Parental Attitudes and Experiences During School Dismissals Related to 2009 Influenza A (H1N1) --- United States, 2009

During the 2009 influenza A (H1N1) pandemic, child care center and school dismissals (i.e., temporary closures) were common and occurred in the majority of states across the United States. However, little is known about the economic and social problems parents face during such dismissals. To learn more about parents' attitudes and experiences after short-term school dismissals related to H1N1, CDC and the Harvard Opinion Research Program (HORP) conducted a randomized telephone poll of 523 parents from 39 states whose child care center or school had been closed temporarily in response to H1N1. This report summarizes the results of that poll, which found that 90% of parents agreed with the dismissal decision, and 85% believed dismissal effectively reduced influenza transmission. In most cases (58%), dismissal lasted ≤3 days. Overall, most parents did not report adverse effects related to dismissals of short duration. Only 3% of respondents said dismissal was a major problem, and 75% reported that it was not a problem. Approximately 20% of parents reported that an adult in the household missed work because of the dismissal, and 19% had a child who missed a free or reduced-cost lunch, but only 2% and <1%, respectively, said these were major problems. The findings in this report underscore that when making a decision to close child care centers or schools, public health officials should consider the acceptability of the resulting disruption to students, families, and communities.

During November 19--December 9, 2009, HORP conducted a nationwide, random-digit--dialed telephone poll in areas of 39 states identified as having any schools reported closed by CDC's School Dismissal Monitoring System.* Social Science Research Solutions, a polling company, oversaw field operations. Starting from a random sample of residential telephone numbers, trained interviewers used screening questions to identify 523 parents from all 39 states with a child aged <18 years whose child care center or school had been closed temporarily in response to H1N1 at any time since the opening of school in late summer or fall 2009. Telephone calls were made during the day and evening on weekdays and weekends, and multiple attempts (a mean of six attempts on nonresponding numbers) were made to reach each respondent before considering a telephone number unreachable. Respondents answered closed-ended questions during a telephone interview lasting approximately 15 minutes. To minimize recall bias, the data collection period was kept relatively short (3 weeks), and parents were polled as close to the period of H1N1-related school dismissals as possible; the time since dismissal ranged from approximately 1 day to 4 months. The response rate was 40.4%.† Data were weighted to match the U.S. Census by sex, age, race, education, number of children in household, and home ownership,§ and by metropolitan area status according to the telephone exchange report¶ to mitigate possible nonresponse biases (1).

Dismissals lasting ≤3 school days were reported by 58% of parents, and 26% reported dismissals for ≥5 school days (Table 1). Most parents (90%) agreed with the school dismissal decision. Among the parents, 81% believed the major reason for dismissal was to reduce transmission of H1N1 by keeping children apart, and 85% thought that dismissal was very or somewhat effective in reducing the number of cases of H1N1 influenza among children in the child care center or school.

When asked whether school dismissal overall was a problem for their families, 75% responded "not at all," 20% said it was a minor problem, and 3% said it was a major problem. When presented with a list of possible consequences, 42% reported they had experienced one or more associated with dismissal (Table 2). The most commonly reported consequences faced by parents and families included missed work (20%) and child missing free or reduced-cost school lunches (19%). Few parents reported feeling at risk of losing their job (2%) or having their child miss health services usually provided by the school (1%). Overall, 7% reported any one of the specified issues posed a major problem.

Among parents, 4% reported problems arranging care for their children (Table 3). Most parents (81%) reported that an adult in the household stayed with the child for some time during the school dismissal. Fewer parents reported that other adults, including family members outside the household (20%), a neighbor or friend (1%), or a babysitter (3%), stayed with the child at least some of the time, and 10% reported that their child stayed at home alone at least some of the time.

A majority of parents (56%) reported their child participated in at least one activity involving persons outside the household during the school dismissal (Table 3). Children spent time with friends at one another's homes (30%), went grocery shopping (30%), and went to fast food restaurants (23%). Fewer parents reported children going to public events such as movies, sporting events, or concerts (17%), large shopping areas or malls (15%), or social events such as parties or dances (6%).

Reported by

GK Steelfisher, PhD, RJ Blendon, ScD, MM Bekheit, JD,Harvard School of Public Health and John F. Kennedy School of Government. N Liddon, PhD, Div of STD Prevention, E Kahn, PhD, Div of Global Migration and Quarantine, R Schieber, MD, Office of Surveillance, Epidemiology, and Laboratory Svcs; K Lubell, PhD, Div of Emergency Operations, CDC.

Editorial Note

This report is the first to describe the attitudes and experiences of a national sample of parents about school dismissals associated with an influenza pandemic. Findings from previous studies were limited to hypothetical scenarios or local investigations of actual dismissals (2--6). The previous studies generally found parents anticipated problems with extended hypothetical dismissals (6) but experienced relatively few problems from actual short-term dismissals (2--4). The findings in this report regarding parental support and beliefs about reasons for dismissal are similar to those reported in local studies of short-term, influenza-related dismissals in the United States (2--4). When deciding whether to close child care centers or schools during influenza epidemics, state and local school and health authorities should weigh high staff and student absenteeism and the health consequences of the disease and its spread against potential negative consequences of dismissals on families (e.g., missing work and disruption of arrangements for care of the child). The results of this poll, similar to other studies (2,4), show that parental support for short-term child care center and school dismissals can be high. However, the findings also show that parents might simultaneously hold perceptions about the intent of the dismissal that might be related to their support. If parents believed schools were dismissed for reasons related to absenteeism, for example, support might be lower. Support also might be contingent on specific community factors, dismissal duration, and perceptions about influenza risk and severity (2,4). Little evidence for or against the effectiveness of school dismissals in interrupting influenza transmission is available (7).

Most school dismissals reported in this study were brief, which might explain why parents reported few problems with missing work or arranging child care. Although only 3% of parents said they experienced major problems, 10% lost pay or income, and 11% incurred additional costs. If the dismissal had lasted much longer, economic loss and child care provision might have become more important. A 12-day dismissal in Australia resulted in approximately half of the adults sampled missing work and reporting less parental support of school dismissal than described in this report (5). In another study, when parents considered hypothetical scenarios of prolonged school dismissals lasting up to 3 months, substantial proportions of parents had concerns about missing work and economic loss (6).

Consistent with other U.S and Australian studies (2--5), most parents in this poll reported that their child participated in social activities outside the home during the dismissal. Whether such congregation poses similar transmission risk as attending child care centers or schools is unknown because of differences in population density, numbers of contacts, and duration and type of physical contact. Although not addressed in this poll, parents might be unfamiliar with the underlying concept of social distancing and its role outside the school environment. Future community mitigation efforts should address the public's basic knowledge of school dismissals as part of nonpharmaceutical interventions that include social distancing in other venues (e.g, workplaces), hand hygiene, covering coughs and sneezes, and encouraging ill persons to stay at home.

Polls are fielded more quickly and have shorter data collection periods than other types of surveys. In the context of a pandemic response, this short turnaround can facilitate integration of findings into policymaking and refinement of guidance needed during the remainder of the pandemic (8). However, the shorter data collection period often results in a lower response rate, compared with traditional surveys conducted over longer periods, and data typically are weighted to key demographics. Research suggests that weighted data from lower response rate polls conducted within days are comparable to data from higher-response surveys conducted over longer periods (1). Thus, although not frequently used, polling might be an effective tool in pandemic and other emergency public health responses (8).

The findings in this report are subject to at least three limitations. First, these findings might not be generalizable to areas with lower levels of influenza activity because the poll focused solely on experiences and perceptions in areas experiencing school dismissals and high levels of influenza activity. Second, sample size did not permit assessment of several factors associated with parental support of dismissals that might be useful to decision makers (e.g., length of dismissal, perceived H1N1 severity or risk, urban or rural setting, or child's age). Finally, the participation rate was greater for respondents in certain groups, and the weighting might not have addressed nonresponse biases completely.

The findings from this poll were presented to the National Association of County and City Health Officials to assist field staff members in making local school dismissal decisions and will be used in developing future pandemic influenza response guidance. When deciding whether to close child care centers or schools during influenza pandemics, school and health officials collaboratively should consider such factors as the level and severity of illness, the need to protect staff members and students at high risk, the likelihood of high absenteeism, and parental or public concerns (9).

References

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2. Gift TL, Palekar RS, Sodha SV, et al., Household effects of school closure during pandemic (H1N1) 2009, Pennsylvania, USA. Emerg Infect Dis 2010;16:1315--7.
3. Johnson AJ, Moore ZS, Edelson PJ, et al. Household responses to school closure resulting from outbreak of influenza B, North Carolina. Emerg Infect Dis 2008;14:1024--30.
4. CDC. Impact of seasonal influenza-related school closures on families---southeastern Kentucky, February 2008. MMWR 2009;58:1405--9.
5. Effler PV, Carcione D, Giele C, et al. Household responses to pandemic (H1N1) 2009-related school closures, Perth, Western Australia. Emerg Infect Dis 2010;16:205--11.
6. Blendon RJ, Koonin LM, Benson JM, et al. Public response to community mitigation measures for pandemic influenza. Emerg Infect Dis 2008;14:778--86.
7. Cauchemez S, Ferguson NM, Wachtel C, et al. Closure of schools during an influenza pandemic. Lancet Infect Dis 2009;9:473--81.
8. Blendon RJ, Benson JM, DesRoches CM, Weldon KJ. Using opinion surveys to track the public's response to a bioterrorist attack. J Health Commun 2003;8(Suppl 1):83--92.
9. CDC. CDC guidance for state and local public health officials and school administrators for school (K--12) responses to influenza during the 2009--2010 school year. Atlanta, GA: US Department of Health and Human Services, CDC; 2010. Available at http://www.cdc.gov/h1n1flu/schools/schoolguidance.htm. Accessed September 2, 2010.

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