key: cord-283277-zmna5ovl authors: Lim, Dwee Wee; Lee, Lay Tin; Kyaw, Win Mar; Chow, Angela title: Psychosocial determinants of influenza vaccination intention: A cross-sectional study on inpatient nurses in Singapore date: 2017-10-01 journal: American Journal of Infection Control DOI: 10.1016/j.ajic.2017.03.017 sha: doc_id: 283277 cord_uid: zmna5ovl Nurses have the closest interaction with inpatients and could transmit influenza to patients. From a self-administered questionnaire survey among inpatient nurses at a tertiary hospital, we observed that the strongest factors associated with intention for future vaccination were perceived benefits of and motivations for vaccination (adjusted odds ratio [aOR], 3.30; 95% confidence interval [CI], 2.55-4.27), and perceived nonsusceptibility to influenza and preference for vaccination alternatives (aOR, 0.26; 95% CI, 0.20-0.34). These factors need to be addressed to increase vaccination uptake and prevent nosocomial transmission. Influenza can be transmitted in health care settings by infected health care workers (HCWs), causing nosocomial outbreaks. 1 The U.S. Advisory Committee on Immunization Practices recommends annual influenza vaccination for HCWs for transmission prevention and reduction in work absenteeism. 2 However, influenza vaccination in HCWs has remained suboptimal. 3 Determinants of influenza vaccination intention differ across countries, hospitals, and occupational groups. 4 Nurses make up most of HCWs in hospitals and have the closest interaction with patients in inpatient settings. It is crucial to understand the psychosocial factors associated with the intention for vaccination uptake among inpatient nurses to tailor effective vaccination promotion interventions. We conducted a cross-sectional study of inpatient nurses in a 1,600-bed adult tertiary hospital in Singapore, from October-November 2012, prior to the hospital's annual seasonal influenza vaccination program, which provides vaccination free-of-charge to HCWs via a mobile clinic. We developed a 41-item (5-point Likert scale), self-administered questionnaire covering content on personal knowledge, attitudes, and beliefs toward influenza vaccination, and the barriers and facilitators of vaccination in the hospital. We also collected data on sociodemographics, vaccination uptake in the last influenza season, and intention for future influenza vaccination. Ethical approval was obtained from the Domain Specific Research Board, National Healthcare Group (Singapore). Principal component analysis with varimax rotation was performed to derive the latent factor structure. Internal consistency of each factor was measured using Cronbach α coefficient. The χ 2 test was used to compare differences in proportions. Stepwise multiple logistic regression analysis was performed to assess for independent factors. A total of 1,042 out of 2,231 inpatient nurses responded to the survey. There were 268 nurses with incomplete data who were excluded from analysis, resulting in a total of 774 subjects in the study. Half (51.7%) of the nurses had received influenza vaccination in the previous season (year 2011). Approximately 71% of the participants intended to receive influenza vaccine in the next influenza season (Table 1) . Principal component analysis revealed 8 latent factors on influenza vaccine, including (1) perceived benefits of and motivations for influenza vaccination, (2) global threat of emerging infectious diseases, (3) effectiveness of hospital's influenza vaccination promotional efforts, (4) personal nonsusceptibility to influenza and preference for alternatives to influenza vaccination, (5) local threat of emerging infectious diseases, (6) reinforcement and cues to action, (7) fear of adverse effects, and (8) accessibility. The Cronbach α coefficient ranged from 0.36 to 0.87 (Table A1 ). One item was removed from factor 7 (fear of adverse effects), and the Cronbach α improved to 0.64. A composite score for the remaining items for factor 7 was calculated. For factors 6 (reinforcement and cues to action) and 8 (accessibility), with poor internal consistency, individual items were included in the final multiple logistic regression model, along with the composite score for factor 7 and the 5 factors with good internal consistency. On univariate analysis, age, ethnicity, workplace, job title, past vaccination uptake, and 6 psychosocial factors were significantly associated with future vaccination intention. In the multivariate model, the strongest predictor for vaccination intention was perceived benefits of and motivations for vaccination (adjusted odds ratio [aOR], 3.30; 95% confidence interval [CI], 2.55-4.27) ( Table 2 ). This was followed by awareness of easy access to influenza vaccination at the occupational health clinic (aOR, 1.80; 95% CI, 1.32-2.45), knowledge that vaccination was provided free-of-charge, (aOR, 1.80; 95% CI, 1.23-2.61), the perceived effectiveness of the hospital's influenza vaccination promotional efforts (aOR, 1.79; 95% CI, 1.37-2.33), and the perceived global threat of emerging infectious diseases (aOR, 1.79; 95% CI, 1.39-2.31). Perceived local threat of emerging infectious diseases was also associated with vaccination intention (aOR, 1.28; 95% CI, 1.01-1.64). Nurses who perceived themselves to be nonsusceptible to influenza and who preferred alternatives to vaccination (aOR, 0.26; 95% CI, 0.20-0.34), and those who feared the adverse effects of vaccination (aOR, 0.84; 95% CI, 0.72-0.99), were 74% and 16% less likely to express the intention for future influenza vaccination (Table 2) . The strongest determinants for future influenza vaccination intention among inpatient nurses were perceived benefits of and motivation for vaccination, awareness of easy access to vaccination at the occupational health clinic, and knowledge that the vaccine was free-of-charge. Our findings corroborate with findings from other local and international studies. [4] [5] [6] [7] In addition, our study found that the perception of global threat of emerging infectious diseases also positively influenced nurses' intention for future influenza vaccination. This could explain the behaviors of Hong Kong nurses whose influenza vaccination uptake declined after the severe acute respiratory syndrome outbreak in 2003 until the avian influenza outbreak in neighboring China in 2005 and the influenza pandemic in 2009. 3 On the other hand, nurses who perceived themselves to be nonsusceptible to influenza and who preferred alternatives to vaccination were less likely to intend to be vaccinated in the future. This is of concern, because HCWs often perceived themselves to be healthy and not at risk of influenza infection. 4, 8 Furthermore, Singapore is a multiracial country where the use of complementary and alternative medicine is prevalent. 9 These beliefs, which could greatly reduce the uptake of vaccination, would need to be addressed. Despite the demonstration of vaccine safety, HCWs continue to be concerned about the adverse effects. 2, 3, 5, 8 Our study found that nurses who feared the adverse effects of influenza vaccination were less likely to intend to receive future vaccination. More targeted interventions would have to be implemented to address these fears. Our findings have several implications. First, influenza vaccination promotional efforts for nurses should address both the positive and negative determinants of vaccination intention. Local epidemiology of influenza and HCWs' risk of infection, benefits and safety of influenza vaccination, and precautions against potential adverse effect should be clearly communicated to support vaccination uptake. Second, early dissemination of information on impending international and local outbreaks can increase influenza vaccination uptake among nurses ahead of epidemics. Finally, accessibility to vaccination should be increased. This could include extension of vaccination clinic hours and encouragement of peer administration of vaccination. 10 This study has shown that personal psychosocial and organizational factors are determinants of nurses' intention for influenza vaccination. Promotional efforts should include disseminating information on infection risk and vaccination benefits, addressing fear of adverse effects, and increasing vaccination accessibility. Factors loadings and Cronbach α coefficient for psychosocial factors generated from principal component analysis Questionnaire items Factor loadings Cronbach α The flu vaccine is effective in preventing flu. Routes of transmission during a nosocomial influenza A(H3N2) outbreak among geriatric patients and healthcare workers Immunization of health-care personnel: recommendations of the advisory committee on immunization practices (ACIP) Declining influenza vaccination coverage among nurses Sociocognitive predictors of the intention of healthcare workers to receive the influenza vaccine in Belgian, Dutch and German hospital settings Survey of healthcare workers' attitudes, beliefs and willingness to receive the 2009 pandemic influenza A (H1N1) vaccine and the impact of educational campaigns attitudes and practices towards pandemic influenza among cases, close contacts, and healthcare workers in tropical Singapore: a cross-sectional survey High coverage of influenza vaccination among healthcare workers can be achieved during heightened awareness of impending threat Seasonal influenza vaccination predicts pandemic H1N1 vaccination uptake among healthcare workers in three countries Complementary and alternative medicine use in multiracial Singapore Influenza vaccination in paediatric nurses: cross-sectional study of coverage, refusal, and factors in acceptance We thank all the nurse managers in the ward who helped in data collection.