Motors of Influenza Vaccination Uptake and Vaccination Advocacy in Healthcare Workers: Development and Validation of Two Short Scales

Health organisations and government bodies consider healthcare workers (HCWs) to be a priority group for vaccination against influenza, but flu vaccine uptake remains low among them. In contrast to models such as the Health Belief Model (HBM) and the Theory of Planned Behavior (TPB) that explain HCWs' choices by conceiving of decision-making as deliberate and rational information processing, this article proposes and tests a complementary theoretical framework, namely the cognitive model of empowerment (CME). The article outlines the development and validation of a 9-item measure of cognitive empowerment towards flu vaccination (MoVac-flu scale) and an 11-item measure of cognitive empowerment towards vaccination advocacy (MovAd scale).

In short, the project involved the development of an online questionnaire to gather information on HCWs' views on the flu vaccination - the goal being to explore why HCWs may want to (rather than believe they need to) get vaccinated against the flu. The questionnaire measured their intrinsic motivation to get vaccinated against the flu through 4 components: the extent to which they felt vaccination was (a) important (example from MovAd: "It matters that I talk openly about vaccination with other people"), (b) impactful (example from MovAd: "People's opinions of vaccination can really be influenced by the conversations I have with them"), and the extent to which they felt (c) knowledgeable about vaccination (example from MovAd: "I feel able to discuss vaccination"), and (d) autonomous in their decision to get vaccinated (example from MovAd: "Discussing vaccination with others is entirely my choice").

Both scales (MoVac-flu and MovAd) were administered to 784 frontline National Health Service (NHS) HCWs in the United Kingdom (UK) with direct patient contact between June 2014 and July 2015. The incremental validity of the MoVac-flu scale was assessed using hierarchical binary logistic regression analysis to determine odds ratios and 95 per cent confidence intervals with 2013-14 influenza vaccination status (1 = vaccinated, 0 = not vaccinated) as a discrete outcome measure. The incremental validity of the MovAd scale was assessed using a hierarchical regression analysis with advocacy behaviour as a continuous outcome to determine regression coefficients and confidence intervals (CIs).

The researchers examined whether the MoVac-flu scale accounted for vaccination behavior over and above demographic statistics, risk perception beliefs, and social cues. In short, the MoVac-flu score was the strongest predictor of all: a 1-point increase on the cognitive empowerment measure resulted in increased odds of vaccination by a factor of 9.74, 95% CI. A secondary objective of the research was to examine whether the MovAd scale contributed to explain advocacy behaviour above and beyond demographics. They found that the MoVad score was a significant and strong predictor of vaccination advocacy behaviour.

In short, the researchers conclude that the scales exhibited "excellent reliability and a clear unidimensional factor structure. An examination of the nomological network of the cognitive empowerment construct in relation to HCWs' vaccination against the flu revealed that this construct was distinct from traditional measures of risk perception and the strongest predictor of HCWs' decisions to vaccinate. Similarly, cognitive empowerment in relation to vaccination advocacy was a strong predictor of HCWs' engagement with vaccination advocacy. These findings suggest that the cognitive empowerment construct has important implications for advancing our understanding of HCWs' decisions to vaccinate as well as their advocacy behavior."

They go on to describe these implications for policy and practice, proposing that the findings "highlight the promise of including considerations of cognitive empowerment above and beyond perceptions of risk and benefits in better understanding vaccine hesitancy issues. The MoVac-flu and MovAd short scales developed can also form a useful toolkit to address vaccine hesitancy among HCWs. For example, Kassianos et al....used these scales to explore and profile HCWs' level of engagement towards flu vaccination and vaccination advocacy across six European countries. Their results showed that hesitancy was mostly driven by neutral (rather than negative) empowerment towards flu vaccination and advocacy. Thus, the MoVac-flu and MovAd short scales can be used as tools to spot the presence and prevalence of HCWs with lower levels of motivation to vaccinate. Such an increase in the granularity of our understanding the motors of vaccination could pave the way for designing more bespoke, and therefore potentially more effective, interventions to target vaccine hesitancy. For example, the identification of the main driver(s) of hesitancy among the four CME assessments of vaccination behavior (value, impact, knowledge, or autonomy) could provide useful insights for hospital administrators in charge of designing communication campaigns or staff development strategies."

Finally, the researchers urge that further research be conducted among HCWs so we can better understand the determinants of their motivations to get vaccinated against the flu and also what interventions, including communication-centred ones, may positively impact on them.