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Czarina Muyargas
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
SIGNIFICANCE OF INFLUENZA VACCINES 3
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
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
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.
SIGNIFICANCE OF INFLUENZA VACCINES 4
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
confidence that they can actually successfully perform the health behavior and recognize all the
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
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
SIGNIFICANCE OF INFLUENZA VACCINES 5
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
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).
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
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
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
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
SIGNIFICANCE OF INFLUENZA VACCINES 7
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
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
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.
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%
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
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
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
SIGNIFICANCE OF INFLUENZA VACCINES 9
for complications (CDC, 2015). The Centers for Disease Control and Preventions Advisory
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.
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
SIGNIFICANCE OF INFLUENZA VACCINES 10
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
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
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
SIGNIFICANCE OF INFLUENZA VACCINES 11
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.
SIGNIFICANCE OF INFLUENZA VACCINES 12
References
Boston University of Public Health. (2013). The Theory of Planned Behavior. Retrieved from
http://sphweb.bumc.bu.edu/otlt/MPH-Modules/SB/SB721-Models/SB721-Models3.html
Centers for Disease Control and Prevention. (2015, August). ACIP Influenza Vaccine
recs/vacc-specific/flu.html
Centers for Disease Control and Prevention. (2015, October 2). Key Facts About Seasonal Flu
http://www.cdc.gov/flu/protect/keyfacts.htm
Centers for Disease Control and Prevention. (2015, September 8). Vaccine Effectiveness - How
Well Does the Flu Vaccine Work?| Seasonal Influenza (Flu) | CDC.
Gatewood, S. B. S., Coe, A. B., Moczygemba, L. R., Goode, J.-V. Kelly R., & Beckner, J. O.
(2012). The use of the health belief model to assess predictors of intent to receive the
https://www.rimed.org/medhealthri/2010-09/2010-09-281.pdf
Myers, L. B., & Goodwin, R. (2011). Determinants of adults' intention to vaccinate against
http://scholarworks.waldenu.edu/cgi/viewcontent.cgi?article=2556&context=dissertations