1N1 vaccine since October 2009, and 

only 22% reported having received the seasonal influenza vaccine 

since August 2009. CDC’s ACIP initially recommended that 

caregivers for children younger than 6 months of age be included 

in the initial target group to receive the pH1N1 vaccine because 

young infants are at high risk for influenza complications, but 

influenza vaccines are not approved for children under 6 months 

old [CDC 2009d]. Despite these recommendations, only 14% 

of child care center employees caring for children 0–5 months 

received the pH1N1 vaccine. CDC’s 2009 ACIP recommendations 

include caregivers of children aged < 5 years in the target group 

for seasonal influenza vaccination [CDC 2009f]. Despite these 

recommendations, only 22% of child care center employees 

reported having received the seasonal influenza vaccine. This is 

well below the target vaccine rate of 60% for noninstitutionalized 

adults set forth by Healthy People 2010 [US DHHS 2000]. These 

findings demonstrate that vaccine promotion in this occupational 

group needs improvement.

No published studies regarding pH1N1 vaccination in child 

care center employees exist to date, and data regarding seasonal 

influenza vaccination rates among this group is limited. Our 

pH1N1 and seasonal influenza vaccine rates were lower than 

the seasonal influenza vaccine rates found by Lee and colleagues 

(26%–51% among child care providers at one Pennsylvania child 

care center between 2002 and 2007) [Lee et al. 2008]. In that 

study, the 51% vaccine coverage rate occurred during the year that 

free on-site vaccination was offered. Two thirds of those who were 

Discussion

Table 14. Variables associated with intention to receive the seasonal influenza vaccine entered into stepwise 

logistic regression model

Variable P value

Annual household income < $35,000 <0.01

Believing in the efficacy of the seasonal influenza vaccine Not significant

Positive attitudes composite score (i.e., having positive attitudes towards the 

seasonal influenza vaccine)

<0.01

Subjective norms composite score (i.e., feeling external pressure to get the seasonal 

influenza vaccine)

<0.01
Page 26 Health Hazard Evaluation Report 2010-0025-3121

Discussion (continued) vaccinated indicated that they would not have been vaccinated 

without the intervention, and one third stated they would not have 

been vaccinated if they needed to pay for it. Other studies have 

also shown that offering free vaccines to healthcare personnel leads 

to higher coverage rates [Ohrt and McKinney 1992; Thomas et al. 

1993; Nafziger and Herwaldt 1994; Nichol and Hauge 1997; Hall 

et al. 1998; Martinello et al. 2003].

Our vaccine rates were also lower than those found by Hayney 

and Bartell (30%–60% among child care staff at five centers in 

Wisconsin between 2002 and 2003) [Hayney and Bartell 2005]. In 

that study, the 60% rate occurred the year the authors conducted 

an education program as part of a regular staff or education 

meeting at each center. Findings from this study demonstrate 

that offering free on-site influenza vaccination and a vaccination 

education program as part of regular staff meetings may 

significantly increase vaccination rates in child care employees.

The vaccine rates of 12% for pH1N1 and 22% for seasonal 

influenza in our group of child care center employees are lower 

than those estimated by a national study of healthcare personnel, 

another group targeted for vaccination, (37% for pH1N1 and 

62% for seasonal influenza) as of mid-January 2010 [CDC 2010b]. 

The 12% pH1N1 vaccine rate among our group of child care 

center employees was also lower than that estimated for persons 

≥ 18 years in the state of Ohio, which was 18% [CDC 2010c]. 

The 22% seasonal influenza vaccine rate among our group of 

child care center employees was also lower than that estimated 

for persons ≥ 18 years in the state of Ohio, which was 41% [CDC 

2010d]. Because survey administration for this evaluation occurred 

in February, the discrepancy in vaccine rates between our child 

care center employees and the general adult population may be 

even greater. This discrepancy demonstrates the need for targeted 

marketing promoting influenza vaccination in this occupational 

group.

The most common main reason cited for receiving the pH1N1 

and seasonal influenza vaccines were to protect oneself and one’s 

family. The most common main reasons cited for not receiving the 

pH1N1 and seasonal influenza vaccine were “I don’t think I need 

the vaccine,” “I don’t think the vaccine will keep me from getting 

the flu,” and “the vaccine is not safe.” This suggests that the three 

major barriers to receiving either vaccine include that many child 

care employees do not believe themselves to be at risk for influenza, 
Health Hazard Evaluation Report 2010-0025-3121 Page 27

Discussion (continued) many do not think that the vaccine is effective, and many do not 

think the vaccine is safe.

These cited reasons are similar to those most commonly cited by 

respondents of a community study examining intent to receive the 

pH1N1 vaccine. These included the belief that they were unlikely 

to be infected, concern over vaccine side effects, and a perception 

that if infected the illness would be mild [CDC 2009c]. The most 

frequently cited reasons for nonvaccination with either vaccine 

among surveyed healthcare personnel in the national study were 

“I don’t need it” and “I may experience side effects” [CDC 2010b]. 

Concern about adverse reactions was the most common primary 

reason cited for not getting the seasonal influenza vaccine among 

registered nurses in one U.S. study [Clark et al. 2009]. Thus, these 

barriers are not exclusive to child care employees and are present in 

healthcare personnel and the general population.

More than 90% of respondents expressed agreement that child 

care providers and children can spread each influenza infection 

amongst each other and more than 80% of respondents expressed 

agreement that each influenza infection is serious. However, 25% 

and 31% of respondents cited “I don’t think I need the vaccine” 

as the main reason for not receiving the pH1N1 and seasonal 

influenza vaccines, respectively. This lack of perceived need has 

also been shown to be a common reason for influenza vaccine 

refusal in healthcare personnel [Norton et al. 2008] and should be 

addressed in vaccine promotion efforts.

Sixteen percent of respondents selected “I don’t think the pH1N1 

vaccine will keep me from getting the pH1N1 flu,” and 29% of 

respondents selected “I don’t think the seasonal influenza vaccine 

will keep me from getting the seasonal flu,” as the main reason for 

not getting each vaccine. However, 42% and 44% of respondents 

believed that the pH1N1 and seasonal influenza vaccines would 

not prevent them from getting the respective influenza infection. 

Thus, almost half of respondents doubt the efficacy of both 

vaccines. In addition, 84% of respondents believed that each 

vaccine “could make me sick” though influenza vaccination cannot 

cause influenza [CDC 2010g]. Belief in these commonly held 

influenza vaccine misconceptions was also found to be associated 

with influenza vaccine declination among healthcare personnel 

in other U.S. studies [Heimberger et al. 1995; Nichol and Hauge 

1997; Martinello et al. 2003; LaVela et al. 2004; Nowalk et al. 

2008; Hollmeyer et al. 2009].
Page 28 Health Hazard Evaluation Report 2010-0025-3121

Discussion (continued) Both the health departments of the county and the city held free 

vaccine clinics for residents throughout the winter. Despite this, 

almost one third of respondents felt that they did not have the 

money to get the pH1N1 and seasonal influenza vaccines, which 

suggests that these offerings were not widely known. Public health 

messages should emphasize that the vaccine will be offered at no 

cost when appropriate.

While pregnancy was significantly associated with receipt of 

each vaccine, reporting other medical conditions associated with 

a high risk of serious seasonal influenza-related complications 

was not. These conditions include diabetes; asthma; cancer; 

immunosuppressive conditions; and kidney, heart, and liver 

disease. This suggests that public health messages targeting vaccine 

promotion in these high risk groups may have been ineffective.

Our bivariate analyses revealed that employees working at 

corporate or university-affiliated child care centers and at chain 

child care centers were more likely to have received the pH1N1 

vaccine. Eleven (24%) of 45 respondents who received the pH1N1 

vaccine reported receiving it at the workplace. Ten of these 11 

respondents worked for the same university-affiliated child care 

center. This center had the highest pH1N1 vaccine rate of all of 

the centers at 83%, and 92% of respondents from this center 

expressed agreement that their manager/employer wanted them 

to get the pH1N1 vaccine. Thus, employer recommendations 

to obtain the vaccine and employer facilitation of receipt of 

the vaccine at the workplace seems to have greatly influenced 

vaccination rates among employees at this center. Employer 

requirement of influenza vaccine has been shown to be associated 

with higher rates of pH1N1 and seasonal influenza vaccination 

among healthcare personnel [CDC 2010b].

We found that self-reported pH1N1 vaccine rates (12%) were 

lower than those for seasonal influenza (22%) in child care center 

employees. Because the pH1N1 vaccine was not available before 

October 2009, this may have contributed to low vaccination levels 

among this group. In addition, respondents who reported no 

intention of receiving the pH1N1 cited reasons including, “I don’t 

know enough about or have enough information on the vaccine” 

and “the vaccine is too new or was created too fast,” as additional 

reasons not to get the vaccine. These are reasons unique to the 

pH1N1 vaccine and were likely a major reason why the pH1N1 

vaccine rate was lower than the seasonal influenza vaccine rate in 

this group.
Health Hazard Evaluation Report 2010-0025-3121 Page 29

Discussion (continued) Factors independently associated with receipt of each vaccine 

included having positive attitudes towards the vaccine, feeling 

external pressure to get vaccinated, and feeling personal control 

over whether or not to get the vaccine. These findings suggest 

that employees’ feelings towards the vaccines and perceptions 

about getting the vaccines were more predictive of receipt of each 

vaccine than demographic and work characteristics and underlying 

medical conditions. Perception of external pressure from managers 

and coworkers likely played a contributory role in the 13 centers 

that had 0% pH1N1 vaccination rates and 4 centers that had 0% 

seasonal influenza vaccination rates among employees.

Having positive attitudes towards the vaccines and feeling external 

pressure to get vaccinated were also independently associated with 

intention to receive each vaccine. Since perceiving pressure to get 

the vaccine from various sources was associated with receipt of and 

intention to receive each vaccine, physicians and employers should 

improve efforts to recommend influenza vaccination for child care 

center employees. Since less than one third of respondents felt 

it was their duty to get either vaccine for their job, public health 

messages emphasizing personal responsibility may also be effective.

Our evaluation was subject to some limitations. First, respondents 

self-reported their receipt of either vaccine, and this may have been 

subject to recall bias. Vaccination was not validated by medical 

records, and respondents may have confused receipt of the pH1N1 

and seasonal influenza vaccinations. Second, because the survey 

period was in early 2010 when pH1N1 and seasonal influenza 

vaccines were widely available, the accuracy of respondents’ 

intention to receive either vaccine is uncertain. Selection bias was 

not likely a limitation given our high participation rate of 95%.
Page 30 Health Hazard Evaluation Report 2010-0025-3121

Employees at child care centers in the county had low rates of 

pH1N1 and seasonal influenza vaccination. Factors associated 

with receipt of either vaccine included having positive attitudes 

towards the vaccine and feeling external pressure from others to 

get the vaccine. Misconceptions about the need for the vaccines 

and the efficacy and safety of the vaccines were the most common 

reasons cited for not receiving either vaccine. Efforts to improve 

vaccination rates among this occupational group should focus on 

eliminating the identified barriers and addressing antivaccination 

ideas.

A comprehensive strategy to prevent the spread of influenza 

in child care centers should include all of the following: 

vaccination of children and providers, hand hygiene, respiratory 

etiquette, observing children for symptoms of respiratory illness, 

and encouraging sick children and employees to stay home. 

Vaccination is a pivotal part of this comprehensive strategy and 

is the most effective method to prevent serious illness and death 

from influenza infection [Cox and Subbarao 1999; Nichol and 

Treanor 2006]. Vaccination has been shown to reduce illness and 

absenteeism caused by influenza. Child care center employees 

should receive influenza vaccination to protect themselves, their 

families, and the children whom they care for from influenza. 

Annual influenza vaccination is now recommended for all persons 

aged ≥ 6 months who do not have contraindications to vaccination 

for the 2010–2011 influenza season [CDC 2010g]. The 2010–2011 

trivalent vaccines will protect against pH1N1 and two other 

influenza viruses [CDC 2010g].

The three key phases to a successful vaccination campaign are 

notification, education, and vaccination [Hofmann et al. 2006]. 

Based on our findings, we recommend actions corresponding 

to these key phases and list them below to increase influenza 

vaccination rates among employees at child care centers.

Recommendations

Conclusions
Health Hazard Evaluation Report 2010-0025-3121 Page 31

Recommendations

(continued) Recommendations for the County 

Department of Jobs and Family Services 

and County Public Health

1. Keep child care center employees and the general population 

informed of vaccination campaigns through television 

spots, local newspapers, radio stations, Internet postings, 

mass e-mails, and social networking sites. A community 

assessment conducted in North Carolina showed that 

knowledge about the pH1N1 vaccine was obtained from 

multiple sources: television (85%), newspapers (52%), radio 

(46%), the Internet (36%), and family or friends (35%) 

[CDC 2009c]. Communication through local newspapers, 

flyers, billboards, internet posting, radio station updates, 

television spots, and mass e-mailing also proved to be 

effective during the pH1N1 vaccination campaign in Skokie, 

Illinois [CDC 2010h]. Free influenza materials in print 

form, Web tools, badges and buttons, and video/audio tools 

can be downloaded from CDC at http://www.cdc.gov/flu/

freeresources/.

2. Address the most frequent antivaccination ideas in public 

health messages. Such concepts include the perceived low 

risk for infection, perceived lack of vaccine efficacy, and lack 

of knowledge of vaccine safety. Messages should address 

these issues and emphasize that the vaccine is offered at no 

cost by the county at various locations. Develop targeted 

messages for child care employees about their job-associated 

risks of infection and the importance of vaccination in 

keeping themselves, their families, the children they care for, 

and their coworkers healthy.

3. Continue to offer free training and consultation services 

to child care centers by the Healthy Child Care Ohio 

program through the county Public Health. These services 

should also be advertised by the county Department of 

Jobs and Family Services to ensure that centers are aware of 

available resources. Consider offering more specific training 

on influenza to child care center employees. Training 

should educate child care employees about their risk for 

infection and severe illness as well as the efficacy and safety 

of the vaccine. Misconceptions about influenza and the 

vaccine should be debunked. Educational messages should 

emphasize that child care providers have a responsibility to 

themselves, their families, the children they care for, and 
Page 32 Health Hazard Evaluation Report 2010-0025-3121

Recommendations

(continued) their coworkers to get vaccinated. An education program 

focusing on information about vaccine-preventable diseases 

as part of a regular staff or education meeting was thought 

to be effective in increasing seasonal influenza vaccination 

rates in five centers in Wisconsin [Hayney and Bartell 2005].

4. Consider offering alternative education programs to those 

referenced in recommendation 3, which may consist of 

off-site seminars, educational films, informational sheets, or 

e-mail communications. These programs should include the 

components listed in the above recommendation.

5. Consider partnering to make influenza vaccination available 

and free at child care centers. Vaccinations should be 

offered to both staff members and to children. Almost one 

third of our surveyed child care center employees felt that 

they did not have the time to get either vaccine. Targeting 

this group by setting up vaccination clinics at 13 child 

care facilities proved to be effective during the pH1N1 

vaccination campaign in Skokie, Illinois [CDC 2010h].

6. Emphasize the importance of influenza vaccination among 

pregnant women and individuals with high-risk medical 

conditions in public health messages and in educational 

programs. These groups are at highest risk for developing 

influenza-related complications [CDC 2010e].

7. Emphasize the importance of influenza vaccination among 

employees who care for children 0–5 months old in public 

health messages and in educational programs. Young 

infants are at high risk for influenza complications, but the 

influenza vaccines are not approved for children under 6 

months old. Therefore, it is essential that those who provide 

care to young infants to get vaccinated to reduce the risk of 

influenza transmission.

Recommendations for Child Care Center 

Employers and Directors 

1. Recommend the influenza vaccine to all employees, 

especially among employees who care for children 0–5 

months old. Young infants are at high risk for influenza 

complications, but the influenza vaccines are not approved 

for children under 6 months old. Encourage employees 

to get vaccinated by including messages in e-mails, center 
Health Hazard Evaluation Report 2010-0025-3121 Page 33

Recommendations

(continued) newsletters, and enclosed in paychecks. Messages should 

be encouraging and highlight motivators such as protecting 

family members and the children for whom employees 

care. Suggested messages are “To protect the health of 

our children, as well as yourself and your family, it’s 

recommended that you get a flu shot,” and “Our children 

and families thank you for helping to keep the flu out of 

[facility name]. Get vaccinated!” or “Protect yourself, the 

children you care for, and your family from the flu by getting 

vaccinated!”

2. Take advantage of the free training and consultation 

services to child care centers offered by the county Public 

Health. This program is a partnership between the Ohio 

Department of Health and the Ohio Child Care Resource 

and Referral Association. A public health nurse serves 

as a Child Care Health Consultant and can provide 

free advice and training on a wide range of topics that 

includes immunizations and communicable diseases. 

More information about these services can be found by 

calling (513) 946-7881 or by going to the county Public 

Health website at http://www.hamiltoncountyhealth.org/

en/programs_and_services/community_health_services/

daycare_centers.html.

3. Obtain up-to-date information on clinics that offer the 

influenza vaccine, encourage your employees to obtain it, 

and share the information with them through e-mail, center 

newsletters, or informational sheets.

4. Identify an employee who can advocate for the receipt of 

the influenza vaccine to coworkers. Provide this employee 

“champion” with information regarding the benefits 

of influenza vaccination, and encourage this employee 

“champion” to share this information throughout the 

workplace. This has been shown to be effective in increasing 

influenza vaccination rates among healthcare personnel 

[Slaunwhite et al. 2009].

5. Develop an employee-management committee to explore 

creating a policy requiring employees to get the influenza 

vaccine as part of a comprehensive influenza prevention 

strategy. Implementing this requirement has been 

demonstrated to be effective among healthcare personnel 

[CDC 2010b].
Page 34 Health Hazard Evaluation Report 2010-0025-3121

Recommendations

(continued) 6. Develop an employee-management committee to explore 

the feasibility of offering seasonal influenza vaccination to 

employees at your child care center. The center with the 

highest pH1N1 vaccination rate of 83% in our evaluation 

offered the vaccine at the workplace. Offer the vaccine to 

employees at no cost whenever possible since almost one 

third of respondents in our evaluation felt that they did not 

have the money to get either vaccine. Consider partnering 

with the local health department or local healthcare 

providers.

7. Consider offering incentives to employees who get 

vaccinated. Suggestions include raffles of a “free” day off or 

gift cards. Attempts to create friendly competition among 

rooms to achieve the highest rates can be considered, and 

the winner could be rewarded with a prize such as a free 

lunch.

8. Obtain more information on other ways to prevent the 

spread of influenza at child care centers at http://www.cdc.

gov/flu/professionals/infectioncontrol/childcaresettings.

htm /.

Recommendations for Child Care Center 

Employees 

1. Get the seasonal influenza vaccine every year. The 

county Public Health is offering the 2010–2011 

seasonal influenza vaccine free of charge at various 

health clinics and community centers throughout the 

county. Vaccination locations can be found by going to 

the county Public Health flu shot location website at 

http://www.hamiltoncountyhealth.org/resourceSearch.

aspx?publish=1&lang=en&type=4 or by calling (513) 931-

SHOT. Additional information for flu shot providers 

nationwide can be found at http://www.flucliniclocator.

org/.

2. Stay informed. Obtain information about influenza and 

the influenza vaccine from reliable sources. The National 

Library of Medicine and the National Institutes of Health 

offer guidelines for evaluating the quality of health 

information at http://www.nlm.nih.gov/medlineplus/

evaluatinghealthinformation.html.
Health Hazard Evaluation Report 2010-0025-3121 Page 35

Recommendations

(continued) 3. Discuss other options for preventing influenza with your 

healthcare provider if you have any contraindications to 

receiving either the influenza injection or nasal vaccine.

4. Be an influenza vaccine “champion,” and encourage your 

coworkers to get the influenza vaccine.

5. Obtain more information on other ways to protect 

yourselves and prevent the spread of influenza at child care 

centers at http://www.cdc.gov/flu/school/.
Page 36 Health Hazard Evaluation Report 2010-0025-3121

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The Hazard Evaluations and Technical Assistance Branch 

(HETAB) of the National Institute for Occupational Safety and 

Health (NIOSH) conducts field investigations of possible health 

hazards in the workplace. These investigations are conducted 

under the authority of Section 20(a)(6) of the Occupational Safety 

and Health Act of 1970, 29 U.S.C. 669(a)(6) which authorizes 

the Secretary of Health and Human Services, following a written 

request from any employer or authorized representative of 

employees, to determine whether any substance normally found 

in the place of employment has potentially toxic effects in such 

concentrations as used or found. HETAB also provides, upon 

request, technical and consultative assistance to federal, state, and 

local agencies; labor; industry; and other groups or individuals to 

control occupational health hazards and to prevent related trauma 

and disease.

The findings and conclusions in this report are those of the 

authors and do not necessarily represent the views of NIOSH. 

Mention of any company or product does not constitute 

endorsement by NIOSH. In addition, citations to websites 

external to NIOSH do not constitute NIOSH endorsement of 

the sponsoring organizations or their programs or products. 

Furthermore, NIOSH is not responsible for the content of these 

websites. All Web addresses referenced in this document were 

accessible as of the publication date.

This report was prepared by Marie A. de Perio, Douglas M. 

Wiegand, and Stefanie M. Evans of HETAB, Division of 

Surveillance, Hazard Evaluations and Field Studies. Data 

management support was provided by Denise Giglio and Elizabeth 

Smith. Statistical support was provided by James Deddens. 

Editorial assistance was provided by Ellen Galloway. Desktop 

publishing was performed by Robin Smith.

Copies of this report have been sent to the county Department of 

Jobs and Family Services, the county Public Health, the state health 

department, management representatives at each participating 

child care center, and the Occupational Safety and Health 

Administration Regional Office. This report is not copyrighted and 

may be freely reproduced. The report may be viewed and printed at 

http://www.cdc.gov/niosh/hhe/. Copies may be purchased from 

the National Technical Information Service at 5825 Port Royal 

Road, Springfield, Virginia 22161.

Acknowledgments and

Availability of Report
Below is a recommended citation for this report:

NIOSH [2011]. Health hazard evaluation report: knowledge, attitudes and practices 

regarding influenza vaccination among employees at child care centers – Ohio. 

By de Perio MA, Wiegand DM, Evans SM. Cincinnati, OH: U.S. Department of 

Health and Human Services, Centers for Disease Control and Prevention, National 

Institute for Occupational Safety and Health, NIOSH HETA No. 2010-0025-3121.

To receive NIOSH documents or information about 

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E-mail: cdcinfo@cdc.gov

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 National Institute for Occupational 

Safety and Health