Introduction: Seasonal influenza is believed to be a common attribution of morbidity and mortality in the children population, and it causes huge disease burden worldwide. Although seasonal influenza vaccination is recommended as the most effective prevention by the World Health Organization and vaccination programs for children have been introduced in many countries, vaccination coverage remains low. Parents are primary decision makers for their children's immunization, therefore it is important to understand the determinants that influence parents' decision-making to provide important information for promoting vaccination uptake against seasonal influenza among children. Objective: To synthesize factors that influence parental decision on children's vaccination against seasonal influenza from published literature. Method: Literature reported factors that influenced parental decision on children's vaccination against seasonal influenza published before/on 31th May, 2013 were searched in PubMed and Web of Science databases. Manual searching was also performed for the citations of the retrieved papers. Both qualitative and quantitative articles consistent with the objective were searched from PubMed and Web of Science databases on 31th May, 2013. Records were screened in the sequence of title, abstract and full text to identify eligible studies, and references of eligible studies were also scrutinized to avoid missing important articles. Influencing factors were extracted from included papers, and the identified factors that influenced parental decision making were then discussed based on theoretical behavioral models. Results: Totally 32 articles met the inclusion criteria. Factors associated with parental decision included demographic factors, which consisted of parental and children’s age, parental gender, ethnicity, household income, residence, insurance status, family characters, parental education level, and children’s health history; psychological factors, including attitudes towards influenza vaccination, knowledge of influenza and vaccination, perceived risk of seasonal influenza, and emotional factors; past behaviors comprising previous frequency of using health care services, children’s seasonal influenza vaccination history, previous absenteeism from school or work, social norm referring cues to action and subjective norms; and environmental factors, meaning access to vaccination facilities. Discussion: An integrated framework based on the Health Belief Model, Triandis’ Theory of Interpersonal Behavior and the Theory of Reasoned Action was constructed to explain the findings. The framework proposes that the parents’ intention to vaccinate their children against seasonal influenza is influenced by demographic variables, attitude towards seasonal influenza vaccination, knowledge and perception of influenza/influenza vaccine, social norms (cues to action and subjective norms), emotion, and past behavior/experience; easy access to vaccination providers as a facilitating condition additionally determine the possibility of turning intention into actual behavior. Interventions such as providing positive knowledge relevant to seasonal influenza vaccination, targeting less intended and more influential decision-makers, ensuring sufficient access to vaccination, and creating action cues may be implemented to promote uptake of seasonal influenza vaccination among children. / published_or_final_version / Public Health / Master / Master of Public Health

Class of 2009 Abstract / OBJECTIVES: To determine patient preference for the type of visit for the receipt of the influenza vaccine from the pharmacist and to determine patient preference for contact method for annual notification of the influenza vaccine program. METHODS: This was a descriptive study using a short telephone survey. The first dependent variable was the preferred type of visit comparing appointment-based and predetermined walk-in clinics. The second dependent variable was the preferred method of contact for annual notification of a pharmacist administered influenza vaccination program (telephone, US post mail, email). RESULTS: The telephone survey was completed by 206 patients. Overall, study participants preferred appointment-based visits ( 81.2 %; p < 0.05) compared to a predetermined walk-in clinic (18.8%). Overall, study participants significantly preferred to be contacted for annual notification of a pharmacist administered influenza vaccination program via telephone (75.7%; p< 0.05) compared with US post mail and email. Based on the percentages observed, the second preferred method of contact was email (12.6%) and US post mail was the third preferred method of contact (11.7%). CONCLUSIONS: Patient preference for type of visit for pharmacist-administered influenza vaccine was appointment-based as opposed to predetermined walk-in clinic based. Patient preference for contact method for annual notification was telephone as opposed to email or postal mail.

Class of 2009 Abstract / OBJECTIVES: To evaluate patients’ perceptions of receiving a pharmacist-administered influenza vaccine in the community pharmacy setting. METHODS: All patients receiving a pharmacist-administered influenza vaccine at a Safeway Pharmacy in Tucson, Arizona were invited to participate in the survey. Participants completed the survey in a waiting area outside the pharmacy. At the completion of the study time frame, surveys were collected, and each response was entered into an Excel spreadsheet for data analysis. RESULTS: Seventy-five patients completed the Flu Shot Survey. One hundred percent of patients reported that getting the influenza vaccine at a grocery store pharmacy is convenient. Respondents reported being either very confident (97.3%) or somewhat confident (2.7%) in pharmacists as immunizers. Only 18.7% reported having never received an influenza vaccine from a pharmacist, and 13.3% reported having no prior knowledge that Arizona pharmacists could administer the influenza vaccine. CONCLUSIONS: All patients responded that receiving the influenza vaccine from a community pharmacist was convenient. Patients wanted to receive the vaccine next year from a pharmacist, and the majority of respondents were confident in the pharmacist as an immunizer. Few patients reported never receiving the influenza vaccine from a community pharmacist, and even fewer patients were unaware that pharmacists in Arizona can immunize.

Research Objectives : Studies indicated that influenza vaccination is a cost-effective clinical prevention for elderly persons. Higher influenza vaccination rate will reduce disease threat and related health care utilizations in a health care system. From 2001, Taiwan provided free influenza vaccine for all of its elderly persons. Nevertheless, the influenza vaccination rate was lower than the expected goal and less than 50%. Therefore, this study aims to evaluate the key factors which affect elderly persons receiving influenza vaccination in Taiwan. Study Design : This is a retrospective study using national representative data from year 2000 to 2004. The vaccination information was linked with outpatient and inpatient records in individual level. The data was also linked with medical institution¡¦s characteristics. We modified Health Belief Model and threat-responsiveness theory to hypothesize previous experiences on vaccination and medical utilization were important factors affecting individual¡¦ s probability of receiving influenza vaccination. Population-based descriptive analysis was conducted to assess the demography characteristics, health status, and health care utilizations. We tested the significance by t-test and Chi-Square test. Moreover, we applied multivariate logistic regression to analyze the associations between controlled factors and the probability of receiving influenza vaccination. Population Studied : People aged 65 years and older were drawn from Taiwan¡¦s national health insurance database from 2000 to 2004. The total sample size is 23,023 elderly persons. Principle Finding: The study results indicated that the most important factor affect elderly persons continue to receive influenza vaccination is whether the person had received influenza vaccination during last flu season or not. Elderly persons who had received influenza vaccination in last flu season were significantly seven times more likely to receive influenza vaccination in this year (OR: 7.66 [95%CI:7.34-8.00]). Other key affecting factors include age, health status, flu-related inpatient and outpatient utilizations in last year, locations of receiving influenza vaccination, and the health care organizations¡¦ levels. Conclusion : This research combines Health Belief Model and threat-responsiveness theory as framework to analyze the national dataset of four year¡¦s elderly influenza vaccination rate change in Taiwan. We found that lagged effects such as vaccination status and flu-related health care use in previous flu season significantly affect the volition of influenza vaccination. Therefore, further research on how to adopt this critical finding and promote higher vaccination rate are in great needs. Implications for Policy, Delivery or Practice: Free coverage and easy access does not guarantee high influenza vaccination rate in Taiwan, even it is under universal health insurance program. This study provides empirical investigations on key factors that might affect the elderly persons¡¦ intention to receive influenza vaccination. Elderly persons¡¦ responses to regular clinical prevention and disease threat were positively associated with probability of having influenza vaccination. By focusing on the major factors and conducting related promotion programs, effective prevention policy can be reinforced. Moreover, this study result could serve as valuable reference for other countries which also has or plans to have free influenza vaccination policy, particularly for those countries also with national health insurance program.

Thesis (M.S. in Management)--Naval Postgraduate School, December 2009. / Thesis Advisor(s): Apte, Aruna. Second Reader: Ferrer, Geraldo. "December 2009." Description based on title screen as viewed on January 27, 2010. Author(s) subject terms: Pandemic Influenza, Vaccine Distribution, Vaccine Distribution with DoD Assets, DoD Pandemic Influenza Response Plan. Includes bibliographical references (p. 63-64). Also available in print.

Background Influenza causes annual, worldwide epidemics of respiratory disease that affects all segments of the population. Mass vaccination of healthy children, who are playing an important role in the transmission of influenza, is promoted to be a complementary approach in prevention and control of influenza. However, lack of published systemic review evidencing the indirect protection of vaccinating healthy children makes the implementation under uncertainty. Method A systemic review was conducted by computerized bibliographic searches in PubMed and the Cochrane Library identifying the published studies on the effectiveness and cost-effectiveness of vaccinating healthy children to control influenza epidemics by reducing transmission in the community. Any study design with vaccinating healthy children as the intervention versus control group with no influenza vaccine was included. Only outcomes measured on the contacts of children, either the community or household members were considered. Result Twenty-two articles were selected to be reviewed in this project, in which 17 of them covered the public health benefit of vaccinating healthy children to protect others in the community against influenza, and five of them were economic studies. Overall the result suggested that vaccinating health children produces a public health benefit in protecting others in the community against influenza and that it is a cost-effective measure. Discussion Targeting vaccines to healthy children should be promoted for optimal vaccine allocation, maximizing the vaccination effectiveness. Community planning on vaccine delivery infrastructure as well as educational and communicational strategies is necessary to improve influenza vaccine coverage. Further well-designed studies such as RCT with larger sample sizes, as well as studies in Hong Kong or other sub-tropical regions should be carried out and included. Moreover, large and population-based studies should be conducted to examine the overall impact of universal childhood influenza immunization. / published_or_final_version / Public Health / Master / Master of Public Health

Objectives: To identify factors that are important for parental decisions on vaccinating their children against seasonal influenza based on a modified health belief model. Study design: Cross-sectional study Subjects: A total of 325 parents who had at least one child aged between 6 months and 3 years were recruited from a women and children’s hospital in Guangzhou, China Methods: Eligible subjects were identified by doctors when parents took their children to the outpatient clinic for regular body examination. Each eligible subject was invited for a face-to-face interview based on a standardized questionnaire. Hierarchical logistic regression models were conducted to identify factors associated with parents' intention to vaccinate their children and children’s actual vaccination uptake against seasonal influenza on the basis of a modified health belief model. Results: Uptake of seasonal influenza within the preceding 12 months among the target children who aged between 6 and 36 months was 47.7%. Around 62.4% parents indicated as being “likely/very likely” to take their children for seasonal influenza vaccination in the next 12 months. The hierarchical logistic regression model showed that children’s age (OR=2.59, 95%CI: 1.43-4.68), social norm (OR=2.08, 95%CI: 1.06-4.06) and perceived control (OR=2.96, 95%CI: 1.60-5.50) were significantly and positively associated with children’s vaccination uptake within the preceding 12 months; children with a history of taking seasonal influenza vaccine (OR=2.50, 95%CI: 1.31-4.76), perceived children’s health status (OR=3.36, 95%CI: 1.68-6.74), worry/anxious about their children influenza infection (OR=2.31, 95%CI: 1.19-4.48) and perceived control (OR=3.21, 95%CI: 1.65-6.22) were positively association with parental intention to vaccinate their children in the future 12 months. However, anticipated more regret about taking children for the vaccination was associated with less likely to vaccinate children within the preceding 12 months (OR=0.21, 95%CI: 0.08-0.52). Conclusions: The modified health belief model provided a good theoretical basic for understanding factors associated with parents’ decisions on their children's vaccination against seasonal influenza. It is important to provide sufficient information related to influenza vaccination benefit and improve parents' confidence to access the seasonal influenza vaccine to promote parents' intention to vaccinate their children against seasonal influenza. Providing information cues such as advice from other parents whose children have been vaccinated to increase adherence to positive social norms would be effective to encourage seasonal influenza vaccination uptake among children. Information communication should also target on reducing anticipated regret about the negative consequence of vaccinating children. / published_or_final_version / Public Health / Master / Master of Public Health

Influenza (IV) and pneumococcal polysaccharide vaccination (PPV) may reduce hospitalization and mortality but the effectiveness of these vaccines in older adults (≥65 years) is controversial. This thesis includes seven parts with a total of ten studies studying different aspects regarding IV and PPV in institutionalized older adults - the group with the highest infection-related morbidity and mortality. 　　 　　In Part I, we presented the controversies about effectiveness of influenza and pneumococcal vaccination in institutionalized older adults. 　　 　　In Part II, we studied a retrospective cohort of 1737 older adults showing that nursing home residence is independent risk factor of infection-related mortality and hospitalization. 　　 　　In Part III, the second and third studies were systematic reviews showing that IV and PPV could reduce pneumonia and death.. 　　 　　In Part IV, we evaluated the effectivenss of IV and PPV through prospective cohorts. The fourth study was a prospective cohort study of 1859 institutionalized older adults showing that IV significantly reduced mortality and hospitalization. The fifth study was a prospective cohort study of 532 institutionalized older adults showing that when the IV strain does not match the circulating strain, PPV provided additional protection in reducing mortality. 　　 　　In Part V, the sixth study was a randomized controlled trial of 100 institutionalized older adults showing that intradermal IV has better immunogenicity than intramuscular vaccination without compromising safety. 　　 　　In Part VI, we identified factors that may affect clinical effectiveness of IV. The seventh and eighth studies were prospective cohort studies of 711 institutionalized older adults showing that vaccine efficacy declined with increasing impaired functional status and renal function. 　　 　　In Part VII, we identified determinants of receiving IV and PPV in institutionalized older adults. The ninth study was a cross-sectional study of 155 institutionalized older adults showing that encouragement from nHCWs was a major facilitator of receiving vaccination. The tenth study was a cross-sectional study of 1300 nHCWs showing that 40.2% of nHCWs had encouraged residents to receive vaccination. 　　 　　In conclusion, ten studies from this thesis demonstrated that IV and PPV are effective in preventing hospitalization and reducing mortality in institutionalized older adults. Different strategies in improving its effectivenss and acceptance were suggested. / published_or_final_version / Medicine / Master / Doctor of Medicine

Pregnant women infected with influenza virus are more likely to experience severe complications compared with their non-pregnant peers. Yet influenza vaccine uptake is low among pregnant women. The purpose of this study was to assess the prevalence and predictors of seasonal influenza vaccine uptake among pregnant women in Hong Kong. Using a multi-centre cross-sectional design, we recruited 2,822 new mothers during their immediate postpartum stay at all eight public obstetric hospitals over a three-month period from April through June 2011. We assessed their antenatal maternal influenza vaccination status as well as health beliefs and perceptions toward influenza and influenza vaccination. Bivariable and multivariable logistic regression was used to identify the predictors of vaccination uptake. Only 49 (1.7%; 95% CI 1.3% to 2.3%) participants were vaccinated during pregnancy. Fears that the vaccine would harm their foetuses or themselves were the most common reasons for not being vaccinated. Being aware of vaccination recommendations (OR=2.69; 95% CI 1.06, 6.82), being advised by a health care provider (HCP) to be vaccinated (OR=6.30; 95% CI 3.19, 12.46), a history of influenza vaccination (OR=2.47; 95% CI 1.25, 4.91), perceived susceptibility to influenza infection (OR=3.67; 95% CI 1.64, 8.22), and perceived benefits of influenza vaccination (OR=9.98; 95% CI 3.79, 26.24) were all independently associated with vaccination. Perceived barriers to vaccination (OR=0.17; 95% CI 0.07, 0.40) were strongly associated with failure to vaccinate. A qualitative descriptive design was also used to explore a broad spectrum of health knowledge and beliefs of participants regarding influenza infection and influenza vaccination during pregnancy. An interview guide was developed based on the Health Belief Model. A sub-sample of participants who completed the quantitative study were invited to take part in the qualitative interviews. A total of 32 postpartum women were interviewed and only two had been vaccinated during pregnancy. Following thematic analysis, three themes emerged that further highlighted the pregnant women’s perceptions toward influenza vaccine and their decision-making process, perceived risk of influenza infection, perceived risk of an influenza vaccine, and decision-making cues. Overall, participants held negative impressions about influenza vaccination during pregnancy. This could be because of misconceptions and underestimation of the threats of influenza infection to themselves and their foetuses. They were also confused about the safety and efficacy of the influenza vaccine. Participants were confused about the differences between preventive strategies and treatment for influenza and HCPs did not offer or recommend vaccination. Because of negative media reports about the pros and cons of vaccination, participants were hesitant to receive the vaccine. Nevertheless, findings suggested that motivating forces for vaccine acceptance were a high prevalence of circulating influenza infection during their pregnancy and HCP recommendations and reassurances that the vaccination was safe, effective, and beneficial for the foetus. Vaccination promotion strategies need to focus on encouraging HCPs to discuss vaccination with their pregnant clients and provide accurate and unbiased information about the risks of influenza infection and the benefits of vaccination. / published_or_final_version / Nursing Studies / Doctoral / Doctor of Nursing

Seasonal influenza, or the flu, impacts over 3 million people each year. Within the health sector, nosocomial infection and absenteeism are frequently associated with the flu. The Centers for Disease Control and Prevention (CDC) recommend flu vaccination for all eligible individuals, especially health care workers (HCWs). Interventions associated with increased HCW vaccination include educational programs and occupational health campaigns to address misconceptions regarding vaccine safety and efficacy. This project evaluated the impact of a voluntary, web-based education module to encourage registered nurse (RN) vaccination. The logic and health belief models served as the theoretical frameworks. In a nonequivalent group design, an educational program addressing evidence-based barriers to vaccination was delivered at 1 acute-care hospital and was not delivered at a comparison hospital within the health system. A total of 192 surveys (116 at intervention facility) were returned over 3 weeks. Statistically significant differences (x2 = 7.210, p = 0.007) were found for RNs who accepted influenza vaccination after education when compared to the RNs not receiving education. The 15% higher vaccination rate for RNs receiving education (91.1% vs. 76.1%) translates into more than 100 additional vaccinated RNs if applied across both hospitals. This project found that a simple but tailored web-based educational program is effective in converting RNs to vaccination acceptance. Increased vaccination produces societal change by reducing nosocomial and community influenza transmission. Reduced influenza infection improves community health as well as patient safety. Future work should address community-wide HCW education initiatives and evaluate their impact on quality and financial indicators at the hospital and community levels.