Influenza Vaccination Among U.S. College or University Students: A Systematic Review

Abstract

Objective:

Influenza is one of the major causes of morbidity. This study summarized major components that influence college/university students’ use of the vaccination using Ecological System Theory; and evaluated racial differences in key predictors of influenza vaccination/intention.

Data Source:

Sixteen engines (e.g., PsycINFO, Academic Search Premier, Science Citation Index) were used to search for cross-sectional studies (2009-2019).

Study Inclusion/Exclusion Criteria:

PI/CO criteria were applied (U.S. students, multidimensional ecological system, influenza vaccination/intention).

Data Extraction:

25 cross-sectional studies were included from the initial 810 citations. Four reviewers performed the cross-checking.

Data Synthesis and Results:

Higher SES (e.g., education, vaccine affordability, healthcare resource) were positively associated with vaccination/intention. Under micro levels, both internal factors (e.g., positive beliefs, perceptions, attitudes) and external factors (e.g., supports/recommendations from physicians, families or peers, information, engagement in campus activities) enhanced influenza vaccination/intention of students. Meso level factors (private university, dorm-residence, or student housing) also influenced influenza vaccination/intention. Despite limited information on the effects of race on influenza vaccination, the current study synthesized the racial variances in vaccination behaviors of students.

Conclusions:

Enhancing positive beliefs, perceptions, or attitudes toward influenza vaccination with students is critical. Information about the safety and effectiveness of vaccination could be provided for students through official media, medical sources/physicians, campaigns, or internet websites. Family-to-student or peer-to-peer awareness campaigns could facilitate the vaccination of students.

Keywords

influenza vaccination young adults multi-dimensional factors ecological system approach racial variance

Objective

National Vital Statistic Report (2017) says that influenza has been one of the 15 leading causes of death in the U.S. for a decade.¹ According to the Centers for Disease Control and Prevention (2019), adults aged 65 years and older are highly exposed to the greatest burden of severe influenza disease, accounting for the majority of seasonal influenza-related deaths (70-90%) and a higher percentage of seasonal influenza-related hospitalizations (50-70%).² Younger adults are no exception. According to a CDC report, influenza caused more deaths in 2014 than any other years for young adults. “In 2014, people age 18-64 represented 61% of all hospitalizations from influenza, which was increased from the previous 3 seasons when this age group represented only about 35% of all such hospitalizations.”³ Influenza vaccination thus becomes more important not only for older adults but also for younger adults.

Importantly, college or university student groups, albeit often overlooked, may need more attention. Physicians argued that younger student groups could unintentionally spread influenza related diseases to other people who are especially vulnerable to higher risks of hospitalizations such as older adults or child/adolescents with weakened immune systems.⁴ However, Franks and Jandu (2017)⁵ reported that only 23% of their college students (within their sample) were vaccinated which is notably lower than the 80% goal set by Healthy People 2020.⁶ Therefore, some scholars^7,8 highlight that college or university students should actively receive influenza vaccine with regard to their living environments. Many students used to spend their daily life in a high-density campus environment and this is conducive to influenza transmission.^9,10 Influenza or influenza-related diseases can cause a severe concern for college or university students, negatively affecting their academic performances.⁷

In an effort to increase vaccination rates, several empirical studies attempted to identify factors that affect college or university students’ decision to get vaccinated.^11

-15 However, there are still limitations in understanding the risk or protective factors of college or university students’ influenza vaccinations, as those studies often had incomparable study samples (i.e., only one racial group is included),^16
-18 and examined only internalized risk or protective factors of their vaccination behaviors (e.g., perceived susceptibility, perceived severity, perceived benefits, or perceived benefits).^18,19 Evaluating and summarizing prior empirical studies’ findings on students’ use of influenza vaccinations are critical to understand internalized or externalized determinants of their decision to vaccinate and to suggest future study directions. Nonetheless, a limited number of systematic review studies targeted college or university students’ vaccination behaviors. Most prior systematic review studies included aggregated young adults, age 18–35 years, as target populations (e.g., both college/university students and non-college/university young adults were included as aggregated younger groups),^20

-23 though college or university students have unique characteristics compared to non student groups.^9,10 Further, some systematic reviews on influenza vaccination, regardless of age groups, mostly focused only on internalized factors of individuals (e.g., vaccine-related beliefs and perceptions).^20,21,23,24 Moreover, none of the systematic reviews examined the heterogeneity of the college students, including racial or ethnic variance on major predictors of influenza vaccination.

In order to address limitations in prior systematic review studies, the current study will (1) systematically summarize both internalized and externalized factors that influence college or university students’ influenza vaccination using Bronfenbrenner’s Ecological System Theory (EST)²⁵ and; (2) summarize racial or ethnic differences on key predictors of influenza vaccination among college or university students, if given information from selected empirical studies is enough to evaluate and summarize.

The EST suggests a conceptual framework to draw attention to individual and environmental determinants of health behavior. “Central to the ecological perspective is the assumption of interaction and reciprocal causation among levels.”^25(p9) Therefore, influenza vaccination of college or university students can be improved by understanding determinants at the different levels (Figure 1). To be specific, microsystem refers to components including family, household, and peers that directly influence individuals while mesosystem includes mid-range communities and organizations that interconnect factors of the microsystem. Exo-and macro-systems overarch social and cultural factors that indirectly influence individuals. In the center of the different system levels, socio-demographic characteristics of individuals are placed (individual factors); the 4 different level contexts can differ based on socio-demographic factors of individuals.²⁵

Figure 1.

Bronfenbrenner’s ecological theory. Adapted from McLaren and Hawe (2005).

Methods

Data Source

The preliminary literature search involved the electronic keyword search of Academic Search Premier, Academic Search Complete, Sciencedirect, Socia Science Citation Index, Science Citation Index, Health Source Nursing/Academic Ed, Psychology and Behavioral Sciences Collection, SocINDEX, CINAHL, Educational Resource Information Center (ERIC), Education Full Text H.W. Wilson, Education Research Complete, MEDLINE, PsycINFO, and SPORTDiscus via EBSCO Host. Search terms were used in various combinations of keywords (Table 1).

Table 1.

Searching Keywords.

Population	AND indicator/Context	AND outcome
Young adults OR Undergraduate students OR University students OR College students OR Graduate students AND USA (United State of America, America)	Internalized factors OR Individual factors OR Belief or Health belief OR Belief in vaccination OR Belief in flu vaccination OR Belief in influenza vaccination OR Health perception or Perception OR Perception to vaccination OR Perception to flu vaccination OR Perception to influenza vaccination OR Risk perception OR Negative perception OR Family factors OR Family behavior OR Family environment OR Family dynamics OR Family communication OR Family relationships OR Communication with parents OR Healthcare communication OR Communication for vaccination OR Peer factors OR Friends or classmates OR Healthcare service utilization behavior OR Healthcare service accessibility OR Resources OR Healthcare provider suggestions OR Physician suggestion OR Doctor recommendation OR Doctor suggestion	Flu vaccine OR Flu vaccination OR Influenza vaccine OR Influenza vaccination OR Flu immunization OR Influenza immunization OR Flu vaccine intention OR Flu vaccination intention OR Influenza vaccine intention OR Influenza vaccination intention OR Preventive behavior OR Influenza care or flu care or Prevention OR Influenza care or flu care or preventive care

Inclusion and Exclusion Criteria

The keywords were structured based on the framework for systematic review suggested by PRISMA and Pollock and Berge (2017).²⁶ Although PRISMA suggests a simple PICO frame for intervention studies (e.g., clinical intervention trials, randomized controlled trials), there is a range of other frameworks which can inform the questions (i.e., criteria) for more complex reviews. Specific criteria for different types of study reviews (e.g., cohort-study review, intervention review, or observational study review) are as follows: PI/CO (population, indicator/context, and outcome) for cross-sectional/longitudinal cohort-studies or survey design studies, PICOS (population, intervention, comparison, outcome, study type) for intervention or observation studies, and PICOT (population, intervention/index/indicator, comparison, outcome, timeframe) for intervention studies.²⁶

The current study used the “Population, Indicator/Context, and Outcome” frame for the systematic review of selected cross-sectional studies. The inclusion criteria were: (1) cross-sectional design using survey with full-text availability, published in English language between 2009 and 2019; (2) original studies that target or include U.S. college or university students; (3) original studies with indicators or contexts including demographic characteristics or internal or external factors associated with outcome(s); and (4) original studies with vaccination intentions to have (or uptake of), a vaccination against influenza. The exclusion criteria were: (1) non-original studies (e.g., summary, editorial, and letter); (2) studies targeting non-college or university students; and (3) studies on animals, genes, stems, or effectiveness of human-subject clinical/laboratory trials.

Data Extraction and Synthesis

For article searching, sorting, and reviewing, the university library system and Endnote X7 software were used. Four reviewers independently applied inclusion and exclusion criteria to screen studies, at 3 stages: title screening, abstract screening, and full text screening. Any disagreements about inclusion and exclusion were settled through discussion after each stage of screening. Information extracted for synthesis was as follows: author and year of publication; sample characteristics; theoretical model used; study design and method; predictors; outcomes; results; and racial or ethnic differences.

As Figure 2 shows, initially, 810 articles were generated. Through article title screening, 288 were excluded (due to duplicates). Out of 522 records, 474 were excluded through the abstract screening process: 204 studies were not original studies, 115 studies were not targeting U.S. university or college students, 92 studies had irrelevant exposure or outcome, and 63 were not English written studies. Then, remaining 48 articles were thoroughly screened (i.e., in-depth full-text screening) and 23 were excluded. Among 23 studies, 20 studies were excluded due to similar issues investigated from the abstract screening, and 3 studies were excluded because they included human subject intervention or gene/clinical lab studies. Searching and sorting schedules (including cross-checking across the team members) were as follows: key word searching was performed from mid June (2019) to end July (2019), title screening was performed from Aug (2019) to Sept (2019), and full text screening was performed from Oct (2019) to Dec (2019).

Figure 2.

Flow chart of searching and reviewing (Inclusion and exclusion for reviews).

By fully depending on the selection criteria (inclusion and exclusion criteria) as well as the PRISMA check list, the 4 reviewers concluded to use 25 studies for the current systematic review. Figure 2 was formulated based on the PRISMA guidelines. To ensure the quality of selected articles, the 4 reviewers of the current study checked whether articles approach expected inclusion criteria, as well as evaluated whether articles were appropriately structured (i.e., background, objectives, methods [data; sample size; study participant characteristics; measures, etc.], analysis strategies, results, conclusions), were providing quantitative statistic findings, and were appropriately interpreted based on statistic standards or not: selected studies had to have 95% Confidence Interval (CI) level restriction. Also, selected studies were appropriately structured and provided clear quantitative statistic findings. The “Article Summary Table 1 (Selected Article Summary)” includes more details: the column of participants includes sample size, race/ethnicity, age or grade (e.g., freshman–senior), and gender. Some studies presented all demographic characteristics but some other studies presented partial demographic characteristics. The column of study design, method, and theory includes types of theoretical frame (e.g., Theory of Planned Behavior or HBM), data collection strategies (e.g., web-based, self-administered, or phone-based survey). The column of predictors includes all predictors that each study originally included (no matter what significant effects of the predictors). The column of outcomes includes the focal outcomes of the selected studies. The results column includes only “significant predictors” associated with the outcomes (based on 95% CI). For significant predictors on influenza vaccination or vaccination intention (from the reviewed studies), the current systematic review study tried to summarize based on EST. Details are introduced in results section.

Results

Twenty-five studies were included in the current systematic review. Mostly, micro level components were included as predictors (internal factors, external factors, and personal life and experiences). Several studies included meso level components such as residential areas and the types of university/college. Table 2, which is based on EST, is presenting predictors of influenza vaccination or vaccination intention in reviewed studies. This table indicated that Individual factors (socio-demographic characteristics), micro, and meso level components were mainly included in selected studies. In the selected studies, exo and macro level components were not clearly described as key factors associated with college or university students’ influenza vaccination or vaccination intention. More details on this (i.e., a lack of information on exo and macro level components) are presented in the discussion section.

Table 2.

Included Key Components of the Ecological System Levels.

Different levels	Indicators/Contexts	Articles
Socio-Demographic Factors	Race, age, gender, education, financial status, marital status, immigration status, acculturation status	^{13,16 -19,27 -33,36,38 -42}
Micro Level (Internal Factors—Perceptions)	Previous experiences on influenza vaccination (ever had a vaccination; side-effects experiences)	^{30,32,40,42,43}
	Positive or negative perceptions toward influenza vaccination	^{15,17,27,30,37,38,40,43}
	Previous experiences in healthcare settings (either negative or positive)	^19,35,41
Micro Levels (Individual factor itself)	Physical health status	^16,29,32,36
Micro Levels (Individual factor itself)	Health Behaviors (e.g., smoking, drinking, exercise, treatment adherence, regular check up)	^17,36
Micro Levels (Internal Factors—Psychological)	General health beliefs	⁴⁰
Micro Levels (Internal Factors—Psychological)	Health Belief Model (HBM) components	^{11,13,15,17,19,30,35,37,40,42,43}
Micro Levels (External Factors)	Influenza vaccine related knowledge	^{17,19,35,41,43}
	Information from media, flyer, advertisement, etc.	^{11,16,19,28,33 -35,39,41}
	Physician recommendation	^{16,18,27,28,30,32,33,36,40}
	Family Components (e.g., Parents’ suggestion, Family dynamics, Family communication, etc.)	^{15,16,18,28,35,40,43}
	Peer Components (e.g., Peer suggestion, observation from peers, etc.)	^{15,28,35,40,43}
	Teacher/professor Components (e.g., suggestion from them, communication, etc.)	⁴¹
	Campus life (activities in student groups)	^18,27,31,33
	Resources (e.g., transportation, translator, insurance, etc)	^{13,16,18,27,29,33,38,40,43}
Meso Levels	Regional area where the target populations live in (e.g., Living in dorm?; Living with their family members?; Living with their peers?)	^27,32,41

Note. Exo and macro level components were not clearly described in selected articles. Possible reasons of this are described in the text specifically.

Selected Studies

The selected 25 studies used 2 outcome measures: influenza vaccination and influenza vaccination intention. Some studies focused only on influenza vaccination^{15,16,27

-36} and other studies focused only on influenza vaccination intention.^{11,17
-19,37

-42,44} The remaining studies targeted both influenza vaccination and vaccination intention.^13,43 Nine studies applied the Health Belief Model (HBM)^{15,17,18,30,42,43} or Theory of Planned Behavior (TPB)^11,19,37 to define significant predictors of influenza vaccination or vaccination intention; other studies did not use specific theories to formulate their studies. For race or ethnicity, some studies included diverse racial groups (3 or more groups) including White, African American, Hispanic, Asians, or others^{15,27,29

-34,36
-38,40,41,43} and the other studies included only one or 2 groups (e.g., white only; white or other groups; African American only). Two studies^13,28 targeted Black/African American university students only and one study targeted immigrant students only.⁴² Most studies applied a cross-sectional study design with a self-administered survey (either paper based or web-based), and one study applied a cross-sectional design with a face-to-face survey.⁴¹ The sample size of 25 reviewed studies was ranged from 79 to 4,090. As mentioned earlier, selected studies had to have 95% CI level restriction for statistic analyses and observed p-value range was from p < .05 through p < .001. Details (i.e., observed p-value range of each study) are presented in the Article Summary Table 1 (Selected Article Summary).

Determinants of Influenza Vaccination or Vaccination Intention

Individual factors: Socio-demographic characteristics

Students, who were older in general^13,35 or age 23–26 years (ref = age 18–22 years),²⁹ female,²⁹ 200–299% Federal Poverty Level (FPL) or > 300% FPL (ref = 0–99% FPL),²⁹ insured,²⁹ had a higher vaccine affordability and cost benefits,¹³ or had usual sources of health care (e.g., regular health exam),^29,33 showed higher levels of influenza vaccination or vaccination intention. If students’ parents were highly educated (e.g., some college education or less, college graduate, or post graduate education),³⁶ students had more influenza vaccine or vaccination intention. Compared to sophomores, freshmen³¹ had more influenza vaccine. Race or ethnicity effects on vaccination or vaccination intention will be discussed in the section entitled, “Racial Difference on Significant Determinants of Influenza Vaccination or Vaccination Intention.”

With regard to race and ethnicity, only 14 out of 25 studies included diverse racial groups (2 or more groups).^{15,27,29

-34,36
-38,40,41,43} The remaining 11 studies included only one racial group (i.e., Whites only) or did not clearly indicate whether they included diverse racial groups or not. Among the 14 studies, 10 studies ^{27,29
-31,33

-36,40,43} investigated whether race or ethnicity were significantly associated with influenza vaccination or intention, and the remaining 4 studies did not perform racial difference tests on vaccination or intention. Out of 10 studies, only 3 studies^30,40,43 found a race or ethnicity effect on influenza vaccination or vaccination intention. To be specific, Nan and Kim (2013)³⁰ included 5 racial groups (Whites [reference group], African Americans, Hispanics, Asians, and Others) and found that African American students compared to White students were significantly less likely to get vaccinated. There was no significant difference on influenza vaccination between Whites and Hispanics, Asians, or Others. Nyhan, Reifler, and Fichey (2012)⁴⁰ targeted Whites, African Americans, Asians, Hispanics, and multi racial groups and indicated that Asian Americans, compared to Whites, were more likely to intend to get vaccinated. Ratnapardipa, Norrenberns, Turner, and Kunerth (2017)⁴³ included White, African American, Hispanic, Asian/Pacific Islander, and other racial groups and found that Asian/Pacific Islander students showed higher levels of vaccination intention compared to White students. Although the controlled main predictors were varied across the 3 studies, the 2 studies^40,43 consistently reported that Asian American students (than White students) showed higher levels of influenza vaccination or intention.

There were 2 studies targeting only one racial group.^13,28 However, the current study could not evaluate whether the 2 studies including the same racial group (i.e., African American) showed consistent or different findings, because the 2 studies used different ecological system levels’ components: one study used internal factors (e.g., beliefs and perceptions)¹³ while the other study used external factors (e.g., information resource, physician components, family components) as predictors of influenza vaccination or vaccination intention.

Micro levels: Internal factors of individuals

Some studies highly focused on internal factors of individuals such as beliefs or perceptions. Higher levels of perceived benefits,^18,19,35,43 susceptibility,^37,42,43 influencers (e.g., safe to use and easy to administer, or follow up on vaccine compliance),¹⁸ availability,⁴³ and self-efficacy^{13,15,17,19,37} were associated with higher levels of influenza vaccination or vaccination intention. Higher levels of positive attitudes toward the vaccine,³⁷ knowledge about influenza and the influenza vaccine,¹⁷ H1N1 vaccine safety concerns,¹⁵ subjective norms,^19,37 information seeking,¹¹ and perceived behavioral control³⁷ were also related to higher levels of influenza vaccination or vaccination intention. Students having perceptions such as “I do not want to get sick,” or “I do not want to give flu to my relatives”¹⁶ were more likely to get vaccinated. With fewer perceived barriers,^{15,18,19,35,42,43} individuals were more likely to receive the influenza vaccine or show vaccination intentions.

When students had negative attitudes or concerns about influenza vaccine (e.g., “flu shot could cause flu,” “vaccine may cause dangerous side-effects,” “I do not believe I am in danger of contracting the flu,” “vaccine could cause autism”), they were less likely to get vaccinated.^16,18,27 Students having such perceptions about themselves as “I am too lazy,” “I do not need vaccines because I am healthy,” or “I do not have enough time to get influenza vaccine”³⁸ were less likely to get vaccinated.

Micro levels: External factors of individuals

Information resources

Receiving information about the influenza vaccine from professionals or media (i.e., receiving of influenza vaccine will reduce risk of transmission of influenza to vulnerable populations such as children or older adults),³⁸ and receiving tangible information from Centers for Disease Control and Prevention (CDC), local health authorities, World Health Organization (WHO), university scientists, scientist in pharmaceutical companies,^28,44 or news media^41,44 were positively associated with influenza vaccination or vaccination intention. Moreover, various types of advertisements such as “the loss-framed text-supported public service advertisement” or “the gain-framed text-supported public advertisement” successfully enhanced influenza vaccination and vaccination intention. One study³⁴ found that in-class presentations (using power point slide), campus printer posters, and university web-sites were top ranked as strong influencers on influenza vaccination.

Recommendations and supports

Recommendations from healthcare providers,^{27,28,30,32,33,36} parents,^16,28,33 family members,⁴¹ relatives,³³ or friends^33,34,41 enhanced influenza vaccination or vaccination intention of college or university students. One study focused on network supports such as spousal, parental, friend, and relatives, and found all of these network supports enhanced intention of receiving the influenza vaccine.⁴⁰ In addition, students who had a family plan to get vaccinated were more likely to get vaccinated⁴³ or show higher levels of vaccination intention.^28,43

Micro levels: Personal life or experiences

There were several micro level influencers in vaccine use. Campus activities such as participation of academic clubs/honor societies and often/very often utilization of email for work/school³¹ were positively associated with influenza vaccination. If students received influenza vaccines in past years^{15,32,36,42,43} or had chronic illnesses (e.g., diabetes, asthma, cardiac disease),^32,36 they were more likely to show influenza vaccination or vaccination intention. According to one³⁵ reviewed study, having friends or families who received the H1N1 vaccine, knowing anyone who got sick from influenza, having a higher level of likelihood of catching H1N1, or having a higher number of people likely to catch H1N1 from an infected person showed more influenza vaccination.

Meso levels: Type of universities/colleges or residential area(s)

At the meso level, given studies included residential areas and different types of universities or colleges. Engaging in private university programs (compared to public university programs)³¹ or living in dorms or student housing³⁵ were associated with higher levels of influenza vaccination.

Conclusions

The current study focused on college or university students’ vaccination behaviors (uptake or intention) regardless of race or ethnicity. The reviewed 25 studies found that individual factors (socio-demographic characteristics), micro level factors, and meso level factors were mostly associated with influenza vaccination or vaccination intention.

Potential/Possible Reasons of Given Trends Among Asians and African Americans

As mentioned earlier, searched and selected articles for the review do not provide us enough information to conclude racial or ethnic differences in influenza vaccination or vaccination intention. Therefore, this review study cannot easily generalize the racial or ethnic differences. However, even with the limited number of studies (i.e., only 10 studies figured out racial or ethnic differences and eventually 3 studies could propose significant racial differences), the current study tried to suggest possible/potential reasons of given findings. See below paragraph.

Although there was no clear information what specific factors of EST (individual factors–macro factors) account for the substantial proportion of racial variance in influenza vaccination or vaccination intention, the current systematic review could find that Asian students were more likely to be vaccinated than other racial groups. Possibly, Asian groups’ immigration status, country of origin, and ability to navigate healthcare services, influenza vaccination behaviors could vary.⁴⁵ Asian students (particularly if they are foreign born students) often struggle as other ethnic minorities do, with language and cultural barriers. They also lack necessary skills to navigate the American system effectively.⁴⁶ Especially, foreign born Asians might not be clear about healthcare services (e.g., ways to contact healthcare providers, steps to get treatments, insurance coverage, or payment methods or procedures). Accordingly, many of the foreign-born Asians want to prevent severe illnesses or advanced stages of flu-related diseases that may require intensive treatments or long term healthcare in the U.S.; and it eventually enhances Asian students’ influenza vaccination behaviors than other domestic students.⁴⁵ The current systematic review also found that African American students were less likely to receive influenza vaccination than White students. For this finding, it would be possible to propose potential reasons: on the basis of race, differences in psychosocial factors between African Americans and Whites could be formed; different psychosocial factors would have implications for the different patterns in which people perceive and adhere to recommended influenza vaccination.⁴⁷ To be specific, SES is definitely influenced by a long history of racism towards African Americans. Racism may reinforce differences in life chances and living conditions, creating inequitable SES.⁴⁸ Inequitable SES, in turn, causes inequitable accessibility to healthcare resources. In addition, it would be possible to talk about African Americans health beliefs have been influenced by the combination of experiences in society, religiosity/spirituality, and family/neighborhood roles.⁴⁸ African Americans often show strong religious and spiritual beliefs, and they may interpret their disease in a frame of “Only God can help me.”⁴⁹ In other words, African American students’ lower levels of influenza vaccination could be understood and interpreted with more complicated manners. Importantly, more future research should explore how these (potential) complicated factors are inter-correlated, in turn, influence African American students’ vaccination behaviors.

Discussions on Significant Micro-Meso Level Factors

Reviewed studies suggested that better socio-economic characteristics were positively associated with vaccination or vaccination intention. Under micro level factors, not only internal factors but also external factors significantly influenced influenza vaccination or vaccination intention of college or university students. Findings from the current systematic review were consistent with prior systematic reviews’ findings.^20,21,23,24 For internal factors, reviewed studies found that students having positive beliefs or perceptions, positive attitudes or perceived fewer barriers showed higher levels of influenza vaccination or vaccination intention than their counterparts. On the contrary, students having negative perceptions or attitudes consistently showed lower levels of influenza vaccination or vaccination intention.

Effective external factors such as, information resources, recommendations from others, and support from networks were reported. Information based on reliable resources was most commonly cited as an effective factor for influenza vaccination or vaccination intention. Recommendations from healthcare providers, parents, and friends were also commonly cited. In addition, students with a history of influenza vaccinations were more likely to get vaccinated, and this could be strongly related to their internal beliefs or perceptions.⁴⁵ Students’ personal experiences with influenza vaccination could cause either positive or negative health beliefs, which in turn facilitates or impedes their vaccination behaviors.^16,18,27 Notably, college or university students’ personal life experiences on campus or within their family were related to their influenza vaccination or vaccination intention. This finding highlights the importance of understanding the unique characteristics or environments of college or university students.^9,10 Following the reviewed studies, involvement in more campus activities could be helpful for encouraging students to get vaccinated. Students who actively engage in campus activities might have more opportunities to find valid and reliable information resources through their campus networks, and eventually they may show higher levels of influenza vaccination.^8,31

Importantly, the current systematic review found that college or university students’ meso level factors were also significantly related to their influenza vaccination. Reflecting students’ unique environmental characteristics, the type of university they attend (private versus public) or housing were significant factors for influenza vaccination. With regard to the fact that students attending private universities or living in dorms or student housing were more likely to get the influenza vaccine, socio-economic status (SES) could be considered as potential predictors of the causal paths (financial status [predictor]—college or university type / residential areas [mediator]—vaccination [outcome]). A prior study found that individuals with better SES status were more likely to get influenza vaccinations than their counterparts⁵⁰ and low-income students could be reluctant to enroll in private universities due to financial struggles.⁵¹ Regarding housing, students living in dorms could have more benefits from vaccination related announcements posted in residential halls or messages from the resident advisers.³¹

Limitations of Selected/Reviewed Studies

The current study identified several limitations of the reviewed empirical studies: First, the information provided from selected 25 studies was not enough to evaluate and conclude whether college or university students of diverse racial groups have unique or similar characteristics (or cultural factors) associated with their influenza vaccination or vaccination intention. Only 3 studies could find significant effects of race or ethnicity on influenza vaccination intention, and even none of the selected 25 studies performed sub-population analyses. Sub-population analyses could separate diverse racial groups and investigate what unique or common factors are significantly related to the outcome (i.e., influenza vaccination or vaccination intention). Accordingly, the current systematic review could not make conclusions about the existence of uniqueness or similarities on vaccination behaviors across diverse racial or ethnic groups. This area should be explored more by future research. Scholars^52,53 have highlighted that cultural background (family or community) could play an important role in each individual’s access and uptake of the influenza vaccine. These scholars also agreed that enhancing cultural competency and relevant approaches to specific racial groups would improve the uptake of vaccination.^52,53 Given the lack of studies on cultural awareness in vaccination-related issues, it is necessary to thoroughly understand what drives each person’s decision to utilize vaccinations, within a cultural context. Second, some studies included family related predictors (communication, recommendation, plans to get vaccinated, and experiences related to vaccination) and they used index type questionnaires for capturing family factors. However, the index type questions may not capture in-depth knowledge about college students’ multidimensional family dynamic status. Strengths of multidimensional measures are to gain knowledge about individuals’ situations or environments as well as their psychological adaptation. College students’ diverse situations or environments in family units can differentially shape and determine behavior, cognition, and affect of students, which in turn generate different patterns of influenza vaccination or vaccination intention. Therefore, future studies should explore more on college students’ family dynamics and environments. Last, prior empirical studies did not fully investigate potential effects of exo or macro level components on college or university students’ influenza vaccination or vaccination intention. As mentioned earlier (i.e., conceptual framework section), exo level components in Bronfebnrenner’s EST²⁵ pertain indirect factors associated with influenza vaccination behaviors. For example, parents’ work status (social structure) or a workplace could cause a mediating condition, in turn, enhance or impede the influenza vaccination behaviors of college or university students. Specifically, if students’ parents are working in the long-distance area so that the family members have very few chances to communicate, family members including students might have very few chances to share tangible information related to flu vaccination. It would be possible to assume that there must be underlying (invisible) exo level components associated with micro or meso level components. Due to the complicated characteristics of exo level components, most of the prior studies possibly could not be able to easily define them. The macro level components represent the actual culture of an individual. The cultural contexts involve life circumstances of individuals that are influenced by socio-economic status or cultural backgrounds. Race is often linked to concepts of the combination of societal factors, environmental situations, and cultural background of individuals. Race should be viewed as a multivariate level variable that circumscribes a constellation of psychosocial and psychological variables that ultimately mediate the relationships between psychosocial factors and influenza vaccination behaviors.⁵⁴ However, as race and ethnicity were very limitedly dealt with in reviewed studies, the current study could not easily conclude how underlying factors related to race or ethnicity affect college or university students’ influenza vaccination behaviors. This indicates that future empirical studies need to add more in-depth knowledge on this area.

Limitations of the Current Systematic Review Study

The current systematic review also has limitations. Even though this review study has helped to explain the importance of internal and external determinants based on ecological system components, only cross-sectional studies with self-administered or face-to-face surveys were included. While cross-sectional designs cannot infer causality, longitudinal studies or clinical intervention trials could give us more in-depth knowledge about influenza vaccination behaviors (uptake or intention) among college or university students. Specifically, longitudinal studies or clinical intervention trials examining changes in internal or external factors of college students would be more informative. Before evaluating causal relationships between predictors and vaccination behaviors, performing and evaluating qualitative research could be also helpful to develop further quantitative research or to explain some of the nuances missing from quantitative studies. In addition, the current review study included both vaccination and vaccination intention as outcomes. Future studies may need to disaggregate vaccination and vaccination intention in order to evaluate whether significant predictors of vaccination will be clearly different from significant predictors of vaccination intention.

Despite the given limitations, the evidence provided in this review proposes realistic and tangible guidelines for public health officials (e.g., physicians and other professionals). Providing education programs to enhance positive beliefs, perceptions, or attitudes toward influenza vaccination of college or university students is critical. Information about the safety and effectiveness of having the vaccine could be provided for target groups through the official media (e.g., public/national or university or college campus based), reliable and valid medical sources (e.g., healthcare professionals or community clinics), campaign programs on campus, or internet web-sites. Given the fact that college or university students’ influenza vaccinations or vaccination intentions were strongly influenced by physicians, family members, or peers, disseminating family-to-student and peer-to-peer awareness campaigns or education programs (provided by physicians) might be useful in encouraging vaccination among college or university students. In addition, even though only 3 studies found effects of race or ethnicity on influenza vaccination or intention of college or university students, racial or ethnic relevant facilitators of vaccination need to be considered: for example, reviewed empirical studies found that African American students were more vulnerable (than White students) to the lack of influenza vaccination or intention.³⁰ Therefore, healthcare professionals should try to reduce the key reasons for African American students’ reluctance to contemplate or use the influenza vaccination.

Most importantly, the current systematic review highlights the fact that few studies are explicating what accounts for the substantial proportion of racial or ethnic variance in influenza vaccination or vaccination intention. Almost individual, micro, meso, exo, and macro level components vary across racial or ethnic groups, meaning they might be of particular relevance to the understanding of adherence disparities. Further research on which types of components (individual-micro-meso-exo-macro levels) are the most critical predictors of adherence to influenza vaccination should be performed. Also, future studies should add more in-depth knowledge of exo and macro level components in EST. As mentioned earlier, there must be complicated underlying factors associated with exo and macro level components.

SO WHAT? Implications for Health Promotion Practitioners and Researchers

What is already known on this topic?

Prior review studies synthesized factors that affect individuals’ decision to get vaccinated, regardless of individuals’ age-range. Most of the prior review studies focused only on psychological components of individuals. Few review studies focused on effects of multidimensional factors on influenza vaccination of university or college students.

What does this article add?

The current study summarized both internalized and externalized factors that influence college or university students’ influenza vaccination using Bronfenbrenner’s Ecological System Theory (EST). Micro level factors were also specifically divided (categorized) into internal and external factors. Also, the current study findings confront us with limited knowledge/information whether each racial or ethnic group has their unique psychosocial factors associated with their influenza vaccination or vaccination intention.

What are the implications for health promotion practice or research?

This review proposes realistic and tangible guidelines for public health officials (e.g., physicians and other professionals). Professionals should consider multidimensional factors (e.g., beliefs, perceptions, peer-to-peer or family-to-student factors, residential status) to enhance university or college students’ influenza vaccination. In addition, the current study clearly mentions the need of future research investigating what unique psychosocial factors significantly influence diverse racial or ethnic groups’ influenza vaccination behaviors.

Supplemental Material

Supplemental Material, sj-pdf-1-ahp-10.1177_0890117120985833 - Influenza Vaccination Among U.S. College or University Students: A Systematic Review

Supplemental Material, sj-pdf-1-ahp-10.1177_0890117120985833 for Influenza Vaccination Among U.S. College or University Students: A Systematic Review by En-Jung Shon, Siyoung Choe, Lena Lee and Youn Ki in American Journal of Health Promotion

Footnotes

Authors’ Note

All authors conceptualized this manuscript. These 4 authors participated in whole systematic review process (i.e., searching, sorting, reviewing, and summarizing). All authors were involved in manuscript writing and approval.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

En-Jung Shon

Supplemental Material

Supplemental material for this article is available online.

References

Tokars

Olsen

Reed

. Seasonal incidence of symptomatic influenza in the United States. Clin Infect Dis. 2017;66(10):1511–1518.

Centers for Disease Control and Prevention. Disease Burden of Influenza. CDC; 2019. Updated October 5, 2020. Accessed December 8, 2019. https://www.cdc.gov/flu/about/burden/index.html

Centers for Disease Control and Prevention. Vaccination Lowered Risk of Having to Go to the Doctor by About 60 Percent for People of All Ages 2014. CDC; 2014. Updated February 20, 2014. Accessed December 8, 2019. https://www.cdc.gov/media/releases/2014/p0220-flu-report.html

Healthessentials. When Young Adults Get Flu Shots, Older Adults Benefit Best: Low-Risk Adults Help Prevent Disease in Higher-Risk Population. Health Essentials in Cleveland Clinic; 2015. Updated 2015. Accessed October 5, 2019. https://health.clevelandclinic.org/when-young-adults-get-flu-shots-older-adults-benefit-best/

Franks

Jandu

. Vaccine rates and protective health behaviors amongst college students during influenza season. J Biomedical Sci. 2017;6(3):1–9. doi:10.4172/2254-609X.100066

National Vaccine Advisory Committee. Strategies to achieve the healthy people 2020 annual influenza vaccine coverage goal for health-care personnel: recommendations from the National Vaccine Advisory Committee. Public Health Rep. 2013;128(1):7–25.

Nichol

Heilly

Ehlinger

. Colds and influenza-like illnesses in university students: impact on health, academic and work performance, and health care use. Clin Infect Dis. 2005;40(9):1263–1270.

Nichol

Tummers

Hoyer-Leitzel

Marsh

Moynihan

McKelvey

. Modeling seasonal influenza outbreak in a closed college campus: impact of pre-season vaccination, in-season vaccination and holidays/breaks. PLoS One. 2010;5(3):1–9.

Guh

Reed

Gould

, et al. Transmission of 2009 pandemic influenza A (H1N1) at a public university—Delaware, April–May 2009. Clin Infect Dis. 2011;52(1): S131–S137.

10.

Uchida

Tsukahara

Kaneko

Washizuka

Kawa

. How the H1N1 influenza epidemic spread among university students in Japan: experience from Shinshu University. Am J Infect Control. 2012;40(3):218–220.

11.

Yang

. Too scared or too capable? Why do college students stay away from the H1N1 vaccine? Risk Anal. 2012;32(10):1703–1716.

12.

Lawrence

. Healthy bodies, toxic medicines: college students and the rhetorics of flu vaccination. Yale J Biol Med. 2014;87(4):423.

13.

Cole

Gill

Fletcher

Shivers

Allen

Mwendwa

. Understanding African American College Students’ H1N1 vaccination decisions. Health Psychol. 2015;34(12):1185–1190.

14.

Sandler

Srivastava

Fawole

Fasano

Feemster

. Understanding vaccine knowledge, attitudes, and decision-making through college student interviews. J Am Coll Health. 2020;68(6):593–602.

15.

Ravert

Zimet

. Reasons for low pandemic H1N1 2009 vaccine acceptance within a college sample. Adv Preve Med. 2012;2012:1–7. doi:10.1155/2012/242518

16.

Koharchik

Hardy

Salman

. Evidence-based initiative to improve influenza immunisation participation among undergraduate nursing students. J Infect Prev. 2012;13(6):186–191.

17.

Kamimura

Trinh

Weaver

, et al. Knowledge and perceptions of influenza vaccinations among college students in Vietnam and the United States. J Prev Med Public Health. 2017;50(4):268–273.

18.

Jadhav

Winkler

Anderson

. Vaccination perceptions of college students: with and without vaccination waiver. Front Public Health. 2018;6:36.

19.

Yang

. Predicting young adults’ intentions to get the H1N1 vaccine: an integrated model. J Health Commun. 2015;20(1):69–79.

20.

Schmid

Rauber

Betsch

Lidolt

Denker

M-L

. Barriers of influenza vaccination intention and behavior—a systematic review of influenza vaccine hesitancy, 2005–2016. PLoS One. 2017;12(1):e0170550.

21.

MacDonald

Cairns

Angus

De Andrade

. Promotional communications for influenza vaccination: a systematic review. J Health Commun. 2013;18(12):1523–1549.

22.

Brien

Kwong

Buckeridge

. The determinants of 2009 pandemic A/H1N1 influenza vaccination: a systematic review. Vaccine. 2012;30(7):1255–1264.

23.

Bish

Yardley

Nicoll

Michie

. Factors associated with uptake of vaccination against pandemic influenza: a systematic review. Vaccine. 2011;29(38):6472–6484.

24.

Kan

Zhang

. Factors influencing seasonal influenza vaccination behaviour among elderly people: a systematic review. Public Health. 2018;156:67–78.

25.

McLaren

Hawe

. Ecological perspectives in health research. J Epidemiol Commun H. 2005;59(1):6–14.

26.

Pollock

Berge

. How to do a systematic review. Int J Stroke. 2017;13(2):138–156.

27.

Benjamin

Bahr

. Barriers associated with seasonal influenza vaccination among college students. Influenza Res Treat. 2016;2016:1–5. doi:10.1155/2016/4248071

28.

Ford

Meshack

Roberts

, et al. H1N1 vaccination uptake among African American college students. Am J Health Stud. 2012;27(3):129–135.

29.

Lau

Adams

Irwin

Jr Ozer

. Receipt of preventive health services in young adults. J Adolesc Health. 2013;52(1):42–49.

30.

Nan

Kim

. Predicting H1N1 vaccine uptake and H1N1-related health beliefs: the role of individual difference in consideration of future consequences. J Health Commun. 2014;19(3):376–388.

31.

Poehling

Blocker

Peters

Wolfson

. 2009-2010 seasonal influenza vaccination coverage among college students from 8 universities in North Carolina. J Am Coll Health. 2012;60(8):541–547.

32.

Ramsey

Marczinski

. College students’ perceptions of H1N1 flu risk and attitudes toward vaccination. Vaccine. 2011;29(44):7599–7601.

33.

Rogers

Bahr

Benjamin

Attitudes and barriers associated with seasonal influenza vaccination uptake among public health students; a cross-sectional study. BMC Public Health. 2018;18(1):1131.

34.

Shropshire

Brent-Hotchkiss

Andrews

. Mass media campaign impacts influenza vaccine obtainment of university students. J Am Coll Health. 2013;61(8):435–443.

35.

Sunil

Zottarelli

. Student utilization of a university 2009 H1N1 vaccination clinic. Vaccine. 2011;29(29-30):4687–4689.

36.

Uddin

Cherkowski

Liu

Zhang

Monto

Aiello

. Demographic and socioeconomic determinants of influenza vaccination disparities among university students. J Epidemiol Commun H. 2009;64(9):808–813.

37.

Agarwal

. A/H1N1 vaccine intentions in college students: an application of the theory of planned behavior. J Am Coll Health. 2014;62(6):416–424.

38.

Bednarczyk

Chu

Sickler

Shaw

Nadeau

McNutt

L-A

. Low uptake of influenza vaccine among university students: evaluating predictors beyond cost and safety concerns. Vaccine. 2015;33(14):1659–1663.

39.

Lee

Y-I

Jin

Nowak

. Motivating influenza vaccination among young adults. Soc Mark Q. 2018;24(2):89–103.

40.

Nyhan

Reifler

Richey

. The role of social networks in influenza vaccine attitudes and intentions among college students in the southeastern United States. J Adolesc Health. 2012;51(3):302–304.

41.

Wilson

Huttlinger

. Pandemic flu knowledge among dormitory housed university students: a need for informal social support and social networking strategies. Rural Remote Health. 2010;10(4):1–9.

42.

Teitler-Regev

Shahrabani

Benzion

Factors affecting intention among students to be vaccinated against a H1N1 influenza: a health belief model approach. Adv Prev Med. 2011;2011:1–8. doi:10.4061/2011/353207

43.

Ratnapradipa

Norrenberns

Turner

Kunerth

. Freshman flu vaccination behavior and intention during a nonpandemic season. Health Promot Pract. 2017;18(5):662–671.

44.

Catellier

JRA

Yang

. Trust and affect: how do they impact risk information seeking in a health context? J Risk Res. 2012;15(8):897–911.

45.

Lee

Martinez

, et al. Barriers to health care access in 13 Asian American communities. Am J Health Behav. 2010;34(1):21–30.

46.

Hirschman

Wong

. The extraordinary educational attainment of Asian-Americans: a search for historical evidence and explanations. Soc Forces. 1986;65(1):1–27.

47.

Lim

Gonzalez

Wang-Letzkus

Ashing-Giwa

. Understanding the cultural health belief model influencing health behaviors and health-related quality of life between Latina and Asian-American breast cancer survivors. Support Care Cancer. 2009;17(9):1137–1147.

48.

Kennedy

Psychosocial model: racism as a predictor of adherence and compliance to treatment and health outcomes among African Americans. J Theory Constr Test. 2009;13:20–26.

49.

Chatters

Taylor

Jackson

Lincoln

. Religious coping among African Americans, Caribbean blacks and non-Hispanic Whites. J Community Psychol. 2008;36(3):371–386.

50.

Lucyk

Simmonds

Lorenzetti

Drews

Svenson

Russell

. The association between influenza vaccination and socioeconomic status in high income countries varies by the measure used: a systematic review. BMC Med Res Methodol. 2019;19(1):153–153.

51.

Kornicker

Impacts of Lower Socioeconomic Status on College Admissions. University of Pennsylvania; 2018.

52.

Kleinman

Benson

. Anthropology in the clinic: the problem of cultural competency and how to fix it. PLoS Med. 2006;3(10): e294.

53.

Yong

Lemyre

Farrell

Young

. Acculturation in preventive health for immigrants: a systematic review on influenza vaccination programs in a socio-ecological framework. Can Psychol. 2016;57(4):340–355.

54.

Magai

Consedine

Adjei

Hershman

Neugut

. Psychosocial influences on suboptimal adjuvant breast cancer treatment adherence among African American women: implications for education and intervention. Health Educ Behav. 2008;35(6):835–854.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.39 MB