Elsevier

Vaccine

Volume 38, Issue 46, 27 October 2020, Pages 7372-7378
Vaccine

The Health Belief Model in predicting healthcare workers' intention for influenza vaccine uptake in Jordan

https://doi.org/10.1016/j.vaccine.2020.09.002Get rights and content

Highlights

  • The Health Belief Model is being used to predict actual influenza vaccine uptake.

  • The Health Belief Model can also predict intention for future vaccine uptake.

  • Perceived benefit and past vaccination are predictors of intention to vaccinate.

  • Influenza vaccination should be encouraged for the first time to make it a habit.

  • Distinct groups of healthcare workers need different tactics to change behavior.

Abstract

Background

Theories of health behavior change are being inadequately adopted to understand the reasons behind low influenza vaccination rates among healthcare workers (HCWs). The Theory of Planned Behavior (TPB) is being used to predict intention-behavior relationship while the Health Belief Model (HBM) is being employed to predict actual behavior. The purpose of this study was to test a conceptual model based on the HBM’s constructs to predict Jordanian HCWs’ intentions for influenza vaccine uptake as an alternative to the TPB.

Method

A cross-sectional questionnaire-based study was conducted in 2016 in a tertiary teaching hospital in Amman-Jordan including a convenience sample of 477 HCWs with direct patient contact. The study instrument was tested for validity and reliability. A conceptual regression model was proposed incorporating the constructs of the primary HBM with some modifications in the threat construct as well as an additional variable about explicit past vaccination behavior (in the past year and/or any previous history of influenza vaccine uptake).

Results

Almost all the constructs of the HBM demonstrated significant differences between participants intending and those who did not intend to vaccinate against influenza. After adjusting for the confounding variables in the final conceptual regression model, past vaccination behavior (OR= 4.50, 95%Confidence Interval 3.38–6.00, P< 0.0005) and the perceived benefit scale (OR= 1.19, 95% Confidence Interval 1.11–1.28, P< 0.0005) were the only significant predictors of intentions to vaccinate against influenza in the next season.

Conclusion

Taking into consideration the altruistic beliefs of HCWs and their explicit past vaccination history augments the utility of the original HBM tool in predicting HCWs’ intentions to vaccinate against influenza in a way that is consistent with the predictive ability of the Theory of Planned Behavior.

Introduction

Annual influenza vaccination is recommended for healthcare workers (HCWs) as they are at increased risk of exposure to influenza viruses compared with the general population potentially compromising their health and their patients' safety [1], [2].

Despite the longstanding recommendations, vaccination coverage among HCWs remains heterogeneous and usually suboptimal with rates well below the minimum targets of 90% according to “The CDC's Healthy People 2020” [3], [4].

Studies investigating influenza vaccination uptake by HCWs in relation to their knowledge, attitudes, and barriers to vaccination have found that adequate knowledge is not the only determinant in the decision to get vaccinated against influenza, and many aggressive campaigns and interventions to promote vaccination were marginally successful [5], [6]. Consequently, behavioral psychology and health behavior change theories are being explored in an attempt to understand HCWs’ influenza vaccination behavior and frame strategies aimed at improving vaccine uptake [7].

The theories often used in this field include the Health Belief Model (HBM), the Theory of Planned Behavior (TPB), Risk Perception Attitude (RPA), and the Triandis Model [2], [7]. The HBM, followed by the TPB, is the most commonly employed model [7], [8]. It includes five key constructs influencing health behaviors: perceived susceptibility to the health threat, perceived severity of the health threat, perceived benefits associated with the behavior, perceived barriers associated with the behavior and cues to action [9].

Nonetheless, the HBM’s utility in predicting intention that, in turn, predicts actual behavior is inadequately studied, as the Theory of Planned Behavior (TPB) is typically the model used. The TPB indicates that the key determinant of behavior remains the behavioral intention that is essentially affected by the individuals’ attitude toward performing that behavior [7], [9], [10].

From an HBM’s standpoint, Cheney et al. have illustrated that individuals who did not intend to receive the influenza vaccine had no previous personal experience on which they based their perceptions [11]. Other authors have affirmed this finding concluding that prior vaccination was one of the key determinants of future influenza vaccination despite being not explicitly incorporated in the HBM [12], [13].

The majority of the research studies investigating these theories included a limited number of geographic areas in the west [7]. A recent review in the Eastern Mediterranean Region (EMR) has drawn attention to substantial research gaps and major disparities across EMR countries including data on influenza vaccine use, recommendations and coverage [14]. Of the 48 included studies, 21 addressed the influenza vaccine among HCW and the only included study from Jordan did not examine the influenza vaccine among HCWs [14], [15]. Thereafter, two more research papers have been published in Jordan: one included HCWs as a subcategory [16] and the other was primarily focused on HCWs [6]. Importantly, the Jordanian Ministry of Health, collaborating with the World Health Organization, offers a yearly influenza vaccine for judicious use where it defines priority levels for vaccine distribution and administrations, due to the usually expected shortage of supplies [17].

Up to our knowledge, none of the studies in the EMR countries explored health behavior change theories. Therefore, the purpose of this survey was to adopt a conceptual model based on the HBM’s constructs along with an explicit past vaccination behavior and examine its utility in predicting Jordanian HCWs’ intention for rather than actual influenza vaccine uptake. Of note, the HBM developers have supported combining and individualizing its main constructs instead of a comprehensive bland application [8], [18].

A secondary outcome was to recognize what specific HBM constructs are equivalent to the “attitude” component of the TPB in predicting intention rather than actual vaccine uptake [10].

Section snippets

Study design and sampling techniques

A cross-sectional questionnaire-based study was performed in a tertiary academic hospital in Amman, Jordan during the period March-May 2016. This hospital is considered a major referral center for more than a half million patients from all over the kingdom [6]. It also offers free influenza vaccine for HCWs [6]. A convenience sample of 477 healthcare workers (HCWs) was interviewed by three trained research assistants after obtaining a verbal informed consent. Participants would be eligible to

Characteristics of the sample

Table 1 shows the demographic characteristics of the study cohort in relation to their intention to receive the influenza vaccine. Most of the participants were physicians, married and non-smokers. A statistically significant difference was found between participants intending to vaccinate against influenza in the upcoming influenza season and those who had no intention to avail of the vaccine next year (P < 0.001), yet none of the demographic variables was significantly associated with the

Discussion

This study is the first one in Jordan to shed light on the factors that determine HCWs' intention to receive the influenza vaccine using a psychological theory of behavior change. We found that 32% of our sample of HCWs had received the influenza vaccine in the previous year, and 50% intended to receive it in the upcoming year. Significant differences in health beliefs and behaviors were identified between participants who intended and those who did not intend to receive the influenza vaccine.

Conclusion

The perceived benefit of the influenza vaccine, coupled with a prior history of vaccination, were the most significant predictors of intention for influenza vaccine uptake among HCWs. Emphasizing the tremendous benefits of the vaccine to the HCWs’ themselves, as well as to their patients, is believed to be a cornerstone to encourage HCWs to get vaccinated for the first time; the first step in making influenza vaccination a habit.

Conducting further longitudinal studies to evaluate the

Study strengths and limitations

This is the first research study examining theory-based behaviors in influenza vaccination among HCWs in an EMR country. Further, the HBM’s constructs were tested for validity and reliability and were essentially in accordance with findings from previous studies. Also, the presence of chronic diseases was included as a confounding variable to ascertain for a principal reason, rather than the occupation, for influenza vaccine uptake. It is believed that recruiting HCWs from different hospital

Ethical considerations

The study was funded by the Deanship of Scientific Research and approved by the IRB committee at the University of Jordan and Jordan University Hospital (reference No. 4/2015).

CRediT authorship contribution statements

Lana Alhalaseh: Conceptualization, Methodology, Formal analysis, Data curation, Writing - original draft, Writing - review & editing, Supervision, Project administration, Funding acquisition. Hanan Fayoumi: Conceptualization, Investigation, Writing - original draft. Bayan Khalil: Conceptualization, Investigation, Writing - original draft.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

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