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Human Vaccines & Immunotherapeutics
ISSN: 2164-5515 (Print) 2164-554X (Online) Journal homepage: http://www.tandfonline.com/loi/khvi20
Community awareness, use and preference for
pandemic influenza vaccines in Pune, India
Neisha Sundaram, Vidula Purohit, Christian Schaetti, Abhay Kudale, Saju
Joseph & Mitchell G Weiss
To cite this article: Neisha Sundaram, Vidula Purohit, Christian Schaetti, Abhay Kudale, Saju
Joseph & Mitchell G Weiss (2015) Community awareness, use and preference for pandemic
influenza vaccines in Pune, India, Human Vaccines & Immunotherapeutics, 11:10, 2376-2388,
DOI: 10.1080/21645515.2015.1062956
To link to this article: http://dx.doi.org/10.1080/21645515.2015.1062956
© 2015 The Author(s). Published with
license by Taylor and Francis Group, LLC©
Neisha Sundaram, Vidula Purohit, Christian
Schaetti, Abhay Kudale, Saju Joseph, and
Mitchell G Weiss
Accepted online: 25 Jun 2015.
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Community awareness, use and preference for
pandemic influenza vaccines in Pune, India
Neisha Sundaram
1,2,3,
*, Vidula Purohit
4,5
, Christian Schaetti
1,2
, Abhay Kudale
4,5
, Saju Joseph
4,5
, and Mitchell G Weiss
1,2
1
Department of Epidemiology and Public Health; Swiss Tropical and Public Health Institute; Basel, Switzerland;
2
University of Basel; Basel, Switzerland;
3
Saw Swee Hock School of
Public Health; National University of Singapore; National University Health System; Singapore, Singapore;
4
Centre for Health Research and Development; The Maharashtra
Association of Anthropological Sciences; Pune, Maharashtra, India;
5
Savitribai Phule Pune University; Pune, Maharashtra, India
Keywords: community study, India, influenza, mixed-methods, pandemic, vaccine hesitancy, vaccine uptake
Abbreviations: WHO, World Health Organization; IIV, Inactivated influenza vaccine; LAIV, Live attenuated influenza vaccine;
FGD, Focus group discussion; SSI, Semi-structured interview; IDI, In-depth interview; EMIC, Explanatory model interview
catalogue; USA, United States of America
Vaccination is a cornerstone of influenza prevention, but limited vaccine uptake was a problem worldwide during
the 2009–2010 pandemic. Community acceptance of a vaccine is a critical determinant of its effectiveness, but studies
have been confined to high-income countries. We conducted a cross-sectional, mixed-method study in urban and rural
Pune, India in 2012–2013. Semi-structured explanatory model interviews were administered to community residents
(n D436) to study awareness, experience and preference between available vaccines for pandemic influenza. Focus
group discussions and in-depth interviews complemented the survey. Awareness of pandemic influenza vaccines was
low (25%). Some respondents did not consider vaccines relevant for adults, but nearly all (94.7%), when asked, believed
that a vaccine would prevent swine flu. Reported vaccine uptake however was 8.3%. Main themes identified as reasons
for uptake were having heard of a death from swine flu, health care provider recommendation or affiliation with the
health system, influence of peers and information from media. Reasons for non-use were low perceived personal risk,
problems with access and cost, inadequate information and a perceived lack of a government mandate endorsing
influenza vaccines. A majority indicated a preference for injectable over nasal vaccines, especially in remote rural areas.
Hesitancy from a lack of confidence in pandemic influenza vaccines appears to have been less of an issue than access,
complacency and other sociocultural considerations. Recent influenza outbreaks in 2015 highlight a need to reconsider
policy for routine influenza vaccination while paying attention to sociocultural factors and community preferences for
effective vaccine action.
Introduction
Vaccination is a critical tool for controlling influenza.
When faced with a pandemic, swift deployment of vaccines is
crucial to limiting spread of the disease before the virus
acquires increased pathogenicity or antiviral resistance.
1
On
11 June 2009, the World Health Organization (WHO)
declared a global influenza pandemic caused by a novel influ-
enza A (H1N1) virus.
2
Effortsweremadetoensureadequate
supply of vaccines. Yet, lower-than-anticipated uptake of the
vaccine was a notable problem, even among high risk
groups.
3-7
Studies exploring vaccine hesitancy and reasons for
poor uptake that limit effectiveness of a pandemic response
have been largely restricted to high-income settings.
8-11
Despite acknowledged cross-cultural differences in public
response to pandemic influenza and need for country-specific
studies,
12,13
few have been conducted in lower income
settings.
A large burden of 2009 H1N1 influenza was borne by low-
income countries.
14,15
India reported 39,977 cases and 2,113
deaths from H1N1 influenza between May 2009 and August
2010.
16
These numbers, which refer to laboratory-confirmed
cases, are likely underestimated. The city of Pune, which suffered
high morbidity and mortality,
17-19
is incidentally home to a large
vaccine manufacturer, Serum Institute of India Ltd. Inactivated
influenza vaccine (IIV, injectable administration) and live attenu-
ated influenza vaccine (LAIV, nasal administration) were avail-
able for public purchase in Pune during the 2009 pandemic.
20
While IIVs alone are licensed for certain groups (children under
2 years, persons 50 years and above and pregnant women), both
© Neisha Sundaram, Vidula Purohit, Christian Schaetti, Abhay Kudale, Saju Joseph, and Mitchell G Weiss
*Corresponding author: Neisha Sundaram; Email: neisha.sundaram@unibas.ch
Submitted: 04/16/2015; Revised: 05/26/2015; Accepted: 06/12/2015
http://dx.doi.org/10.1080/21645515.2015.1062956
This is an Open Access article distributed under the terms of the Creative Commons Attribution-Non-Commercial License (http://creativecommons.org/licenses/
by-nc/3.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. The
moral rights of the named author(s) have been asserted.
2376 Volume 11 Issue 10Human Vaccines & Immunotherapeutics
Human Vaccines & Immunotherapeutics 11:10, 2376--2388; October 2015; Published with license by Taylor and Francis Group, LLC
RESEARCH PAPER
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types of vaccines are considered efficacious and safe for the larger
population.
21-27
Demand for vaccines varied widely in India. In some cases,
influenza vaccines were eagerly sought
28,29
but at other times
there were few takers.
30,31
This variability highlights the impor-
tance of understanding community acceptance and facilitators
and barriers for vaccine uptake. Although nasally administered
LAIV is generally considered less invasive than IIV by health pro-
fessionals, and it was available at a lower cost than IIVs in Pune,
it is nonetheless a relatively new form of vaccine administration
in India and questions arise about its community acceptability
for influenza vaccination. Addressing questions about commu-
nity preferences for one or other vaccine is likely to contribute to
our understanding of vaccine hesitancy or confidence in their
sociocultural context, which are critical determinants of effective
influenza vaccine action.
Acknowledging sociocultural differences and differences in
access to health services in urban and rural communities, we con-
ducted a mixed-method study in low-resource and middle-
income urban areas, and in accessible and remote rural areas of
Pune, India.
32
The first part of the study exploring community
understanding and experience of pandemic influenza has recently
been reported.
33
In this paper, we focus on the community-per-
ceived role of vaccines with the objectives of (a) determining
community awareness and views of pandemic influenza vaccina-
tion, (b) analyzing experience and reasons for vaccination or
non-vaccination against H1N1 influenza during the 2009 pan-
demic and (c) clarifying community perceptions and preferences
for either injectable or nasal influenza vaccines. A review of expe-
rience and community perceptions of vaccines for pandemic
influenza in India provides a unique opportunity to inform plan-
ning for other immunization initiatives and recurring influenza
outbreaks.
Results
Sample characteristics
Focusgroupdiscussions(FGDs)wereconductedinJuly
2012, semi-structured interviews (SSIs) from August to
December 2012 and in-depth interviews (IDIs) between
March and April 2013. Five FGDs (each with 5–6 partici-
pants), 12 IDIs and 436 SSIs have been analyzed (Table 1).
Among SSI respondents, those from the urban sites had
received more education and had higher incomes; more details
have been reported elsewhere.
33
Awareness of vaccines: in general and for pandemic influenza
Awareness of the role of vaccines in preventing illnesses
was noted: “A vaccine is given for prevention of an illness
which we may get in the future” (man, rural FGD). How-
ever, confusion about the preventive versus curative aspect of
vaccines was also noted among some respondents. For exam-
ple, a 65-year-old rural woman stated: “[By taking the vac-
cine] the illness could have been prevented and she would
have got cured” (SSI).
Vaccines were sometimes distinguished by their mode of
delivery. “It is an injection and it has medicine in it” (27 years,
rural woman, IDI). They were also explained by terms appropri-
ate for other vaccines that respondents were familiar with. A
woman during a FGD in a rural area explained her idea of a vac-
cine by stating: “We call it dose - triple, polio.”
Some respondents thought vaccines were relevant only for
children and expressed concern about their use for adults.
“All children are vaccinated. But adults are not vaccinated. I
think the vaccine is effective for ages 1 to 5. We don’t have
experience with vaccines being effective at later ages” (man,
rural FGD).
Over a quarter of respondents said they were aware of a vac-
cine administered as a nasal spray for swine flu (Table 2) There
was a significant difference in awareness based on age group (the
younger age group of 18–45 years had higher awareness than the
older age group of 46–65 years) and area of residence, with high-
est awareness in the urban middle-income area (47.1%) and low-
est in the remote rural area (8.3%). Slightly fewer respondents
(23.4%) reported awareness of an injectable vaccine to prevent
swine flu.
When respondents were asked whether they had received
advice regarding vaccines for swine flu from their health care pro-
viders, 15.8% of respondents reported that they had (Table 2).
A larger percentage of these respondents were from the younger
age group and from the urban sites.
Views on benefits and problems with pandemic influenza
vaccines
Respondents were asked whether they thought a vaccine
could have prevented swine flu. Most (94.7%) said yes, and
significantly more who said yes were from the younger age
group (97.3%) compared to the older age group (92.0%,
pD0.017).
An analysis of narratives indicated confidence and trust in vac-
cines by a large percentage of respondents. A 47-year-old man
who was confident of the benefits of a pandemic influenza vac-
cine stated: “[If he had taken the vaccine] he would have been
protected. Swine flu can happen only to those who have not
taken the vaccine” (rural SSI). A few raised concerns about the
efficacy of pandemic influenza vaccines, while maintaining their
support of vaccines in general. For example, an urban woman
said:
“Getting vaccinated is definitely a good thing but I am not
sure whether this vaccine is a proven one like other vaccines. I
knew 100 percent about the vaccines that were given in early
times but is there any data available for this new vaccine which
proves that those who have taken it have not got swine flu? If
someone asks me to take it, I won’t deny. I would believe in it
and would go for it” (45 years, SSI).
Some who thought vaccines were helpful nevertheless had a
fatalistic attitude toward the illness that did not preclude the vac-
cine. A 57-year-old urban woman explained: “The illness will
happen anyhow if it has to happen but there is no harm in taking
the vaccine” (SSI).
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Others, however, suggested that destiny made any precaution
including vaccines irrelevant: “It will happen if it is destined to
happen even if she maintains cleanliness or takes any other pre-
caution” (56 yr, woman, rural SSI). Very few distrusted the vac-
cine itself or had serious safety concerns.
Respondents were also specifically asked whether they knew of
any problems with either the nasal or injectable pandemic influ-
enza vaccines. Almost half (48.2%) said that nasal vaccines did
not cause any problems and a majority (56.7%) said the same
about injectable vaccines. Men were more likely than women to
say there was no problem with pandemic influenza vaccines, and
that perception was applicable to both nasal (57.7% men, 38.9%
women, p <0.001) and injectable (65.1% men, 48.4% women,
p<0.001) vaccines. A third of respondents were unable to say
whether nasal or injectable vaccines caused any problems. The
main anticipated problems for the nasal vaccine were discomfort
or irritation in the nose and throat (12.8%) and runny nose or
sneezing (4.4%). For injectable vaccines, identified problems
included pain or swelling (8.9%) and fever or chills (3.7%).
Only one person anticipated a serious adverse effect of the vac-
cines, and this person who lived in the urban low-resource area,
said death might result from receiving the vaccine.
Experience with pandemic influenza vaccines
Of the 436 SSI respondents, 8.3% reported having personally
received a pandemic influenza vaccine and 10.6% said someone
else in their household had taken it (Table 2). The urban mid-
dle-income area had the highest proportion of vaccine acceptors,
while the remote rural area had the lowest proportion. The more
accessible rural area had more vaccine acceptors than the low-
resource urban area.
Reasons for vaccine use
Narratives of those who had indicated household experi-
ence with the pandemic influenza vaccine (either personal use
or someone else in the household who received it), were ana-
lyzed to identify key reasons for vaccine uptake. Salience,
Table 1. Summary of sample characteristics
Number of participants
Focus group
discussion (FGD)
a
,
nD28
Semi-structured
interview (SSI),
nD436
In-depth
interview
(IDI), nD12
Age
b
18–25 5 76 1
26–35 5 85 5
36–45 5 62 2
46–55 4 119 1
56–65 3 94 3
Sex
Female 13 221 10
Male 15 215 2
Site
Urban 10 215 6
Rural 18 221 6
Area
Urban middle-income 5 102 5
Urban low-resource 5 113 1
Rural more accessible 6 113 6
Rural less accessible 12 108 0
a
Five focus groups were conducted, each with 5–6 participants. Two focus
groups were conducted with women, two with men and one with both
men and women.
b
Specific ages for one focus group with 6 participants at the rural site were
not collected. Hence, the total number of participants categorized by age
for the focus groups does not add up to 28.
Table 2. Awareness, health care provider recommendation and use of pandemic influenza vaccines
Overall (%) Age group (%)
a
Area of residence (%) Sex (%)
Younger Older P value
b
Urban
middle-
income
Urban
low-
resource
Rural more
accessible
Rural less
accessible P value
b
Female Male P value
b
nD436 n D223 n D213 n D102 n D113 n D113 n D108 n D221 n D215
Awareness of vaccines to prevent swine flu
Nasal vaccine
c
26.6 31.4 21.6 * 47.1 25.7 26.6 8.3 *** 25.8 27.4
Injectable vaccine
d
23.4 26.0 20.7 28.4 26.6 17.7 21.3 21.7 25.1
Recommendation by health care provider
To take a swine flu vaccine
e
15.8 20.6 10.8 ** 23.5 20.4 13.3 6.5 ** 13.1 18.6
Uptake of swine flu vaccine
Personal use
f
8.3 9.4 7.0 13.7 6.2 9.7 3.7 * 5.9 10.7
Others in household
g
10.6 NA NA 19.6 7.1 14.2 1.9 *** NA NA
a
Younger age group: 18–45 years, Older age group: 46–65 years; NA: Not applicable.
b
Fisher’s exact test was used to compare proportions across age groups, area of residence and sex: *p 0.05, **p 0.01, *** p 0.001.
c
Frequency of affirmative responses to the question: “Are you aware of a vaccine that is sprayed into a person’s nose to protect against swine flu?”
d
Frequency of affirmative responses to the question: “Are you aware of a vaccine that is injected into a person’s upper arm to protect against swine flu?”
e
Frequency of affirmative responses to the question: “Has your health care provider ever recommended your taking a vaccine to protect against swine flu?”
f
Frequency of affirmative responses to the question: “Have you ever taken a vaccine to prevent swine flu?”
g
Frequency of affirmative responses to the question: “Has anyone else in your household ever taken a vaccine to prevent swine flu?”
All questions were enquired in the local language, Marathi, and translations have been provided here.
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social and medical influences, and the influence of media
were discussed.
Salience of pandemic influenza: exposure to serious a swine flu-
related illness or death
The decision to vaccinate for pandemic influenza was strongly
motivated by having seen someone suffer from the illness or hav-
ing heard of a death from swine flu. A 31-year-old urban woman
explained: “My sister’s colleague’s son suffered from it. He is
alive but his friend who used to play with him died. When I
heard about this, I became seriously concerned and I vaccinated
my son” (IDI). A rural woman who had taken the vaccine
explained that fear drove her to action after a pregnant woman in
her village had died from swine flu:
“After one lady died and my son had swine flu, everyone was
scared. They felt that if this continues, everyone in the village
would die. Nobody from the government came here so members
of a youth group called a private doctor so that our villagers
would get the vaccine” (45 years, IDI).
She also recounted her experience at the hospital while caring
for her son with suspected swine flu illness as follows:
“I observed that when a person was admitted with breathless-
ness, that person would die immediately. Yes, I have seen such
people in Sassoon hospital. Once the person was taken inside the
ICU, only their dead body would come out. People were there-
fore preoccupied with fear.”
Social influence
Conduct of free vaccination camps in one’s neighborhood or
at school were reported as reasons for taking the vaccine. In a vil-
lage where a vaccination camp was conducted, peer effects
seemed to motivate vaccine uptake. A 45-year-old rural woman
explained: “Everyone in the village took the vaccine, so I also
took it to prevent anything before it happens” (IDI).
Medical influence
Recommendation by a health care provider in the family
influenced vaccine uptake for some. An urban woman explained
her reasons for taking the vaccine as follows: “The epidemic was
at a peak and my nephew is a doctor. He was giving the vaccine
to his friends and relatives. He is our close relative and we trust
that he will not cheat us.” (65 yr, IDI). Other connections with
the health system, such as working in a hospital, also influenced
vaccine uptake. An urban woman said: “I took the vaccine. I
work as a security guard in a private hospital. It was given free of
cost in our hospital (33 yr, SSI).
Influence of media
Information from media reports was an important factor for
people who actively sought the vaccine. An urban man explained:
“When I read the newspapers, I understood its seriousness, and
thought that I should not waste time and therefore took the vac-
cine immediately” (64 yr, IDI). But they acknowledged the
importance of information on where they could get vaccinated
from pamphlets from provided by the Pune Municipal Corpora-
tion or volunteers who came door-to-door. However, it was often
noted that while the media was a useful source of information,
doctors were consulted before taking the vaccine: “The media
was discussing availability of vaccines. But we didn’t rely on the
media, we always consulted doctors” (37 yr, urban IDI).
Reasons for vaccine non-use
When SSI-respondents were asked why they or anyone in
their household had not taken the vaccine for swine flu, several
common reasons were reported (Table 3).
Low perceived risk
A majority (55.0%) indicated low risk attributed to influenza
or a sense that they were not personally at risk. Men were more
likely to say that than women. Common accounts referred to the
following points: First, if there were no cases of swine flu in
the respondent’s neighborhood, a vaccine seemed unnecessary. In
the urban areas, this was explained largely in terms of a lack of
observable symptomatic cases in the neighborhood: “If somebody
from our housing society gets swine flu, then I would go and take
it. If there are no such cases around, then why should I take the
vaccine?” (57 yr, urban woman, IDI). Similar explanations were
noted in the rural area, but complemented by assertions that
swine flu was an urban problem that had not reached rural areas.
A readily apparent epidemic was required to convince people of
the salience of the illness. A man articulated this sentiment meta-
phorically: “Suppose, there is a violent and rampant dog biting
everyone, only then will a concerted effort be made to kill him.
Similarly, in the absence of an epidemic, people will not take the
vaccine.” (rural FGD). Second, the respondent’s idea that personal
strength and good health would confer protection from illness was
mainly reported by men. For example: “We don’t need the vac-
cine. I am physically fit, I am a sportsman; mostly we won’t get
it” (26 yr, rural man, SSI). Women frequently referred to reduced
chances of contracting the illness because they stayed at home:
“Men are exposed to the outside, but we are always at home,
hence we do not consider ourselves at risk of catching the illness”
(27 yr, urban woman, SSI). Faith in God as a basis for perceived
protection was also mentioned. “We believe in our god. We
believed that we won’t ever get swine flu, and we haven’t” (35 yr,
urban man, SSI). Lastly a low priority for prevention, due to con-
fidence in effective treatment was also noted: “When there are ill-
nesses in the rural areas, then a cure is made available there.
Nobody takes prior care” (25 yr, rural woman, SSI).
Other preventive measures make vaccines unnecessary
Adequacy of other preventive measures apart from vaccines
was reported by 15.8% as a reason for not taking the vaccine,
more so by urban than rural respondents (p <0.001). Widely
mentioned alternative preventive measures included the use of
face masks (often referred to tying a handkerchief around the
nose and mouth), maintaining personal hygiene, keeping sur-
roundings clean and avoiding crowds. Some also referred to
the use of preventive drugs, specifically mentioning antiviral
drugs: “We did not feel the need to take it since there were
other things like masks and Tamiflu” (24 yr, urban man, SSI).
A few also mentioned herbal preventive measures: “We used
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prevention measures – wearing a mask, using camphor and
nilgiri [eucalyptus] oil. So, wedidnotfeeltheneedtotake
the vaccine” (33 yr, urban man, SSI).There was also infre-
quent mention of chanting of prayer and ritual purification
(‘agnihotra’).
Lack of information about the vaccine
Some (11.7%) respondents were unaware of the existence of a
vaccine against pandemic influenza. The largest proportion of
such respondents was from the rural remote area, followed by the
urban low-resource area and the lowest proportion was from the
urban middle-income area. A rural woman explained: “Two years
ago when there was an outbreak of swine flu, we were not even
aware that there was a vaccine for swine flu” (28 yr, SSI). This
reason was often mentioned in combination with problematic
access, i.e., not knowing where to obtain the vaccine.
Problems with access and cost
Difficulties relating to obtaining the pandemic influenza vac-
cine were noted by 14.7% of SSI respondents, with significantly
more from rural than urban areas. The most frequently men-
tioned problem was that the vaccine was not delivered to the
respondents’ neighborhoods. Rural respondents expected that
important interventions would be delivered by government
health workers. They were not sure how or where to get a vaccine
if it was not brought to their villages. A rural woman explained
why she did not take the vaccine as follows: “The most important
reason was that the vaccine did not come here, and we do not
know where to go and get it” (35 yr, SSI). Another problem for
accessing the vaccine was not having a clinic nearby. A few
respondents also noted the vaccine was available only for children
and not adults. A 22-year-old woman who also drew a parallel
with polio vaccine campaigns said: “It hasn’t come here yet. For
children up to 5 years they come to give the polio vaccine. For
swine flu also they came here to vaccinate children but not
adults” (urban SSI).
A few noted unavailability of the vaccine during the pandemic
as a reason: “There was no vaccine at that time when the illness
more widespread. The vaccine came later” (46 yr, urban man,
SSI). Nine respondents indicated that they wished to take the
vaccine but were unable to do so as it was out of stock due to
high demand. Seven respondents said they had no time to spare
to go and get the vaccine.
Financial constraints as a reason for not taking the vaccine
were reported by 5%. Among these respondents, many stated
that they would have taken it if the government had provided the
vaccine for free or at a discounted price.
Insufficient indication of vaccine priority
Some respondents explained that health care providers, the
government or people they knew had not clearly indicated the
importance of vaccination or encouraged it. An urban woman
stated: “No one forced me or urged me to take the vaccine. No
one asked me to come along to take it. Had someone urged me, I
would have taken it. Neither the doctor nor family members
urged me” (57 yr, SSI). The lack of a mandate by the govern-
ment for pandemic influenza vaccination was also indicated as a
reason by some: “The government did not carry out any promo-
tional activities and there was no compulsion by the government
to take the vaccine” (62 years, rural man, RM223).
Other concerns
Four respondents expressed concerns about vaccine effective-
ness; 4 indicated a general avoidance of medication, and 1 men-
tioned a fear of adverse reactions. No one indicated other
Table 3. Reasons for non-use of pandemic influenza vaccines
Reasons for not taking
the pandemic influenza
vaccine (personally or for
someone in the
household)
a
Overall (%) Area of residence (%) Sex (%)
Urban
middle-
income
Urban
low-
resource
Rural
more
accessible
Rural
less
accessible P value
b
Female Male P value
b
nD436 n D102 n D113 n D113 n D108 n D221 n D215
Low risk attributed to
influenza
55.0 46.1 57.5 60.2 55.6 49.8 60.5 *
Sufficient precautionary
measures already taken
15.8 29.4 25.7 6.2 2.8 *** 15.8 15.8
Access (where and how to
get it)
14.7 7.8 9.7 17.7 23.1 ** 11.8 17.7
Unaware of vaccine 11.7 2.0 13.3 12.4 18.5 *** 12.7 10.7
Cost of vaccine 5.0 4.9 8.0 3.5 3.7 5.9 4.2
a
Response to the question: “For you or anyone in your household who did not take the vaccine for swine flu, were there any particular reasons not to take
it? Can you explain why some (or all) did not take it?”were coded into categories described in the table. Multiple categories could have been mentioned
and coded for each respondent. 7.3% of respondents did not provide a reason. Categories reported by less than 5% are not presented. They included: lack
of encouragement by health care provider (3.9%), other miscellaneous (3.4%), vaccine shortage due to high demand (2.1%), no time to take the vaccine
(1.6%), doubts about vaccine effectiveness (0.9%), and general avoidance of medication (0.9%).
b
Fisher’s exact test was used to compare proportions across area of residence and sex: *p0.05, **p0.01, ***p0.001. No differences were observed across
age groups and they have hence not been presented.
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concerns about the vaccine or type of administration as a reason
for not having taken the vaccine.
Preference for injectable or nasal vaccine
Data indicate a strong preference for injectable over nasal vac-
cines. Twice as many respondents reported preference for an
injectable vaccine and considered it safer (Table 4). Among those
who considered a nasal vaccine safer, more were from the urban
middle-income area, followed by the accessible rural area, the
urban low resource and finally the rural remote area. When
respondents were asked which vaccine they considered more
powerful, 44.3% opted for the injectable and 32.6% for the
nasal. Those who reported no specific preference for either vac-
cine referred to (a) a sense of urgency in obtaining whichever vac-
cine was available, (b) prioritizing convenience and getting the
vaccine that was most easily available, (c) the need to follow a
doctor’s advice and to not question what the doctor recommends,
or (d) lack of their own opinion due to lack of experience with
this new illness. Main themes that emerged from the narrative
data of SSIs and IDIs in explaining preference for either the
injectable vaccine or the nasal vaccine are described in the next
section, with narratives quoted in Table 5.
Reasons for preferring an injectable vaccine
Injectable vaccine considered more powerful than nasal one. A
commonly cited reason for preferring an injectable vaccine was
that the vaccine would be directly absorbed in the blood and thus
more effective. This account was frequently described in contrast
to nasal vaccines, which were perceived as ineffective because
they were likely to be expelled easily while breathing, and fail to
reach all parts of the body. Ideas that injections work faster and
had a longer duration of protection than nasal vaccines were also
suggested to explain preferences. A few respondents said pain
from an injection was an indication of its power.
Fear of side effects from a nasal vaccine. Many referred to fear of
side effects from the nasal vaccine as a reason they preferred the
injectable one. The numerous perceived side effects from nasal
vaccines that were mentioned included irritation in the throat,
burning sensation in the eyes, sneezing, pain in the nose, vomit-
ing, breathlessness, a tingling sensation or numbness in the head,
a bitter taste in the mouth and general discomfort. Others, who
were unable to identify specific side effects, referred merely to
being unable to tolerate a nasal vaccine.
Experience and familiarity with injections. Past experience and
familiarity with injections compared to a relatively new nasal vaccine
was another major reason for preferring injectable vaccines. Many
respondents had an implicit trust in injections. Conversely, absence
of familiarity and fear of relatively unknown nasal vaccines were fre-
quently reported as reasons for preferring injectable vaccines.
Favorable attitude toward injections and preference regardless of
perceived efficacy. A favorable attitude toward injections in general
was observed and while this is linked to the theme of perceiving
an injectable vaccine as powerful, it was qualitatively distinct in
Table 4. Preference for injectable or nasal pandemic influenza vaccine
Overall Age group Area of residence Sex
Younger Older p value
a
Urban-
middle
income
Urban
low-
resource
Rural
more
accessible
Rural
less
accessible p value
a
Female Male p value
a
nD436 n D223 n D213 n D102 n D113 n D113 n D108 n D221 n D215
More powerful vaccine (%)
b
Neither 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0
Both equal 3.0 2.7 3.3 2.9 3.5 1.8 3.7 3.6 2.3
Injection 44.3 44.4 44.1 42.2 51.3 40.7 42.6 45.2 43.3
Nasal spray 32.6 36.3 28.6 33.3 31.0 37.2 28.7 26.2 39.1 **
Cannot say 20.2 16.6 23.9 21.6 14.2 20.4 25.0 24.9 15.3 *
Safer vaccine (%)
c
Neither 0.7 0.5 0.9 0.0 0.9 0.0 1.9 0.9 0.5
Both equal 9.6 11.7 7.5 9.8 5.3 14.2 9.3 12.2 7.0
Injection 57.1 54.7 59.6 46.1 64.6 54.9 62.0 * 55.2 59.1
Nasal spray 27.5 29.6 25.4 42.2 24.8 25.7 18.5 ** 25.8 29.3
Cannot say 5.0 3.6 6.6 2.0 4.4 5.3 8.3 5.9 4.2
Personal preference (%)
d
No preference 11.2 8.1 14.6 * 9.8 6.2 10.6 18.5 * 12.7 9.8
Injection 58.5 59.2 57.8 52.9 65.5 54.9 60.2 59.3 57.7
Nasal spray 30.3 32.7 27.7 37.3 34.5 28.3 21.3 28.1 32.6
a
Fisher’s exact test was used to compare proportions across age groups, area of residence and sex, *p0.05, **p0.01, ***p0.001
b
Frequency of responses to the question: “Do you think either of these vaccines (the nasal spray or the injection) would be more powerful and better able
to protect you against swine flu? ... Why?”
c
Frequency of responses to the question: “Which one of these vaccines (nasal spray or injection) do you think would be safer for you? ... Why?”
d
Frequency of responses to the question: “If you could choose either of these vaccines to protect yourself against swine flu, which one would you prefer,
the nasal spray or the injection? ...Why?”
All questions were enquired in the local language, Marathi, and translations have been provided here.
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that injections were considered a panacea for all illnesses and
the best form of administering any drug. A 65-year-old man
explained: “Now suppose you want to take a vitamin supple-
ment. You get it in the form of tablets, injections and liquid.
But, of these, the injection spreads throughout the body”
(urban SSI). On a similar note, a rural woman said:
“Weakness reduces on administering the injection ... one
feels better after taking them” (47 yr, SSI). A few respondents
reported preference for an injectable vaccine, despite their
belief that nasal vaccines were more effective.
Reasons for preferring a nasal vaccine
Nasal vaccine considered more powerful than an injectable one.
Those who preferred a nasal vaccine believed in the superior
power of nasal vaccines to reach all parts of the body through
one’s breathing. Immediacy of effect was also noted. Administra-
tion through the nose was a perceived advantage because that was
also the point of entry for germs causing swine flu. Some referred
to physical sensations after receiving the vaccine as an indication
of the vaccine doing its job. This was considered a desirable side
Table 5. Reasons for preferring an injectable vaccine or a nasal vaccine for pandemic influenza
A) Reasons for preferring an injectable vaccine
Theme Illustrative quote
Perceived powerfulness of vaccine
Injectable vaccine spreads through the body from
absorption in the blood
“In our village it is believed that the medicine reaches the whole body only through an injection”(29 yr,
rural woman)
Injectable vaccine spreads faster in the body “An injectable vaccine spreads all over quickly. The nasal one takes time while the injection spreads faster”
(23 yr, urban man)
Injectable vaccine has longer lasting effects “Injectable vaccine because its effect will last for long”(31 yr, rural man)
Nasal vaccine may be expelled while breathing,
sneezing or in mucus
“The injectable vaccine allows the medicine to disperse internally. The medicine if administered through
the nasal route will get expelled through breath. It won’t go inside”(64 yr, rural man)
Nasal vaccine may not reach all parts of the body “Injectable vaccine is better because the nasal vaccine will travel with the breath and only reach the lungs
while the injectable one will circulate through the blood in the entire body”(60 yr, rural man)
Pain caused by injectable vaccine is an indication
of its powerfulness
“Actually, pain at the injection site is considered as good sign”(rural woman, FGD)
Side effects or safety concerns of alternative
Fear of numerous side effects from nasal vaccine “If given in the nose then it creates irritation in the throat, and the whole mouth becomes bitter”(46 yr,
rural woman)
Familiarity and trust
Past experience and familiarity with injections “I will prefer the injectable vaccine since we are used to taking injections. We have never taken it through
the nose”(27 yr, urban man)
Implicit trust in injections “Injection- all I can understand is that, it will be effective when we take it”(50 yr, woman)
Fear of relatively unknown nasal vaccine “A person fears taking it through the nose. There is no fear in an injection. I fear the nasal one”(48 yr,
rural woman)
B) Reasons for preferring a nasal vaccine
Theme Illustrative quote
Perceived powerfulness of vaccine
Nasal vaccine can reach all parts of the body
through breath
“[I prefer] nasal as when we breathe it reaches the whole body. Injection does not affect the body so fast”
(59 years, urban woman)
Nasal vaccine has a more immediate effect “Will take it through the nose. It will have an immediate effect”(50 yr, rural woman)
Nasal vaccine is administered through the nose
where germs enter
“Nasal [is preferred] because we would have the disease through there...Its effect would be more than
injectable”(21 yr, rural man)
Nasal vaccine has desirable side effects indicative
of vaccine doing its job
“Nasal administration must cause tingling and stinging....You don’t feel anything after taking the
injectable vaccine but you can feel the medicine going inside and also the stinging caused when
administered through the nose”(47 yr, rural man)
Side effects or safety concerns of alternative
Fear of needles or pain caused by injectable
vaccines
“The nasal one is better. With an injection, there is inflammation or pain later”(57 yr, urban man)
Concerns regarding potential re-use of needles in
injectable vaccines
“There is a risk associated with the injection because an already used syringe may be used again, unlike in
case of a nasal vaccine which I think spreads in the entire body in the vapour form”(65 yr, urban man)
Table 5(A) lists main themes and illustrative quotes distilled from respondent narratives regarding why an injectable vaccine was preferred over a nasal one.
Narratives from focus group discussions and open questions in semi-structured interviews were analysed thematically grouped under broad domains of
perceived powerfulness (or efficacy), side effects or safety concerns and familiarity, trust. Explanations provided were either perceived advantages of the
injectable vaccine or perceived disadvantages of the nasal vaccine. Similarly, in Table 5(B), explanations for preference of the nasal vaccine were due to
either perceived benefits of the nasal vaccine or perceived disadvantages of the injectable vaccine.
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effect of nasal vaccines. On a similar note, the idea that the nasal
vaccine can spread to the brain was lauded as a measure of its
powerfulness by a few who explained their preference for nasal
vaccines. However, the same point was regarded as an adverse
effect for those shunning the nasal vaccine.
Safety concerns for injectable vaccines and fear of needles. Some
preferred a nasal vaccine due to concern about the safety of needles,
which might have been previously used. This concern was noted
onlybyurbanrespondents.Painorswellingfromaninjectionwasa
reason for preferring a nasal vaccine, but stated only by a few.
Discussion
Findings suggest trust in vaccines in general and for pandemic
influenza vaccines in rural and urban communities of Pune dis-
trict. A clear understanding of the rationale, however, of vaccines
designed primarily for healthy individuals to prevent disease was
lacking. Many respondents suggested no need for a pandemic
influenza vaccine in the absence of fever or symptoms. A news
report in Pune during the pandemic exemplifies the misconcep-
tion. A young man suffering from symptoms of influenza who
purchased a LAIV from a pharmacy and had it administered in a
hospital subsequently died.
34
Some respondents thought vaccines
were only relevant for children and irrelevant for adults. Data
from rural Pune during and after the pandemic suggest that inci-
dence of hospitalized H1N1 influenza was highest among 5-29
year olds.
35
Both the epidemiology and our findings suggest the
need for promoting awareness of the public and health care pro-
viders of the value of vaccination for adults, and awareness of
contraindications and precautions for vaccination.
21
Awareness of the role of vaccines in preventing pandemic
influenza was relatively low at 25%. A study in Bareilly, Uttar
Pradesh, during the pandemic reported awareness of vaccines
against swine flu among 47% of studied school students.
36
Not-
withstanding low awareness in our study, most respondents,
when asked about pandemic influenza vaccines, reported them as
potentially helpful in preventing swine flu. Problems or side
effects of the vaccine were mostly localized and seldom reported
as a barrier to vaccine uptake. This is unlike studies from other
countries
9,10,37
or studies in India among health care workers
38,39
where perceived side effects from the vaccine were reported as a
deterrent to influenza vaccination intention. Although for the
majority a vaccine with fewer side effects was preferred, the find-
ing that for some, a localized reaction or physical sensation after
vaccination was an indicator of vaccine efficacy and hence desir-
able, was unique to our study. It is also interesting to note that
some considered an injection as less invasive than a nasal vaccine.
It was said that “one does not feel anything or one feels good”
after taking an injection, while nasal vaccines were perceived to
have many more potential side effects. Fear of injections was
noted by just a few and concerns about re-use of needles for
injectable vaccines were reported largely in the urban middle-
income area.
Study findings show a majority of the community preferred
injectable compared to nasal vaccines. Excessive, often
unnecessary use of injections has been documented in India
40
and in other parts of Asia.
41,42
The placebo effect offered by
injections has provided an argument for widely using injections
in India and is often demanded by patients. A study by Green-
halgh
43
in 1987 questioned blind faith in injections, and our
findings suggest that these perceptions continue to hold true.
While inactivated injectable vaccines are required for special
groups, live-attenuated vaccines offer practical advantages for
control of pandemics among the general population in a country
as highly populated as India. They are easier to administer and
easier to produce larger quantities at lower cost.
20
Our findings
suggest lack of community familiarity, rather than confidence,
with this relatively new form of vaccine administration. Respond-
ents from the urban middle-income area were more aware of
nasal vaccines and more likely to consider them as the safer vac-
cine. Thus, gaining public support is not likely to pose a problem
if implemented with effective communication and engagement.
The success of the oral polio vaccine campaign in India demon-
strates good prospects for widespread public acceptance of this
new form of vaccine administration. Paterson and Larson recom-
mend public engagement by building trust and learning about
public concerns to be addressed,
44
and by communicating
openly, honestly and proactively with the public and other stake-
holders.
45
Our study identified the following key concepts that
study communities attributed to the vaccine they preferred, either
nasal or injectable, that should be well-understood and convinc-
ing, namely, the: ability of the vaccine to spread to all parts of the
body and immediacy of effect. Properties of the vaccine itself –
whether it was live attenuated or inactivated – were never men-
tioned spontaneously or questioned by any respondents. It is
likely not a distinction of practical significance for respondents.
Findings suggest a blurring of urban-rural distinctions in the
rapidly urbanizing Pune district. Notwithstanding highest aware-
ness and vaccine uptake in the urban middle-income area, aware-
ness of nasal influenza vaccines, belief in safety of nasal compared
to injectable vaccines and use of pandemic influenza vaccine were
reported by more respondents from the accessible rural area than
from the low-resource urban area. The urban-rural dichotomy
may be superseded by other factors with regard to vaccine policy
and planning in such rapidly urbanizing settings
46
where people
in accessible rural areas may have higher incomes and better
access to information than persons in urban slums. More men
than women had confidence in the power of nasal vaccines and
anticipated no problems with pandemic influenza vaccines; yet
they were also more likely to perceive a low risk for themselves in
getting swine flu. Age-specific differences in awareness of nasal
vaccines and in the ability of vaccines to prevent influenza indi-
cate a need to inform older segments of the population.
The reported swine flu vaccine uptake rate was 8.3% in our
study, but limitations in production and access may help explain
the low figure. Vaccines were only available many months into
the pandemic.
47,48
There was no state-wide initiative for mass
vaccination in Maharashtra although the Pune Municipal Corpo-
ration provided vaccines without charge to health care workers
toward the end of the pandemic.
49
Furthermore, some hospitals
and groups conducted their own vaccination camps. The nature
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of vaccine uptake varied. It was passive acceptance for some when
the vaccine was made available in their neighborhood, and active
demand for others who made an effort to go and get it them-
selves.
50
The Indian Medical Association and Indian Academy of
Pediatrics officially recommended the pandemic influenza vac-
cine,
51
but individuals had to purchase it privately. The public
health dissemination strategy for communicating information
from the state about vaccine recommendations was unclear. The
media played a major role in public communication, but this did
not appear to be state-directed. Furthermore, the response to the
pandemic by the state government seemed to focus on treatment
with antivirals rather than preventive measures.
The influence of salience of the illness from personal experi-
ence with cases or deaths in the neighborhood was a powerful
motivator for vaccine uptake in our study. A similar finding was
reported by SteelFisher et al
10
in a study done in the United
States of America (USA). A study using self-administered ques-
tionnaires among health care workers in Pune noted “self-protec-
tion against illness” as the main reason for accepting H1N1
influenza vaccination.
52
Inasmuch as we surveyed community
residents, we were able to identify additional practical reasons for
vaccine acceptance, such as health system affiliation, health care
provider recommendation, influence of peers and media impact.
A majority considered the illness as very serious or serious.
33
Nevertheless, some who acknowledged the seriousness did not
consider themselves to be personally at risk. According to the
health belief model, without perceived personal risk, considering
an illness as serious may not translate into protective behavior.
53
Gendered explanations of perceived personal risk were notable.
Men regarded themselves as too strong to catch the illness (a
‘man of steel’ perception) and women considered themselves at
reduced risk from being homebound. The above findings on low
risk perception for oneself along with the belief that it was an
urban but not a rural problem, suggest an optimism bias
54
where
people consider themselves unlikely to catch an illness that they
consider serious for others.
Access was a barrier because of community expectations that a
vaccine, if relevant, would be delivered through a campaign in one’s
neighborhood. Such expectations may be a result of community
experience with the vertical polio vaccination program in India. A
clear message from the government endorsing pandemic influenza
vaccines, which the community indicated was lacking in the 2009
influenza pandemic, may promote vaccine uptake. Education of
health care providers needs to ensure they make appropriate recom-
mendations of vaccines. With respect to the SAGE Working
Group framework of vaccine hesitancy,
55
our findings indicate that
lack of confidence in pandemic influenza vaccines may not be a
serious problem for uptake, but convenient access, complacency,
and other sociocultural considerations take precedence.
Dissemination activities
The research team had planned community dissemination
activities from the outset. After completing the field research and
initial analysis, insights and information gained from the study
were presented in meetings with urban and rural study communi-
ties. Urban and rural community members participated in
meetings at their respective study sites, and a dissemination work-
shop was held in Pune for various levels of policy makers in
November 2014. Officials from the central government, munici-
pality and subdistricts participated. A brochure for community
residents and a policy brief for policy makers was prepared, dis-
tributed and discussed at these events.
Strengths
The need and value in engaging the public in vaccination ini-
tiatives has been well-established.
44,56,57
Recently documented
challenges of introducing new vaccines in India,
58-60
highlight
the importance of studies that focus on understanding commu-
nity perceptions, underlying issues and contextual influences that
may influence vaccine acceptance. To the best of our knowledge,
our study is the first to explore community views, preferences
and uptake of pandemic influenza vaccination in India. One
other study considered community perceptions of influenza dur-
ing the pandemic in India,
61
but was limited in its study of views
of vaccines. Multiple methods used in our study – focus group
discussions, semi-structured interviews and in-depth interviews –
made triangulation of results possible. Quantitative survey find-
ings indicated not only what the issues are but the relative fre-
quency of particular perceptions and priorities; qualitative
narrative data from SSIs helped explain what these ideas meant
and IDIs enriched qualitative detail.
Limitations
The study was designed to provide relevant information and
guidance in a local cultural context. Generalizations for other
parts of the country must therefore be made with caution. The
survey was cross-sectional, and community views and perceptions
are subject to change over time and in response to other social or
policy changes. Vaccine uptake was documented through self-
report and the idea of a preventive vaccine was not clearly appre-
ciated by some respondents. We did not confirm whether
respondents who said they had taken a pandemic influenza vac-
cine actually did. By assuring participants that there were no right
or wrong answers, assuring confidentiality, and presenting inter-
viewers as independent researchers we attempted to minimize
response bias. There is a possibility of recall bias since data collec-
tion for this study began 2 years after the officially declared end
of the pandemic in 2010.
62
Persisting media coverage of swine
flu and consideration of vaccines, however, even during our data
collection ensured a public memory of the illness and its control.
Conclusion
This study has elucidated cultural perceptions and ideas about
the value of vaccines for pandemic influenza among urban and
rural communities of Pune, India, which have practical implica-
tions for pandemic influenza control. In the 2009–2010 influ-
enza pandemic, a community mass vaccination was not
conducted in Pune. People had to pay the full price for a vaccine
and display considerable initiative to obtain it. Our study exam-
ined reasons for use and non-use of influenza vaccines in this con-
text largely through qualitative approaches. Policy implications
from study findings highlight good prospects for use of influenza
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vaccines for pandemic control given community trust in vaccines.
If a mass vaccination were to be planned for influenza control in
the future, attention to the following recommendations may help
enhance vaccination coverage: (1) Increase community awareness
about influenza vaccines, (2) Emphasize their relevance for
adults, (3) Emphasize risk for urban and rural communities, men
and women, (4) Promote vaccination through health care pro-
viders, community leaders and government endorsement, (5)
Deliver the vaccine right to communities at an affordable cost,
(6) If nasal vaccines are considered, they need to be explained
through effective communication addressing community con-
cerns, (6) Plans should consider setting-specific differences within
urban and rural areas. Questions about use of vaccines for control
of seasonal influenza among high-risk groups and the general
population also require further consideration and study. This is
especially relevant in the light of recent large outbreaks of H1N1
influenza,
63,64
which is now considered a seasonal strain. Lack of
priority for routine use of influenza vaccines at present
65
despite
production capacity for influenza vaccines in India, suggests that
reconsideration of policy, and sociocultural community studies
are needed to guide further development of vaccine policy for
effective action.
Methods
Study area
This study was conducted in Pune district, a focus of the
2009–2010 (H1N1) influenza pandemic in India. The district
had a large number of cases and recorded the country’s first death
from H1N1 influenza in 2009. Study sites were selected in urban
and rural areas. Two urban sites were low-resource densely popu-
lated (slum) settlements in Sangamwadi and middle-income
neighborhoods of Erandawane in Pune city. The rural sites com-
prised villages in Maval subdistrict that were more accessible to
Pune city due to their location along a highway and more remote
villages in Velhe subdistrict that were relatively difficult to access.
Further details on setting are reported elsewhere.
32,33
Study design
A mixed-methods, cross-sectional and community-based
study was conducted in urban and rural areas of Pune district.
The present analysis focuses on community awareness, preference
and use of vaccines to prevent pandemic influenza, and primarily
had a qualitative focus. We employed multiple methods includ-
ing focus group discussions, cultural epidemiological semi-struc-
tured interviews integrating qualitative and quantitative data,
and qualitative in-depth interviews. Formative focus group dis-
cussions (FGDs) provided insight on the setting and guided
development of questions and categories of semi-structured inter-
views (SSIs). SSIs were developed based on the explanatory
model interview catalogue (EMIC)
66
framework for cultural epi-
demiology
67
to obtain representative distributions of perceptions
of pandemic influenza and the role of vaccines. Additional in-
depth interviews (IDIs) were conducted to gain a deeper under-
standing of experiences and motivations of those who took the
pandemic H1N1 influenza vaccine, and the views, potential bar-
riers or hesitation among those who did not do so.
Instruments and respondent selection
Inclusion criteria for FGDs, SSIs and IDIs were resident
adults (18–65 years) in the community with conversational flu-
ency in Marathi and ability to mentally and physically withstand
the interview or discussion.
Respondents for SSIs were randomly selected from voters’ lists
for each of the study areas.
33
Voters’ lists, which were the most
comprehensive of available records, were obtained for each of the
study areas. One hundred and ten households were randomly
selected for each area using a random number generator. To
avoid selection bias inherent to use of voters’ lists, selected house-
holds were located but not interviewed. The neighboring house-
hold to the right was approached for interview instead. If no
member of the household satisfied the inclusion criteria or if
there were no willing participants, the adjacent household to the
right was approached, until a suitable respondent was found. An
equal balance of men and women and younger (18–45 years)
and older (46–65 years) age groups was maintained. Questions
related to awareness, preferences, uptake of pandemic influenza
vaccines and barriers to vaccine use were considered for this
report. Quantifiable coded responses were collected and any
quantitative data presented in this report came from the analysis
of SSIs. Specific questions that the coded responses correspond
to have been included as footnotes to the tables. Narratives in
response to open questions in the SSIs complement the quantita-
tive data. IDIs were conducted with a purposively-selected sub-
sample from the SSIs. The IDIs provided accounts enriched by
context and reasons for vaccine use or non-use. FGDs were con-
ducted in urban and rural study areas based on a convenience
sample recruited by community leaders or community health
volunteers. The FGD agenda covered similar broad topics on
ideas about vaccines including perceived benefits, problems and
use of pandemic influenza vaccines.
We designed instruments for all 3 methods during several
workshops based on a literature review and previous work on vac-
cine acceptance.
68-70
Instruments were revised based on feedback
from other experts and public health professionals. Instruments
were pilot tested and further revised after translation into
Marathi.
Data collection
Research assistants conducting the SSIs had Masters-level
qualifications in social sciences, were native Marathi speakers and
received training in interview skills and data management. They
worked in pairs with one person conducting the interview and
the other maintaining data records. SSIs lasted for 45 minutes on
average. Data sheets were checked for accuracy and discrepancies
resolved while in the field.
FGDs and IDIs were conducted by one of 2 bi-lingual senior
researchers with doctoral and masters-level degrees in social sciences,
accompanied by a note taker. The average duration of FGDs was
1 hour and IDIs was 40 minutes. Facilitators and note takers dis-
cussed impressions and compared notes after each FGD and IDI.
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Interviewer and respondent characteristics were matched
where possible. For example, a female facilitator conducted focus
groups with women. Researchers did not have a prior relation-
ship with study participants. All interviews and discussion were
conducted in Marathi. FGDs, SSIs and IDIs were audio recorded
with participants’ consent.
Data management and approach to analysis
Qualitative analysis
Narrative data from SSIs were first entered in a word processor
in Marathi and then translated into English. Supervisors regularly
checked transcriptions and translations for quality. FGD and IDI
transcripts were translated into English and entered in a word
processor on an ongoing basis while constantly monitoring data
quality with reference to study objectives.
FGDs, narrative data from SSIs and IDI data were imported
into MAXQDA v.11 (VERBI Software, Germany) for data man-
agement and analysis. Analysis was rooted in the objectives of
this paper. Thematic coding was done using a deductive
approach for first-level coding. Inductive coding was used for sec-
ondary and tertiary level codes. Qualitative data collected from
the 3 different methods were regarded as complementary in this
analytic process of triangulation.
Quantitative analysis
Quantitative data from SSIs were entered by the interview
team into Epi Info v. 3.5.3 (CDC, USA). For double-entry veri-
fication, a second entry of quantitative data was done indepen-
dently by a member of another team. Questions that required
affirmation or negation were coded on a 4 point Likert scale,
ranging from a clear yes or no (values of 3 or 0), to a qualified yes
or no (values of 2 or 1) for responses. Variables with few qualified
responses were dichotomised for analysis. To assess the influence
of gender, area of residence and age on views and vaccine uptake,
systematic comparisons were analyzed for age group, sex and
study area. Significant differences at the 0.05 level have been pre-
sented in this paper, using Fisher’s exact test to compare propor-
tions across different groups. Quantitative variables were also
imported into MAXQDA to review narratives of interest based
on quantitative associations, thus facilitating integrated analysis
of quantitative and qualitative data. Data analysis was done with
STATA v. 12.1 (StataCorp, USA) and SAS v. 9.3 (SAS Institute
Inc., USA).
Ethical considerations
The Institutional Ethics Committee of the Maharashtra Asso-
ciation of Anthropological Sciences, Pune, the Ethics Commis-
sion of Basel and the WHO Research Ethics Review Committee
provided ethical approval for this study. Written informed con-
sent was obtained prior to conduct of interviews and FGDs. No
financial or other incentives were provided to participants.
Disclosure of Potential Conflicts of Interest
No potential conflicts of interest were disclosed.
Acknowledgments
We gratefully acknowledge the participation of study commu-
nities and the commitment of field supervisors and research assis-
tants who conducted the interviews.
Funding
This research study was supported through funds from the
World Health Organization, Switzerland. The funders had no
role in study design, data collection and analysis, decision to pub-
lish, or preparation of the manuscript.
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