Running head: SIGNIFICANCE OF INFLUENZA VACCINES 1

Significance of Influenza Vaccines

Czarina Muyargas

HSC 421 Health Behavior

California State University, Long Beach

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One of the greatest medical advances of modern times is known to be vaccines. They

have revolutionized modern-day medicine in a number of different ways that benefit the health

and quality of life of people who receive them. According to the Public Health Journal (2010),

in the past 160 years vaccines have saved hundreds of millions of lives since their introduction

(Public Health Journal, 2010). There have been, and continue to be, various breakthroughs and

advancements over the course of vaccines. A very common and widely known vaccine is the

influenza vaccine. Influenza, commonly known as the flu, is a viral infection that attacks your

respiratory system and is extremely contagious (Mayo Clinic, 2015). The flu is a serious disease

that can lead to hospitalization and sometimes its complications can be deadly. Over a period of

30 years between 1976 and 2006, estimates of flu-associated deaths in the United States range

from a low of about 3,000 to a high of about 49,000 people (Centers for Disease Control and

Prevention, 2015). In 2013, more than 3,600 people died from it (Mayo Clinic, 2015). The CDC

(2015) says 200,000 Americans are hospitalized with the flu each year (Centers for Disease

Control and Prevention, 2015). Beginning October and ending in May at the latest is considered

to be flu season. During this time, flu viruses are circulating at greater levels in the United

States population. The best defense to reduce the likelihood of being diagnosed with the

seasonal flu and spreading it to others is to receive an annual flu vaccine. In return, when more

people get vaccinated against the flu, less flu is transmitted to others in that community. In this

paper, we will look at three different studies that relate to the acceptance of receiving influenza

vaccines based on the Health Belief Model, the Transtheoretical Model, and the Theory of

Planned Behavior.

The flu is unpredictable and its severity can vary widely from one season to the next.

Influenza is also a preventable disease, against which vaccination is the primary means of
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protection (Wallace, 2015). Certain people have a greater risk of experiencing serious

complications if they catch the flu. This includes elderly, young children, women who are

pregnant and those with certain health conditions such as asthma, diabetes, or heart disease

(Centers for Disease Control and Prevention, 2015). Last year, 135 million doses of flu vaccine

were distributed (Wallace, 2014). Wallace (2014) also recognized that although this represents

only 14% of our population, this is indeed a large number. According to the CDC (2015), 49.9%

of children 6 months to 17 years received an influenza vaccination during the past 12 months,

31.2% of adults 18-49 years, 45.5% of adults 50-64 years, followed by 70.0% of adults 65 years

and over (Centers for Disease Control and Prevention, 2015). Although there has been some

controversy over how effective the flu vaccine is, recent studies show that the vaccines

effectiveness definitely varies depending on who is receiving the vaccination and can range from

season to season. While determining how well a flu vaccine works is challenging, in general,

recent studies have supported the conclusion that flu vaccination benefits public health,

especially when the flu vaccine is well matched to circulating flu viruses (Centers for Disease

Control and Prevention, 2015)

For the purpose of this paper, we will start by discussing the health behavior theories that

were mentioned earlier. The first model we will discuss is the Health Belief Model, a

psychological model that attempts to explain and predict health behavior. Additionally, the

Health Belief Model is used in evaluating health-behavior interventions by concentrating on the

beliefs and attitudes of a certain individual. It contains six different constructs: perceived

susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action, and lastly

self efficacy.
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Perceived susceptibility is an individuals judgment on whether or not they are at risk if

they do not choose to perform a particular health behavior. Perceived severity relates to an

individuals belief about the seriousness of not using the behavior, as well as how common it is

and how it can possibly affect their health. The perceived benefits refer to the individuals belief

that by performing a certain health behavior when needed will benefit them in the long run. The

perceived barriers form the potentially negative aspects of using the health behavior and why

they are unable to perform that behavior. Cues to action can be external cues, such as

advertisements or internal cues, such as pain. Lastly, self-efficacy relates to an individuals

confidence that they can actually successfully perform the health behavior and recognize all the

benefits associated with that behavior.

The next model we will examine is the Transtheoretical Model. This model assesses an

individuals willingness to undertake a new health behavior or quit the unhealthy behavior. It

offers processes of change that guide the individual through the stages of change. If successful, it

will result in action and maintenance. The Transtheoretical Model is comprised of four

constructs, which include the stages of change, decisional balance, self-efficacy, and processes of

change. The stages of change are then broken down into six different parts, known as

precontemplation, contemplation, preparation, action, maintenance, and termination.

Precontemplation is when an individual has no intention, thought, or plan to change the

behavior in the near future. They are often unaware that their behavior is a problem or may not

have much knowledge about the unhealthy behavior. Precontemplators are not intending to

change the behavior within the next six months. Contemplation is when an individual is aware

that a problem exists and is seriously taking into consideration changing the behavior but has not

made any commitments to performing that action. Individuals in this stage begin by weighing
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out the pros and cons of the behavior change and understanding behavioral conditions that

followed in a previous unsuccessful attempt to change. They know what they need to change but

are not fully prepared to. Individuals in this stage also state they are seriously thinking of

changing the behavior in the following six months. Preparation is the stage where a person

intends to take action in changing the behavior within the next month. In the action stage an

individual is finally able to successfully alter and perform the behavior for up to six months. In

the maintenance stage the person is working to avoid relapse and strengthen the achievements

made during the action. They consistently maintain the change for at least six months to an

indefinite period past the initial action. In the final stage, the termination stage, the behavior has

truly been eliminated and is no longer present in an individuals behavior at all.

Decisional balance is based on weighing the pros and cons of a certain behavior. This

also includes considering the pros and cons of modifying the behavior (Janie and Mann, 1977).

The pros consist of the benefits of changing, while the cons involve the costs of change. Self-

efficacy refers to ones confidence in ones ability to perform a given behavior (Bandura, 1977).

One can engage in the healthy behavior across various situations that are challenging. The fourth

construct, processes of change, refers to any activity that you introduce to aid in altering the

behavior.

The last theory we will discuss is the Theory of Planned Behavior. This theory provides

the framework about the association between attitudes and behavior. The key

component to this model is behavioral intent; behavioral intentions are influenced by the attitude

about the likelihood that the behavior will have the expected outcome and the subjective

evaluation of the risks and benefits of that outcome (Boston University of Public Health, 2013).

It attempts to predict an individuals intentions to participate in a certain behavior, as well as

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recognize motivational influences on behavior. The Theory of Planned Behavior claims that

behavioral success depends on both motivation (intention) and ability (behavioral control)

(Boston University of Public Health, 2013). There are six constructs to this theory that together

characterize an individuals control over a behavior. These include behavioral intention, attitudes,

subjective norms, social norms, perceived power, and perceived behavioral control.

Behavioral intention refers to the factors that motivate and influence a particular behavior

where the stronger the intention to perform the behavior, results in more success in performing

the behavior (Boston University of Public Health, 2013). The more motivated a person is, the

more likely they will be willing to engage in the behavior. Attitudes refer to the degree to which

a person has a positive or negative assessment of the behavior of interest (Boston University of

Public Health, 2013). It takes into account the consequences of performing the behavior and the

evaluation of them. Subjective norms relate to an individuals perception of whether or not

people supports or dont support the behavior. It particularly refers to a persons thoughts about

if their peers agree and approve of them engaging in the behavior. Social norms focus more on a

larger cultural society rather than just a certain group of people. It refers to how society

identifies a behavior. Perceived power refers to the perceived existence of factors that can

possibly encourage or inhibit an individual to perform a behavior (Boston University of Public

Health, 2013). The last construct is perceived behavioral control, which refers to an

individuals insight of whether engaging in the behavior will result in ease or hardship.

Depending on the situation, perceived behavioral control could vary which results in an

individual experiencing different views of behavioral control.

Now we will examine how each theory is applied to the health behavior of receiving

influenza vaccines that was discussed. Doctors from the National Institutes of Health conducted
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a study that investigated participants perception of the influenza virus and identified factors that

impacted intention to receive the influenza vaccine (Gatewood et al., 2012). The objectives of

this study were to: assess each participant perceptions and attitudes about the severity,

susceptibility, and risk of the influenza virus and vaccine, evaluate their perceived benefits and

barriers to the vaccination, identify their cues to action, and determine the relationship between

demographic and attitudinal variables and participants intention to receive the influenza

vaccination (Gatewood et al., 2012).

The doctors performed a cross-sectional descriptive analysis to conduct their study by

providing a thirty-six item questionnaire based on the Health Belief Model to individuals at

Ukrops Super Market, Inc. in Central Virginia area and at Virginia Commonwealth University

(VCU), Monroe Park Academic Campus, Richmond, Virginia. It contained twenty-seven

questions based upon the Health Belief Model, three questions about participants intentions to

receive the vaccine and intention to vaccinate their child, if applicable, and six demographic

questions.

Ukrops pharmacists, student pharmacists, and pharmacy technicians invited Ukrops

patron to participate in the survey while they were picking up or dropping off their prescriptions

or receiving their influenza vaccination. Patrons who agreed to answer the questionnaire were

asked to fill out the survey and return their completed questionnaire to the pharmacy staff.

Similarly, the researchers and student pharmacists at VCU administered the questionnaire to the

students who agreed to participate in the study. The total number of participants that completed

the survey was 664 individuals. The majority of the participants were patrons from Ukrop

(86.3%) as well as aged 25-64 years old (66.9%) (Gatewood et al., 2012). Approximately 69%

of participants were female (Gatewood et al., 2012).

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The results of the study using the Health Belief Model theoretical framework found that

for influenza vaccination the domains of perceived susceptibility, benefits, and barriers were

predictive of health behaviors (Gatewood et al., 2012). For perceived severity of the virus,

majority of participants agreed that if I get the influenza virus I will get sick. For perceived

susceptibility to the virus, most answered I am at risk for getting the influenza virus. For

perceived clinical barriers to vaccinations, I will have side effects from the influenza vaccine

was the most common answer. For perceived access barriers, majority said that the influenza

vaccine is expensive. Lastly, for perceived benefits of receiving the vaccine, most agreed that

if I receive the influenza vaccine, I will not get sick from the virus (Gatewood et al., 2012). In

the study perceived clinical barriers, history of influenza vaccination in the previous year, and

physician recommendations were significant predictors of intention to accept the vaccine,

whereas perceived susceptibility was not (Gatewood et al., 2012). As for the cues to action as

predictors of intention to receive the influenza vaccine results were as followed: participants

received vaccine recommendations from their physicians (28.2%), pharmacists (20.7%), and

nurses (16.1%) (Gatewood et al., 2012). Those who didnt receive a recommendation from their

physician were less likely to intend to receive the vaccine.

In another study, John and Cheney (2010) did an experiment that used results from 74

participants in eight focus groups to assess healthcare workers who did not receive influenza

vaccines in 2009-2010. They used the Transtheoretical Model as a means to explore ways to

increase the uptake of influenza vaccines among healthcare workers. Unvaccinated healthcare

workers can transmit influenza virus unknowingly to high-risk patients prior to the onset of

symptoms (CDC, 2015). Annual influenza vaccinations for healthcare workers can prevent

workers from becoming ill and may decrease morbidity and mortality among patients at high risk
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for complications (CDC, 2015). The Centers for Disease Control and Preventions Advisory

Committee on Immunization Practices (2015) has recommended healthcare worker annual

influenza vaccination to protect both healthcare workers and patients from infection.

The study was conducted in cooperation with the Rhode Island Department of Health and

local health care facilities. A survey was given to registered nurses, licensed practical nurses,

and certified nursing assistants about influenza vaccination. After conducting the study, the

researchers found that most respondents perceived influenza as a mild disease and

demonstrated a low level of concern, despite the fact that 81% had one of the high-risk

characteristics or health conditions for which CDC indicates high priority for annual influenza

vaccination and 23% worked in a healthcare setting or with children (John & Cheney, 2010).

Neither two-thirds of these healthcare workers either never had a flu shot or had not had one for

more than ten years (John & Cheney, 2010). One-third of all the participants believed the vaccine

made them sick while the final one-third were not restraint, but cited some inconvenience as

a barrier (John & Cheney, 2010). Some believed that they had become naturally immune to

influenza, while others felt that by adhering to common precautions like washing their hands,

they could avoid the virus. Lastly, 20% of respondents did not intend to get the vaccination next

year.

When applied to the Transtheoretical Model, researchers focused analysis of survey

responses on two groups: those in maintenance who represent the ideal, and those in

precontemplation who account for those least likely. Results showed that unfortunately 12% of

respondents were in the precontemplation stage and neither received vaccine in the past nor

intend to seek it in the future (John & Cheney, 2010). Individuals in the maintenance stage

comprised the largest group. When asked to comment on circumstances that might increase the
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likelihood of getting flu vaccine next year, most respondents in the maintenance stage said that

they already intended to receive the vaccine, regardless of circumstance (John & Cheney, 2010).

However, those in the precontemplation stage indicated that they would be more likely to get the

vaccine under particular circumstances (John & Cheney, 2010). Finally, researchers asked

respondents to evaluate the vaccine in relation other preventatives, such as good hygiene.

Precontemplators were more likely than those in the maintenance stage to agree that natural

immunity and taking good care of myself were preferable to getting vaccine (John & Cheney,

2010).

The last study I am going to talk about utilizes the Theory of Planned Behavior. This

study was conducted by Myers and Goodwin (2011) and aimed to predict intention to receive a

influenza vaccination in an adult population in the UK. The Theory of Planned Behavior

provided the theoretical framework for this study. Three hundred and sixty two adults from the

UK completed a questionnaire that investigated intention to receive influenza vaccination. Data

was then collected and the Theory of Planned Behavior predicted 60% of adults intention to

have get the vaccination with attitude, subjective norm, perceived control, anticipating feelings

of regret, intention to have a seasonal vaccine this year, one perceived barrier, and two perceived

benefits, being significant predictors of intention (Myers & Goodwin, 2011). The respondents

perceived barrier was I cant be bothered to get the influenza vaccination, while the two

perceived benefits were vaccination decreases my chances of getting the virus or its

complications and if I get vaccinated for influenza, I will decrease the frequency of having to

consult my doctor (Myers & Goodwin, 2011).

Influenza has been and continues to be a very contagious disease that result in a number

of serious health complications and even death. The extent and severity of influenza varies by
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different factors discussed in this paper. Widespread illness can be greatly prevented by simply

getting an annual vaccination. Not only are you protecting your health, but you are also reducing

the chance of transmitting to another individual. Increasing a persons self-efficacy will not only

increase the likelihood of them choosing to get vaccinated, but also will improve their health as

well as those in their community. The theories and models presented in this paper discussed the

ways to increase influenza vaccine uptake so that each individual can live a healthier life.

Through the different studies mentioned, the Health Belief Model, the Transtheoretical Model,

and the Theory of Planned Behavior can successfully explain, predict, or modify this health

behavior.
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References

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http://scholarworks.waldenu.edu/cgi/viewcontent.cgi?article=2556&context=dissertations