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Pless A, McLennan SR, Nicca D, Shaw DM, Elger BS. Reasons why nurses decline influenza vaccination: a qualitative study. BMC Nurs 2017; 16:20. [PMID: 28465672 PMCID: PMC5410084 DOI: 10.1186/s12912-017-0215-5] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Accepted: 04/20/2017] [Indexed: 12/11/2022] Open
Abstract
Background To explore reasons of non-vaccinated nursing staff for declining seasonal influenza vaccination. The annual influenza vaccination of healthcare workers reduces morbidity and mortality among vulnerable patients. Still, vaccination rates remain very low, particularly in nursing staff. While several studies have explored barriers for healthcare workers to get vaccinated, most have used a quantitative approach. Methods Data were collected by in-depth individual semi-structured interviews with 18 nurses from a range of fields, positions in organizational hierarchy, work experience and hospitals in two German-speaking cantons in Switzerland. Interviews were transcribed and analysed using conventional content analysis. Results Three interconnected themes explaining why nurses decline influenza vaccination were identified: Firstly, the idea of maintaining a strong and healthy body, which was a central motif for rejecting the vaccine. Secondly, the wish to maintain decisional autonomy - especially over one's body and health. Thirdly, nurses' perception of being surrounded by an untrustworthy environment, which restricts their autonomy and seemingly is in opposition to their goal of maintaining a strong and healthy body. Conclusion Nurses tend to rely on conventional health beliefs rather than evidence based medicine when making their decision to decline influenza vaccination. Interventions to increase influenza vaccination should be tailored specifically for nurses. Empowering nurses by promoting decision-making skills and by strengthening their appraisal may be important factors to consider when planning future interventions to improve vaccination rates. The teaching of evidence-based decision-making should be integrated on different levels, including nurses' training curricula, their workspace and further education.
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Affiliation(s)
- Anina Pless
- Institute for Biomedical Ethics, University of Basel, Bernoullistrasse 28, 4056 Basel, Switzerland
| | - Stuart R McLennan
- Institute for Biomedical Ethics, University of Basel, Bernoullistrasse 28, 4056 Basel, Switzerland.,Institute for History, Ethics and Philosophy of Medicine, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Dunja Nicca
- Institute of Nursing Science, University of Basel, Bernoullistrasse 28, 4056 Basel, Switzerland
| | - David M Shaw
- Institute for Biomedical Ethics, University of Basel, Bernoullistrasse 28, 4056 Basel, Switzerland
| | - Bernice S Elger
- Institute for Biomedical Ethics, University of Basel, Bernoullistrasse 28, 4056 Basel, Switzerland
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Paterson P, Meurice F, Stanberry LR, Glismann S, Rosenthal SL, Larson HJ. Vaccine hesitancy and healthcare providers. Vaccine 2016; 34:6700-6706. [PMID: 27810314 DOI: 10.1016/j.vaccine.2016.10.042] [Citation(s) in RCA: 483] [Impact Index Per Article: 60.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Revised: 10/05/2016] [Accepted: 10/17/2016] [Indexed: 11/29/2022]
Abstract
While most people vaccinate according to the recommended schedule, this success is challenged by individuals and groups who delay or refuse vaccines. The aim of this article is to review studies on vaccine hesitancy among healthcare providers (HCPs), and the influences of their own vaccine confidence and vaccination behaviour on their vaccination recommendations to others. The search strategy was developed in Medline and then adapted across several multidisciplinary mainstream databases including Embase Classic & Embase, and PschInfo. All foreign language articles were included if the abstract was available in English. A total of 185 articles were included in the literature review. 66% studied the vaccine hesitancy among HCPs, 17% analysed concerns, attitudes and/or behaviour of HCPs towards vaccinating others, and 9% were about evaluating intervention(s). Overall, knowledge about particular vaccines, their efficacy and safety, helped to build HCPs own confidence in vaccines and their willingness to recommend vaccines to others. The importance of societal endorsement and support from colleagues was also reported. In the face of emerging vaccine hesitancy, HCPs still remain the most trusted advisor and influencer of vaccination decisions. The capacity and confidence of HCPs, though, are stretched as they are faced with time constraints, increased workload and limited resources, and often have inadequate information or training support to address parents' questions. Overall, HCPs need more support to manage the quickly evolving vaccine environment as well as changing public, especially those who are reluctant or refuse vaccination. Some recommended strategies included strengthening trust between HCPs, health authorities and policymakers, through more shared involvement in the establishment of vaccine recommendations.
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Affiliation(s)
- Pauline Paterson
- London School of Hygiene & Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom.
| | - François Meurice
- GSK Vaccines, Avenue Fleming 20, Parc de la Noire Epine, B-1300 Wavre, Belgium.
| | - Lawrence R Stanberry
- Columbia University College of Physicians and Surgeons and New York-Presbyterian/Morgan Stanley Children's Hospital, New York, NY, USA.
| | - Steffen Glismann
- GSK Vaccines, Avenue Fleming 20, Parc de la Noire Epine, B-1300 Wavre, Belgium.
| | - Susan L Rosenthal
- Columbia University College of Physicians and Surgeons and New York-Presbyterian/Morgan Stanley Children's Hospital, New York, NY, USA.
| | - Heidi J Larson
- London School of Hygiene & Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom; Department of Global Health, University of Washington, Seattle, USA.
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53
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Smith S, Sim J, Halcomb E. Australian general practice nurse's knowledge, attitudes and practices regarding influenza vaccination: a cross-sectional survey. J Clin Nurs 2016; 25:2502-10. [DOI: 10.1111/jocn.13287] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2016] [Indexed: 12/01/2022]
Affiliation(s)
- Sarah Smith
- School of Nursing; University of Wollongong; Wollongong NSW Australia
| | - Jenny Sim
- School of Nursing; University of Wollongong; Wollongong NSW Australia
| | - Elizabeth Halcomb
- School of Nursing; University of Wollongong; Wollongong NSW Australia
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54
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Smith S, Sim J, Halcomb E. Nurses' knowledge, attitudes and practices regarding influenza vaccination: an integrative review. J Clin Nurs 2016; 25:2730-44. [PMID: 27206347 DOI: 10.1111/jocn.13243] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/28/2016] [Indexed: 01/05/2023]
Abstract
AIMS AND OBJECTIVES To critically analyse the literature describing nurses' knowledge, attitudes and practices regarding influenza vaccination. BACKGROUND Influenza is a serious illness that has significant impacts on productivity, health outcomes and healthcare costs. Despite the recommendations for nurses to be vaccinated annually against influenza, the vaccination rates remain suboptimal. DESIGN Integrative literature review. METHODS An integrative review was conducted as described by Whittemore and Knafl (2005). A search of CINAHL, Cochrane Library, ProQuest Central, ClinicalKey, ScienceDirect, Wiley Online Library, and Informit was undertaken to identify relevant papers. Given the heterogeneity of included studies, a narrative approach was used to analyse the data. RESULTS There was limited research available on this topic area, with only 10 papers identified as meeting the inclusion criteria. Five themes were identified: the relationship between knowledge and influenza vaccination, perception of risk, motivators for influenza vaccination, barriers to influenza vaccination and impact of demographics on vaccination. CONCLUSIONS Despite the evidence for the protective effects of influenza vaccination, rates of vaccination among nurses remain sub-optimal. Nurses' influenza vaccination practices likely relate to their level of knowledge and perception of risk; the greater nurses' knowledge regarding influenza and influenza vaccination the higher their perception of risk and the more likely they are to be vaccinated. This also translates to the advice that they give patients with vaccinated nurses more inclined to recommend vaccination than those unvaccinated. RELEVANCE TO CLINICAL PRACTICE The practices of nurses related to influenza vaccination may translate to the advice that they give their patients. Understanding the knowledge levels, practices and attitudes of nurses can assist in developing strategies to enhance education of nurses.
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Affiliation(s)
- Sarah Smith
- School of Nursing, University of Wollongong, Wollongong, NSW, Australia.
| | - Jenny Sim
- School of Nursing, University of Wollongong, Wollongong, NSW, Australia
| | - Elizabeth Halcomb
- School of Nursing, University of Wollongong, Wollongong, NSW, Australia
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55
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Influenza vaccination competence of nurses in France: A survey in nursing schools. Am J Infect Control 2016; 44:236-8. [PMID: 26585251 DOI: 10.1016/j.ajic.2015.09.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Revised: 09/09/2015] [Accepted: 09/11/2015] [Indexed: 11/20/2022]
Abstract
Since 2008, French nurses have been allowed to vaccinate against influenza without medical prescription. Our survey aimed at assessing nursing students' knowledge and perception of this prerogative. Among 213 responders, 61% were aware of this matter, and 47.5% were familiar with its requirements. Most (75.6%) were positive about it. Influenza vaccination without medical prescription is well-known and validated by nursing students. This new competence may improve vaccination coverage.
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56
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Thomson A, Robinson K, Vallée-Tourangeau G. The 5As: A practical taxonomy for the determinants of vaccine uptake. Vaccine 2015; 34:1018-24. [PMID: 26672676 DOI: 10.1016/j.vaccine.2015.11.065] [Citation(s) in RCA: 242] [Impact Index Per Article: 26.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Revised: 11/24/2015] [Accepted: 11/25/2015] [Indexed: 10/22/2022]
Abstract
Suboptimal vaccine uptake in both childhood and adult immunisation programs limits their full potential impact on global health. A recent progress review of the Global Vaccine Action Plan stated that "countries should urgently identify barriers and bottlenecks and implement targeted approaches to increase and sustain coverage". However, vaccination coverage may be determined by a complex mix of demographic, structural, social and behavioral factors. To develop a practical taxonomy to organise the myriad possible root causes of a gap in vaccination coverage rates, we performed a narrative review of the literature and tested whether all non-socio-demographic determinants of coverage could be organised into 4 dimensions: Access, Affordability, Awareness and Acceptance. Forty-three studies were reviewed, from which we identified 23 primary determinants of vaccination uptake. We identified a fifth domain, Activation, which captured interventions such as SMS reminders which effectively nudge people towards getting vaccinated. The 5As taxonomy captured all identified determinants of vaccine uptake. This intuitive taxonomy has already facilitated mutual understanding of the primary determinants of suboptimal coverage within inter-sectorial working groups, a first step towards them developing targeted and effective solutions.
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Affiliation(s)
| | - Karis Robinson
- Department of Psychology, Kingston University, Kingston upon Thames, UK
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57
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Hawken S, Kwong JC, Deeks SL, Crowcroft NS, McGeer AJ, Ducharme R, Campitelli MA, Coyle D, Wilson K. Simulation study of the effect of influenza and influenza vaccination on risk of acquiring Guillain-Barré syndrome. Emerg Infect Dis 2015; 21:224-31. [PMID: 25625590 PMCID: PMC4313628 DOI: 10.3201/eid2102.131879] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Under typical conditions, such as influenza incidence rates of >5% and vaccine effectiveness >60%, vaccination reduced risk. It is unclear whether seasonal influenza vaccination results in a net increase or decrease in the risk for Guillain-Barré syndrome (GBS). To assess the effect of seasonal influenza vaccination on the absolute risk of acquiring GBS, we used simulation models and published estimates of age- and sex-specific risks for GBS, influenza incidence, and vaccine effectiveness. For a hypothetical 45-year-old woman and 75-year-old man, excess GBS risk for influenza vaccination versus no vaccination was −0.36/1 million vaccinations (95% credible interval −1.22 to 0.28) and −0.42/1 million vaccinations (95% credible interval, –3.68 to 2.44), respectively. These numbers represent a small absolute reduction in GBS risk with vaccination. Under typical conditions (e.g. influenza incidence rates >5% and vaccine effectiveness >60%), vaccination reduced GBS risk. These findings should strengthen confidence in the safety of influenza vaccine and allow health professionals to better put GBS risk in context when discussing influenza vaccination with patients.
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58
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Valdez AM. First Do No Harm: Prevention Strategies for Influenza Season. J Emerg Nurs 2015; 41:525-7. [PMID: 26318377 DOI: 10.1016/j.jen.2015.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Leong R. Knowledge, attitudes, risk perception of influenza and influenza vaccination among final year nursing students in Singapore: an exploratory study. Antimicrob Resist Infect Control 2015. [PMCID: PMC4474685 DOI: 10.1186/2047-2994-4-s1-p19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Cortes-Penfield N. Mandatory influenza vaccination for health care workers as the new standard of care: a matter of patient safety and nonmaleficent practice. Am J Public Health 2014; 104:2060-5. [PMID: 24328628 PMCID: PMC4202972 DOI: 10.2105/ajph.2013.301514] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2013] [Indexed: 11/04/2022]
Abstract
A growing body of literature defends the efficacy of seasonal influenza vaccination for health care workers in reducing the mortality of hospitalized patients. I review the evidence concerning influenza vaccination, concluding that universal vaccination of health care workers against influenza should be considered standard patient care and that nonvaccination represents maleficent care. I further argue that the ethical responsibility to ensure universal vaccination of staff against seasonal influenza lies not only with individual health care providers but with each individual health care institution.
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61
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While AE. Are nurses fit for their public health role? Int J Nurs Stud 2014; 51:1191-4. [DOI: 10.1016/j.ijnurstu.2014.01.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Accepted: 01/14/2014] [Indexed: 11/16/2022]
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Biologically hazardous agents at work and efforts to protect workers' health: a review of recent reports. Saf Health Work 2014; 5:43-52. [PMID: 25180133 PMCID: PMC4147232 DOI: 10.1016/j.shaw.2014.03.006] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Revised: 03/25/2014] [Accepted: 03/29/2014] [Indexed: 11/24/2022] Open
Abstract
Because information on biological agents in the workplace is lacking, biological hazard analyses at the workplace to securely recognize the harmful factors with biological basis are desperately needed. This review concentrates on literatures published after 2010 that attempted to detect biological hazards to humans, especially workers, and the efforts to protect them against these factors. It is important to improve the current understanding of the health hazards caused by biological factors at the workplace. In addition, this review briefly describes these factors and provides some examples of their adverse health effects. It also reviews risk assessments, protection with personal protective equipment, prevention with training of workers, regulations, as well as vaccinations.
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63
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Cornally N, Ann Deasy E, McCarthey G, McAuley C, Moran J, Weathers E, McAuley C. Student nurses' intention to get the influenza vaccine. ACTA ACUST UNITED AC 2014; 22:1207-11. [PMID: 24280920 DOI: 10.12968/bjon.2013.22.21.1207] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
INTRODUCTION There is no national or international recommendation for nursing students to receive the influenza vaccine. Nurses are among the group of health professionals who traditionally have a low uptake of the vaccine and who arguably have the closest contact with patients. AIM To investigate the uptake of influenza vaccination among student nurses, explore reasons for either declining or receiving it in the past, and establish if and to what extent the theory of planned behaviour (TPB) can explain vaccination behaviour. METHODS A quantitative, descriptive, correlational design was used. Data were collected with a researcher-developed questionnaire; 131 student nurses participated. Ethical approval was gained. RESULTS 79% (n=104) had never received the vaccine. The most common reason was 'I don't need it as I rarely get ill'. Low mean 'intention' scores indicated that students were unlikely to get the vaccine once qualified. Past behaviour was significantly associated with future intentions. The TPB explained 41.9% of the variance in intention. Attitude emerged as the greatest predictor. CONCLUSION Student nurses do not have strong intentions to get the vaccine. Results serve to guide future educational and occupational health initiatives, which would benefit from a framework based on TPB.
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Affiliation(s)
- Nicola Cornally
- Research Support Officer, Clinical Research Nurse, Centre for Gerontology and Rehabilitation, School of Medicine
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64
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Wheelock A, Miraldo M, Parand A, Vincent C, Sevdalis N. Journey to vaccination: a protocol for a multinational qualitative study. BMJ Open 2014; 4:e004279. [PMID: 24486678 PMCID: PMC3913205 DOI: 10.1136/bmjopen-2013-004279] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Revised: 12/19/2013] [Accepted: 01/10/2014] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION In the past two decades, childhood vaccination coverage has increased dramatically, averting an estimated 2-3 million deaths per year. Adult vaccination coverage, however, remains inconsistently recorded and substandard. Although structural barriers are known to limit coverage, social and psychological factors can also affect vaccine uptake. Previous qualitative studies have explored beliefs, attitudes and preferences associated with seasonal influenza (flu) vaccination uptake, yet little research has investigated how participants' context and experiences influence their vaccination decision-making process over time. This paper aims to provide a detailed account of a mixed methods approach designed to understand the wider constellation of social and psychological factors likely to influence adult vaccination decisions, as well as the context in which these decisions take place, in the USA, the UK, France, India, China and Brazil. METHODS AND ANALYSIS We employ a combination of qualitative interviewing approaches to reach a comprehensive understanding of the factors influencing vaccination decisions, specifically seasonal flu and tetanus. To elicit these factors, we developed the journey to vaccination, a new qualitative approach anchored on the heuristics and biases tradition and the customer journey mapping approach. A purposive sampling strategy is used to select participants who represent a range of key sociodemographic characteristics. Thematic analysis will be used to analyse the data. Typical journeys to vaccination will be proposed. ETHICS AND DISSEMINATION Vaccination uptake is significantly influenced by social and psychological factors, some of which are under-reported and poorly understood. This research will provide a deeper understanding of the barriers and drivers to adult vaccination. Our findings will be published in relevant peer-reviewed journals and presented at academic conferences. They will also be presented as practical recommendations at policy and industry meetings and healthcare professionals' forums. This research was approved by relevant local ethics committees.
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Affiliation(s)
- Ana Wheelock
- Faculty of Medicine, Imperial College London, London, UK
| | | | - Anam Parand
- Faculty of Medicine, Imperial College London, London, UK
| | - Charles Vincent
- Department of Experimental Psychology, University of Oxford, Oxford, UK
| | - Nick Sevdalis
- Faculty of Medicine, Imperial College London, London, UK
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Layton H. Commentary on Zhang J, While AE and Norman IJ (2012) Development and testing of an instrument to assess nurses' knowledge, risk perception, health beliefs and behaviours related to influenza vaccination. Journal of Clinical Nursing
21, 2636-2646. J Clin Nurs 2014; 23:296-7. [DOI: 10.1111/jocn.12099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Helen Layton
- Faculty of Health and Social Care; University of Hull; Hull UK
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66
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Zhang J, While AE, Norman IJ. Nurses’ vaccination against pandemic H1N1 influenza and their knowledge and other factors. Vaccine 2012; 30:4813-9. [DOI: 10.1016/j.vaccine.2012.05.012] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2011] [Revised: 05/04/2012] [Accepted: 05/09/2012] [Indexed: 01/07/2023]
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67
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Henriksen Hellyer JM, DeVries AS, Jenkins SM, Lackore KA, James KM, Ziegenfuss JY, Poland GA, Tilburt JC. Attitudes toward and uptake of H1N1 vaccine among health care workers during the 2009 H1N1 pandemic. PLoS One 2011; 6:e29478. [PMID: 22216290 PMCID: PMC3245279 DOI: 10.1371/journal.pone.0029478] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2011] [Accepted: 11/29/2011] [Indexed: 01/04/2023] Open
Abstract
Background Though recommended by many and mandated by some, influenza vaccination rates among health care workers, even in pandemics, remain below optimal levels. The objective of this study was to assess vaccination uptake, attitudes, and distinguishing characteristics (including doctor-nurse differences) of health care workers who did and did not receive the pandemic H1N1 influenza vaccine in late 2009. Methodology/Principal Findings In early 2010 we mailed a self-administered survey to 800 physicians and 800 nurses currently licensed and practicing in Minnesota. 1,073 individuals responded (cooperation rate: 69%). 85% and 62% of Minnesota physicians and nurses, respectively, reported being vaccinated. Accurately estimating the risk of vaccine side effects (OR 2.0; 95% CI 1.5–2.7), agreeing with a professional obligation to be vaccinated (OR 10.1; 95% CI 7.1–14.2), an ethical obligation to follow public health authorities' recommendations (OR 9.9; 95% CI 6.6–14.9), and laws mandating pandemic vaccination (OR 3.1; 95% CI 2.3–4.1) were all independently associated with receiving the H1N1 influenza vaccine. Conclusions/Significance While a majority of health care workers in one midwestern state reported receiving the pandemic H1N1 vaccine, physicians and nurses differed significantly in vaccination uptake. Several key attitudes and perceptions may influence health care workers' decisions regarding vaccination. These data inform how states might optimally enlist health care workers' support in achieving vaccination goals during a pandemic.
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Affiliation(s)
| | - Aaron S. DeVries
- Infectious Disease, Epidemiology, Prevention and Control Division, Minnesota Department of Health, St. Paul, Minnesota, United States of America
| | - Sarah M. Jenkins
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Kandace A. Lackore
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Katherine M. James
- Biomedical Ethics Research Unit, Mayo Clinic, Rochester, Minnesota, United States of America
- * E-mail:
| | - Jeanette Y. Ziegenfuss
- Division of Health Care Policy and Research, Mayo Clinic, Rochester, Minnesota, United States of America
- Survey Research Center, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Gregory A. Poland
- Mayo Vaccine Research Group, Mayo Clinic, Rochester, Minnesota, United States of America
- Program in Translational Immunovirology and Biodefense, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Jon C. Tilburt
- Biomedical Ethics Research Unit, Mayo Clinic, Rochester, Minnesota, United States of America
- Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
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