INT’L. J. PSYCHIATRY IN MEDICINE, Vol. 46(1) 1-13, 2013

FACTORS ASSOCIATED WITH INFLUENZA VACCINATION DECISIONS AMONG PATIENTS WITH MENTAL ILLNESS

RAYMOND A. LORENZ, PHARMD, BCPP AltaPointe Health Systems and University of South Alabama College of Medicine, Mobile MEGHAN M. NORRIS, PHARMD, BCPP G. V. (Sonny) Montgomery VAMC, Jackson, Mississippi LEAH C. NORTON, BS Auburn University Harrison School of Pharmacy, Mobile, Alabama SALISA C. WESTRICK, PHD Auburn University Harrison School of Pharmacy, Auburn, Alabama

ABSTRACT

Objective: To determine influenza (flu) vaccination status among the mentally ill population and identify factors associated with vaccination status. Method: A non-interventional, cross-sectional study was conducted. A self-administered survey to investigate the vaccination status and perceptions related to flu vaccine was administered between October 2011January 2012 in an outpatient psychiatry clinic that served the indigent, severely mentally ill population of Alabama. All statistical analyses were based upon a significance level of 0.05. Results: Of the 736 patients invited, 302 participated (41%). Only 28.4% were vaccinated in 2010-2011 and 24.2% had been vaccinated at the time of the survey for 2011-2012. Respondents who had private health insurance, received a recommendation from healthcare providers, and who perceived a greater degree of vaccine effectiveness were more likely to obtain flu vaccination while respondents who had education beyond high school and were more in agreement that they 1 Ó 2013, Baywood Publishing Co., Inc. doi: http://dx.doi.org/10.2190/PM.46.1.a http://baywood.com

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can get the flu from the vaccine were less likely to obtain flu vaccination. All of the above factors accounted for 26.7% of vaccination decisions. Conclusions: The flu vaccination rate among this study’s population was lower than the general population. Interventions targeting the above factors should help increase vaccination rates among the mentally ill population. (Int’l. J. Psychiatry in Medicine 2013;46:1-13)

Key Words: influenza, vaccination, immunization, perception, mentally ill

BACKGROUND Vaccinations are recommended in order to decrease morbidity and mortality related to preventable diseases. Each year in the United States, influenza (flu) contributes to greater than 200,000 hospitalizations and 36,000 deaths [1]. The Centers for Disease Control (CDC) reported that during the 2010-2011 flu season 40.9% of persons aged 18 years old or older received a flu vaccination [2]. These numbers are well below the benchmarks set by Healthy People 2020, which specifies a goal of 80% flu vaccination for non-institutionalized adults 18-64 years old, and 90% in non-institutionalized adults 65 years or older [1]. Since flu vaccination is effective in preventing flu, the Advisory Committee on Immunization Practices (ACIP) recommends that all adults obtain flu vaccinations. Previous studies have reported that patients’ demographics, knowledge, and attitudes were associated with patients’ decisions to obtain a flu vaccination. These factors included race [3], age [4], education [5], knowledge [6], insurance status [5], regular source of care [5], awareness [7], fear of side effects [7], efficacy concerns [7, 8], doctor recommendation [7], and fear that the vaccine causes flu [7, 9]. With a good understanding of the effect of these factors on patient decisions to obtain vaccination, healthcare providers may be in a better position to improve flu vaccination rates among their patients. This study was the first identifiable study that explored the relationships between patient factors and their vaccination decisions among patients diagnosed with mental illness. Vaccinations among persons with mental illness are of particular importance for many reasons. Research has found that patients with mental illness have lower rates of preventative care and have worse health and a shorter life expectancy [10, 11]. In addition, many of these patients have comorbidities which place them in a “high risk” category for flu infection. Patients considered at “high risk” for flu infection include: chronic pulmonary disease, cardiovascular disease, immunocompromised, residents of chronic care facilities, and patients that are morbidly obese [12]. Additionally, a correlation between mental illness and smoking has been demonstrated [13, 14]. This correlation is important because studies have found that smoking increases the risk of flu

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infection and is often related to more severe infections [15]. Furthermore, this population has higher rates of homelessness and institutionalization, which increases the risk for communicable illnesses. Patients with mental illness have been shown to have a higher rate of cardiovascular disease and cardiovascular risk factors which, in turn, is associated with higher risk of flu [16]. All of these factors may place patients with mental illness at a higher risk for flu and possibly flu related morbidity and mortality than the general population. Due to the above factors, it is important for healthcare providers who treat patients with mental illness to help improve flu vaccination rates among this population. The purpose of this study was to determine influenza (flu) vaccination status in the mentally ill population and identify factors associated with vaccination status including demographics and perceptions regarding the influenza vaccination. Understanding perceptions about the influenza vaccine in this population may help target practices to increase vaccination rates, therefore reducing morbidity and mortality associated with influenza among patients with mental illness. METHODS A non-interventional, cross-sectional study was conducted to investigate the vaccination status and assess factors associated with vaccination decisions among patients with mental illness. Two sources of data were utilized. First, a voluntary and confidential survey was completed by all patients ³19 years old, able to read and communicate in English, diagnosed with a mental illness, and seeking care at an outpatient psychiatry clinic between October 1, 2011 and January 31, 2012. Second, electronic medical records were used to obtain patients’ demographic information including age, sex, race, psychiatric diagnosis, living arrangements, and education level. Patients were excluded if the medical record was not available. The study protocol was reviewed and approved by the Institutional Review Boards at the authors’ institutions. Patients were recruited from a community-based outpatient psychiatry clinic serving the indigent, severely and persistently mentally ill population of Mobile and Washington counties in Alabama. Patients were recruited by survey administrators to complete the self-administered questionnaire while waiting to see one of the medical providers at the clinic including psychiatrist, psychiatric nurse practitioner, or psychiatric pharmacist. Using unique patient identifiers, the patients’ demographic information was obtained after the survey was completed and turned in to the study coordinator. The survey administrators did not intervene to advocate for or against flu vaccination before or during the time of the survey. The two-page self-administered questionnaire had two parts. The first part asked the respondents to identify their vaccination status in 2010-2011 (Yes, No) and 2011-2012, and whether any healthcare provider has recommended a flu vaccine (Yes, No). Since the survey began in October 2011 and concluded in January 2012 while the flu administration season was still going on, respondents’

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vaccination status in 2011-2012 at the time of the survey was categorized as: they had no plan to obtain vaccination, they were uncertain about their plan, they were planning to get it, and they have already received it. The second part of the questionnaire asked respondents to rate the level of agreement/disagreement with five statements: a) the flu vaccine is effective at preventing the flu, b) they can get the flu from the vaccine, c) they can get the flu vaccine without getting a shot (injection), d) vaccines can cause mental illness, and e) vaccines can worsen their mental illness. The response categories ranged from strongly disagree (1) to strongly agree (5). Data were analyzed using SPSS Statistic version 19.0 for MAC. Descriptive statistics were used to describe respondents’ characteristics included in the analysis. Data was compared using Chi-squared for categorical data and independent t-tests for continuous data. A logistic regression was completed to determine factors associated with the vaccination status. All statistical analyses were based upon a significance level of 0.05. RESULTS Of the 736 patients who were randomly invited to participate in the study, 302 patients agreed to complete the survey (41%). While a potential non-response bias was not formally investigated, the patient demographics of those who completed the survey reflect the general population of the outpatient clinic. Respondents’ Characteristics Table 1 summarizes demographic characteristics of respondents. Of the 302 who participated, 4 incomplete questionnaires were excluded and 298 complete questionnaires were included in the analysis. The majority of respondents were female (60.4%), had at least a high-school level education (62.4%), and lived with relatives (61.1%). A little over half (52%) were white; and the majority of non-white was black. The average age of respondents was 43.95 (SD = 12.50, data not shown in Table 1). Regarding insurance status, 33.9% had Medicaid, 21.5% had Medicare, and 17.1% had private insurance; while the rest (27.5%) had no insurance. About one-third (33.6%) had a disability status. The majority of respondents had a primary diagnosis of schizophrenia (30.9%) or depression (30.5%). Regarding self-reported characteristics specific to flu vaccinations (Table 2), about one-third (32.6%) of respondents recalled a recommendation for the flu vaccine by healthcare providers. Only 28.4% of respondents reported receiving flu vaccine in 2010-2011. When asked about flu vaccination status in 2011-2012, about one-fourth (24.2%) had already been vaccinated. As for those who had not been vaccinated, 43.7% had no plan to get vaccinated, 19.1% were uncertain about their plan, and 13% had planned to get vaccinated. In the subsequent analyses (presented below), two groups were generated based on their vaccination status in

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Table 1. Demographic Characteristics of Respondents (N = 298) Variable

N (%)

Sex Male Female

118 (39.6) 180 (60.4)

Race/Ethnicity White Non-whitea

155 (52.0) 143 (48.0)

Education < High school High school > High school

112 (37.6) 150 (50.3) 36 (12.1)

Living arrangement Living alone Living with relatives Group or boarding homes Unknown

73 (24.5) 182 (61.1) 31 (10.4) 12 (4.0)

Insurance status Self-pay Medicaid Medicare Private insurance

82 (27.5) 101 (33.9) 64 (21.5) 31 (17.1)

Disability status Yes No

100 (33.6) 198 (66.4)

Primary psychiatric diagnosis Schizophrenia Depression Bipolar Schizoaffective Othersb

92 (30.9) 91 (30.5) 58 (19.5) 22 (7.4) 35 (11.7)

aNon-white consists of Black, Asian, and Hispanic groups; there were fewer than five respondents who reported being Asian and Hispanic. bOthers include anxiety disorder, personality disorder, substance abuse, and other diagnoses.

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Table 2. Characteristics of Respondents Specific to Flu Vaccinations (N = 298) Variable

Na (%)

Healthcare provider recommendation for the flu vaccine No Yes Do not know

169 (56.7) 97 (32.6) 32 (10.7)

Flu vaccination status in 2010-2011 Not vaccinated Vaccinated

204 (71.6) 81 (28.4)

Flu vaccination status in 2011-2012 No plan Uncertain Plan to be vaccinated Already been vaccinated

128 (43.7) 56 (19.1) 38 (13.0) 71 (24.2)

aTotals may vary due to missing data.

2011-2012. Specifically, those who had no plan and those who were uncertain were combined into one single group, entitled “unvaccinated group (62.8%),” while those who planned to be vaccinated and those who were already vaccinated at the time of the survey were combined into the “vaccinated group (37.2%).” Characteristics and Perceptions of Flu Vaccine by Vaccination Status Five characteristics differed between unvaccinated group (n = 184) and vaccinated group (n = 109) including age, level of education, insurance status, vaccination status in 2010-2011, and vaccine recommendation from healthcare providers (Table 3). The average age in the unvaccinated group was 42.49 (SD = 12.40) while the average age for the vaccinated group was 46.45 (SD = 12.30); the difference was statistically significant (F = 6.70, p < 0.01, data not shown in Table 3). The majority of those who had greater than high school education (80.6%) or those who had no insurance (78.8%) were in the unvaccinated group. A great majority (82.1%) of those who received vaccination during the previous season were included in the vaccinated group during the current season. Conversely, the majority (80.7%) of those who were not vaccinated last season were included in the unvaccinated group for this current season. Next, 62.1% of those who received a flu vaccine recommendation from healthcare providers were included in the vaccinated group.

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Table 3. Relationships between Respondents’ Characteristics and Vaccination Status in 2011-2012 (N = 293) Unvaccinateda

Vaccinatedb

Sex Male Female

66 (57.4) 118 (66.3)

49 (42.6) 60 (33.7)

Race/Ethnicity White Non-whitec

100 (65.4) 84 (60.0)

53 (34.6) 56 (40.0)

72 (65.5) 83 (56.5) 29 (80.6)

38 (34.5) 64 (43.5) 7 (19.4)

46 (64.8) 115 (63.9) 16 (53.3) 7 (58.3)

25 (35.2) 63 (36.1) 14 (46.7) 5 (41.7)

63 (78.8) 64 (64.0) 32 (50.8) 25 (50.0)

17 (21.2) 36 (36.0) 31 (49.2) 25 (50.0)

55 (56.1) 129 (66.2)

43 (43.9) 66 (33.8)

49 (54.4) 58 (64.4) 38 (66.7) 14 (66.7) 25 (71.4)

41 (45.6) 32 (35.6) 19 (33.3) 7 (33.3) 10 (28.6)

Vaccination status in 2010-2011 Not vaccinated Vaccinated

163 (80.7) 14 (17.9)

39 (19.3) 64 (82.1)

Recommendation from providerse No Yes

125 (74.9) 36 (37.9)

42 (25.1) 59 (62.1)

Variable

Education < High school High school > High school Living arrangement Living alone Living with relatives Group or boarding homes Unknown Insurance status Self-pay Medicaid Medicare Private insurance Disability status Yes No Primary psychiatric diagnosis Schizophrenia Depression Bipolar Schizoaffective Othersd

c2 (df) 2.1 (1)

0.9 (1)

7.7 (2)*

1.5 (3)

16.2 (3)**

2.8 (1)

4.4 (4)

95.3 (1)**

34.9 (1)**

a Those who had no plan to be vaccinated and those who were uncertain about getting vaccinated. b Those who planned to be vaccinated and those who had been vaccinated in 2011. c Non-white consists of Black, Asian, and Hispanic groups; there were fewer than five Asian and Hispanic respondents. d Others included anxiety disorder, personality disorder, substance abuse, and other diagnoses. e Don’t know was excluded from the analysis. *p < 0.05; **p < 0.01.

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Unvaccinated and vaccinated groups differed in their perceptions concerning the flu vaccine and its effect (Table 4). Five statements were given to the respondents to rate the level of disagreement/agreement. The score for each item ranged between 1 (strongly disagree) to 5 (strongly agree) while 3 was being neutral. Specifically, respondents in the vaccinated group perceived the vaccine to be more effective than those in the unvaccinated group (3.63 vs. 3.19). Also, vaccinated respondents were less in agreement to the statement about a possibility of getting the flu from the vaccine (2.38 vs. 3.04). As for the statement, “I can get the flu vaccine without getting a shot,” both groups tended to disagree with the statement (as the score was less than 3). Lastly, respondents in both groups tended to be in disagreement with states of vaccines causing and worsening mental illness. Factors Associated with Vaccination Status A logistic regression analysis was conducted to identify factors associated with respondents’ vaccination status (Table 5). All factors associated with the vaccination status in 2011-2012 (presented in Tables 3 and 4) were included in the analysis except for the vaccination status in 2010-2011. The reason for excluding the 2010-2011 vaccination status was because it was a similar decision to the dependent variable (vaccination status in 2011-2012). All of the factors included

Table 4. Mean Agreement for Statements Concerning Flu Vaccine by Vaccination Status in 2011-2012 (N = 293)a Vaccination status in 2011-2012 Unvaccinated Mean (SD)

Vaccinated Mean (SD)

F

The flu vaccine is effective in preventing the flu

3.19 (1.04)

3.63 (1.34)

9.82**

I can get the flu from the flu vaccine

3.04 (1.25)

2.38 (1.19)

19.90**

I can get the flu vaccine without getting a shot

2.68 (1.21)

2.62 (1.30)

0.13

In general, vaccines can cause mental illness

2.04 (0.95)

1.94 (1.10)

0.65

In general, vaccines can worsen my mental illness

2.11 (0.97)

1.97 (1.13)

0.25

Statement

*Response categories ranged from 1 (strongly disagree) to 5 (strongly agree). **p < 0.01.

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Table 5. Odds Ratio (OR) and 95% Confidence Interval (CI) from Logistic Regression Analysis Explaining Vaccination Status in 2011-2012 (n = 250)a b

OR

95% CI

0.01

1.01

0.98-1.04

0.45 –1.23

1.57 0.29*

0.82-3.00 0.09-0.96

Insurance statusc Medicaid Medicare Private insurance

0.15 0.87 1.36

1.16 2.38 3.91**

0.50-2.66 0.95-5.96 1.48-10.36

Recommendation from healthcare providersd Yes

1.42

4.12**

2.17-7.82

Perceived effectiveness of vaccine in preventing the flu

0.28

1.33*

1.00-1.75

Perception that they can get the flu from the vaccine

–0.45

0.64**

0.49-0.82

Variable Age Educationb High school More than high school

aCox and Snell R square = 0.267. bThe comparison group was < high school. cThe comparison group was self pay. dThe comparison group was no recommendation from providers.

*p < 0.05; **p < 0.01.

in the logistic model together accounted for 26.7% of vaccination status. The results indicated education, insurance status, recommendations from healthcare providers, perceived effectiveness of vaccine in preventing the flu, and perception that they can get the flu from the vaccine were significant factors associating with the vaccination status. Specifically, respondents with more than a high school education were 71% less likely to be vaccinated than those who had less than a high school education. Having private insurance plans (compared to self-pay) and recommendations from healthcare providers increased the likelihood of being vaccinated by 3.91 and 4.12 times, respectively. Next, respondents were coded on a 5-point scale ranging from strongly disagree (1) to strongly agree (5) with the statements “the flu vaccine is effective in preventing the flu” and “I can get the flu from the flu vaccine.” For the statement about its effectiveness,

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every one-unit shift toward “strongly agree” category corresponded with an increased likelihood of being vaccinated by 1.33 times. As for the second statement, for every one-unit shift toward “strongly agree” category, the likelihood of being vaccinated decreased by 0.64 times. DISCUSSION According to a recent systematic review, there was strong evidence that individuals with mental illness, compared to those without mental illness, had lower frequency of preventive care including flu vaccination [17]. Realizing the need to address this disparity, this study identified flu vaccination status among adult patients with mental illness and explored factors associated with the flu vaccine uptake among this population. This study found that only 28.4% were vaccinated in 2010-2011 and 24.2% had been vaccinated at the time of the survey. These statistics were lower than the national vaccination rate of 40.9% for the 2010-2011 flu season [2]. Further, these vaccination rates found in this study were also lower than the vaccination rate (> 60%) among the elderly population with depressive symptoms in United Kingdom [18]. Therefore, the need to increase flu vaccination rates among non-elderly adult patients with mental illness warrants immediate attention from healthcare providers. This is especially true for healthcare providers who work in outpatient psychiatric clinics. Oftentimes mental health is the focus of the treatment in this specialty clinic and disease prevention strategies are rarely discussed. Mental health clinic settings may be one of few opportunities that the patients are interacting with healthcare providers. As such, results from this study should help mental health providers design effective strategies to address patients’ concerns and increase patients’ acceptance of flu vaccination. Consistent with previous studies [7, 19], respondents who received recommendations from healthcare providers were four times more likely than their counterparts to obtain flu vaccination. Also, a systematic review conducted by Ndiaye and colleagues found strong evidence that provider reminder systems are effective in improving vaccination rate [20]. As such, this study recommends the use of provider reminder systems such as computerized reminder system in providers’ clinics. Through the use of a reminder system, healthcare providers would be informed when individual patients are due for specific vaccinations. This study further suggests that, when healthcare providers offer recommendations for flu vaccine during patients’ regularly scheduled visits, they should stress the benefits of vaccination against the flu especially concerning the effectiveness of the vaccine. This simple intervention may be able to increase the vaccination rate. It is important to note that, while strong evidence supports the use of provider reminder systems in provider clinics, its effectiveness may be limited to clinics serving the general population. Therefore, future research should examine the effectiveness of the provider reminder systems when used to recommend the flu vaccine to patients with mental illness.

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When comparing the perceptions of the flu vaccine between the population with mental illness being studied in this current project and the general population with low income [21], certain similarities in their perceptions were found. In the low-income population, negative beliefs about vaccine safety and efficacy were highly predictive of decisions to be vaccinated [21]. Similarly, in this current study, misperceptions that the flu vaccine could cause the flu affected their decisions. While certain symptoms such as malaise, sore throat, and a runny nose can occur after receiving the flu vaccination, by its very nature, the inactivated flu vaccine cannot cause the flu [22]. By educating patients about the adverse effects of the flu vaccine, patients may be more willing to obtain a flu vaccine knowing that it does not cause the flu. Furthermore, some patients found in this study also thought that the flu vaccine was ineffective at protecting against the flu. The flu vaccine is developed months before the actual start of the flu season based on several factors including which flu strains are circulating and how well current vaccines protect against the flu. Once the vaccine is administered, it takes about 2 weeks for the vaccine to produce the required antibodies. These two factors may contribute to the perception that the flu vaccine is ineffective because either the flu strain that is circulating may not be a good match for the vaccine and/or the patient may have been exposed to the flu virus before the vaccine is fully effective [22]. Again, educating patients on these limitations are paramount in our effort to increase the vaccination rate among patients with mental illness. Financial barrier is another key factor that should be addressed. Almost 80% of those without health insurance were not vaccinated against flu virus. To increase the vaccination rate among this group, it is important for healthcare providers to be aware of clinics and/or pharmacies in the area that provide free flu vaccination and subsequently refer the patients to these free sites. Further, even though there is no cost to the patients who have health insurance to obtain flu vaccine, more than half of this group was not vaccinated. Perhaps, these patients are unaware that co-pays and deductibles are not applicable for flu vaccine. Hence, for patients in this group, healthcare providers should educate their patients that obtaining flu vaccine is free of charge. There are several limitations to this study that should be noted. First, a nonresponse bias investigation was not conducted. It is possible that characteristics of those who participated and those who did not participate may differ. Additionally, using minimum standards of having at least 10 responses for each independent variable were included in the analyses, and obtaining 250 respondents was acceptable in the multivariate analysis used in this study [23, 24]. The second limitation is that it was a cross-sectional study. As such, it can only identify important associations with vaccination status. Third, there may be other characteristics of respondents that were not measured and included in the analysis that contribute to vaccination status. Fourth, potential errors due to social desirability and recall biases need to be recognized when interpreting the results. Lastly, this

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study was conducted in a mental health clinic. As such, results may have limited generalizability to other types of clinics as the population may be different. CONCLUSION About one-fourth of patients at our outpatient mental health center received the flu vaccine for the 2010-2011 season. Compared to 40.9% of the general population who received the flu vaccine in 2010, it is apparent this rate needs to be increased. Respondents who had private health insurance, received a recommendation from healthcare providers, and who perceived a greater degree of vaccine effectiveness were more likely to obtain flu vaccination, while respondents who had education beyond high school and more in agreement that they can get the flu from the vaccine were less likely to obtain flu vaccination. Interventions targeting these factors should help increase vaccination rates among the mentally ill population. REFERENCES 1. U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion, Healthy People 2020, Washington, DC. Retrieved June 21, 2012 from http://www.healthypeople.gov/2020/topicsubjectives2020/overview.aspx? topicid=23 2. Centers for Disease Control and Prevention, Interim Results: State-Specific Influenza Vaccination Coverage, Morbidity and Mortality Weekly Report 2011;60(22):737-743. 3. Setse RW, Euler GL, Gonzalez-Feliciano AG, et al. Influenza vaccination coverage— United States, 2000-2010, Morbidity and Mortality Weekly Report (MMWR) 2011; 60:38-41. 4. Van Essen GA, Kuyvenhoven MM, Melker RA. Why do healthy elderly people fail to comply with influenza vaccination? Age and Ageing 1997;26(4):275-279. 5. Rangel MC, Shoenbach VJ, Weigle KA, Hogan VK, Strauss RP, Bangdiwala SI. Racial and ethnic disparities in influenza vaccination among elderly adults. Journal of General Internal Medicine 2005;20(5):426-431. 6. Martinello RA, Jones L, Topal JE. Correlation between healthcare workers’ knowledge of influenza vaccine and vaccine receipt. Infection Control and Hospital Epidemiology 2003;24(11):845-847. 7. Centers for Disease Control and Prevention. Reasons reported by Medicare beneficiaries for not receiving influenza and pneumococcal vaccinations—United States, 1996. Morbidity and Mortality Weekly Report(MMWR) 1999;43:886-889. 8. Fiebach NH, Viscoli CM. Patient acceptance of influenza vaccination. American Journal of Medicine 1991;91:393-400. 9. Nichol KL, Lofgren RP, Gapinski J. Influenza vaccination: Knowledge, attitudes, and behavior among high-risk outpatients. Archives of Internal Medicine 1992;152: 106-110. 10. Xiong GL, Losif A, Bermudes RA, McCarron RM, Hales RE. Preventive medical services use among community mental health patients with severe mental illness: The influence of gender and insurance coverage. Primary Care Companion Journal of Clinical Psychiatry 2010;12(5):PMC3026000.

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11. De Hert M, Dekker JM, Wood D, et al. Cardiovascular disease and diabetes in people with severe mental illness position statement from the European Psychiatric Association (EPA), supported by the European Association for the Study of Diabetes (EASD) and the European Society of Cardiology (ESC). European Psychiatry 2009;24(6):4412-4424. 12. Hibberd P. Seasonal influenza vaccination in adults. In UpToDate, Basow DS, editor, Waltham, MA, 2012. 13. Leonard S, Adler LE, Benhammou K, et. al. Smoking and mental illness. Pharmacology, Biochemistry, and Behavior 2001;70(4):561-570. 14. Lasser KL, Boyd W, Woolhandler S, et al. Smoking and mental illness. Journal of the American Medical Association 2000;284(20):2606-2610. 15. Arcavi L, Benowitz NL. Cigarette smoking and infection. Archives of Internal Medicine 2004;8;164(20):2206-2216. 16. Newcomer JW, Hennekens CH. Severe mental illness and risk of cardiovascular disease. Journal of the American Medical Association 2007;298(15)1794-1796. 17. Lord O, Malone D, Mitchell AJ. Receipt of preventive medical care and medical screening for patients with mental illness: A comparative analysis. General Hospital Psychiatry 2010;32(5):519-543. 18. Mangtani P, Breeze E, Kovats S, Ng ES, Roberts JA, Fletcher A. Inequalities in influenza vaccine uptake among people aged over 74 years in Britain. Preventive Medicine 2005;41(2):545-553. 19. Nichol KL, Mac Donald R, Hauge M. Factors associated with influenza and pneumococcal vaccination behavior among high risk adults. Journal of General Internal Medicine 1996;11(11): 673-677. 20. Ndiaye S, Hopkins D, Shefer A, et al. Interventions to improve influenza, pneumococcal polysaccharide, and hepatitis B vaccination coverage among high-risk adults. American Journal of Preventive Medicine 2005;28:5S. 21. Redelings MD, Piron J, Smith LV, Chan A, Heinzerling J, Sanchez KM, Bedair D, Ponce M, Kuo T. Knowledge, attitudes, and beliefs about seasonal influenza and H1N1 vaccinations in a low-income, public health clinic population. Vaccine 2012; 30(2):454-458. 22. Centers for Disease Control and Prevention. Key facts about seasonal flu vaccine. Atlanta, GA. Retrieved August 8, 2012 from http://www.cdc.gov/flu/protect/ keyfacts.htm 23. Nunnally JC, Bernstein IH. Psychometric theory (3rd Edition). New York, NY: McGraw-Hill, 1994. 24. Vittinghoff E, McCulloch CE. Relaxing the rule of then events per variable in logistic and cox regression. American Journal of Epidemiology 2007;165(6):710-718.

Direct reprint requests to: Raymond A. Lorenz, PharmD, BCPP 30548 Westminster Gates Dr. Spanish Fort, AL 36527 e-mail: [email protected]

Factors associated with influenza vaccination decisions among patients with mental illness.

To determine influenza (flu) vaccination status among the mentally ill population and identify factors associated with vaccination status...
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