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Title

PredictingintentiontouptakeH1N1influenzavaccineinauniversitysample.ClaireByrne1,JaneWalsh1,SusannaKola2,andKiranSarma1*

1SchoolofPsychology,NUIGalway,RepuplicofIreland2DepartmentofBehaviouralandSocialSciences,UniversityofHuddersfield,UKCorrespondingauthor:DrKiranSarma,SchoolofPsychology,NUIGalway,RepublicofIrelandEmail:kiran.sarma@nuigalway.ie

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Abstract

Objective:GlobalpandemicH1N1wasatypicalofinfluenzainthatitwas

associatedwithhighsymptomseverityamongyoungadults.Highereducation

institutionswerethereforeunderstandablyconcernedaboutthepotentialfor

highinfectionratesamongstudents.Thisstudyexaminedintentiontouptake

H1N1vaccinebetweenNovemberandDecember2009,whentheviruswas

classifiedbytheWHOasbeinginthepandemicphase.

Design:Across‐sectionalsurveydesignwasemployed.

Method:Two‐hundreduniversitystudentscompletedaquestionnairebattery

comprisedofhealth,belief/attitudes,andbehaviouralintentionmeasures.

Results:Findingssuggestedthatnon‐intentiontovaccinateisassociatedwitha

strongdisbeliefinitsefficacy,innegativeattitudestowardsvaccinations,andin

lackofperceivedthreat,whichisunderscoredbyadisinterestinothers’

opinions,includingauthoritativebodies.Findingsalsosuggestedthatthereis

resistancetotheideaofvaccinationsbeingmandatory.

Conclusions:Vaccinationintentisinsomewaylinkedtoarangeofattitudesand

beliefs.Theimplicationforhealthpractitionersisthatbehaviourintentmaybe

opentoinfluencewherepsycho‐educationcancreatepro‐vaccineattitudesand

beliefs.

Keywords:H1N1,HBM,swineinfluenza,TPB,vaccination.

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1.Introduction

Influenzaisamajorpublichealthchallenge,affecting5‐30percentoftheglobal

populationeachyear(WHO,2003).TheWorldHealthOrganisation(WHO)

estimatesthatannualinfluenzaepidemicscausebetweenthreeandfivemillion

casesofsevereillnessworldwide,andpotentiallyhalfamilliondeaths(WHO,

2009).OnJune11,2009WHOdeclaredaphase6pandemicalertforinfluenzaA

(H1N1),commonlyreferredtoas‘swineflu’,anovelrecombinantofpreviously

identifiedviruses.H1N1wasatypicalofinfluenzainthatitdisproportionately

impactedthoseundertheageof35.Bymid‐September2009H1N1hadspreadto

over70countrieswith500,000confirmedcasesandinexcessof3,000deaths

(Girard,Tam,Assossou,&Kieny,2010).

TheglobalresponsetoH1N1wastointroduceimmunisation

programmes.IntheRepublicofIrelandvaccineswereinitiallymadeavailableto

keytargetgroups(October‐December2009)andlaterthebroaderpopulation

(early2010).ByAugust10th,2010,whentheWHOdeclaredH1N1tobeinpost‐

pandemicphase,morethan1000peoplehadbeenhospitalisedsufferingfrom

H1N1‐relatedcomplicationsintheRepublicofIreland,100hadbeentreatedin

intensivecareunits(ICUs)and27deathshadbeenrecorded(Departmentof

HealthandChildren,2010).EightypercentofallcasesrecordedbytheHealth

ProtectionSurveillanceCentre(HPSC)herewereamongthoseundertheageof

35.

Thesuccessofimmunisationprogrammesismoderatedbythelevelof

vaccineuptakeinthepopulation,andthusconsiderableefforthasbeeninvested

ininvestigatingfactorsthatinfluenceandpredictintentiontouptakevaccines.A

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numberofsocialcognitivetheorieshavebeenappliedtothisbehaviourinthe

past,inparticulartheTheoryofPlannedBehaviour(TPB)(Ajzen,1985)andthe

HealthBeliefModel(HBM)(Becker,1974;Becker&Rosenstock,1987).TheTPB

isanextensivelyappliedhealthpsychologymodelandpostulatesthatthemost

immediatedeterminantofaperson’sbehaviouris‘behaviouralintent’.Although

ithasbeensuccessfullyappliedtomanyhealthbehavioursinthepast(e.g.

Hagger,Chatzisarantis,&Biddle,2001;Mason&White,2008),recentresearch

onintentionstovaccinateagainstinfluenzarevealedthattheonlyTPBvariable

thatsignificantlypredictedintentiontovaccinatewassubjectivenorm,

explaining48%ofthevarianceinintention(Gallagher&Povey,2006).

TheHBMhasbeenappliedinmanycontextsincludingresponsetoillness

symptoms,preventivescreening,andobtainingvaccinations(Becker&

Rosenstock,1987;Chen,Fox,Cantrell,Stockdale,&Kagawa‐Singer,2007;deWit,

Vet,Schutten,&vanSteenbergen,2005;Harrison,Mullen,&Green,1992;Lewis

&Marlow,1997;Stretcher&Rosenstock,1997;Umeh&Rogan‐Gibson,2001;

Weinsteinetal.,2007).TheunderlyingconceptoftheHBMisthatbeliefsabouta

disease,andstrategiestoreduceitsoccurrence,determinehealthbehaviour.The

HBMcontainsfourmaincomponents:perceivedsusceptibilityto,andperceived

severityofadisease;andperceivedbarriersandperceivedbenefitsof

preventativestrategies(e.g.vaccinating)againstadisease.

Zijtregtopetal.recentlyexaminedintentiontouptakevaccinationfora

pre‐pandemicinfluenza(‘avianflu’;H5N1)inanationalsamplefromthe

Netherlands(Zijtregtopetal.,2010).Thestudyoutcomeswereanintentionto

vaccinate‘iftherewasapandemic’or‘atthemoment’ifrequestedbythe

government–bothhypotheticalscenarios.Theresearchwasheavilyinfluenced

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bytheHBM.Coincidentallythetimeofsurveyadministration(April2009)

coincidedwiththeWHOpre‐pandemicalertforH1N1.Of508respondents,34.5

percentreportedanegativeintentiontovaccinate.Negativeintentionwas

significantlyassociatedwithlow:perceivedriskofinfection;riskofdeathif

infected;certaintythatvaccinationwillprotectagainstfutureinfection;

perceivedriskamongthose‘close’totheparticipant;andwillingnesstoaccept

advicefromthegovernment.Being‘againstapandemicinfluenzavaccinationin

particular’wasalsoassociatedwithnegativeintent.Thesesixfactorscorrectly

classified80%ofthesample(Zijtregtopetal.,2010).

Thepresentresearchbuildsonthistheme,butdiffersinanumberof

respects.First,itexaminesintentiontouptakevaccineduringadeclared

pandemic,andattheheightofthatpandemicalert.Thisimprovesthevalidityof

findingsinthatthecross‐sectionalsnap‐shotwastakenatatimewhenmedia

campaignspromotingvaccineuptakewouldnormallybedisseminated.

Second,theoutcomevariable,intentiontovaccinate,wasnot

hypothetical.TheIrishgovernmentwasactivelypromotingvaccinationfrom

H1N1andparticipantswereaskedabouttheiractualbehaviouralintentrather

thanpresentinga‘whatif’scenario.

Third,thestudydealswithaspecificat‐riskgroup,universitystudents,

whoareatriskofinfluenzaduetolife‐style,mobility,andsocialinteraction

(Henrich&Holmes,2009;Van,McLaws,Crimmins,MacIntyre,&Seale,2010),

butwereofparticularconcerngiventheclinicalpatternofH1N1.

Fourth,itincludesadditionalvariablesofinterest,includingself‐efficacy,

conscientiousness,comparativeoptimismandtrust‐in‐authoritieswhichhave

beenassociatedwithhealthdecisionmakingelsewhere(Anderson&Tverdova,

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2001;Bogg&Roberts,2004;Colgrove&Bayer,2005;Friedmanetal.,1995;

Goodwin&Freidman,2006;Jerusalem&Schwarzer,1992;Raynor&Levine,

2005;Walton&Roberts,2004;Wilson,Schneider,Arnold,Bienias,&Bennett,

2007).Trustinauthorities,ameasureoftheperceivedtrustworthinessofthe

Governmentanditsagents,wasincludedspeculativelyastheRepublicofIreland

wasinaperiodofeconomicdeclineandincreasedpublicdissatisfactionwiththe

Government.Trustinauthoritiesmaybeassociatedwithawillingnessto

vaccinatewhenrecommendedtodosobytheState.Self‐efficacyhasbeenshown

topredictawiderangeofhealthbehavioursincludingweightcontrol,

contraception,smokingandexerciseandresearchsuggeststhatinterventions

targetingself‐efficacycanhaveanimpactonbehaviourchange(Strecher,

McEvoyDeVellis,Becker&Rosenstock,1986).

Optimisticbias,inthecontextofhealthbehaviour,referstoabeliefthat

thechanceofexperiencinganillnessislowerforoneselfthanothers.Itis

believedthatthebiasinfluencesmotivationtoengageinpreventativehealth

behavioursandhasbeenshowntopredictperceivedsusceptibilitytoarangeof

illnesses(forareviewseeHelweg‐Larsen&Shepperd,2001).Conscientiousness

wasmeasuredasthereisaconsiderablebodyofliteraturesuggestingthatthe

trait,andrelatedtraits,arerelatedtolongevityandthishasbeensupportedbya

meta‐analysisinthearea(Bogg&Roberts,2004).

Basedontheliteraturecitedearlier(Gallagher&Povey,2006;Zijtregtop

etal.,2010),weexaminedthepredictiveutilityofhealthbeliefvariables

(susceptibility,severity,barrierstovaccinationandbenefitsofprevention),and

exploredtheadditionalvalueofincludingsubjectivesocialnormsrelatingto

vaccination(Gallagher&Povey,2006).Wehypothesisedthatmeasuresof

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individualdifference(conscientiousnessandoptimismbias)andtheHBM

variableswouldbesignificantpredictorsofbehaviouralintent,andthat

subjectivesocialnorms,wouldaddadditionalexplanatoryvaluetotheinitial

model.

2.Method

2.1.Designandparticipants

Asampleof200students(142femalesand58males)in3rdlevel

educationattheNationalUniversityofIrelandGalwayservedasstudy

participantsinthiscross‐sectionalsurvey.Allparticipantswereundertakingthe

firstsemesterofanundergraduateprogramandstudentswererecruitedfrom

generalartsandhealth‐relatedstudies(medicine,occupationaltherapyand

speechandlanguagetherapy)inordertoachievearepresentativesample.The

questionnairewasself‐administeredingroups.

2.2.Materialsandmeasures

The106‐itemquestionnaireincorporatedelementsoftheprotocolused

byZijtregtopetal.(2010)andassessedbehaviouraldeterminantsofintentionto

vaccinatebasedoncomponentsoftheHBMandotherrelevantvariablesof

interest,detailsofwhichareprovidedbelow.

2.3.Outcomemeasure

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TheprimaryoutcomewastheintentiontobeimmunisedagainstH1N1

whichwasmeasuredbyasingleitem;“Ifthegovernmentrequestsallstudentsto

havetheswine’fluvaccination(SFV),wouldyoutakethevaccinationwhenmade

available?”.Respondentshadthechoicetoreplyyes,no,ordon’tknow.Priorto

completingtheitemsrelatingtoinfluenza,thequestionnairedescribedH1N1as

‘anewstrainof‘flu(swineinfluenza)whichisknowntobepandemic,i.e.ithas

spreadthroughouttheworld’.

Healthstatus(medicaldeterminant)wasmeasuredusingtheHealth

ServiceExecutive’s(HSE)listofat‐riskpopulationsforH1N1.Thelistcomprised

10itemsincludinglong‐termlungdisease,diabetes,andimmuno‐suppression,

whererepliesofyesornoindicatedapositiveornegativepresenceofachronic

illness.

TrustinAuthoritieswasmeasuredusingitemsthataddressedtrustinthe

governmentandintheHealthServiceExecutive(HSE)inproviding“thebest

possibleadviceregardingmyhealth”.Participantsreportedtheiragreement

withthestatementonascalefrom0to100,andameanofthetwoitemswas

usedasameasureof‘trust’.

ComparativeoptimismwasmeasuredusingHarrisandMiddleton’s14‐

itemscale(Harris&Middleton,1994)toassesstheperceivedlikelihoodof

contracting,incomparisontoanotherperson,14medicalconditions.

Participantsratedeachpotentialhealthproblemonafive‐pointlikert‐scalefrom

muchmorelikely(1),tomuchlesslikely(5).Themeanofeachrespondent’s

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fifteenratingswasthentakenasameasureofgeneralizedcomparativeoptimism

relatingtoperceivedhealththreats,withahigherscoreindicatinggreater

optimism.

Conscientiousnesswasevaluatedusinga48‐itemsubscalefromthe

RevisedNEOPersonalityInventory(Costa&McCrae,1992).Responseoptions

werescoredonafive‐pointlikertscalerangingfromstronglyagree(5)to

stronglydisagree(1),withreversedscoringwhereappropriate.Ahigherscore

indicatesgreaterlevelsofconscientiousness.

Self‐efficacywasassessedbytheGeneralisedSelf‐EfficacyScale

(Jerusalem&Schwarzer,1992)comprising10itemsreflectinganindividual’s

generalizedself‐efficacybeliefs.Statementswerepositivelyphrasedsuggesting

goodcopingabilities(e.g.,“Itiseasyformetosticktomyaimsandaccomplish

mygoals”).Respondentsratedstatementswithscoresrangingfromnottrueat

all(1)toexactlytrue(4).Ahigherscoreindicatesgreaterlevelsofself‐beliefin

abilitytocopewithavarietyofdifficultdemandsinlife.

QuestionspertainingtothecomponentsfromtheHBMwerebasedon

previousinfluenzaresearch(Zijtregtopetal.,2010),andadditionalvariables

measuringattitudesandsocialinfluencewerealsoadoptedfromthissourceand

adaptedtorelatetoH1N1.Themeasuresareasfollows:

ThePerceivedbenefitsofvaccinationwereassessedbythreeitems–not

contractingH1N1ifvaccinated;enduringlessseveresymptomsifcontracted;

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andnotinfectingothers.Responseswereonafive‐pointlikertscaleranging

fromstronglyagree(5)tostronglydisagree(1).Ahigherscoreindicatesgreater

perceivedbenefitsofbeingimmunised.

Perceivedsusceptibilitywasmeasuredwithtwoitemsthatprobed

perceivedriskofcontractingH1N1andriskofotherscatchingH1N1.The

responseformatwasafive‐pointlikertscalefromstronglyagree(5)tostrongly

disagree(1).Ahigherscoreindicatesgreaterperceivedsusceptibilitytoswine

flu.

Perceivedseveritypertainedtothedangersperceivedbytherespondentif

theyweretocontractH1N1,andincludeddangertoself,toothers,riskof

infectingothers,andriskofdying.Answersweregivenonafive‐pointlikert

scalerangingfromstronglyagree(5)tostronglydisagree(1)forquestionswitha

positiveoutcomeforintentiontovaccinate,withreversescoringforquestions

withanegativeoutcome.Ahigherscoreindicatesgreaterperceivedseverityof

H1N1.

Perceivedbarrierstowardsintentiontovaccinateweremeasuredbythree

items,andresponsesweregivenonafive‐pointlikertscalerangingfrom

stronglyagree(5)tostronglydisagree(1).Barriersincludedbeingagainst

vaccinationingeneral,H1N1vaccinationinparticular,andabeliefthatswine’flu

vaccination(SFV)cancauseH1N1.Ascodedduringanalyses,ahigherscore

indicatesgreaterperceivedbarrierstowardsbeingimmunisedagainstH1N1.

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Attitudeswereevaluatedbyaskingparticipantstorespondtosixitems

whichincludedsocialandpersonalbeliefs(e.g.‘IcanprotectmyselfagainstSF

bytakingSFV’;‘ItisimportanttofollowtheadviceofthegovernmentaboutSFV’;

and‘IfpeopleinmyenvironmentgetvaccinatedagainstSF,itisunnecessaryfor

metogetavaccination’).Responsesweremeasuredonafive‐pointlikertscale

rangingfromstronglyagree(5)tostronglydisagree(1).Ascodedhere,ahigher

scoreindicatesmorepositiveattitudestowardsimmunisationagainstH1N1.

Socialinfluenceswereindicatorsoftheimportanceofothersandtheir

opinions,andparticipantswereaskedtorespondtothreeitemsonafive‐point

likertscalerangingfromstronglyagree(5)tostronglydisagree(1).Social

influencesweremeasuredbyusingthestem‘Itisimportanttofollowtheadvice

of….’andincludedarangeofsignificantothers,namelytrustedauthorities

(governmentanddoctor),andfamilyandfriends.Ahigherscoreindicates

greatersocialinfluence.

2.4.Procedure

Participantswereprovidedwithadocumentexplainingthenatureand

intentionoftheresearchasexaminingpsychologicalpredictorsofhealth

behaviouramonguniversitystudents.Subsequentlytheycompletedaninformed

consentdocumentandcompletedthequestionnairebattery.Participationinthe

researchwasvoluntaryandstudentswerenotrequiredtoparticipateaspartof

theirprogrammeofstudy.

2.5.Statisticalanalysis

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DatawereanalysedusingSPSSforwindows(version17).Median

differencesinbehaviouraldeterminantsbasedonsplitsontheoutcomemeasure

wereanalysedusingKruskal‐Wallis,associationsbetweenintentionand

categoricalvariableswereanalysedusingChi‐Square.Logisticregressionwas

performedtoassesstheimpactofthebehaviouraldeterminantsonintentionto

bevaccinated.

3.Results

3.1.Group‐basedcomparisons

One‐hundredandtwentyseven(63.5%)respondentsindicatedthatthey

intendedtobeimmunised(yesgroup)ifthegovernmentrequestedallstudents

tohavetheswine’fluvaccination.Thirty‐five(17.5%)didnotintendtovaccinate

(nogroup)and36(18%)saidtheydidnotknow(don’tknowgroup).Eight(4%)

respondentspurportednottohaveheardofswine’flu,and190(96%)saidthey

had.Onehundredandtwenty(65%)reportedthattheyknewsomeoneintheir

environmentwhohadhadswine’flu.

Forty‐onerespondents(29=yesgroup,8=nogroup,4=don’tknow

group)listedthemselvesintheat‐riskcategoriesasdelineatedbytheHSE

representing20.5percentofthesample.Twenty‐eightofthese(68%)suffered

long‐termlungdisease(asthma),whilepregnancy,immunosuppression,

haemoglobinopathies,morbidobesity,andlong‐termheart,kidney,liverand

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neurologicaldiseaseseachaccountedforlessthatonepercent.Themajorityof

people(71%)whoself‐reportedthemselvesas‘at‐risk’intendedtovaccinate.

Themeans,standarddeviations,andCronbachforpredictorvariables

areprovidedinTable1.Nodifferencesacrossgroupsemergedforlevelsof

conscientiousness,self‐efficacy,optimism,severityandsusceptibility.

Differencesdidemergeforattitudes(H(2)=69.84,p<.0005),perceivedbarriers

(H(2)=46.64,p<.0005),externalsocialinfluence(H(2)=27.06,p<.0005)and

perceivedbenefits(H(2)=6.12,p<.05).Post‐hoctestsindicatedthattheno

group(M=15.81,SD=2.83)expressedsignificantlylesspositiveattitudes

towardstheintentiontovaccinatethanboththeyesgroup(M=21.53,SD=2.99,

U=336,z=‐7.261,p<.005,r=‐.58)andthedon’tknowgroup(M=18.18,SD=

2.71,U=302,z=‐3.123,p=.002,r=‐.39).Significantdifferenceswerealso

foundbetweenthosewhosaidyesanddon’tknow(U=865.5,z=‐5.281,p<.005,

r=‐.42).Barrierswererevealedtobesignificantlyhigherinthenogroup(M=

9.19,SD=2.67)thantheyesgroup(M=5.88,SD=1.95,U=609.5,z=‐6.087,p<

.005,r=‐.49)andthedon’tknowgroup(M=7.47,SD=1.67,U=297,z=‐3.204,

p=.001,r=‐.40).Thedon’tknowgroupalsoperceivedmorebarriersto

vaccinationthantheyesgroup(U=1164.5,z=‐4.039,p<.001,r=‐.32).Social

influencehadalesserimpactonthenogroup(M=8.60,SD=2.87)thanthose

whointendedtovaccinate(M=11.3,SD=1.69,U=967.5,z=‐5.079,p<.001,r=

‐.40)andthedon’tknowgroup(M=10.94,SD=1.64,U=326.5,z=‐3.536,p<

.001,r=‐.42).Benefitsperceivedbythenogroup(M=8.21,SD=2.23)andthe

yesgroup(M=9.36,SD=2.13,U=1558,z=‐2.408,p=.016,r=‐.19)werejustat

significancelevels.

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Age,however,variedwithintentiontovaccinate(H(2)=8.3,p<.05),and

Mann‐Whitneyposthoctestswereusedtofollowupthisfinding,witha

Bonferronicorrectionapplied.Theyrevealedthatthenogrouphadtheoldest

profile(M=23.60,SD=8.27),withsignificantdifferencesbetweenboththem

andtheyesgroup(M=20.45,SD=6.33,U=1555,z=‐2.832,p=.005,r=‐.22)

andthedon’tknowgroup(U=422.5,z=‐2.446,p=.014,r=‐.29)whowerethe

youngest(M=19,SD=2.19).Achi‐squareanalysisrevealednoassociation

betweengenderandintentiontovaccinate(χ2(2)=.33,p>.05).Trustin

authoritieswasalsonon‐significant.

3.2.Correlationanalyses

Subsequentanalysiswasrestrictedtothosewhodointendanddonot

intendtovaccinate.‘Don’tknows’wereexcludedfromtheanalyses.Biserial

correlationswereconductedforintentionagainstallthepredictorsduetothe

dichotomousnatureofthedependentvariable(Table2).Allothercorrelations

conductedwereSpearman’srho.Multicollinearitydiagnosticsrevealednostrong

relationshipsbetweenthepredictorvariables(r<.9).VIF(<10)andtolerance

(>.1)valueswerealsoadequate(Howitt&Cramer,2008).Zero‐order

correlationswithintentionarereportedamonggender,trustintheauthorities,

optimism,conscientiousness,self‐efficacy,andsomecomponentsoftheHBM.

Age(rpb=‐.22),attitude(rpb=.58),socialinfluence(rpb=.41),andperceived

barriers(rpb=.49)weresignificantlycorrelatedwithintentionatp<.01,and

perceivedbenefits(rpb=.19)atp<.05.

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Logisticregressionwasperformedwithintentiontovaccinate(yes/no)as

criterionandthestatisticallysignificantcorrelatesofintention(age,barriers,

benefits,attitudesandsocialinfluence)aspredictors(Table3).Variableswere

enteredinblocks,withageinblock1,perceivedbarriersandperceivebenefits

(HBM)inblock2,andsocialinfluenceandattitudesinblock3.At‘block0’the

analysisassumedthefullsampleintendedtovaccinate,meaningthatatbaseline

themodelcorrectlyidentifiedallthosewhointendtovaccinate(100%),but

noneofthosewhodidnotintendtovaccinate(0%).Addingageintotheanalysis

atblock1increasedthespecificityofthemodel,correctlypredicting6.7percent

ofthosewhodidnotintendtovaccinate,and97.5percentofthosewhodid,and

79.1percentofallcases.Addingperceivedbarriersandperceivedbenefitsin

block2enabledthemodeltocorrectlyidentify40.0percentofthosewhodidnot

intendtovaccinate,and94.9percentofthosewhodid(overall83.8percentof

casescorrectlyidentified).Finally,addingsocialinfluenceandattitudesledtoa

modelcorrectlyidentifying73.3percentofnon‐intenders,and96.6percentof

thosewhodidintendtovaccinate(overall91.9%).

Eachstageoftheanalysiswasstatisticallysignificantandsummary

resultsarepresentedinTable3.Thefullmodelcontainingallthepredictorswas

statisticallysignificant2(5)=83.28,p<.0005,indicatingthatthemodelcould

distinguishbetweenthosewhohadanegativeintentiontovaccinateandthose

whointendedtovaccinate.Themodelasawholeshowedgoodpredictiveutility,

correctlyclassifying91.9percentofcases,andexplainingbetween43percent

(CoxandSnellR2=.43)and68percent(NagelkerkeR2=.68)ofthevariancefor

anegative‐intentiontovaccinate.Inthefinalblockonlytwoofthepredictor

variables,attitudes(Wald=16.6,p<.00051.89)andbarriers(Wald=7.68,p<

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.01),emergedassignificantpredictors,althoughagehadbeensignificantin

block1(Wald=7.04,p<.005).

Subsequentanalysesofthebarrierandattitudevariables(Table4)

showedthatsignificantlygreaterdoubtsareexpressedbythenogroupastothe

efficacyofvaccinations,andinparticulartowardstheH1N1vaccine.Incontrast,

theyesgroupdisplayedgreaterpositiveattitudestowardthevaccinationissue.

Itisalsoimportanttonotethatinpreliminaryanalysisthatexcluded

‘attitudes’fromtheregression,socialinfluencewasasignificantcontributorto

themodel(Wald=5.14,p=.023),whichmaysuggestthat‘attitudes’occludedthe

importanceofsocialinfluenceinthemodelreportedhere.Thisisconsideredin

greaterdetaillaterinthispaper.

4.Discussion

Theresearchidentifiedanumberofimportantaspectsofthevaccination

climateintheRepublicofIrelandatatimewheninfectionwasatpeaklevelsand

theauthoritieswereengagedinintensivepublichealthcampaignstopromote

uptake.Inthisclimate,64percentofuniversitystudentsinoursamplereported

anintentiontohavethevaccination.IntheOctober‐Decemberadministration

window,peopleweredyinginIrelandfromH1N1,theviruswasinpandemic

stage,studentswereaspecificat‐riskpopulation,andtheauthoritieswere

heavilyinvestedinpublichealthcampaignseducatingaudiencesabouttherisks

ofH1N1andtheimportanceofvaccination.Thefindingwouldsuggestthatthis

campaignwasworkingforalargeproportionofthestudentpopulation.

Eighteenpercentofoursampledidnotintendtotakeupthevaccination.

ThisisconsiderablylowerthanthatreportedintheDutchstudyreviewed

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earlier(Zijtregtopetal.,2010)probingvaccinationintentforH5N1avianflu,

where34.5percentofthepopulationsamplereportedthattheywouldnotbe

vaccinated.Thisdiscordancecanbeexplained,atleastinpart,bythefactthatthe

Dutchfigurewasforpre‐pandemicinfluenzaandbydifferencesinsample

designs.Furthermore,theDutchstudyposedahypotheticalquestionwhere

respondentswereaskediftheywouldtakethevaccinationifaskedbythe

authorities.Inourstudy,vaccinationforH1N1wasavailableandtheauthorities

intendedtovaccinatethepopulation.

Thesecondimportantfindinghereisthatadistinctprofileemergedfor

thosewhodidnotintendtovaccinate.Incomparisontothosewhointendedto

vaccinate,thosewhodidnotreportedsignificantlyfewerpositiveattitudes

towardsvaccination(largeeffectsize),greaterperceivedbarrierstovaccination

(mediumeffectsize),werelessinfluencedbyexternalinfluences(GPandfamily

andfriends)encouragingvaccination(mediumeffectsize)andperceivedless

benefitsofvaccination(smalleffectsize).Thisgroupwasalsosignificantlyolder

thatthosewhointendtovaccinate(smalleffectsize).

Lookingspecificallyatcomponentsofthesebehaviouraldeterminants,a

numberofitemsemergedasbeingimportant.Incontrasttothosewhointended

tovaccinate,thosewhodidnotreportedgreateroppositiontovaccinationsin

general,andalsospecificallytoH1N1vaccination.Conversely,thosewho

intendedtovaccinatereportedastrongerbeliefthatvaccinationforH1N1

protectsagainsttheinfectionandthatvaccinationshouldbemandatory.Thisis

inlinewithresearchsuggestingthatwhereimmunizationprogrammesare

obligatory,thereisagreateruptakeinvaccinations(Colgrove&Bayer,2005).

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Ofparticularinteresttohealthpromotionpractitioners,thosewho

intendedtovaccinatereportedhigherlevelsofpro‐vaccineattitudesamongtheir

GPsandclose‘others’thanthosewhodidnotintendtovaccinate,potentially

pointingtowardsanimportantsocialinfluencemechanisminvaccinebehaviour.

Thesefindingsareofgreatimportanceastheypointtowardsapossible

causallinkbetweenattitudesandbehaviour.Whiletheoriginsoftheseattitudes

needfurtherexploration,theyarelikelytobemanifestationsofprevious

knowledgegarneredfrompastexperience,peers,authoritativebodies,andthe

media(Jewell,2001;Zajonc,1984).Thereisscopehereforfurtherinvestigation

toelucidatehowsuchabeliefbecomesestablishedandwhetherornotthe

findingsholdforanationallyrepresentativesample.Thisinvestigationshould

includevariablesthatmorecloselymapontotheTheoryofPlannedBehaviour

(TPB).

Inapredictivemodelcontainingbehaviouraldeterminantsofintention,

theperceivedbarriersandattitudestowardsvaccinationpredictedbetween43

percentand68percentofintention,inlinewithpreviousresearch(Hofmann,

Ferracin,Marsh,&Dumas,2006;Hollmeyer,Hayden,Poland,&Buchholz,2009).

Perceivedbarrierstovaccination,andabeliefthatitisimportanttoget

vaccinatedevenifthoseintheenvironmentarevaccinated,weresignificant

contributorstothemodel.Theformerfindingresonateswiththeexistent

literature,withperceivedbarrierstoactionassociatedwithcompliancewith

recommendedhealthbehaviour(Hollmeyeretal.,2009;Janz&Becker,1984;

Umeh&Rogan‐Gibson,2001),includinginoculation(Hofmannetal.,2006).

Contrarytoexpectations,perceivedbenefitsofvaccinationandsocial

influencedidnotcontributetothismodel.Thismayreflectlowinternal

19

consistencyofthe2‐itembenefitsscale(=.52)andaneedtoreconsiderhow

besttomeasureperceivedbenefit.Certainlyresearchandtheoryisstrongly

suggestiveoftheimportanceofbothbeliefsandperceivedbenefitsin

determiningbehaviourchange(Becker&Rosenstock,1987).

Theroleofsocialinfluenceislesseasilyexplained.Theitemsmeasuring

‘attitude’includedonethatrelatedto‘followingadvice’,whichpotentially

overlappedwithsocialinfluence.Moreover,thevariablessocialinfluenceand

attitudeswerestronglycorrelated(r=.63,p<.01).Thisraisesthepotentialforthe

attitudesvariabletooccludethecontributionofthesocialinfluencevariablein

theresults.Whenthelogisticregressionwasre‐runwithouttheattitudes

variable,socialinfluenceemergedasasignificantcontributor.Thishas

importantimplicationsforfutureresearch,whichshouldcarefullyconsiderhow

attitudesandsocialinfluencecanbebestmeasured.CertainlytheTheoryof

PlannedBehavior(TPB),whichensuresthatattitudesandsocialinfluencesare

measuredasdistinctconcepts,providesausefulframeworkforaddressingthis

limitationofthecurrentstudy.

Self‐efficacy,comparativeoptimismandconscientiousnesswerenon‐

significantcorrelatesofintentiontobevaccinated.Ononelevel,thesenegative

findingsmayinpartreflectthewayH1N1wasportrayedinmediacoverageof

thepandemic.Theillnesswasdescribedaseasilypreventablethrough

vaccination‐thusself‐efficacymaybelessrelevantinthisspecificdisease.

Similarly,itwasportrayedasspreadingeasilyfromoneindividualtothenext,so

evenbeliefsthatinfectionissomethingthatismorelikelytobeexperiencedby

others(optimistbias)wouldlogicallyincreasethelikelihoodofinfectionofthe

respondent.

20

Onasecondlevel,themeasuresmayhavelackedsensitivityinpredicting

intentiontovaccinate.Behaviourspecificmeasuresofself‐efficacyand

conscientiousnessmayhaveresultedinabettertestoftheimpactofthese

factorsonintendedbehaviourandthisshouldbeconsideredinfutureresearch

inthisarea.

Theresearchwouldconcludethatintentiontovaccinateislinkedto

behaviouraldeterminantsthatgobeyondonetheoreticalmodelofbehaviour.

PerceivedbarrierstowardsvaccinationemergedfromtheHBMasapredictorof

behaviourintent.‘Attitudes’alsoemergedasimportant.Whilethestudydidnot

directlytesttheTheoryofPlannedBehaviour(TPB),attitudesiscentraltothis

theoryandfutureresearchshouldprobethistheorymoredirectly.

Itisalsoimportanttonotethatthefindingsreportedherearenot

necessarilyvalidinunderstandingotherhealthbehaviours.Atthetimeof

administrationH1N1wasapotentiallyfatalillnessforuniversitystudents,the

dangerwasimmediate,andthebarrierstoimmunizationarelow(e.g.,Painteret

al.,2010).Thisisincontrasttootherillnesssuchascoronaryheartdisease,

wherepreventionrequireslong‐termcommitment(Armitage,2005),andthe

immediatesalienceofdeathbycoronaryheartdiseasemaybelow.Forsuchan

illness,perceivedbehaviouralcontrolmaybeamorepowerfulpredictorof

behaviourintent(Johnstonetal.,2004).

Theexternalvalidityofthefindingstothebroader3rdleveleducation

studentpopulationislikelytohavebeenhamperedbyamarginalunder‐

samplingforprobingapredictivemodel.Itisreassuringthatthe95%confidence

intervalsofexp(B)didnotspanacross1,butitisstillanticipatedthatalarger

samplewouldhavebeenmoresensitivetoalargerpredictivemodel.Asnoted

21

earlier,thereisalsosomeconcernabouttheitemsmeasuringperceivedbenefits

ofvaccination,andwewouldrecommendthatfuturestudiesre‐thinkhowsucha

conceptshouldbemeasured.Itwouldalsobeusefultoextendtheenquiryand

consideraffectivepredictorsofbehaviourintent,includinganticipatedregret,

whichmaybeparticularlyimportantinunderstanding,andrespondingto,those

whodonotintendtovaccinate.

Itisimportanttoreiteratethatthisstudytargetedaspecificat‐risk

population.Thematterofbroaderpopulationrepresentativenessisnotanissue,

andnoinferenceastobroaderpopulationuptaketrendsarebeingmadehere.

Wewouldnote,however,thatthesampleutilisedhere,whilebroadly

representativeofundergraduatestudentsattendingauniversityintheWestof

Ireland,isnotnecessarilyrepresentativeofthestudentpopulationnationally.

Amorepressinglimitationofthisresearchisthattheitemsusedto

measureperceivedbarriers,severityandattitudeswerebasedlargelyon

researchfromotherjurisdictions(Zijtregtopetal.,2010)andfutureresearch

shouldincludeprimaryexploratoryresearchtoensuremeasuresaresensitiveto

cultural‐specificbeliefsandattitudes.

Despitetheselimitations,itisclearthatvaccinationintentisinsomeway

linkedtoarangeofattitudesandbeliefs.Theimplicationforhealthpractitioners

isthatbehaviourintentmaybeopentoinfluencewherepsycho‐educationcan

createpro‐vaccineattitudesandbeliefs.Evenatthisearlystageitwouldbe

usefultoexposethisconclusiontoempiricaltestinginaninterventiondesign

thatteststheefficacyofspecifictypesofmessagesinchangingattitudesand

beliefsandifsuchchangeimpactsonvaccineintent.

22

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