Published online October 1, 2007
PEDIATRICS Vol. 120 No. 4 October 2007, pp. e783-e787 (doi:10.1542/peds.2007-0052)
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ARTICLE

Validity of Parental Report of Influenza Vaccination in Children 6 to 59 Months of Age

Myrick C. Shinall, Jr, BAa, Erin J. Plosa, MDb and Katherine A. Poehling, MD, MPHb

a Vanderbilt University Schools of Medicine and Divinity, Nashville, Tennessee
b Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee


   ABSTRACT
TOP
 ABSTRACT
PATIENTS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
OBJECTIVE. The objective of this study was to assess the validity of parental report of influenza vaccinations.

PATIENTS AND METHODS. A cross-sectional study of children who were 6 to 59 months of age and presented to a large, pediatric residency clinic from February through April 2005 was performed. A standardized, parental questionnaire ascertained the influenza vaccination status of children during the 2004–2005 influenza season and was compared with the medical chart, the criterion standard. Children were classified as being at high risk when they had a specific influenza vaccine recommendation in 2004–2005 by age (6–23 months of age) or by chronic medical condition.

RESULTS. Of 218 parents approached in the pediatric residency clinic, 198 (95%) children who were 6 to 59 months of age were enrolled, and 84 (42%) were vaccinated according to the medical chart. More children who were 6 to 23 months than those who were 24 to 59 months of age were vaccinated (63% vs 21%). Children with chronic medical conditions were more likely to be vaccinated than healthy children who were 24 to 59 months of age (57% vs 11%), but no difference was observed for children who were 6 to 23 months of age (79% vs 60%). In comparison with the medical chart, parental report of influenza vaccination had a sensitivity of 88%, a specificity of 90%, and a {kappa} coefficient of 0.78. For children who were 6 to 23 months of age or had a chronic medical condition (n = 123), parental report had a sensitivity of 89%, a specificity of 81%, and a {kappa} coefficient of 0.71.

CONCLUSIONS. Parental report of influenza vaccination among children who were 6 to 59 months of age had reasonable sensitivity, specificity, and reliability as compared with the medical chart in this study population.

Key Words: influenza vaccine • parent • children • validity • accuracy

Abbreviations: CI—confidence interval

Influenza infects many children and adults each winter and causes significant morbidity. To protect individuals who are at increased risk for hospitalization or death from influenza infection, the Advisory Committee on Immunization Practices and the American Academy of Pediatrics have had long-standing recommendations to vaccinate all children at high risk who are ≥6 months of age and their families. With the recent studies highlighting the inpatient and outpatient burden of influenza in young children,1–5 the recommendations for influenza vaccination have been expanded. They specifically recommended the vaccine for all children who are 6 to 23 months of age beginning in 2004–2005 and all children who are 24 to 59 months of age beginning in 2006–2007.6,7

Because influenza vaccine is given during a limited period and because children can receive influenza vaccine from multiple providers (primary care clinic, health department, or other clinics), physicians may need to use parental report to determine the influenza vaccine status for children. Although the validity of self-report of influenza vaccination has been reported for elderly patients,8,9 the validity of parental report of influenza vaccinations for children has not been well described. The purpose of this study was to evaluate the validity of parental report of influenza vaccinations in 2004–2005, when the vaccine was specifically recommended for all children who were 6 to 23 months of age and children who were ≥6 months of age and had specific chronic medical conditions.


   PATIENTS AND METHODS
TOP
 ABSTRACT
 PATIENTS AND METHODS
RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Study Population
All children who were 6 to 59 months of age and received primary care from a large, university-affiliated pediatric residents’ clinic and whose parent/guardian spoke English were eligible. A trained interviewer systematically approached parents of young children who presented to the clinic from February through April 2005 and administered the survey. When multiple eligible children presented at the same time, the parent of the child who most recently registered in the clinic was approached. When multiple children in 1 family presented to the clinic, only the youngest eligible child was enrolled.

Informed Consent
We obtained written, informed consent from parents and explained that the purpose of this study was to understand better the parental viewpoint of influenza vaccine in children. The consent stated that the vaccination records would be verified. To facilitate this verification, we asked the parent the child's name and date of birth, which were recorded on a separate piece of paper and then were removed and destroyed after the vaccine verification data were recorded. The Vanderbilt University institutional review board approved this study.

Questionnaire
A trained interviewer administered the standardized parental questionnaire in English. The questionnaire obtained the demographic information, medical history, and influenza vaccination status for 2004–2005 for the enrolled child from the parent.10,11 The primary outcome was, "Did your child receive a flu shot last fall or winter?"

Age, race, and gender were obtained by parental report. Race was characterized as white, black, Hispanic, or other, with biracial children being classified as other. The 6- to 23-month and 24- to 59-month age groups were determined by the age of the child as of December 31, 2004. Parents were asked whether the child had any high-risk medical conditions, as listed in the 2003 Red Book.12 Parental report of vaccination status was considered positive when a parent reported that his or her child received at least 1 dose of vaccine after September 1, 2004.

Medical Chart
A review of computerized medical charts and the Tennessee State Immunization Registry, a voluntary state registry to which health departments and this practice submit vaccination records, was conducted. All data were entered without personal identifiers.

Data Analysis
All data were double-entered into an Access 2002 (Microsoft, Redwood, WA) database to verify the accuracy of data entry. The primary outcome, receipt of any influenza vaccine in 2004–2005, and all variables except for race were coded as dichotomous variables. We also collected data on number of doses received that season from the parent and the medical chart.

We compared the parental report of the child's influenza vaccination status for 2004–2005 with the criterion standard, influenza vaccination status for that season in the computerized medical chart or the Tennessee State Immunization Registry. Demographic information and the proportion of children who were vaccinated by the presence of a chronic medical condition and by age group were evaluated using 2-sided {chi}2 tests. The primary outcome was the sensitivity, specificity, and {kappa} coefficient of parental report of any influenza vaccine and the 95% confidence intervals (CIs) for each using the binomial distribution. The {kappa} coefficient measured the extent to which the influenza vaccination status according to the parental report and medical chart agreed beyond that predicted by chance. In a subanalysis, we separately analyzed none, 1 dose, and 2 doses of influenza vaccine for all children who were 6 to 59 months of age. All statistical analyses were performed by using Stata 8.1 (Stata Corp, College Station, TX).


   RESULTS
TOP
 ABSTRACT
 PATIENTS AND METHODS
 RESULTS
DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Of 218 parents approached, 208 (95%) consented to participate; 200 (92%) children were 6 to 59 months of age on December 31, 2004, and 198 (91%) children had available medical charts. The gender, age group (6–23 and 24–59 months), and racial distribution of the 198 study children reflected the overall clinic population (Table 1). Approximately one fifth of the enrolled children had a chronic medical condition.


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  		TABLE 1 Description of Study Population Overall and by 2004–2005 Influenza Vaccination Status According to the Medical Chart

 
Of the 198 enrolled children, 84 (42%) were vaccinated according to the medical chart. Children in the 6- to 23-month age group and those with chronic medical conditions were more likely to have received the influenza vaccine (Table 1). When analyzed by age group, the significant relationship between chronic medical conditions and vaccination status was observed only for children who were 24 to 59 months of age (Table 2).


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  		TABLE 2 2004–2005 Influenza Vaccination Status According to the Medical Chart for Children by Age Group and Presence or Absence of Chronic Medical Conditions

 
Most parents (177 [89%] of 198) reported the same influenza vaccination status of their child as was recorded in the medical chart. The 95% CIs for the sensitivity, specificity, and {kappa} coefficient of parental report overlapped for all children; for children who were or were not at high risk (6–23 months of age or had a chronic medical condition); and for parents who reported 0, 1, or 2 doses of influenza vaccine in 2004–2005 (Table 3).


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  		TABLE 3 Sensitivity, Specificity, and {kappa} Coefficient of Parental Report of the 2004–2005 Influenza Vaccination Status by High-Risk Status and Number of Doses Received as Compared With That in the Medical Chart

 

   DISCUSSION
TOP
 ABSTRACT
 PATIENTS AND METHODS
 RESULTS
 DISCUSSION
CONCLUSIONS
 REFERENCES
 
With expanding influenza vaccine recommendations, the limited period to administer influenza vaccines, the 2 doses recommended the first year that a child <9 years of age is vaccinated, and the fact that some children receive vaccines from multiple providers, pediatric providers need to know the accuracy of parental report. We find that parental report is reasonably accurate with an overall sensitivity of 88%, a specificity of 90%, and a {kappa} coefficient of 0.78.

The results of this study can be compared with several pediatric studies that evaluated parental report of a child's vaccination status and 2 adult studies that evaluated self-report of influenza vaccinations. Our {kappa} coefficient is similar to that reported in some pediatric and adult studies; however, there is a wide range of {kappa} coefficients reported for vaccination status of both children and adults. The methods used by these studies and the way that questions were asked, as discussed next, are 2 key components that may help explain this variation noted in the literature.

We found a similar sensitivity but a higher specificity and {kappa} coefficient for parental report of influenza vaccination status than 2 pediatric studies from 1 site (sensitivity 85%–86%, specificity 66%–69%, and {kappa} coefficient 0.43–0.50).13,14 There were important differences in these studies of urban children in resident clinics. A trained interviewer completed a face-to-face interview of parents in our study, whereas a mailed survey was used in the other studies. We enrolled 95% of eligible parents who were approached. The total response rate for the mailed surveys was ~45%, yet medical charts could be reviewed only for surveys that were received before the start date of the Health Insurance Portability and Accountability Act, yielding effective response rates of ~25%.13,14 In studies with low response rates, the representativeness of respondents can be difficult to assess. We performed our study in 2004–2005, when influenza vaccine was recommended for all children 6 to 23 months of age, whereas the other studies were performed in 2002–2003, when influenza vaccine was "encouraged" for healthy children 6 to 23 months of age. Importantly, previous studies indicated that the estimated parental accuracy can vary on the basis of wording of the question.15,16 In our survey, we asked, "Did your child receive a flu shot last fall or winter?" In the other surveys, the authors wrote, "Parents were asked whether their child had received 1, 2, or no flu shots during the previous flu season."14 The inclusion of information about when the influenza vaccine is typically administered in our study question may have influenced parental response, particularly by improving the specificity and {kappa} coefficient of parental responses.

Results from this study can also be compared with previous studies in adults ≥65 years of age. Zimmerman et al8 found that influenza vaccination self-report in adults had a sensitivity of 98%, specificity of 38%, and {kappa} coefficient of 0.36. Mac Donald et al9 reported that self-report of influenza vaccine had a sensitivity of 100%, specificity of 79%, and {kappa} coefficient of 0.72. In comparison, we found a lower sensitivity and a higher specificity than both of these studies and a {kappa} coefficient similar to the latter.

The accuracy of parental report of routine childhood vaccinations has been evaluated for the diphtheria-tetanus-pertussis vaccine, oral polio vaccine, and measles-mumps-rubella vaccine15–22 and for pneumococcal conjugate vaccine.23 The accuracy of parental recall as compared with medical chart varied by vaccine type and study population; for example, the {kappa} coefficient for measles-mumps-rubella vaccine ranged between 0.15 and 0.76.15–18,20,22 Parental accuracy varied by the age of the child but not by other demographic or socioeconomic characteristics.15,23 Furthermore, the wording of questions influenced the results (ie, asking whether a child was up-to-date for childhood vaccinations was better than asking the specific number of doses for each vaccine15,16).

We found that 63% of children who were 6 to 23 months were vaccinated in our study population, which is higher than national (33% [95% CI: 32%–35%]) and local (35% [95% CI: 27%–43%]) estimates for all children 6 to 23 months of age from the 2005 National Immunization Survey.24 In this clinic, we made a practice-based effort to increase the influenza vaccination status of children 6 to 23 months of age and children with chronic medical conditions by mailing reminders, specifically recommending influenza vaccine, scheduling influenza vaccine clinics, and vaccinating children at both well and ill visits. Although our proportion vaccinated is higher than national estimates, our results fall within the estimates reported for some states (eg, Massachusetts [59% (95% CI: 50%–68%)]).

The study had several potential limitations. Because the number of eligible children in clinic at any given time varies, not all parents of eligible children were approached. Moreover, this single-site study reflected the English-speaking patient population at an urban medical center, which may not be representative of all children. In this predominantly Medicaid practice (90%), income and parental education levels were not collected. To minimize interviewer bias, the interviewer was trained to administer and record responses on a standardized questionnaire. Because some children could have received vaccines at other clinics that would not be detected in our review of their medical chart or the state registry, the sensitivity may have been underestimated and specificity may have been overestimated.


   CONCLUSIONS
TOP
 ABSTRACT
 PATIENTS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
REFERENCES
 
Until we have a universal vaccination registry, many providers will use a combination of vaccination records and history to determine whether a child needs influenza vaccination and the number of doses needed. We find that parental report of influenza vaccine status has reasonable sensitivity, specificity, and {kappa} coefficient. Nonetheless, the advantages of timely entry into and access to universal vaccination registries needs to be emphasized, because obtaining a copy of vaccine records remains preferable although not always feasible during a clinic visit. Universal vaccination registries could reduce potential errors (both undervaccination and repeat vaccination) associated with an incomplete vaccination history. Furthermore, they provide the opportunity for providers and the public health community to use recall and reminder systems and other public health strategies that target areas with lower vaccination coverage.


   ACKNOWLEDGMENTS
 
We thank all of the parents of young children who so willingly contributed to this work; research assistant Robin McClenton; and the entire clinic staff under the leadership of Gregory Plemmons, MD, and Rebecca Swan, MD. We also thank the anonymous reviewers, whose insights enhanced this work.


   FOOTNOTES
 
Accepted Mar 3, 2007.

Address correspondence to Katherine A. Poehling, MD, MPH, Wake Forest University Medical Center, Department of Pediatrics, Medical Center Boulevard, Winston-Salem, NC 27157. E-mail: kpoehlin{at}wfubmc.edu

The authors have indicated they have no financial relationships relevant to this article to disclose.

Dr Poehling's current affiliation is Department of Pediatrics, Wake Forest University Medical Center, Winston-Salem, NC.


   REFERENCES
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 ABSTRACT
 PATIENTS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 

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PEDIATRICS (ISSN 1098-4275). ©2007 by the American Academy of Pediatrics



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