What Predicts Influenza Vaccination Status in Older Americans over Several Years? Melissa Tabbarah, PhD, MPH, à Richard Kent Zimmerman, MD, MPH, à w Mary Patricia Nowalk, PhD, à Janine E. Janosky, PhD, à Judith A. Troy, MS, à Mahlon Raymund, PhD, à and Ilene Katz Jewell, MS Hyg w OBJECTIVES: To examine the correlates of repeat influen- za vaccination and determine whether there are age-group (50–64, 65) differences in decision-making behavior. DESIGN: Longitudinal survey study. SETTING: Two community health centers in Pittsburgh, Pennsylvania. PARTICIPANTS: Two hundred fifty-three patients aged 50 and older in 2001 who visited one of the health centers and completed telephone surveys in 2002 and 2003 after the respective influenza seasons. MEASUREMENTS: Influenza vaccination status, demo- graphic characteristics, and decision-making behavior were self-reported. Vaccination status was identified for three sea- sons: 2000–2001, 2001–2002, and 2002–2003. A three-level outcome was defined as unvaccinated all 3 years, vaccinated one to two times over 3 years, and vaccinated all 3 years. Factor analysis identified three decision-making behaviors. RESULTS: Predictors of being vaccinated across 3 years included being older, the belief that social forces influence vaccination behavior, and disagreement with the view that vaccine is detrimental. CONCLUSION: National educational efforts should be intensified to dispel the myths about alleged adverse events, including contracting influenza from inactivated influenza vaccine. Physicians should continue to share their personal experiences of treating patients with influenza, including the incidence of hospitalization and death. J Am Geriatr Soc 53:1354–1359, 2005. Key words: influenza; vaccination; decision-making behavior I nfluenza and pneumonia combined are the sixth-leading cause of death in the United States and the fifth-leading cause in adults aged 65 and older. In the 1990s, influenza- related deaths increased to approximately 36,000 per year. 1 The number of deaths can increase to 40,000 during epi- demics. Each year, there is an average of about 226,000 primary influenza-related respiratory and circulatory hos- pitalizations; this figure climbs to more than 400,000 in some epidemics. 2 Despite these statistics, data on the safety and efficacy of influenza vaccine show that the vaccination rate was only 68% for influenza in adults aged 65 and older in the second quarter of 2002. 3 Vaccination rates of elderly minority populations were even lower, at 47% for Hispanics and 52% for African Americans of non-Hispanic origin, show- ing racial disparity. 4 For this reason, immunizations are one of the areas of racial disparity that are targeted for elim- ination in the U.S. Public Health Service 2010 Objectives for the Nation. 5 A recent study compared initial influenza vaccination in the elderly with repeat vaccinations and found that re- peat vaccinations reduced all-cause mortality an additional 15% and, during epidemics, reduced mortality 28%. 6 In- terruption of annual vaccination led to increased mortality, whereas restarting vaccination resulted in a mortality re- duction similar to repeat vaccinations. 6 Thus, repeat vac- cination in the elderly is important in reducing mortality. What, then, are the correlates of repeat vaccination? This study examined the correlates of repeat influenza vac- cinations in inner-city health centers serving the poor and minorities, who experience higher rates of morbidity and mortality from influenza and pneumonia. In addition, differences across age groups (50–64, 65) in decision- making behavior that influences historical patterns of reported influenza vaccination were analyzed. METHODS Sample and Response In 2003, patients from two health centers who were orig- inally surveyed in 2002 were resurveyed. The Institutional Review Board of the University of Pittsburgh approved this project. For each survey, patients were interviewed by Address correspondence to Mary Patricia Nowalk, PhD, RD, Department of Family Medicine and Clinical Epidemiology, University of Pittsburgh School of Medicine, 35l8 Fifth Avenue, Pittsburgh, PA 15261. E-mail: tnowalk@pitt.edu DOI: 10.1111/j.1532-5415.2005.53424.x From the à Department of Family Medicine and Clinical Epidemiology, School of Medicine, and w Department of Behavioral and Community Health Sciences, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania. JAGS 53:1354–1359, 2005 r 2005 by the American Geriatrics Society 0002-8614/05/$15.00