Vaccine 38 (2020) 7372–7378

Contents lists available at ScienceDirect

Vaccine
journal homepage: www.elsevier.com/locate/vaccine

The Health Belief Model in predicting healthcare workers’ intention for

influenza vaccine uptake in Jordan
Lana Alhalaseh ⇑, Hanan Fayoumi, Bayan Khalil
Department of Family and Community Medicine, School of Medicine, University of Jordan. Amman, Jordan

a r t i c l e i n f o a b s t r a c t

Article history: Background: Theories of health behavior change are being inadequately adopted to understand the rea-
Received 13 January 2020 sons behind low influenza vaccination rates among healthcare workers (HCWs). The Theory of Planned
Received in revised form 27 August 2020 Behavior (TPB) is being used to predict intention-behavior relationship while the Health Belief Model
Accepted 1 September 2020
(HBM) is being employed to predict actual behavior. The purpose of this study was to test a conceptual
Available online 16 September 2020
model based on the HBM’s constructs to predict Jordanian HCWs’ intentions for influenza vaccine uptake
as an alternative to the TPB.
Keywords:
Method: A cross-sectional questionnaire-based study was conducted in 2016 in a tertiary teaching hos-
Influenza vaccine
Healthcare worker/ personnel
pital in Amman-Jordan including a convenience sample of 477 HCWs with direct patient contact. The
Intention study instrument was tested for validity and reliability. A conceptual regression model was proposed
Health Belief Model incorporating the constructs of the primary HBM with some modifications in the threat construct as well
Theory of Planned Behavior as an additional variable about explicit past vaccination behavior (in the past year and/or any previous
Jordan history of influenza vaccine uptake).
Results: Almost all the constructs of the HBM demonstrated significant differences between participants
intending and those who did not intend to vaccinate against influenza. After adjusting for the confound-
ing variables in the final conceptual regression model, past vaccination behavior (OR= 4.50, 95%
Confidence Interval 3.38–6.00, P< 0.0005) and the perceived benefit scale (OR= 1.19, 95% Confidence
Interval 1.11–1.28, P< 0.0005) were the only significant predictors of intentions to vaccinate against influ-
enza in the next season.
Conclusion: Taking into consideration the altruistic beliefs of HCWs and their explicit past vaccination
history augments the utility of the original HBM tool in predicting HCWs’ intentions to vaccinate against
influenza in a way that is consistent with the predictive ability of the Theory of Planned Behavior.
Ó 2020 Elsevier Ltd. All rights reserved.

1. Introduction aggressive campaigns and interventions to promote vaccination

Annual influenza vaccination is recommended for healthcare
workers (HCWs) as they are at increased risk of exposure to influ-
enza viruses compared with the general population potentially
compromising their health and their patients’ safety [1,2].
Despite the longstanding recommendations, vaccination cover-
age among HCWs remains heterogeneous and usually suboptimal
with rates well below the minimum targets of 90% according to
‘‘The CDC’s Healthy People 2020” [3,4].
Studies investigating influenza vaccination uptake by HCWs in
relation to their knowledge, attitudes, and barriers to vaccination
have found that adequate knowledge is not the only determinant
in the decision to get vaccinated against influenza, and many
⇑ Corresponding author at: P O Box 851182 Sweifieh, 11185 Amman, Jordan.
E-mail address: l.halaseh@ju.edu.jo (L. Alhalaseh).
were marginally successful [5,6]. Consequently, behavioral psy-
chology and health behavior change theories are being explored
in an attempt to understand HCWs’ influenza vaccination behavior
and frame strategies aimed at improving vaccine uptake [7].
The theories often used in this field include the Health Belief
Model (HBM), the Theory of Planned Behavior (TPB), Risk Percep-
tion Attitude (RPA), and the Triandis Model [2,7]. The HBM, fol-
lowed by the TPB, is the most commonly employed model [7,8]. It
includes five key constructs influencing health behaviors: per-
ceived susceptibility to the health threat, perceived severity of the
health threat, perceived benefits associated with the behavior, per-
ceived barriers associated with the behavior and cues to action [9].
Nonetheless, the HBM’s utility in predicting intention that, in
turn, predicts actual behavior is inadequately studied, as the The-
ory of Planned Behavior (TPB) is typically the model used. The
TPB indicates that the key determinant of behavior remains the

https://doi.org/10.1016/j.vaccine.2020.09.002
0264-410X/Ó 2020 Elsevier Ltd. All rights reserved.
L. Alhalaseh et al.
behavioral intention that is essentially affected by the individuals’
attitude toward performing that behavior [7,9,10].
From an HBM’s standpoint, Cheney et al. have illustrated that
individuals who did not intend to receive the influenza vaccine
had no previous personal experience on which they based their
perceptions [11]. Other authors have affirmed this finding conclud-
ing that prior vaccination was one of the key determinants of
future influenza vaccination despite being not explicitly incorpo-
rated in the HBM [12,13].
The majority of the research studies investigating these theories
included a limited number of geographic areas in the west [7]. A
recent review in the Eastern Mediterranean Region (EMR) has drawn
attention to substantial research gaps and major disparities across
EMR countries including data on influenza vaccine use, recommen-
dations and coverage [14]. Of the 48 included studies, 21 addressed
the influenza vaccine among HCW and the only included study from
Jordan did not examine the influenza vaccine among HCWs [14,15].
Thereafter, two more research papers have been published in Jor-
dan: one included HCWs as a subcategory [16] and the other was pri-
marily focused on HCWs [6]. Importantly, the Jordanian Ministry of
Health, collaborating with the World Health Organization, offers a
yearly influenza vaccine for judicious use where it defines priority
levels for vaccine distribution and administrations, due to the usu-
ally expected shortage of supplies [17].
Up to our knowledge, none of the studies in the EMR countries
explored health behavior change theories. Therefore, the purpose
of this survey was to adopt a conceptual model based on the HBM’s
constructs along with an explicit past vaccination behavior and
examine its utility in predicting Jordanian HCWs’ intention for
rather than actual influenza vaccine uptake. Of note, the HBM
developers have supported combining and individualizing its main
constructs instead of a comprehensive bland application [8,18].
A secondary outcome was to recognize what specific HBM con-
structs are equivalent to the ‘‘attitude” component of the TPB in
predicting intention rather than actual vaccine uptake [10].
2. Methodology
2.1. Study design and sampling techniques
A cross-sectional questionnaire-based study was performed in a
tertiary academic hospital in Amman, Jordan during the period
March-May 2016. This hospital is considered a major referral cen-
ter for more than a half million patients from all over the kingdom
[6]. It also offers free influenza vaccine for HCWs [6]. A conve-
nience sample of 477 healthcare workers (HCWs) was interviewed
by three trained research assistants after obtaining a verbal
informed consent. Participants would be eligible to participate in
the study if they were physicians or other medical staff with direct
patient contact. The physicians’ group included consultants, spe-
cialists, fellows, and interns across all specialties like emergency
doctors, internists, intensivists, family physicians, surgeons and
pediatricians, among others. The medical staff group included
nurses, clinical pharmacists, physiotherapists, occupational thera-
pists and other technicians with direct patient contact. Eligible par-
ticipants were informed about the voluntary nature of the study
and the penalty-free choice to withdraw.
A power analysis was conducted to determine the number of
participants needed in this study using the G*Power 3.1.7 software
[19,20].
2.2. Questionnaire
The study instrument was constructed by the lead author, after
reviewing related surveys in the literature, to incorporate most of
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Vaccine 38 (2020) 7372–7378
the constructs of the health belief model (HBM), in addition to
the basic demographic and social information, chronic health con-
ditions, and past and anticipated flu vaccination behavior.
The HBM-based statements included 4-point Likert-scale ques-
tions that are relevant to our population [8] and covering the five
constructs: perceived susceptibility to the influenza infection, per-
ceived severity of the disease, perceived vaccine benefit, perceived
barriers and cues-to-action. Although self-efficacy construct is
being routinely added to the HBM, we elected not to add it to
our HBM, as it does not appear to be a determinant factor in simple
health behaviors like obtaining an influenza vaccination [11,13].
Outcomes related to the uptake of influenza vaccination were
measured by three yes/no questions: any history of a previous
influenza vaccine uptake while working at the institution, a history
of vaccine uptake in the past year, and intention to avail of the vac-
cine in the upcoming influenza season 2016/2017.
The format, content, and validity of the HBM were tested and
used in different languages and cultures including the Arabic lan-
guage [8]. Two language experts translated the English question-
naire into Arabic and two different independent language experts
back-translated it to English according to Beaton’s recommended
guidelines [21].
2.3. Validity and reliability
A pilot study was conducted on 30 HCWs to examine the read-
ability, relevance, and reliability of the questionnaire items. Relia-
bility and internal consistency were adequate for the overall model
and the perceived benefit subscale with standardized Cronbach a
of 0.693 and 0.746, respectively. For the HBM’s constructs with<3
variables, Spearman correlation coefficients were computed to
assess the collinearity between the items. These included: suscep-
tibility variables (Spearman’s rho 0.145, P= 0.002), belief barrier
variables (Spearman’s rho 0.713, P< 0.001), perceived harm barrier
variables (Spearman’s rho 0.243, P< 0.001), perceived access bar-
rier variables (Spearman’s rho 0.347, P< 0.001), and cues to action
(Spearman’s rho 0.322, P< 0.001). A high correlation (r> 0.85) was
taken to indicate that potential collinearity exists between two
variables [22].
Perceived susceptibility included an additional question about
the increased susceptibility of patients in direct contact with the
HCWs to influenza. This element is not present in the original
model, and it was hypothesized that it offsets the altruistic behav-
ior of HCWs who are less inclined to believe in their own suscep-
tibility versus their patients’ susceptibility to contracting
influenza [2,23].
Perceived threat subscale was computed by multiplying the
responses for perceived susceptibility to infection and perceived
severity of the infection and applying the equation (Threat = sus
ceptibility + [susceptibility
severity]) [8,18]. Whereas perceived
benefit, perceived belief barriers, perceived harm barriers and per-
ceived access barriers subscales were calculated simply by sum-
ming the variables on the ‘‘compute” order in the SPSS.
2.4. Data analysis
Data were entered into the SPSS version 23. The association
between the categorical demographic variables and the intention
to receive the influenza vaccine was analyzed using cross-
tabulation where the Chi-square test was reported for dichoto-
mous variables and Chi-square for linear trend was used for
polychotomous variables. A chi-square test of homogeneity or
Fisher’s-Exact test was also conducted for the Likert questions to
compare the responses of HCWs who intended and those who
did not intend to vaccinate against influenza. Post hoc analysis
involved pairwise comparisons using the z-test of two proportions
L. Alhalaseh et al. Vaccine 38 (2020) 7372–7378

or multiple Fisher’s exact tests (2
2) with a Bonferroni correction
was done when needed.
Vaccination behavior scale was computed by summing the
responses of the questions: ‘‘have you ever had the flu shot?”
and ‘‘did you take the flu shot in the past influenza season of
2015/2016?” The scale ranged from 0 to 2. Because the data were
non-normally distributed, the difference between the two groups
of the dichotomous variable ‘‘intention to receive the influenza
vaccine” across the continuous variable ‘‘vaccination behavior
scale” was assessed using independent-samples Mann-Whitney U
test. A P value of<0.05 was considered statistically significant.
2.5. Logistic regression analysis
In the binomial regression model, the main HBM’s constructs
predicting the dichotomous dependent variable intention to vacci-
nate were loaded separately to test for significance and subse-
quently all the variables were tested for inclusion in the final
multivariate model using the forward stepwise method based on
the likelihood ratio. To include the sociodemographic confounding
variables in the final model, dichotomous variables (gender, mari-
tal status, smoking status, and HCW category) were individually
tested, while polychotomous categorical variables (age groups
and levels of education) were first recoded as dummy variables
before being tested for inclusion. All models were tested for fit
and significance. The final adjusted logistic regression model was
statistically significant, v2(2) = 39.339, p< 0.001. It explained 14%
of the variance in intention for vaccine uptake and correctly classi-
fied 61% of the cases. However, incorporating past vaccination
variables was significantly associated with the intention to receive
the influenza vaccine.
3.2. Vaccination behavior
Fig. 1 shows the vaccination behavior of the study groups with
regard to the intention to receive the influenza vaccine next year.
246 (51.6%) participants have ever had the influenza vaccine vs.
153 (32.1%) who have received the influenza vaccine in the past
year. Participants intending to receive the influenza vaccine had
significantly higher mean vaccination scores compared to those
who did not intend to. Therefore, any history of vaccine uptake,
whether it was in the past year or the years before, was signifi-
cantly associated with more intention to receive the influenza vac-
cine next year. Sociodemographic details in relation to vaccination
behavior are provided in a supplementary table.
3.3. Health Belief model constructs
Table 2 represents the constructs of the HBM according to the
intention to vaccinate against influenza.
90%
Has ever had
80% n=184 (76.7%)
influenza vaccine
70% Has had the vaccinate
Percentage Vaccinated

behavior in the final conceptual model as per Chapman & Coups n= 128 (53.3%) in the past year
60%
[13] explained 41% of the variance and correctly classified 76.3% ** P < 0.0005
50%
of the cases.
40%
30% n=62 (23.3%)
3. Results
20%
n= 25(10.5%)
3.1. Characteristics of the sample 10%
0%
Table 1 shows the demographic characteristics of the study Intentding to vaccinate Not intentding to vaccinate
cohort in relation to their intention to receive the influenza vac- (n=240) (n=237)
cine. Most of the participants were physicians, married and non- (Mean Vaccinaon Score (Mean Vaccinaon Score
smokers. A statistically significant difference was found between 1.30±0.79)** 0.37±0.66)**
participants intending to vaccinate against influenza in the upcom-
ing influenza season and those who had no intention to avail of the Fig. 1. Mean vaccination scores and vaccination history in relation to intention to
receive the influenza vaccine next year.
vaccine next year (P < 0.001), yet none of the demographic

Table 1
Sociodemographic description of the study sample in relation to intention to vaccinate against influenza next year.

Demographic variables Total number (%) Intending to vaccinate Not intending to vaccinate P-Value*
Age (years) 20–29 233 (48.8%) 122 (52.4%) 111 (47.6%) 0.415
30–39 135 (28.3%) 64 (47.4%) 71 (52.6%)
40–49 82 (17.2%) 43 (52.4%) 39 (47.6%)
+50 27 (5.7) 11 (40.7%) 16 (59.3%)
Gender Female 221 (46.3%) 112 (50.7%) 109 (49.3%) 0.882
Male 256 (53.7%) 128 (50.0%) 128 (50.0%)
Marital status Single 171 (35.8%) 82 (48.0%) 89 (52.0%) 0.441
Married 306 (64.2%) 158 (51.6%) 148 (48.4%)
Educational attainment School 25 (5.2%) 12 (48.0%) 13 (52.0%) 0.296
College 41 (8.6%) 21 (51.2%) 20 (48.8%)
Bachelor 223 (46.8%) 104 (46.6%) 119 (53.4%)
Higher Education 188 (39.4%) 103 (54.8%) 85 (45.2%)
Smoking Current 93 (19.5%) 50 (53.8%) 43 (46.2%) 0.472
Non-smoker 383 (80.5%) 190 (49.6%) 193 (50.4%)
Job description Physicians 321 (67.3%) 158 (49.2%) 163 (50.8%) 0.493
Medical staff 156 (32.7%) 82 (52.6%) 74 (47.4%)
Total 477 240 (50.3%) 237 (49.7%) <0.0005
*
Chi square test of independence and chi square for trend.

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Table 2
The HBM’s constructs in relation to intention to vaccinate against influenza.

HBM constructs Strongly Agree Disagree Strongly P value of v2

agree N (%) N (%) disagree
N (%) N (%)
A. Perceived threat of the influenza infection
1. Perceived susceptibility to infection
Being an HCW increases my risk of contracting influenza compared to the general population 414.0 59.0 3.0 1.0 0.187
(86.8) (12.4) (0.6) (0.2)
Positive intention 89.6% 9.6% 0.8% 0.0%
Negative intention 84% 15.2% 0.4% 0.4%
HCWs can transmit a bad influenza to their elderly & high-risk patients 328.0 101.0 46.0 2.0 <0.0005
(68.8) (21.2) (9.6) (0.4)
Positive intention 79.2%* 15.0% 5.4% 0.4%
Negative intention 58.2%* 27.4% 13.9% 0.4%
2. Perceived severity of infection
Influenza infection and its complications may be serious 332.0 118.0 23.0 4.0 0.174
(69.6) (24.7) (4.8) (0.8)
Positive intention 73.3% 20.4% 5.4% 0.8%
Negative intention 65.8% 29.1% 4.2% 0.8%
B. Perceived benefit of the influenza vaccine
HCWs should receive the influenza vaccine to protects themselves against seasonal influenza 294.0 142.0 40.0 1.0 <0.0005
(61.6) (29.8) (8.4) (0.2)
Positive intention 73.3%* 23.3% 3.3%* 0.0%
Negative intention 49.8%* 36.3% 13.5%* 0.4%
HCWs should receive the influenza vaccine to protects themselves against pandemic influenza 371.0 78.0 26.0 2.0 0.005
(77.8) (16.4) (5.5) (0.4)
Positive intention 83.8%* 14.2% 2.1%* 0.0%
Negative intention 71.7%* 18.6% 8.9%* 0.8%
HCWs should receive the influenza vaccine to protect their patients against influenza 251.0 145.0 75.0 6.0 0.001
(52.6) (30.4) (15.7) (1.3)
Positive intention 61.3%* 26.3% 12.1% 0.4%
Negative intention 43.9%* 34.6% 19.4% 2.1%
The vaccine should be given before pilgrimage 391.0 43.0 37.0 6.0 0.018
(82.0) (9.0) (7.8) (1.3)
Positive intention 87.1%* 5.4%* 6.3% 1.3%
Negative intention 76.8%* 12.7% 9.3% 1.3%
*
Influenza vaccine decreases absenteeism from work 196.0 129.0 145.0 7.0 0.002
(41.1) (27.0) (30.4) (1.5)
Positive intention 50.0%* 23.3% 25.8% 0.8%
Negative intention 32.1%* 30.8% 35.0% 2.1%
Influenza vaccine is a must if I have a chronic disease 295.0 111.0 66.0 5.0 0.020
(61.8) (23.3) (13.8) (1.0)
Positive intention 67.9%* 19.6% 12.1% 0.4%
Negative intention 55.7%* 27.0% 15.6% 1.7%
‘‘Would rather get the influenza vaccine than get the flu” 262.0 127.0 79.0 9.0 0.001
(54.9) (26.6) (16.6) (1.9)
Positive intention 64.2%* 22.1% 12.5% 1.3%
Negative intention 45.6%* 31.2% 20.7% 2.5%
C. Perceived barriers against vaccination
1. Belief barriers
Do not catch flu normally 232.0 131.0 107.0 7.0 0.762
(48.6) (27.5) (22.4) (1.5)
Positive intention 48.8% 25.8% 23.8% 1.7%
Negative intention 48.5% 29.1% 21.1% 1.3%
Have a strong immune system 242.0 125.0 105.0 5.0 0.973
(50.7) (26.2) (22.0) (1.0)
Positive intention 50.5% 26.3% 22.9% 0.8%
Negative intention 51.5% 26.2% 21.1% 1.3%
2. Harm barriers
Influenza vaccine can cause more harm than good 116.0 144.0 210.0 7.0 0.001
(24.3) (30.2) (44.0) (1.5)
Positive intention 18.8% 27.5% 51.7%* 2.1%
Negative intention 30.0% 32.9% 36.3%* 0.8%
Side effects of the vaccine are serious 147.0 115.0 210.0 5.0 0.256
(3.8) (24.1) (44.0) (1.0)
Positive intention 31.7% 20.8% 46.7% 0.8%
Negative intention 30.0% 27.4% 41.4% 1.3%
3. Access Barriers
Unavailability of the vaccine in the right place and time is a barrier against immunization 150.0 117.0 195.0 15.0 0.252
(31.4) (24.5) (40.9) (3.1)
Positive intention 34.2% 23.3% 40.4% 2.1%
Negative intention 28.7% 25.7% 41.4% 4.2%
Cost of the vaccine is a set back 104.0 77.0 278.0 18.0 0.766
(21.8) (16.1) (58.3) (3.8)
Positive intention 23.3% 15.8% 57.5% 3.3%
Negative intention 20.3% 16.5% 59.1% 4.2%

(continued on next page)

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Table 2 (continued)

HBM constructs Strongly Agree Disagree Strongly P value of v2

agree N (%) N (%) disagree
N (%) N (%)
D. Cues to action
Influenza vaccine is especially protective as it is recommended in most of the guidelines 294.0 87.0 91.0 5.0 0.009
(61.6) (18.2) (19.1) (1.0)
Positive intention 69.2%* 14.6% 15.8% 0.4%
Negative intention 54.0%* 21.9% 22.4% 1.7%
The presence of news of a bad influenza season makes me want to get the Influenza vaccine 229.0 120.0 121.0 7.0 0.015
(48.0) (25.2) (25.4) (1.5)
Positive intention 55.0%* 23.3% 20.4% 1.3%
Negative intention 40.9%* 27.0% 30.4% 1.7%
*
Post-hoc Bonferroni tests.

 Perceived susceptibility to influenza infection: All study partic- vaccinate against influenza next year. Almost all the main con-
ipants agreed on the increased susceptibility of HCWs to influ- structs were significantly predictive of the intention to vaccinate.
enza infection, yet only those who intended to receive the In the conceptual model incorporating explicit vaccination
vaccine agreed that their high-risk and elderly patients were behavior, the perceived benefit construct was the only one signifi-
susceptible to influenza (P< 0.0005). cantly predictive of the intention to receive the vaccine in the
 Perceived severity of influenza infection: Both study groups upcoming season.
were agreeable on the unquestionable severity of influenza
and its complications. 4. Discussion
 Perceived benefit of influenza vaccine: The group who intended
to receive the influenza vaccine endorsed its benefits across all This study is the first one in Jordan to shed light on the factors
the domains whereas those who did not intend to receive the that determine HCWs’ intention to receive the influenza vaccine
vaccine questioned its benefits against the seasonal as well as using a psychological theory of behavior change. We found that
the pandemic flu. 32% of our sample of HCWs had received the influenza vaccine in
 Barriers: Both groups believed in their immune system against the previous year, and 50% intended to receive it in the upcoming
influenza infection, and similarly perceived accessibility as a year. Significant differences in health beliefs and behaviors were
barrier to vaccination. Nevertheless, individuals who had no identified between participants who intended and those who did
intention to receive the vaccine were more likely to perceive not intend to receive the influenza vaccine.
it as harmful (P= 0.001). Previous studies in Jordan have shown comparable vaccination
 Cues to action: The presence of news of a bad influenza season, rates among HCWs ranging from 18% to 36% [6,16]. These rates are
as well as the recommendations of the guidelines, only had a comparable to the global vaccination rates and the median cover-
significant impact on those already intending to get the vaccine. age of 28.2% in the EMR countries [2,14,24].
It is striking that being a physician was not associated with a
Table 3 documents the results of the logistic regression analysis higher likelihood of intending to receive the influenza vaccine,
of the HBM constructs to predict whether an individual intends to despite the presumably greater knowledge of the vaccine among
physicians compared to the other categories of HCWs [2,25–28].
Table 3 An explanation is highlighted in the literature where the increased
Predictors of intention to vaccinate against influenza next year. knowledge of HCWs is offset by misperceptions varying according
to the category of HCWs [2,25–28]. Contrary to this notion, other
HBM constructs Odds 95% Significance
Ratio Confidence P  0.05 studies have found that the higher the education of HCWs, the
Interval more acceptance of the influenza vaccine there was, hence, nurses
1. Perceived threat 1.52 1.14–2.02 0.004* have proven to have lower rates of vaccination compared to physi-
Susceptibility scale 1.73 1.36–2.21 < 0.0005* cians [2,29–32]. That being said, further research is needed to
2. Perceived Benefits Scale 1.20 1.12–1.28 < 0.0005* frame pedagogical strategies that target misperceptions pertinent
Protection against seasonal flu 2.00 1.34–2.97 0.001
to each category of HCWs instead of a broad-based approach [33].
Protection against pandemic flu 1.53 1.05–2.24 0.028
3. Perceived barriers
Our findings of the HBM show that HCWs have diametrically
Belief barriers 1.02 0.91–1.15 0.69 divergent beliefs of influenza infection and vaccination that deter-
Harm barriers 0.84 0.73–0.96 0.01 mine the difference in their intention to receive the influenza vac-
Influenza vaccine causes more 0.64 0.51–0.80 < 0.0005* cine. These beliefs begin with differences in the perceived
harm than good
susceptibility to infection; those who intended to vaccinate were
Access barriers 0.92 0.82–1.04 0.20
4. Cues to action 1.31 1.14–1.50 < 0.0005* significantly more likely to acknowledge the increased susceptibil-
Recommended in the guidelines 1.32 1.05–1.67 0.017 ity of their sick patients, besides their own risk. Correspondingly,
Death news in the media 1.29 1.04–1.61 0.022 when the belief of self-protection is aligned with protecting others,
Adjusted y HBM the altruistic behaviors of HCWs are mitigated and vaccine uptake
Perceived Benefits Scale 1.19 1.12–1.27 < 0.0005*
Perceived Harm Scale 0.87 0.752–0.995 0.042
is higher [2,23].
y
Conceptual adjusted model including vaccination behavior Noteworthy, HCWs’ awareness of the increased susceptibility of
Perceived Benefits Scale 1.19 1.11–1.28 <0.0005* their patients to influenza infection is inadequately accounted for
Vaccination Behavior 4.50 3.38–6.00 < 0.0005* in the HBM’s threat construct [8]. Therefore, incorporating a ques-
*
P value significant at 0.01. tion about it is believed to accentuate the discriminative capacity
y
Adjusted for the sociodemographic variables. of the threat variable which, in turn, would be expected to offset
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HCWs’ altruism thus enhancing the overall model’s sensitivity. 5. Conclusion

Practically, emphasizing the reasons for getting vaccinated against
influenza should be through stressing on the HCWs’ liability and The perceived benefit of the influenza vaccine, coupled with a
moral responsibility towards their patients [26,32–34]. prior history of vaccination, were the most significant predictors
This discrepancy in the perceived susceptibility of HCWs and of intention for influenza vaccine uptake among HCWs. Emphasiz-
their patients to influenza infection is coupled with a significant ing the tremendous benefits of the vaccine to the HCWs’ them-
difference in the perceived benefit of the vaccine against seasonal selves, as well as to their patients, is believed to be a cornerstone
and pandemic influenza; HCWs intending to vaccinate were signif- to encourage HCWs to get vaccinated for the first time; the first
icantly subscribing to much more favorable opinions of the vaccine step in making influenza vaccination a habit.
including its benefit in protecting their patients. The predictive Conducting further longitudinal studies to evaluate the effec-
ability of the susceptibility and benefit constructs has also been tiveness and versatility of this HBM-based conceptual framework
illustrated in the literature [12–13,26,28,31,35–36]. is presumably essential to anticipate HCWs’ future behaviors more
Analyzing the third construct of the HBM, perceived harm was precisely and to evaluate subsequent pilot interventions aiming to
the only barrier significantly predicting the intention to receive increase HCWs’ influenza vaccine uptake, and outline policies at
the vaccine, which is also seen in similar studies [28,33]. Accord- the national and regional levels.
ingly, focusing on dispelling this specific conviction rather than
providing free vaccines or increasing their availability is expected
6. Study strengths and limitations
to be more successful in expanding vaccination coverage in our
institution.
This is the first research study examining theory-based behav-
The last construct of the HBM demonstrated that HCWs intend-
iors in influenza vaccination among HCWs in an EMR country. Fur-
ing to vaccinate against influenza were positively motivated by the
ther, the HBM’s constructs were tested for validity and reliability
existing cues to action whereas those who did not intend to receive
and were essentially in accordance with findings from previous
it ignored or even dismissed these cues. In this regard, depending
studies. Also, the presence of chronic diseases was included as a
on extrinsic cues to action to promote our HCWS’ vaccine uptake
confounding variable to ascertain for a principal reason, rather
might be a waste of time, even if the cue to action was to reduce
than the occupation, for influenza vaccine uptake. It is believed
the threat to their patients. This is because HCWs’ intrinsic beliefs
that recruiting HCWs from different hospital departments would
of benefit and harm were more motivating to their intention for
add different points of views enriching our results.
vaccine uptake than the extrinsic cues.
Conversely, the HBM has its limitations such as the absence of
After adjusting for the confounding variables in the final Health
adequate combinatorial rules for its variables and the small predic-
Belief Model before including vaccination behavior, the perceived
tive capability of the model as a whole and its individual variables
benefit of the vaccine and the perceived harm barriers were proved
[18]. Despite that, our HBM- based conceptual model has explained
to be the only significant predictors of our HCW’s intention to vac-
a modest amount of the variability in intention to receive the influ-
cinate. These results mean that regardless of a previous history of
enza vaccine. Consequently, combining other TPB’s elements is
vaccine uptake, HCWs weigh the benefits and harms of the vaccine
suggested to increase the amount of variance explained by the pro-
before making any conscious decision to embark on this experi-
posed conceptual health behavior model based on the HBM. Future
ence. Research on the Theory-of-Planned-Behavior (TPB) has sup-
research projects comparing both models simultaneously and test-
ported these results showing that intention is primarily affected
ing interventions based on those findings are believed to be a blue-
by the ‘‘attitude” component which, in turn, demonstrated a pre-
print for policies to clarify the causal direction of belief–behavior
dictive ability equivalent to both the perceived benefits and the
relationships and improve influenza vaccination rates among
perceived barriers of the HBM’s constructs, emphasizing a compa-
HCWs. Finally, the results of this study are not intended to explain
rable role of both models in predicting the intention for influenza
HCWs’ intention to vaccinate against other infections that include
vaccine uptake [10,13,35–36].
hepatitis B and Tetanus-Diphtheria and Pertussis (Tdap), among
Furthermore, the conceptual model integrating previous vacci-
others.
nation behavior showed that a prior history of vaccination and
the perceived benefit of the vaccine were the mere determinants
of HCWs’ intentions for future vaccine uptake. In other words, hav- 7. Ethical considerations
ing received the vaccine previously gives a new perspective based
on that experience especially if one has obtained the merits of the The study was funded by the Deanship of Scientific Research
vaccine neglecting the proposed harms that they might have heard and approved by the IRB committee at the University of Jordan
of before trying it themselves. This finding is mirrored in studies and Jordan University Hospital (reference No. 4/2015).
demonstrating that the perceived benefit construct is a crucial pre-
dictor of influenza vaccine uptake among HCWs while the per-
ceived barriers’ construct, which includes harm, is a less robust CRediT authorship contribution statements
predictor [7,10–11,26,28].
It is important to keep in mind that intention does not automat- Lana Alhalaseh: Conceptualization, Methodology, Formal anal-
ically translate into a 100% future vaccination rate thus under- ysis, Data curation, Writing - original draft, Writing - review & edit-
standing the factors that positively affect this intention-behavior ing, Supervision, Project administration, Funding acquisition.
relationship would substantially improve future influenza vaccine Hanan Fayoumi: Conceptualization, Investigation, Writing - origi-
uptake [11,13]. nal draft. Bayan Khalil: Conceptualization, Investigation, Writing -
In summary, HCWs intending to receive the influenza vaccine, original draft.
contrary to those who did not intend to vaccinate, appreciated
the increased risk of influenza infection in their patients and them- Declaration of Competing Interest
selves and perceived the benefit of the vaccine. They also disre-
garded the ‘‘harmful” effects of the vaccine, were more likely to The authors declare that they have no known competing finan-
have a previous history of vaccination against influenza and were cial interests or personal relationships that could have appeared
propelled by the existing cues to action. to influence the work reported in this paper.
7377
L. Alhalaseh et al.
Appendix A. Supplementary material
Supplementary data to this article can be found online at
https://doi.org/10.1016/j.vaccine.2020.09.002.
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