"I don't see an added value for myself": a qualitative study exploring the social cognitive variables associated with influenza vaccination of Belgian, Dutch and German healthcare personnel

Impact of COVID-19 on vaccine confidence and uptake: A systematic literature review

During the coronavirus disease 2019 (COVID-19) pandemic, scheduled vaccinations were postponed, mass vaccination programmes were suspended and opportunities for healthcare workers to administer vaccines ad hoc decreased. The aims of this systematic literature review were to determine the impact of the COVID-19 pandemic on vaccine confidence, intent and uptake in preexisting routine childhood or adult vaccination programmes, and to identify factors associated with changes in acceptance, intent and uptake of preexisting vaccines. Medline and Embase were searched for studies in Australia, Brazil, Canada, China, Japan, the USA, and European countries, published between 1 January 2021 and 4 August 2022. A complementary gray literature search was conducted between 11 and 13 October 2022, and supplemented with additional gray research in October 2023. In total, 54 citations were included in the review. Study design and geography were heterogeneous. The number of adults who received or intended to receive an influenza or pneumococcal vaccine was higher during the pandemic than in previous seasons (n = 28 studies). In addition, increased acceptance of adult vaccinations was observed during 2020-21 compared with 2019-20 (n = 12 studies). The rates of childhood vaccinations decreased during the COVID-19 pandemic across several countries (n = 11 studies). Factors associated with changes in intention to receive a vaccination, or uptake of influenza vaccine, included previous vaccination, older age, higher perceived risk of contracting COVID-19, anxiety regarding the pandemic and fear of contracting COVID-19. Acceptance and uptake of influenza and pneumococcal vaccines generally increased after onset of the COVID-19 pandemic.

Maternal pertussis vaccination behavior: Psychosocial, attitudinal and organizational factors

BACKGROUND

In December 2019, the maternal pertussis vaccination (MPV) became part of the Dutch National Immunization Program. This study aims to study MPV behavior and associated psychosocial, attitudinal and organizational factors of pertussis vaccination behavior during pregnancy in the Netherlands.

METHODS

We conducted a cross-sectional survey among pregnant women and recent mothers, up to six months post-partum. The primary outcome measure of this study was MPV behavior. Associations between psychosocial, attitudinal and organizational factors and MPV behavior were assessed using univariate and multivariate binary logistic regression analysis.

RESULTS

In total 1348 participants filled out the questionnaire, including 1282 (95.1%) MPV acceptors and 66 (4.9%) MPV refusers. The most important factors associated with MPV behavior were: attitude (aOR: 10.19; 95%CI: 4.30-24.16), outcome expectations (aOR: 8.94; 95%CI: 3.60-22.21), omission bias (aOR: 0.11; 95%CI: 0.02-0.59) and physical accessibility (aOR: 7.44; 95%CI: 3.37-16.46).

CONCLUSION

Pregnant women make their decision about the MPV primarily based on attitudinal and psychosocial factors, such as outcome expectations and attitude. A combination and variation of different messages, about the advantages (effectiveness) and disadvantages (side effects) of maternal vaccination, can be used in reaching pregnant women with a positive and negative attitude about the MPV. In addition, strategies to increase MPV uptake should not only focus on providing information, but also decrease experienced practical barriers, such as poor physical accessibility, in people that are intended to receive the MPV but are not getting vaccinated.

Deliberation, context, emotion and trust - understanding the dynamics of adults' COVID-19 vaccination decisions in Germany

BACKGROUND

Willingness to vaccinate against coronavirus disease 2019 (COVID-19), which is vital to successful vaccination campaigns, is wavering and suboptimal. In Germany, quantitative research highlighted concerns regarding the safety and efficacy of COVID-19 vaccines as barriers to uptake, but qualitative insights regarding individuals' decisions about COVID-19 vaccines and how personal perceptions reflect or refute existing behavioral theories are lacking.

METHODS

To identify how individuals make COVID-19 vaccination decisions within real-life contexts, we conducted 33 semi-structured, in-depth qualitative interviews with individuals in Germany between March and April 2021 using maximum variation sampling, focusing on perceptions of COVID-19 vaccines. Analysis, informed by a framework approach, began in the field via debriefings and was amplified upon the conclusion of data collection.

RESULTS

Four interconnected themes (deliberation, context, emotion, trust) shaped respondents' decisions about vaccination. Personal deliberation regarding benefits and risks of vaccines and perceptions of the broader social and political context sparked a spectrum of emotions that underpinned vaccination decisions. Trust in science and researchers emerged as a powerful protective factor facilitating the decision to get vaccinated even amidst a rapidly changing context and disconcerting information.

CONCLUSIONS

Our findings add to ongoing debates about the breadth of vaccination decisions by highlighting how respondents are influenced by their perceptions of the political context and the emotional heft of their decisions. The role of cognitive evaluation, context, and emotions mirrors other decision-making frameworks, particularly the Risk as Feelings Theory. We extend on the elements of this theory by highlighting trust as a protective factor when making decisions particularly in highly uncertain contexts. Success of vaccination campaigns, more important than ever as new variants of COVID-19 emerge, is interwoven with an ability to bolster trust in science. Communicating public-health decisions and information about vaccines transparently without instilling fear offers promising chances to strengthen public trust in COVID-19 vaccines.

TRIAL REGISTRATION

German Clinical Trials Register ( DRKS00024505 ).

The Role of Existential Concerns in the Individual's Decisions regarding COVID-19 Vaccine Uptake: A Survey among Non-Vaccinated Italian Adults during the Third Wave of the Pandemic

Recent studies have suggested that health constructs embraced by the Terror Management Theory (TMT) and the Basic Psychological Needs Theory (BPNT) may drive individuals' COVID-19 health-related decisions. This study examines the relationships between existential concerns (ECs; within the TMT), basic psychological needs (BPNs; within the BPNT) and COVID-19 vaccine hesitancy (VH), as well as the mediating role of negative attitudes toward COVID-19 vaccines. A cross-sectional survey was carried out from April to May 2021 on a sample of two hundred and eighty-seven adults (Mage = 36.04 ± 12.07; 59.9% females). Participants provided information regarding existential concerns, basic psychological needs, attitudes toward COVID-19 vaccines and vaccine hesitancy for Pfizer-BioNTech and AstraZeneca vaccines separately. Higher vaccine hesitancy (32.1%) and vaccine resistance (32.8%) rates were found for AstraZeneca than for Pfizer-BioNTech COVID-19 vaccine (22.3% and 10.1%, respectively). Structural equation modeling showed that existential concerns were related to Pfizer-BioNTech and AstraZeneca vaccine hesitancy both directly and indirectly through negative attitudes toward potential side effects of COVID-19 vaccines. The findings of the study confirm that the TMT is efficient in explaining COVID-19 vaccine hesitancy. Targeted efforts are needed to increase the acceptance of COVID-19 vaccines.

Nurses’ Influenza Vaccination and Hesitancy: A Systematic Review of Qualitative Literature

Vaccine hesitancy (VH) is defined as “delaying or refusing a secure vaccine despite its availability”. This hesitancy affects caregivers and more specifically nurses. The purpose of this study is to assess determinants of influenza VH in the nurse’s community. We conducted a systematic review of qualitative literature according to criteria of Preferred Reporting Items for Systematic Review and Meta-Analysis and Enhancing Transparency in Reporting the synthesis of Qualitative Research from 2009 until October 2020. Eleven qualitative studies analysed (ten thematic content analyses and one grounded theory method) found three main factors in VH. The first determinant was the benefit–risk equation considered as unfavourable due to an ineffective vaccine and fears about adverse effects as the pain of the injection. Wrong immunological beliefs brought into hesitancy. Disease barriers (hand washing and masks) and personal immunity were regarded as more effective than the vaccine. Lastly, dehumanised vaccination and the difficulties of access to healthcare were institutional determinants. Nurses ask for a vaccine promotion by hierarchy and doctors with transparent information and respect for autonomy. The availability of vaccines and methods of pain control seem to be some tracks to reduce nurses’ VH.

Procesos cognitivos implicados en conductas de protección ante COVID-19 (SARS-CoV-2)

Las conductas de riesgo o protección ante enfermedades virales pueden verse influenciadas por la forma como la población construye cogniciones sobre esta realidad, tales cogniciones resultan clave para comprender cómo actúan las personas respecto a situaciones que representan riesgos para su salud. Este estudio evalúa el papel de procesos cognitivos como los sesgos o falsas creencias, la intención conductual y las creencias de eficacia, en relación con la enfermedad COVID-19, procurando determinar su influencia en los comportamientos de protección incluida la probabilidad de vacunarse. A través de un estudio transversal predictivo se evaluó a 794 personas en Colombia durante el primer pico pandémico de 2020, empleando cuestionarios en línea y se construyeron modelos de regresión para pronosticar las conductas de protección recomendadas por la Organización Mundial de la Salud (lavado de manos, aislamiento social, uso de mascarillas). Los hallazgos señalan alta frecuencia en el sesgo de control y el optimismo ilusorio, al igual que altas expectativas de efectividad del cuidado, los cuales pronostican las conductas de protección y la intención de vacunarse. A partir de los resultados se discute que los sesgos relativos al optimismo no necesariamente implican asumir conductas de exposición a la enfermedad, de hecho, parecen tener un papel funcional en el cuidado.

Vaccination anxiety when vaccinations are available: The role of existential concerns

This study examined how existential fears are related to COVID-19 vaccination anxiety and followed the Terror Management Theory (TMT) by examining the contribution of two existential concerns, subjective nearness-to-death (SNtD) and death anxiety, to COVID-19 vaccination anxiety during the first month of COVID-19 vaccinations. Data were collected during January 2021, when Israel was in lockdown, from a convenience sample of 381 Jewish Israelis (M = 55.39, SD = 17.17). Participants completed questionnaires examining demographics, SNtD, death anxiety and COVID-19 vaccination anxiety. A hierarchical regression analysis examined the connections between these variables and COVID-19 vaccination anxiety while controlling for demographics and for receiving COVID-19 vaccinations. In line with the hypotheses, SNtD and death anxiety were each positively associated with COVID-19 vaccination anxiety, and death anxiety levels moderated the positive connection between SNtD and COVID-19 vaccination anxiety, as this association was not significant for individuals with low death anxiety. The findings of this study provide preliminary evidence concerning the role of death anxiety in moderating the effect that SNtD has on COVID-19 vaccination anxiety. These findings are in line with the TMT and justify further investigation and may be utilized in future research in order to address COVID-19 vaccination anxiety more effectively.

Healthcare workers' perceptions and experiences of communicating with people over 50 years of age about vaccination: a qualitative evidence synthesis

BACKGROUND

Infectious diseases are a major cause of illness and death among older adults. Vaccines can prevent infectious diseases, including against seasonal influenza, pneumococcal diseases, herpes zoster and COVID-19. However, the uptake of vaccination among older adults varies across settings and groups. Communication with healthcare workers can play an important role in older people's decisions to vaccinate. To support an informed decision about vaccination, healthcare workers should be able to identify the older person's knowledge gaps, needs and concerns. They should also be able to share and discuss information about the person's disease risk and disease severity; the vaccine's effectiveness and safety; and practical information about how the person can access vaccines. Therefore, healthcare workers need good communication skills and to actively keep up-to-date with the latest evidence. An understanding of their perceptions and experiences of this communication can help us train and support healthcare workers and design good communication strategies.

OBJECTIVES

To explore healthcare workers' perceptions and experiences of communicating with older adults about vaccination.

SEARCH METHODS

We searched MEDLINE, CINAHL and Scopus on 21 March 2020. We also searched Epistemonikos for related reviews, searched grey literature sources, and carried out reference checking and citation searching to identify additional studies. We searched for studies in any language.

SELECTION CRITERIA

We included qualitative studies and mixed-methods studies with an identifiable qualitative component. We included studies that explored the perceptions and experiences of healthcare workers and other health system staff towards communication with adults over the age of 50 years or their informal caregivers about vaccination.

DATA COLLECTION AND ANALYSIS

We extracted data using a data extraction form designed for this review. We assessed methodological limitations using a list of predefined criteria. We extracted and assessed data regarding study authors' motivations for carrying out their study. We used a thematic synthesis approach to analyse and synthesise the evidence. We used the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach to assess our confidence in each finding. We examined each review finding to identify factors that may influence intervention implementation and we developed implications for practice.

MAIN RESULTS

We included 11 studies in our review. Most studies explored healthcare workers' views and experiences about vaccination of older adults more broadly but also mentioned communication issues specifically. All studies were from high-income countries. The studies focused on doctors, nurses, pharmacists and others working in hospitals, clinics, pharmacies and nursing homes. These healthcare workers discussed different types of vaccines, including influenza, pneumococcal and herpes zoster vaccines. The review was carried out before COVID-19 vaccines were available. We downgraded our confidence in several of the findings from high confidence to moderate, low or very low confidence. One reason for this was that some findings were based on only small amounts of data. Another reason was that the findings were based on studies from only a few countries, making us unsure about the relevance of these findings to other settings. Healthcare workers reported that older adults asked about vaccination to different extents, ranging from not asking about vaccines at all, to great demand for information (high confidence finding). When the topic of vaccination was discussed, healthcare workers described a lack of information, and presence of misinformation, fears and concerns about vaccines among older adults (moderate confidence). The ways in which healthcare workers discussed vaccines with older adults appeared to be linked to what they saw as the aim of vaccination communication. Healthcare workers differed among themselves in their perceptions of this aim and about their own roles and the roles of older adults in vaccine decisions. Some healthcare workers thought it was important to provide information but emphasised the right and responsibility of older adults to decide for themselves. Others used information to persuade and convince older adults to vaccinate in order to increase 'compliance' and 'improve' vaccination rates, and in some cases to gain financial benefits. Other healthcare workers tailored their approach to what they believed the older adult needed or wanted (moderate confidence). Healthcare workers believed that older adults' decisions could be influenced by several factors, including the nature of the healthcare worker-patient relationship, the healthcare worker's status, and the extent to which healthcare workers led by example (low confidence). Our review also identified factors that are likely to influence how communication between healthcare workers and older adults take place. These included issues tied to healthcare workers' views and experiences regarding the diseases in question and the vaccines; as well as their views and experiences of the organisational and practical implementation of vaccine services.

AUTHORS' CONCLUSIONS

There is little research focusing specifically on healthcare workers' perceptions and experiences of communication with older adults about vaccination. The studies we identified suggest that healthcare workers differed among themselves in their perceptions about the aim of this communication and about the role of older adults in vaccine decisions. Based on these findings and the other findings in our review, we have developed a set of questions or prompts that may help health system planners or programme managers when planning or implementing strategies for vaccination communication between healthcare workers and older adults.

Medical students' knowledge and attitudes regarding vaccination against measles, influenza and HPV. An international multicenter study

Introduction

Inaccurate information leads to increased scepticism concerning vaccinations among health care workers. Therefore, a proper education of medical students on vaccination is important.

Methods

During summer term 2015, we performed a paper-based survey to identify the knowledge and attitudes of medical students on vaccinations against measles, influenza and HPV in seven medical schools in Germany, Austria and Switzerland.

Results

Altogether, 3,652 questionnaires were analyzed. Knowledge of country-specific public recommendations increased significantly with the number of semesters of medical studies. Concerning the knowledge about vaccinations against measles, influenza and HPV, one third of the answers were given correctly. Again, a strong correlation between the knowledge and the semester of medical studies could be observed. The attitudes concerning vaccinations in general and especially for HCWs were highly positive.

Conclusions

This study provides some important arguments for the development of a comprehensive vaccination education for medical students.

Increasing healthcare workers' uptake of seasonal influenza vaccination in a tertiary-care pediatric hospital in Greece with a low-cost, tailor-made, multifaceted strategy

BACKGROUND

Healthcare workers' (HCW) seasonal influenza vaccination (SIV) is critical to prevent nosocomial influenza. However, HCW vaccination rates remain unacceptably low in many European institutions. A two-year three-step initiative was implemented at a tertiary-care pediatric hospital with 750 beds in Athens, Greece with the aim of increasing SIV among HCW.

METHODS

Α cross-sectional anonymous survey of HCWs was conducted during the 2015-16 influenza season with the aim to evaluate attitudes, knowledge, and specific barriers and facilitators for SIV. Stratified analysis was used to identify factors associated with no prior history of influenza vaccination. Multifaceted interventions were implemented in the 2016-2017 season. These included 1) education around influenza disease and SIV, and 2) communication of availability and opportunity (time and place) of SIV. Interventions were designed to target HCWs with the lowest SIV rates in the previous three years.

RESULTS

We achieved a 67% response rate, with 363 respondents (106 doctors, 145 nurses, 101 other hospital staff; 11 did not provide their profession). Most (64%) had not been vaccinated in the previous three years; only 14% received the vaccine annually. Non-vaccination rates were significantly higher among nurses (76%) and cleaning and food-service workers (73%) compared to doctors (40%) (P < 0.001). Protection of self, family, patients and colleagues were the most common motivations. Concerns about the safety and effectiveness of the vaccine, the belief that one does not belong to a high-risk group were the most common barriers. The interventions led to an increase in SIV uptake by the HCWs in the hospital, from 19% to 31%.

CONCLUSIONS

In a country with very low reported rates of vaccination among HCWs, a simple, low-cost, tailor-made intervention strategy can lead to an increase in SIV uptake. Stratifying data according to vaccination history may reveal a diversity of targets for improvement that might otherwise be missed.

Health Beliefs of Wearing Facemasks for Influenza A/H1N1 Prevention: A Qualitative Investigation of Hong Kong Older Adults

Although vaccination is the first-line strategy controlling and preventing influenza A/H1N1 for older adults, personal protective measures, such as wearing facemasks, are also important preventive behaviors to reduce the risk of becoming infected with influenza A/H1N1 during a pandemic. In the current study, we aimed to explore the belief-related psychological factors of wearing facemasks for influenza A/H1N1 prevention in a sample of Hong Kong older adults. Community-dwelling Chinese adults (N = 137) aged between 65 and 80 years (M_age = 75.10; SD_age = 6.49) participated in semistructured interviews. Data were analyzed using theoretical thematic analysis and identified themes were matched deductively within the belief-based processes of the health belief model. Results revealed beliefs that underpinned 4 general dimensions of facemask wearing: (1) perceived susceptibility and seriousness of influenza A/H1N1 pandemic (e.g., influenza A/H1N1 as contagious and lethal), (2) modifying factors (e.g., social responsibility to prevent influenza), (3) cues to action (e.g., seeing others doing it), and (4) perceived benefits and barriers (e.g., protects oneself and others, difficult to breathe). Future interventions can target these beliefs to improve facemask wearing of older adults and, thus, curb preventable infection rates during an influenza A/H1N1 pandemic.

Social connectedness and engagement in preventive health services: an analysis of data from a prospective cohort study

BACKGROUND

Evidence of the possible health benefits of social connectedness is increasing. We aimed to examine poor social connectedness as a possible barrier to participation in preventive health services among older people (aged 53-69 years).

METHODS

We analysed data from a prospective cohort study of 5362 socially stratified births from the Medical Research Council National Survey of Health and Development enrolled in England, Scotland, and Wales in March 1946. At ages 68-69 years, participants reported participation in blood pressure and cholesterol measurement, eyesight and dental check-ups, influenza immunisation, and bowel and breast cancer screening. Our primary outcome measure summed participation across all these tests and services at ages 68-69 years. We tested associations between structural and functional social connectedness from ages 53 years to 69 years and total count of participation in these preventive services in Poisson models controlling for sex, education, occupational class, employment, chronic illnesses, and general practitioner consultations for health problems.

FINDINGS

940 (44%) of 2132 participants attended all preventive services within the recommended timeframes. At ages 68-69 years, being unmarried or not cohabiting (incident rate ratio [IRR] 1·33, 95% CI 1·20-1·47) and small personal social networks (IRR 1·51, 1·32-1·71) were independently associated with non-participation in more services, with associations consistent across most services. High social relationship quality at ages 68-69 years (IRR 0·91, 95% CI 0·87-0·95) and increasing social relationship quality from ages 53 years to 69 years (IRR 0·93, 0·89-0·97) were associated with low risk of non-participation.

INTERPRETATION

Individuals with poor social connectedness appear to be at greater risk of not engaging in the full range of preventive services than individuals with good social connectedness. Improvement of access to social contacts and networks in older ages is already recommended for the maintenance of good mental health. This study suggests that social connectedness could also improve participation in a wide range of preventive health services, and hence could improve use of the health-care system and population health.

FUNDING

UK Medical Research Council.

Attitudes, believes, determinants and organisational barriers behind the low seasonal influenza vaccination uptake in healthcare workers - A cross-sectional survey

BACKGROUND

Seasonal influenza threatens hospitalised patients and residents of nursing homes annually. Due to age and chronic disease their protection following immunisation is diminished. Additional immunisation of direct contacts and in particular healthcare workers (HCWs) has proven added value. As vaccination coverage in HCWs remains low, we aimed to gain insight in the factors behind the demotivation for influenza vaccination.

METHODS

Attitudes and believes towards influenza vaccination and socio-demographic and professional determinants were surveyed in 5141 Belgian HCWs from 13 hospitals and 14 nursing homes. Additionally, influenza campaign coordinators of the participating healthcare institutions were interviewed about the factors of success/failure in their campaigns.

RESULTS

The mean vaccination coverage registered by the participating healthcare institutions was 40.4% in the hospitals and 45.3% in the nursing homes. Overall, up to 90% of HCWs found it important not to infect their patients. However, only 20% of non-vaccinated HCWs considered influenza vaccination a duty to not harm their patients. Up to 40% of unvaccinated staff believed they could get influenza after vaccination and that vaccination weakens their immune system. Also, only about 20% of unvaccinated staff thought to have a high chance of getting influenza. Reasons for unvaccinated staff to get vaccinated in the future are self-protection and protection of family members. Factors that positively influenced vaccination coverage are encouragement by supervisors (OR, hospitals: 7.1, p < 0.001; nursing homes: 7.5, p < 0.001) and well-organized vaccination campaigns with on-site vaccination. Factors that negatively affected vaccination coverage are misconceptions about influenza and its vaccine (OR, range 0.1-0.7, p < 0.001 for most misconceptions) and underestimation of the risk of contracting influenza by patients or HCWs (OR of perceived susceptibility, range 2.1-5.1, p < 0.001 for most factors).

CONCLUSION

There is a need for guidance for the organization of seasonal influenza campaigns, in which education, communication and easy accessible vaccination are promoted.

Seasonal influenza vaccination of healthcare workers: systematic review of qualitative evidence

Background

Most countries recommend that healthcare workers (HCWs) are vaccinated seasonally against influenza in order to protect themselves and patients. However, in many cases coverage remains low. A range of strategies have been implemented to increase uptake. Qualitative evidence can help in understanding the context of interventions, including why interventions may fail to achieve the desired effect. This study aimed to synthesise evidence on HCWs’ perceptions and experiences of vaccination for seasonal influenza.

Methods

Systematic review of qualitative evidence. We searched MEDLINE, EMBASE and CINAHL and included English-language studies which reported substantive qualitative data on the vaccination of HCWs for seasonal influenza. Findings were synthesised thematically.

Results

Twenty-five studies were included in the review. HCWs may be motivated to accept vaccination to protect themselves and their patients against infection. However, a range of beliefs may act as barriers to vaccine uptake, including concerns about side-effects, scepticism about vaccine effectiveness, and the belief that influenza is not a serious illness. HCWs value their autonomy and professional responsibility in making decisions about vaccination. The implementation of interventions to promote vaccination uptake may face barriers both from HCWs’ personal beliefs and from the relationships between management and employees within the targeted organisations.

Conclusions

HCWs’ vaccination behaviour needs to be understood in the context of HCWs’ relationships with each other, with management and with patients. Interventions to promote vaccination should take into account both the individual beliefs of targeted HCWs and the organisational context within which they are implemented.

Electronic supplementary material

The online version of this article (10.1186/s12913-017-2703-4) contains supplementary material, which is available to authorized users.

Planning theory- and evidence-based behavior change interventions: a conceptual review of the intervention mapping protocol

This paper discusses the Intervention Mapping (IM) protocol for planning theory- and evidence-based behavior change interventions. IM has been developed in the field of health promotion in 1998 and has mostly been applied in that field, but applications in other fields are emerging. IM can be used for any intervention that involves changing behavior. The paper discusses the protocol and its basic issues and presents in-depth examples of its use in- and outside the health promotion field: Empowerment, return to work, safety interventions, implementation, energy conservation, and academic performance. IM is characterized by three perspectives: a social ecological approach, participation of all stakeholders, and the use of theories and evidence. Through a series of six iterative steps - from needs assessment to implementation and evaluation - which are each broken down into specific tasks, correct application of the protocol is meant to produce behavior change interventions that fit into the local context and that have the best chances of effectiveness. IM helps intervention planners develop the best possible interventions targeting health behaviors, but also targeting behaviors related to other societal issues, such as environmental concerns, safety and discrimination.

Using campaigns to improve perceptions of the value of adult vaccination in the United States: Health communication considerations and insights

Vaccines have much relevance and promise for improving adult health in the United States, but to date, overall use and uptake remain far below desired levels. Many adults have not received recommended vaccinations and many healthcare providers do not strongly and actively encourage their use with patients. This has led some public health and medical experts to conclude that adult vaccines are severely undervalued by the U.S. public and healthcare providers and to call for campaigns and communication-based efforts to foster increased appreciation, and in turn, higher adult immunization rates. A narrative integrative review that draws upon the vaccine valuation and health communication literatures is used to develop a framework to guide campaign and communication-based efforts to improve public, provider, and policymakers' assessment of the value of adult vaccination. The review does this by: (1) distinguishing social psychological value from economic value; (2) identifying the implications of social psychological value considerations for adult vaccination-related communication campaigns; and (3) using five core health communication considerations to illustrate how social psychological notions of value can be integrated into campaigns or communication that are intended to improve adult vaccination value perceptions and assessments, and in turn, motivate greater support for and uptake of recommended adult vaccines.

The benefit of the doubt or doubts over benefits? A systematic literature review of perceived risks of vaccines in European populations

OBJECTIVES

The success of vaccination strategies depends in part on population perceptions of benefits and risks of vaccines and related confidence in vaccination. Better knowledge of public concerns about vaccines and what is driving them is needed to inform vaccination strategies and communications. This literature reviewer examined studies on vaccine and vaccination risk perceptions and concerns across European populations.

METHODS

A systematic literature review was conducted to identify studies published between 2004 and 2014 in Europe. A descriptive analysis was performed.

FINDINGS

A total of 145 articles were selected, most of which were conducted in the UK, the Netherlands and France and studied seasonal influenza, HPV and pandemic influenza vaccination. Across all countries and vaccines, the primary area of concern was vaccine safety, followed by perceptions of low likelihood of contracting vaccine-preventable diseases (VPDs), perceived low severity of VPDs, beliefs that vaccines do not work, and overall lack of information. Concerns were found to be vaccine-, country- and population-specific.

CONCLUSION

In addition to identifying concerns about vaccination in Europe, this study confirmed the notion that individuals have many safety concerns about vaccination and often believe that the risks of vaccination outweigh their benefits. More research needs to be conducted to explore the impact of different types of communication strategies, which would frame the benefits of vaccination as well as risks of not vaccinating. Strategies to better inform public perceptions of vaccines should include the provision of unbiased, comprehensive information tailored to population information needs, and delivered using multiple and new communication technologies such as social media.

Attitudinal variables and a possible mediating mechanism for vaccination practice in health care workers of a local hospital in L'Aquila (Italy)

Active immunization is an important concern for health care workers (HCWs) susceptible subjects and potential sources of infection for patients. However, the vaccine coverage for vaccine preventable diseases (VPDs) is below recommended standards. The aims of the study were to estimate the hospitals' HCWs' susceptibility and vaccination coverage rates for VPDs and to analyze the role of HCWs' attitudes and knowledge as determinants of the immunization practices. A cross-sectional study enrolled 334 HCWs (physicians, nurses, others) at local hospital in L'Aquila (Italy). By means of an anonymous questionnaire, self-report data about history of disease and active vaccination for seasonal influenza, chickenpox, measles-mumps-rubella and hepatitis B were collected, as well as attitudes and knowledge about vaccination in HCWs. The employees showed high levels of susceptibility and insufficient vaccination coverage rates, particularly for influenza. Specific trends were detected for different VPDs across age strata and professional categories, not always consistent with literature. Overall, the level of knowledge about recommended vaccination for HCWs was low, in all categories. The active immunization status against influenza was found the most clearly associated with difference levels in 3 psychometric variables: personal responsibility, beliefs on usefulness and beliefs on risk of vaccination. A mediation mechanism was analyzed between these constructs, and an interesting indirect effect was highlighted for beliefs that could enhance the advantage of increased responsibility for HCWs. Further effort in research is needed to evaluate the black-box of longitudinal intervention studies (education, environmental changes, policies), to improve HCWs immunization.

Intention to Accept Pertussis Vaccination for Cocooning: A Qualitative Study of the Determinants

Context

Several countries have reported a resurgence of pertussis in the last decades. This puts infants (especially <6 months) at risk of severe complications, because they are too young to be fully protected by vaccination. The global pertussis initiative has proposed pertussis vaccination of young infants’ close contacts, in order to reduce pertussis transmission and the burden of the disease on infants. Our aim is to explore the perceived determinants (barriers and facilitators) of intention to accept vaccination among the possible target groups of pertussis vaccination for cocooning. Consideration of these determinants is necessary to optimise the uptake of the vaccination.

Methods

We conducted 13 focus groups and six individual semi-structured interviews with members of possible target groups for pertussis cocooning (i.e. parents, maternity assistants, midwives, and paediatric nurses) in the Netherlands. Here, both maternal pertussis vaccination as well as pertussis cocooning has not been implemented. The topic list was based on a literature review and a barrier framework. All interviews were transcribed verbatim and two researchers performed thematic content analysis.

Findings

The participants’ risk perception, outcome expectations, general vaccination beliefs, moral norms, opinion of others, perceived autonomy, anticipated regret, decisional uncertainty, and perceived organisational barriers were all factors that influenced the intention to accept pertussis vaccination for cocooning.

Discussion

This study has identified nine perceived determinants that influence the intention to accept pertussis cocooning vaccination. We add the following determinants to the literature: perceived cost-effectiveness (as a concept of outcome expectations), justice (as a concept of moral norms), anticipated regret, and decisional uncertainty. We recommend considering these determinants in vaccination programmes for pertussis cocooning vaccination. Experience, information and trust emerged as predominant themes within these determinants. These themes require particular attention in future research on vaccination acceptance, especially with regard to their role in use and implementation in policy and practice.

Changing the default to promote influenza vaccination among health care workers

BACKGROUND

The prevention of health care acquired infections is an important objective for patient safety and infection control in all health care settings. Influenza vaccination uptake among health care workers (HCWs) is the most effective method to prevent transmission to patients, but vaccination coverage rates are low among HCWs. Several educational campaigns have been developed to increase the influenza vaccination coverage rates of HCWs, but showed only small effects. The aim of this study was to test an opt-out strategy in promoting uptake among HCWs in a tertiary care center for patients with complex chronic organ failure.

METHODS

HCWs were randomly assigned to one of two conditions. In the opt-out condition (N=61), participants received an e-mail with a pre-scheduled appointment for influenza vaccination, which could be changed or canceled. In the opt-in condition (N=61), participants received an e-mail explaining that they had to schedule an appointment if they wanted to get vaccinated.

RESULTS

The findings show no statistically detectable effect of condition on being vaccinated against influenza. However, HCWs in the opt-out condition were more likely to have an appointment for influenza vaccination, which in turn increased the probability of getting vaccinated.

CONCLUSION

To change the default to promote influenza vaccination among HCWs might be an easy and cost-effective alternative to the complex vaccination campaigns that have been proposed in recent years.

Association between Psychological Flexibility and Health Beliefs in the Uptake of Influenza Vaccination among People with Chronic Respiratory Diseases in Hong Kong

It is common for elderly people and those with such chronic disorders as respiratory diseases to suffer severe complications from influenza, a viral infection. The voluntary uptake of vaccination is vital to the effectiveness of influenza prevention efforts. The Health Belief Model (HBM) is the most commonly used framework in the field of vaccination behavior to explain the decision that people make to accept or refuse vaccination. In addition, psychological flexibility is considered helpful in causing people to be open to adopting new practices that are consistent with their values. This study examined the role of psychological flexibility and health beliefs in predicting the uptake of influenza vaccination among people in Hong Kong. Eligible participants were Hong Kong permanent residents aged 18 years or above with a history of chronic respiratory diseases (CRD). A convenience sample of 255 patients was recruited to participate in a cross-sectional survey in which HBM components and factors of psychological flexibility were assessed. The following variables were found to be significant predictors of vaccination: age, smoking status, comorbidity, previous hospitalization, perceived susceptibility, perceived severity, and psychological flexibility. Enhancing psychological flexibility might be a potential new direction for motivating people to accept influenza vaccination.

Examining Perceptions about Mandatory Influenza Vaccination of Healthcare Workers through Online Comments on News Stories

BACKGROUND

The aim of this study was to understand online public perceptions of the debate surrounding the choice of annual influenza vaccinations or wearing masks as a condition of employment for healthcare workers, such as the one enacted in British Columbia in August 2012.

METHODS

Four national and 82 local (British Columbia) Canadian online news sites were searched for articles posted between August 2012 and May 2013 containing the words "healthcare workers" and "mandatory influenza vaccinations/immunizations" or "mandatory flu shots and healthcare workers." We included articles from sources that predominantly concerned our topic of interest and that generated reader comments. Two researchers coded the unedited comments using thematic analysis, categorizing codes to allow themes to emerge. In addition to themes, the comments were categorized by: 1) sentiment towards influenza vaccines; 2) support for mandatory vaccination policies; 3) citing of reference materials or statistics; 4) self-identified health-care worker status; and 5) sharing of a personal story.

RESULTS

1163 comments made by 648 commenters responding to 36 articles were analyzed. Popular themes included concerns about freedom of choice, vaccine effectiveness, patient safety, and distrust in government, public health, and the pharmaceutical industry. Almost half (48%) of commenters expressed a negative sentiment toward the influenza vaccine, 28% were positive, 20% were neutral, and 4% expressed mixed sentiment. Of those who commented on the policy, 75% did not support the condition to work policy, while 25% were in favour. Of the commenters, 11% self-identified as healthcare workers, 13% shared personal stories, and 18% cited a reference or statistic.

INTERPRETATION

The perception of the influenza vaccine in the comment sections of online news sites is fairly poor. Public health agencies should consider including online forums, comment sections, and social media sites as part of their communication channels to correct misinformation regarding the benefits of HCW influenza immunization and the effectiveness of the vaccine.

Accounting for personal and professional choices for pandemic influenza vaccination amongst English healthcare workers

BACKGROUND

Healthcare workers (HCWs) are encouraged to get vaccinated during influenza pandemics to reduce their own, and patients', risk of infection, and to encourage their patients to get immunised. Despite extensive research on HCWs' receipt of vaccination, little is known about how HCWs articulate pandemic influenza vaccination advice to patients.

AIMS

To explore HCWs' uptake of the A/H1N1 vaccine during the pandemic of 2009-2010, their recommendations to patients at the time, and their anticipated choices around influenza vaccination under different pandemic scenarios.

METHOD

We conducted semi-structured interviews and focus groups with eight vaccinated and seventeen non-vaccinated HCWs from primary care practices in England. The data was analysed using thematic analysis.

RESULTS

The HCWs constructed their receipt of vaccination as a personal choice informed by personal health history and perceptions of vaccine safety, while they viewed patients' vaccination as choices made following informed consent and medical guidelines. Some HCWs received the A/H1N1 vaccine under the influence of their local practice organizational norms and values. While non-vaccinated HCWs regarded patients' vaccination as patients' choice, some vaccinated HCWs saw it also as a public health issue. The non-vaccinated HCWs emphasised that they would not allow their personal choices to influence the advice they gave to patients, whereas some vaccinated HCWs believed that by getting vaccinated themselves they could provide a reassuring example to patients, particularly those who have concerns about influenza vaccination. All HCWs indicated they would accept vaccination under the severe pandemic scenario. However, most non-vaccinated HCWs expressed reticence to vaccinate under the mild pandemic scenario.

CONCLUSIONS

Providing evidence-based arguments about the safety of new vaccines and the priority of public health over personal choice, and creating strong social norms for influenza vaccination as part of the organizational culture, should increase uptake of influenza vaccination among primary care HCWs and their patients.

Beliefs and Opinions of Health Care Workers and Students Regarding Influenza and Influenza Vaccination in Tuscany, Central Italy

Immunization of health care workers (HCWs) against influenza has been associated with improvements in patient safety. The aim of this study is to assess the beliefs, attitudes, and knowledge of HCWs and health profession students regarding influenza. An anonymous questionnaire was distributed to HCWs in three local Florentine healthcare units, at Careggi University Teaching Hospital, and to students in health profession degree programs. A total of 2576 questionnaires were fully completed. A total of 12.3% of subjects responded that they were "always vaccinated" in all three of the seasonal vaccination campaigns studied (2007-2008 to 2009-2010), 13.1% had been vaccinated once or twice, and 74.6% had not received vaccinations. Although the enrolled subjects tended to respond that they were "never vaccinated," they considered influenza to be a serious illness and believed that the influenza vaccine is effective. The subjects who refused vaccination more frequently believed that the vaccine could cause influenza and that it could have serious side effects. More than 60% of the "always vaccinated" group completely agreed that HCWs should be vaccinated. Self-protection and protecting family members or other people close to the respondent from being infected and representing potential sources of influenza infection can be considered motivating factors for vaccination. The results highlight the importance of improving vaccination rates among all HCWs through multi-component interventions. Knowledge of influenza should be reinforced.

The intention to get vaccinated against influenza and actual vaccination uptake of Dutch healthcare personnel

Health Authorities recommend annual vaccination of healthcare personnel (HCP) against influenza to protect vulnerable patients. Nevertheless, vaccination rates have been low among European HCP. Here we report on a longitudinal survey study to identify social cognitive predictors of the motivation to obtain influenza vaccination, and to test whether intention is a good predictor of actual vaccination behaviour. Dutch HCP (N=1370) were invited to participate in a survey (baseline). To link intention to behaviour, participants who completed the first survey (N=556) were sent a second survey after vaccinations were offered (follow-up). Multinominal regression analysis showed that HCP with a positive attitude and a higher frequency of past vaccinations were more likely to have a high intention to get vaccinated. A negative attitude, high feelings of autonomy in the decision whether to get vaccinated, a preference of inaction over vaccination, a lesser sense of personal responsibility, and high self-protection motives increased the probability of no intention to get vaccinated. Social cognitive predictors were identified that explain the intention to get vaccinated against influenza of HCP, which in turn proved to be a good predictor of behaviour. Future interventions should focus on these variables to increase vaccination coverage rates.