Accepted Manuscript Pattern of exposure to information and its impacts on seasonal influenza vaccination uptake in nurses Edward Ka Hin Cheung, Sing Lee, Shui Shan Lee PII:

S0195-6701(17)30449-8

DOI:

10.1016/j.jhin.2017.08.005

Reference:

YJHIN 5194

To appear in:

Journal of Hospital Infection

Received Date: 24 June 2017 Revised Date:

0195-6701 0195-6701

Accepted Date: 6 August 2017

Please cite this article as: Cheung EKH, Lee S, Lee SS, Pattern of exposure to information and its impacts on seasonal influenza vaccination uptake in nurses, Journal of Hospital Infection (2017), doi: 10.1016/j.jhin.2017.08.005. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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Pattern of exposure to information and its impacts on seasonal influenza vaccination uptake

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in nurses

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Edward Ka Hin CHEUNGa, Sing LEEb, Shui Shan LEEa, *

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a

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Postgraduate Education Centre, Prince of Wales Hospital, Shatin, Hong Kong

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b

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Kong

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Email: [email protected], [email protected], [email protected]

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(family name capitalized)

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Stanley Ho Centre for Emerging Infectious Diseases, The Chinese University of Hong Kong, 2/F

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Department of Psychiatry, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong

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Correspondence:

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Prof. Shui Shan LEE

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Stanley Ho Centre for Emerging Infectious Diseases,

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2/F Postgraduate Education Centre, Prince of Wales Hospital, Shatin, Hong Kong

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Phone: (852) 22528812; fax: (852) 26354977

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Email: [email protected]

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Running title: Information exposure and vaccination

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ABSTRACT

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Background: Coverage of annual influenza vaccination of healthcare workers (HCWs) varies and remains

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at a sub-optimal level in many countries. As HCWs are often exposed to a variety of information on

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vaccination, their pattern of exposure may impact their decision, which deserves further investigation.

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Method: Practising nurses in Hong Kong were invited to participate in an anonymous online survey in

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February 2015, after the winter seasonal peak. The questionnaire covered demographics, work nature

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and experiences, vaccination uptake history and reasons for vaccination decisions. Two categories of

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behaviors with regards to information access were defined – (A) passive exposure to information, and (B)

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active information-seeking, as differentiated by the source, type and nature of information accessed.

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Chi-square test, Mann-Whitney U test, logistic regression were performed to compare between

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vaccinated and unvaccinated nurses.

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Results: A total of 1177 valid returns were received from nurses who had a median age of 32, of whom

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86% were female. The overall vaccination rate was 33%. Passive exposure to information from

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workplace, professional body and social network did not predict vaccination decision, while mass media

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did (OR:1.78). Active information-seeking involving consulting seniors (OR:2.46), having organized

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promotion activities (OR:2.85) and performing information search (OR:2.43) were significantly

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associated with increased vaccination uptake. Cumulative effect could be demonstrated for active

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information seeking (OR:1.86) but not passive exposure to information.

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Conclusion: Current strategy of promotions and campaigns for seasonal influenza vaccination in HCWs

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may not be effective in increasing vaccination coverage. Measures targeting information-seeking

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behaviors may serve as an alternative approach.

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Keywords: influenza; influenza vaccination; nurses; survey; exposure to information; vaccination

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intention

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BACKGROUND

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Seasonal influenza is an important public health concern. During influenza seasons, infected elderly

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people, children, pregnant women and patients with chronic illnesses are especially vulnerable to

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complications including pneumonia and myocarditis owing to their weakened immunity.1-2 At the

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community level, annual seasonal influenza vaccination is an essential measure to reduce virus

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transmission, so as to decrease subsequent morbidity and mortality.3-4 In the healthcare setting, high

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vaccination coverage among health care workers (HCWs) could help prevent nosocomial transmission in

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a cost-effective manner.5-6 This could in turn minimize the exposure of the vulnerable community to

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influenza diseases. Although many HCWs perceived seasonal influenza as a risk both for themselves and

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their patients,7 concerns of the effectiveness and safety of vaccine had led to a variable vaccination

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coverage of between 4-77% in HCWs.8-9

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Studies have shown that HCWs’ decision of vaccination is profoundly affected by behavioural factors,10-11

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as has been demonstrated in many published studies.8,12,13 Behaviour theories such as Health Belief

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Model, Theory of Planned Behaviour, Triandis’ Model of Interpersonal Behaviour and Risk Perception

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Attitude Framework were used to explain such behaviours.11,14,15 Some of the studies further integrated

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such theories into multivariate prediction models.15 Nevertheless, there is no single model that can be

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applied to all scenarios. Such prediction models may not correctly interpret observations in different

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settings due to variations of human behaviours and socioeconomic factors.14 To raise the coverage of

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seasonal influenza vaccination among HCWs, governments and health institutes often campaign for its

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importance prior to the influenza season every year. Research has shown that effectiveness of these

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promotions varies widely.16 High vaccination rates were observed in several states of United States and

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provinces of Canada that have implemented mandatory vaccinations.16-19 Worldwide implementation of

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mandatory vaccination policy however remains controversial. Knowingly, herd immunity is achieved

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when a vaccination rate of 83-94% among high risk population is reached.20 Yet vaccination coverage in

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most countries were way below the desirable rate.9 Some studies showed that misconceptions and

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myths were highly correlated with unsatisfactory uptake.21-22

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In Hong Kong, there are 2 influenza seasons each year – winter season with a peak between January and

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February, and Summer Season peaking in August or September. Free influenza vaccination is provided to

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HCWs in the public service during the months before the winter seasonal peak, which is often regarded

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as the main season. Similar to the situation in many other countries, detailed information on influenza

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vaccination is often delivered to HCWs through different channels by the government and professional

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organizations. Nevertheless, the precise impact of increasing exposure of HCWs to such information on

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their vaccination rate is not specifically known. This study has been designed to determine the latest

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seasonal influenza vaccination rate among nurses, the largest group of HCWs in Hong Kong, before the

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winter influenza season of 2015-16. Predictive factors of vaccination uptake were investigated. To fill

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the knowledge gap between information exposure and vaccination uptake, the analysis address

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specifically the relationship between the patterns of exposure to influenza information and nurses’

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decision of vaccination in preparation for the impending influenza season.

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METHOD

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The Association of Hong Kong Nursing Staff (AHKNS) is the largest professional body of nurses, which

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has a membership of around 24 000, out of 50 000 nurses registered in Hong Kong (statistics from the

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Nursing

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http://www.nchk.org.hk/en/statistics_and_lists_of_nurses/statistics/index.html Accessed 29 Dec, 2016)

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In late February 2016, invitation letters were sent to all members of AHKNS, about six months after the

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Council

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government’s launching of vaccination scheme for HCWs in anticipation of the 2015-16 winter season.

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The letters were delivered by post followed by email reminders, the latter for those with an available

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email address. Objectives and nature of the study, including the determination of vaccination rate and

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investigation of factors predicting vaccination behaviours, were explained. The QR code and website of

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an anonymous online questionnaire were included in the letter for facilitating participation in the survey.

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During the study period, promotional materials were distributed to public and private hospitals, to

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publicize the survey. The online questionnaire could be accessed by nurses over a 10-week study period.

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Taking reference of the 27.6% vaccination coverage rate in a survey conducted in the preceding year,23

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recruitment of an estimated 913 subjects would be required to obtain a result with 2.9% precision at

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95% confidence interval.

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The questionnaire was constructed in the Chinese language as most of the practising nurses in Hong

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Kong are Chinese-speaking. The questionnaire consisted of 4 parts, including 1. demographic

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characteristics (sex, age, professional qualification); 2. work nature (work institute, frequency of patient

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contact, staff rank); 3. past vaccination history and reasons for vaccination decisions and 4. information

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access. Two main categories of behaviours with regards to information access were inquired – (A)

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passive exposure to information, and (B) active information-seeking, as differentiated by the source,

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type and nature of information accessed. A total of 12 questions in the questionnaire were used for

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categorization of exposure, forming 4 items for each category. A twenty Hong Kong dollar meal coupon

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(equivalent to USD 2.56) was offered to each respondent returning a completed survey form as a

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compensation for their time for participation.

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Statistical analysis was made to compare between one’s vaccination status before the 2015-16 season

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and information-seeking behaviours. Chi-square test was used for the comparison of binary variables.

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Mann-Whitney U test was applied for the comparison of age. Univariate and multivariate logistic

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regression were performed to compare ordinal variables, adjusting for potential confounding factors

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and executing sensitivity analysis. Statistical significance was defined as p

Pattern of exposure to information and its impact on seasonal influenza vaccination uptake in nurses.

Uptake of annual influenza vaccination of healthcare workers (HCWs) varies, and remains at a suboptimal level in many countries. As HCWs are often exp...
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