American
Journal Volume
19
of Infection Number
4
Control August
1991
ARTICLES
Influenza and hepatitis acceptance: A survey health care workers Margaret Spokane,
A. Christian, Washington
B vaccine of
RN, MA, CIC
To assist in the nonrequired vaccine program evaluation at Valley Hospital and Medical Center in Spokane, Washington, a survey of all employees (M = 379) was conducted, with a 63.3% return rate. The most common reasons for not accepting influenza vaccine were wish to avoid medications whenever possible (47%, 96/203), concern about getting influenza from the vaccine (45%, 89/199), and concern about severe reactions such as Guillain-Barre syndrome (37%, 731196). The most common reasons for not accepting hepatitis B vaccine were not enough exposure to hepatitis B to get vaccinated (52%, 5711 lo), wish to avoid medications whenever possible (44%, 5 1/ 117), and concern about side effects (43%, 501117). Twelve percent (221177) of the respondents who reported potential exposure identified the belief of “not enough exposure” as a reason to refuse hepatitis B vaccine. It was also noted that health care workers who rejected hepatitis B vaccine indicated that fear of “getting AIDS from the vaccine” did not influence them (96%, 1081113). (AM J INFECT CONTROL 1991;19:177-84)
Acceptance by health care workers of vaccines that are recommended but not required is a concern at Valley Hospital and Medical Center, a 123-bed, acute-care hospital in Spokane, Washington. Influenza immunizations are offered to all employees annually. The Centers for Disease Control (CDC)’ recommends that “administrators of all health-care facilities should arrange for influenza vaccine to be offered to all personnel before the influenza season.” The CDC states that there should be “particular emphasis on vaccination of persons who care for high-risk paFrom the Infection ical Center. Reprint Hospital 99216.
Control
Department,
requests: Margaret and Medical Center,
Valley
Hospital
and
Med-
A. Christian, RN, MA, CIC, Valley 12606 East Mission, Spokane, WA
tients (e.g., staff of intensive-care units and staff of medical/surgical units).” “Influenza infections cause significant morbidity, some mortality, and excessive resource consumption.“2 During the 1988-89 influenza season 19 (4.6%) of 407 employees took advantage of the hopsital influenza vaccine program. During the 1989-90 season the response increased to approximately 5.6%. In addition to the CDC recommendations, the Washington Industrial Safety and Health Administration (WISHA) requires a hepatitis B vaccine program.3 A recombinant hepatitis B vaccine is offered at the time of employment to all employees at Valley Hospital; those who refuse may change their minds at any time in the future. During 1988 the vaccine was offered to 102 new employees. Fifteen new employees already had taken the vaccine and 44 requested the vaccine through the hospital program, for an acceptance 177
178 Table
C’hrisrim
I.
Presclrvey
hepatitls
6 vaccine
acceptance
rates No.
Department
Obstetric nurses IV therapy nuws OR scrub technlclans Emergency personnel CU nurses Nursery nurses OR circulating nurses Laboratory technicians Labora!ory aide (phlebotomis!)
vrcclwtd
OF THE
. ..__._ Total
wlployees 16 4 19 25 18
4
10 12 4
4 1
LITERATURE
People’s beliefs, values, and social intluences may have a significant impact on the extent to which they follow any recommended regimen.J Such variables as age, sex, race, educational Icvel, marital status, cultural attributes, socioeconomic level, and religion have been studied as determinants of adherence to a treatment rcgimen. These variables arc not a reliable cxplanation for compliance.’ Why pcoplc do not use health care services when they are easily accessible is one of the crucial questions in medical care. In regard to adherence to a variety of treatment regimens, “estimates of noncompliance range from 4% to 92%, and average from 30% to 3 ” Initially proposed by Rosenstock (1966) and revised by Becker and Maiman (1975), the health belief model is one of the few models available that attempts to explain health behavior and/or compliance.“’ Becker states the health belicf model has been shown to be associated with individuals’ decisions to accept immunizations.” This model includes perceived susceptibility, perceived severity, pcrccivcd benefits, and pcrceivrd costs or barriers. The patient-practitioner relationship and physician continuity arc modifving factors that motivate compliance. Becker has argued that this model is a useful framework j%."9
.-___----.-~.-_
12 3 7 17 12 6
rate of 58%. Twelve (27%) of the 44 requesting the vaccine did not start the series. In 1989, 20 of 81 new employees previously had the vaccine, 35 requested the vaccine, and 14 (40%) of those did not start the scrics. In 1989 the new employee acceptance rate was 68%. Table 1 shows the hepatitis B vaccine acceptance rates in selected departments at Valley Hospital and Medical Center. REVIEW
_-.-
11
__. ----_
.-
..-
.
Percent accfqtanca 75 75 ‘0 68
67 LA ., 43 33 25
for Inten~ention.5 If the health belieiscan be idtntilied, changes can be made in programs to incrcasc compliance. There arc few available data on hospital employees’ acceptance of or attitudes to;vard vaczinc recommendations.: Weingartrn et a!.’ S;liveyed physicians and nurses and showed that only 2.1% received the 1986-87 triva!eni inlluenza vaccine and 3.2% received the monovalent Taiwan vaccine before the 1986-87 influenza season. “Fear of adverse reactions, avoidance of medications, and the inconvenience of vaccine administration were frequently cited reasons for declining immunizations.“’ Hanacik et al .’ collected subjective opinions on hepatitis B immunization programs through a survey of infection controi practitioners at a national conference. Their sur-ve?; showed that there are employees who arc unaware of risk and who are unaware of the vaccine offer.’ In 1985 a statewide survey in Michigan found that fear of vaccine-associated acquired immunodeficiency syndrome (AIDS) was most frequently cited as the primary reason for vaccine refusal.” In reporting on the suri.e>‘, Sicnko et al. concluded “that unwarranted Tears about the vaccine’s safety riced to be dispelled.” In 1983 researchers at Rhode Island Hospital surveyed 1500 employees regarding acceptance of hepatitis B vaccine. They concluded “that rhe beliefs of health care providers. particularly regarding the safety and efficacy of hepatitis B vaccine, have a major impact on thcil. decision to accept or reject vaccine.“’ Other beliefs that were less important determinants concerned the likelihood of contracting hepatitis B and the chance of becoming severely ill. “A marked variation in the rate of acceptance of vaccine among heaith care personnel has been reported ranging from
Volume 19 Number August 1991
4
Influenza and hepatitis B vaccine acceptance
Table 2. Influenza 1. m Please circle 2. Y 3. Y 4. 5. 6.
Y Y Y
(flu) and hepatitis y for yes
B vaccine
179
questionnaire
f or n for no. n n
Please
n 22. y 23. y n 24. y n If YES to 22, 23, or 24: Thank you, you’re finished. If NO to 22, 23, AND 24, please continue. Did the following reasons influence you to not take 25. y n 26. y n n 27. y n 28. y 29. y n 30. y n n 31. y 32. y n n 33. y 34. y n n 35. y n 36. y 37. y n n 38. y 39. y n n 46 Y
58% to as low as 27%.“’ Crossley et al.‘O reported acceptance rate of 38% in 1982 at two universityaffiliated teaching hospitals. A Merck Sharp & Dohme publication in the spring of 1990 stated that “only 30% to 40% of high-risk health care workers have opted to re-
m if you
are male
or f if
you are female.
Does your work involve contact with patients? Have you had flu symptoms (a fever with either a sore throat, cough, or a runny nose) since Dec. 1, 1989? Did you work while ill with flu symptoms? Did you take amantadine (Symmetrel) to prevent flu? Did you get the flu vaccine for the 1989-90 flu season?
n n n
If YES, skip to question 21. If NO, please continue with the next question. Did the following reasons influence you to not take n 7. Y n 8. Y n 9. Y 10. y n 11. y n n 12. y 13. y n n 14. y 15. y n 16. y n 17. y n n 18. y n 19. y 20. y n n 21. y
circle
flu
vaccine? Avoid medications whenever possible. Vaccine administration inconvenient. Concern about severe reactions like Guillain-Barre. Concern about getting flu from the vaccine. Vaccine not effective. Concern about pain and discomfort. Prior adverse reaction to the vaccine. Cost to employee. Allergic to the vaccine. No one recommended it to me. Flu is not a serious disease. I’m not likely to get the flu. Friends decided not to get vaccine. Other (write in) Does your job include the possibility of exposure to patients’ blood/body fluids at least once a month? Have you had the disease hepatitis B? Have you completed the hepatitis B vaccine series? Are you currently taking the vaccine and “on schedule”?
hepatitis B vaccine? (If female) Concerns of pregnancy or breast feeding. Newness of vaccine. Schedule of doses too complicated. Concern of side effects. Avoid medications whenever possible. Concern of getting AIDS from the vaccine. Not enough exposure to hepatitis B to get vaccinated. Hepatitis B is not a serious disease. Vaccine is not effective. Cost to employee. Concern about pain and discomfort. Vaccine administration inconvenient. No one recommended it to me. Friends recommended against it. Concern about getting hepatitis B from the vaccine. Other (write in) Just Fold and Route
ceive hepatitis B vaccine.“” Two successful programs were cited. One was able to achieve a compliance rate of 80.6% of employees at risk, and the other had an initial compliance rate of 67%.” A nationwide survey of 200 persons found that only half had been vaccinated and “more than
American
100
Table
Christian
3.
Attitudes
!NFECTION
influencing
acceptance
of influenza
Jourw
0:
fONTF!O1~
vaccine _____-
AnRude
Yes/tot&l
%
No/Total
%
7. Avoid medications 8. Inconvenient 9. Severe reaction concern 10. Get flu from vaccine
961203 371194 731196 891199
47 19 37 45
107/203 571194 1231196 1101199
53 81 63 55
11, 12. 13. 14. 15. 16. 17. 18. 19. 20.
411185 301197 391199 141195 121193 481196 45/190 561193 51190 561213
22 15 20 7 6 2.5 24 29 3 26
1441185 1671197 1601199 1811195 1831193 1481196 1451190 137/193 185/190 1571213
78 85 80 93 94 76 76 7: 97 74
Vaccine ineffective Pain and discomfort Prior reaction cost Allergy No recommendation Flu not serious Not likely to get flu Friends do not get vaccine Write in
30% of emergency workers surveyed did not know a vaccine is available.“” Most of the research reviewed addressed acceptance of only hepatitis B vaccine. That vaccine was released in 1982, just after AIDS was recognized in 198 1. Since the cause of AIDS was unknown at the time, there was concern that the hepatitis B vaccine could transmit AIDS. That belief was “based on the fear that those considered to be at high risk for infection with the human immunodeficiency virus had donated serum for the manufacture of the vaccine.“13 The fear persisted “in spite of the fact that several clinical studies provided assurances of the safety of the Heptavax-B product .“I3
The health care workers studied included all employees of Valley Hospital for the following reasons: 1. Although the influenza vaccine recommendation specifies workers having extensive contact with patients who have high-risk chronic medical conditions, any employee may be implicated in influenza transmission in a small community hospital such as Valley Hospital and Medical Center. 2. Hepatitis B vaccine is offered to all employees. Since the attitudes of high-risk employees regarding refusal of the vaccine are especially important, a question identifying the employee’s risk was asked. High-risk is defined as having potential for exposure to patients’ blood or body fluids at least once a month. The sample represented a convenient and logical cluster, which included several sets of
subgroups: employees involved in patient care and those not involved in patient care, employees with the opportunity of exposure to blood and body fluids at least once a month and those expecting no exposure, and male and female employees.
A questionnaire (Table 2) was used to collect data regarding the variables. The instrument, along with a cover letter, was attached to each employee’s time sheet on March 19, 1990. The cover letter explained how the survey would-be used, how the results would be shared with them, and whom to contact with questions and was signed by the chief operating o&cer to show administrative approval. The light green questionnaire consisted of one page so that it would not appear to be an overwhelming task to complete it. Instructions were included to “just fold and route“; the design included routing instruction for the “in-house mail” system. A second letter was sent to all departments a week later to encourage participation and thank those who completed the questionrmaire. Managers were also reminded during meetings to encourage employees to complete the questionnaire. The study closed on April 16, 1990. An attempt was made to survey non-responders by asking the department managers to take questionnaires back to their departments and request anyone who had not completed one to do so. However, only one response was received from the use of this technique. A problem with this design was that commonly used inferential statistics were not appropriate
volume August
19 Number 1991
4
Influenza
Table 4. Influenza
vaccine,
write-in
Reaffirm questions 7-l 9 Did not think about it Pregnancy or breast feeding Not a priority or not interested Nos. 7-19 not marked but written Do not like shots Other medical condition Procrastinatinglforgot Not in high-risk group Did not know it was available Doctor said “no”
25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40.
influencing
acceptance
in
of hepatitis
acceptance
181
No. of responses
%
11/52 7152 6152 6152 6152 4152 3152 3152 3152 2152 l/52
20 13 12 12 12 8 6 6 6 4 2
B vaccine
Attitude
Yes/total
%
No/total
%
Pregnancy/breast feed Newness Complicated schedule Side effects Avoid medications Get AIDS from vaccine Not enough exposure Not a serious disease Vaccine not effective cost Pain and discomfort lncovenience Not recommendation Friends against Get hepatitis B Write in
141110 21/116 91114 501117 511117 51113 571110 71110 31107 al108 171112 171110 201113 l/110 261109 241124
13 18 8 43 44 4 52 6 3 7 15 16 18 1 24 19
961110 951116 105ll14 671117 661117 108/113 531110 103/110 104llO7 1001108 951112 931110 931113 109/110 831109 1001124
87 82 92 57 57 96 48 94 97 93 85 85 82 99 76 81
for analyzing data that resulted from the study. The study was exploratory in nature, and a majority of the results were descriptive statistics. The Statistical Package for the Social Sciences (SPSS) on the Vax at Gonzaga University was used to compile data for the tables. One inferential statistic, a x2 analysis, was used to evaluate the difference between men and women accepting hepatitis B vaccine. ETHICAL
B vaccine
attitudes
Attitude
Table 8. Attitudes
and hepatitis
ISSUES
“Persuasion by rational means, by offering a person reasons why he ought to act in some way, treats him as an equal and respects his right of free and informed choice.“14 The questionnaire includes “reasons” that have influenced other health care workers not to take the vaccine. Many of these reasons are not valid or true. However, just reading them may influence the Valley Hospital employees not to take the vaccine in the future. For each employee to make an informed
choice, future education programs must address correction of misinformation. Confidentiality was not an issue, since the questionnaire was completed anonymously. RESULTS
Of 379 questionnaires distributed 240 were returned, for a 63.3% return rate. The attitudes that did and did not influence health care workers to take the influenza vaccine are shown in Table 3, and a summary of write-in results for refusing influenza vaccine is presented in Table 4. The most common attitude given for not taking influenza vaccine was No. 7, “avoid medications whenever possible.” Forty-seven percent (96/203) of the respondents who answered that question said it influenced their behavior. Second most common was No. 10, “concern about getting flu from the vaccine” (45%, 89/ 199). Third was No. 9, “concern about severe reactions like Guillain-Barre” (37%, 731196). Fourth was No.
182
American INFECTON
Christian
TaMe 8. Hepatitis B vaccine write-in attitudes Attitude Reaffirm questions 25-39 Other medical condition Did not think/know about Procrastinating Doctor said “no” Do not like shots Not interested Plan to get it
No. of responses
it
6124 4124 3124 3124 2124 2124 2124 1124
% 25 17 13 13 8 8 8 4
18, “I’m not likely to get the flu” (29%, 561193). The most common attitude that did not influence the health care workers was No. 19, “friends decided not to get vaccine” (97%, 185/ 190). Second was No. 15 “allergic to the vaccine” (94%, 181/ 193). Third was No. 14, “cost to employee” (93%, 181/195). There currently is a $2 administration fee for influenza vaccine. Table 5 shows attitudes that did and did not influence health care workers to accept hepatitis B vaccine, and Table 6 presents a summary of write-in reasons for refusing hepatitis B vaccine. The most common attitude given for not accepting hepatitis B vaccine was No. 31, “not enough exposure to hepatitis B to get vaccinated.” Fifty-two percent (57/l 10) of the responders said it influenced their behavior. Second most common was No. 29, “avoid medications whenever possible” (44%, 511117). Third was No. 28, “concern of side effects” (43%, SO/ 117). Fourth was No. 39, “concern about getting hepatitis B from the vaccine” (24%, 261109). The most common attitude that did not influence health care workers to reject hepatitis B vaccine was No. 38, “friends recommended against it” (99%, 109/110). Second was No. 33, “vaccine is not effective” (97%, 104/107). Third was No. 30, “get AIDS from vaccine” (96%, 108/113). Table 7 shows a comparison of dependent variables and selected independent variables according to gender. There were 192 persons who gave reasons for not accepting the flu vaccine. Many gave more than one reason. The mean number of reasons was 3, the median was 4.5, and the mode was 1. The N - 1 SD was 1.795. There were 110 persons who gave reasons for not accepting hepatitis B vaccine. The mean was 2.9, the median was 5, the mode was 1. The N - 1 SD was 1.939.
Jourw oi CONTROL
There was a cluster of the top three variables for each of the vaccines. When the fourth variable was added to each list, the beliefs that influenced behavior were comparable, with some order reversal (Table 8). According to the health belief mode1,5 Valley Hospital and Medical Center can increase compliance with vaccine recommendations by addressing these issues. The results showed some other interesting points. Eighty-two percent (1961240) of the respondents had patient contact; of those, 10% (20/ 196) had taken flu vaccine. Twenty-two of the total respondents (9%) reported having taken flu vaccine. These are both higher rates than the 4.6% and 5.6% calculated through the hospital vaccine program. Very few health care workers took Amantadine to prevent the flu (6/240). Seventy percent of the health car& workers who had flulike symptoms (1001240) reported that they worked while ill (76/100). Perhaps a higher influenza vaccine acceptance rate would decrease the possibility of disease transmission within the hospital. Of the 82% (196/240) of the health care workers who had patient contact, 88% (172 / 199) also had potential exposure to blood and body fluids. Of the 44 (18%) who did not have patient contact, 5 (11%) reported potential exposure to blood and body fluids. This result reaffirms the policy to offer hepatitis B vaccine to all personnel. Twelve percent (22 / 177) of the respondents who reported potential exposure identified the belief “not enough exposure” as a reason not to take hepatitis B vaccine. This is an important misconception that needs to be addressed. Sixty-two percent (109/177) of the health care workers who reported potential exposure to blood and body fluids have had the hepatitis B vaccine or are on schedule in taking the series of inoculations. This rate fits in well with the 58%: and 68% new employee vaccine acceptance rates, Only 8 (3.3%) health care workers reported a history of hepatitis B. Crossley et al.” surveyed health care workers in two hospitals who did not accept hepatitis B vaccine and found that 6% and 16% of them marked the response “I’ve had hepatitis B” as a reason for refusal. He quoted the literature as showing that “hepatitis B virus infection ranges from 10% to 40% in physicians, dental staff, nurses and laboratory personnel.” The rate in questionnaire respondents may be artificially low, since there was no serologic analysis.
Volume19
Number
4
Influenza
August1991
Table 7. Comparison
of response
and hepatitis
B vaccine
Variable Patient contact Yes No Accept flu vaccine Yes No Blood and body fluid exposure Yes No Accept hepatitis B vaccine Yes No Vaccine on schedule Yes No
8. Comparison
of beliefs
influencing
rejection
Female %
No.
%
36 5
88 12
159 36
82 18
2 38
5 95
20 175
10 90
31 10
76 24
145 47
76 24
27 14
66 34
83 112
43 57
2 36
5 95
14 168
8 92
of vaccines Hepatitis
47% 45% 37% 29%
Avoid medications Get flu from vaccine Severe reaction concern Not likely to get flu
analysis
of male/female
Accept vaccine Reject vaccine Total
(n = 195)
No.
Influenza
Table 8. Chi-square
I83
by gender Male (n = 41)
Table
acceptance
B
Not enough exposure Avoid medications Concern of side effects Get hepatitis B from vaccine
acceptance
of hepatitis
52% 44% 43% 24%
B vaccine
Male
Female
Total
27( 19) 14(22) Ti
83(91) 112(104) 195
110 126 236 (O-E)2
0
E
O-E
27 83 14 112
19 91 22 104
-8 -8
8
8
Another difference noted in this study was the 66% hepatitis B vaccine acceptance rate for males as compared to the 43% acceptance rate for females. A total of 46.6% (110/236) accepted the vaccine overall. Chi-square analysis (Table 9) showed x2 = 7.595 (p = 0.01). The other comparisons noted in Table 7 were strikingly similar, as expected from reading the literature. It was also noted that among the reasons that did not influence health care workers to reject vaccine was the variable “get AIDS from vaccine”
(O-E)2 64 64 64 64
E 3.368 0.703 2.909 0.615 x2 = 7.595
(96%, 108 / 113). This was quite a change from the 1985 survey by Sienko et a1.8 and may show that educational programs and use of recombinant vaccines have changed health care workers’ beliefs. The following recommendations for Valley Hospital and Medical Center’s immunization program are a result of this study: 1. Use the employee newsletter to share the survey response rate and questionnaire results. 2. Give the first dose of hepatitis B vaccine at
184
3.
4.
5.
6.
7.
Christian the time of the physical examination to decrease the number of new employees who request and never start the series. Address misinformation issues through the existing mandatory education program. Specifically include risk of disease exposure and concern about getting disease as a result of the vaccine. Emphasize that the fact that a belief was listed in the questionnaire does not make it true. Publicize national recommendations for health care workers to accept influenza vaccine to protect patients in the hospital. Use any of the formal and informal communications systems (staff meetings, nursing council, ancillary forum, memos, and guest relations publications) that are available to share appropriate vaccine information. Drop the $2 administration fee for influenza vaccine, as has recently been done for hepatitis B vaccine. Take influenza and hepatitis B vaccine into the employees’ departments for administration.
LtMtTATtONS
OF THE STUDY
The 63.3% response rate and the small number of employees may make it difficult to generalize the data to the larger population of health care workers. An effective follow-up system was sacrificed by ensuring the employee’s anonymity. After the study was completed, a cross-check with payroll records showed that 10 nursery employees and 4 cafeteria employees were missed when the questionnaires were attached to the time sheets. This study was exploratory in nature, and the majority of the results were descriptive statistics rather than inferential. Physician response at Valley Hospital to vaccine recommendations is unknown. Scheckler’” cites an 8% physician acceptance rate of hepatitis B vaccine. It would have been helpful to include physicians in the study. Overall, the survey raised health care workers’ level of awareness of the vaccine program. As the recommendations are implemented, an increase in compliance can be expected. However, during the spring of 1990 there was a measles outbreak in the state of Washington.16 With emphasis on measles immunity, the influenza and hepatitis B vaccine acceptance rates may suffer.
Thanks are extended to Michael R. Carey, Assistant Professor of Organizational Leadership in the School of Professional Studies, Gonzaga University, for his crirical review of this research project and assistance with the statistical component at Gonzaga University. Michael Liepman, Chief Opet ating Officer of Valley Hospital and Medical Center in Sp+ kane, Washington, is also thanked for his administrative support. Thanks also go to Scott Weingarten, Mary Riedinger , Linda Burnes Bolton, Peggy Miles, and Mark Ault ft)r providing a copy of the survey instrument used in their study u! barriers to influenza vaccine acceptance iA&? J INFWL CO% TKOL 1989;17:202-7).
References for Disease Control, Prevention and Control ol 1. Centers Influenza. MMWR 1990;39:1-15. 2. Weingarten S, Riedinger M, Bolton LB, Miles P, Ault M. Barriers to influenza vaccine acceptance. AM J IE~FECT CONTROL 1989;17:202-7. 3. Hutchins CD. WISHA regional directive: subject. Enforcement procedures for occupational exposure to hepatitis B virus (HBV) and human immunodeficienry virus (HIV). Olympia, Washington: Division of Industrial Safety and Health, 1989. 4. Falvo D. Effective patient education: a guide to increased compliance. Rockville, Maryland: Aspen Systems 1985. 5. Feuerstein M, Labbe E, Kuczmierczyk A. Health psychology. New York: Plenum Press, 1987:248-58. 6. Sackett D, Haynes RB. Compliance with therapeutic regimens. Baltimore: Johns Hopkins University Press, 1976: 41-7. 7. Hanacik LJ, Iversen NM, Conrad KA, Lowenberg G. Hepatitis B vaccine programs give ICPs a shot in the arm. AM J INFECT CONTROL 1989;17:148-53. 8. Sienko D, Anda RF, McGee HB, et al. Hepatitis B vaccination programs for hospital workers: results of a statewide survey. AM J INFECT CONTROL 1988; 16: 193-7, 9. Bodenheimer HC, F&ton JP, Kramer PD. Acceptance of hepatitis B vaccine among hospital workers. Am J Public Health 1986;76:252-5. 10. Crossley KB, Gerding DN, Petzel RA. Acceptance of hepatitis B vaccine by hospital personnel. Infect Control 1985;6:146-9. Il. Merck Sharp & Dohme. Keys to compliance in HBV vaccination. Impact 1990; l(2): l-2. on AIDS and hepatitis B. New York: 12. Pease N, ed. Forum Professional Education Publications, Nov. 20-1, 1989:7 13. Lancaster D, Elam S, Kaiser AB. Immunogenicity of the intradermal route of hepatitis B vaccination with the use of recombinant hepatitis B vaccine. AM J INFXT CO~~ROI. 1989;17:126-9. 14. Regan T, ed. Just business: new introductory essays ir; business ethics. New York: Random House, 1984:250. 15. Scheckler WE. A creative method for determining the immunization status of a community hospital medical staff. AM J INFECT CONTROL 1988;16:147-51. 16. Centers for Disease Control. Measles-Washington, 1990. MMWR 1990;28:473-6.
Journal Volume
19
of Infection Number
4
Control August
1991
ARTICLES
Influenza and hepatitis acceptance: A survey health care workers Margaret Spokane,
A. Christian, Washington
B vaccine of
RN, MA, CIC
To assist in the nonrequired vaccine program evaluation at Valley Hospital and Medical Center in Spokane, Washington, a survey of all employees (M = 379) was conducted, with a 63.3% return rate. The most common reasons for not accepting influenza vaccine were wish to avoid medications whenever possible (47%, 96/203), concern about getting influenza from the vaccine (45%, 89/199), and concern about severe reactions such as Guillain-Barre syndrome (37%, 731196). The most common reasons for not accepting hepatitis B vaccine were not enough exposure to hepatitis B to get vaccinated (52%, 5711 lo), wish to avoid medications whenever possible (44%, 5 1/ 117), and concern about side effects (43%, 501117). Twelve percent (221177) of the respondents who reported potential exposure identified the belief of “not enough exposure” as a reason to refuse hepatitis B vaccine. It was also noted that health care workers who rejected hepatitis B vaccine indicated that fear of “getting AIDS from the vaccine” did not influence them (96%, 1081113). (AM J INFECT CONTROL 1991;19:177-84)
Acceptance by health care workers of vaccines that are recommended but not required is a concern at Valley Hospital and Medical Center, a 123-bed, acute-care hospital in Spokane, Washington. Influenza immunizations are offered to all employees annually. The Centers for Disease Control (CDC)’ recommends that “administrators of all health-care facilities should arrange for influenza vaccine to be offered to all personnel before the influenza season.” The CDC states that there should be “particular emphasis on vaccination of persons who care for high-risk paFrom the Infection ical Center. Reprint Hospital 99216.
Control
Department,
requests: Margaret and Medical Center,
Valley
Hospital
and
Med-
A. Christian, RN, MA, CIC, Valley 12606 East Mission, Spokane, WA
tients (e.g., staff of intensive-care units and staff of medical/surgical units).” “Influenza infections cause significant morbidity, some mortality, and excessive resource consumption.“2 During the 1988-89 influenza season 19 (4.6%) of 407 employees took advantage of the hopsital influenza vaccine program. During the 1989-90 season the response increased to approximately 5.6%. In addition to the CDC recommendations, the Washington Industrial Safety and Health Administration (WISHA) requires a hepatitis B vaccine program.3 A recombinant hepatitis B vaccine is offered at the time of employment to all employees at Valley Hospital; those who refuse may change their minds at any time in the future. During 1988 the vaccine was offered to 102 new employees. Fifteen new employees already had taken the vaccine and 44 requested the vaccine through the hospital program, for an acceptance 177
178 Table
C’hrisrim
I.
Presclrvey
hepatitls
6 vaccine
acceptance
rates No.
Department
Obstetric nurses IV therapy nuws OR scrub technlclans Emergency personnel CU nurses Nursery nurses OR circulating nurses Laboratory technicians Labora!ory aide (phlebotomis!)
vrcclwtd
OF THE
. ..__._ Total
wlployees 16 4 19 25 18
4
10 12 4
4 1
LITERATURE
People’s beliefs, values, and social intluences may have a significant impact on the extent to which they follow any recommended regimen.J Such variables as age, sex, race, educational Icvel, marital status, cultural attributes, socioeconomic level, and religion have been studied as determinants of adherence to a treatment rcgimen. These variables arc not a reliable cxplanation for compliance.’ Why pcoplc do not use health care services when they are easily accessible is one of the crucial questions in medical care. In regard to adherence to a variety of treatment regimens, “estimates of noncompliance range from 4% to 92%, and average from 30% to 3 ” Initially proposed by Rosenstock (1966) and revised by Becker and Maiman (1975), the health belief model is one of the few models available that attempts to explain health behavior and/or compliance.“’ Becker states the health belicf model has been shown to be associated with individuals’ decisions to accept immunizations.” This model includes perceived susceptibility, perceived severity, pcrccivcd benefits, and pcrceivrd costs or barriers. The patient-practitioner relationship and physician continuity arc modifving factors that motivate compliance. Becker has argued that this model is a useful framework j%."9
.-___----.-~.-_
12 3 7 17 12 6
rate of 58%. Twelve (27%) of the 44 requesting the vaccine did not start the series. In 1989, 20 of 81 new employees previously had the vaccine, 35 requested the vaccine, and 14 (40%) of those did not start the scrics. In 1989 the new employee acceptance rate was 68%. Table 1 shows the hepatitis B vaccine acceptance rates in selected departments at Valley Hospital and Medical Center. REVIEW
_-.-
11
__. ----_
.-
..-
.
Percent accfqtanca 75 75 ‘0 68
67 LA ., 43 33 25
for Inten~ention.5 If the health belieiscan be idtntilied, changes can be made in programs to incrcasc compliance. There arc few available data on hospital employees’ acceptance of or attitudes to;vard vaczinc recommendations.: Weingartrn et a!.’ S;liveyed physicians and nurses and showed that only 2.1% received the 1986-87 triva!eni inlluenza vaccine and 3.2% received the monovalent Taiwan vaccine before the 1986-87 influenza season. “Fear of adverse reactions, avoidance of medications, and the inconvenience of vaccine administration were frequently cited reasons for declining immunizations.“’ Hanacik et al .’ collected subjective opinions on hepatitis B immunization programs through a survey of infection controi practitioners at a national conference. Their sur-ve?; showed that there are employees who arc unaware of risk and who are unaware of the vaccine offer.’ In 1985 a statewide survey in Michigan found that fear of vaccine-associated acquired immunodeficiency syndrome (AIDS) was most frequently cited as the primary reason for vaccine refusal.” In reporting on the suri.e>‘, Sicnko et al. concluded “that unwarranted Tears about the vaccine’s safety riced to be dispelled.” In 1983 researchers at Rhode Island Hospital surveyed 1500 employees regarding acceptance of hepatitis B vaccine. They concluded “that rhe beliefs of health care providers. particularly regarding the safety and efficacy of hepatitis B vaccine, have a major impact on thcil. decision to accept or reject vaccine.“’ Other beliefs that were less important determinants concerned the likelihood of contracting hepatitis B and the chance of becoming severely ill. “A marked variation in the rate of acceptance of vaccine among heaith care personnel has been reported ranging from
Volume 19 Number August 1991
4
Influenza and hepatitis B vaccine acceptance
Table 2. Influenza 1. m Please circle 2. Y 3. Y 4. 5. 6.
Y Y Y
(flu) and hepatitis y for yes
B vaccine
179
questionnaire
f or n for no. n n
Please
n 22. y 23. y n 24. y n If YES to 22, 23, or 24: Thank you, you’re finished. If NO to 22, 23, AND 24, please continue. Did the following reasons influence you to not take 25. y n 26. y n n 27. y n 28. y 29. y n 30. y n n 31. y 32. y n n 33. y 34. y n n 35. y n 36. y 37. y n n 38. y 39. y n n 46 Y
58% to as low as 27%.“’ Crossley et al.‘O reported acceptance rate of 38% in 1982 at two universityaffiliated teaching hospitals. A Merck Sharp & Dohme publication in the spring of 1990 stated that “only 30% to 40% of high-risk health care workers have opted to re-
m if you
are male
or f if
you are female.
Does your work involve contact with patients? Have you had flu symptoms (a fever with either a sore throat, cough, or a runny nose) since Dec. 1, 1989? Did you work while ill with flu symptoms? Did you take amantadine (Symmetrel) to prevent flu? Did you get the flu vaccine for the 1989-90 flu season?
n n n
If YES, skip to question 21. If NO, please continue with the next question. Did the following reasons influence you to not take n 7. Y n 8. Y n 9. Y 10. y n 11. y n n 12. y 13. y n n 14. y 15. y n 16. y n 17. y n n 18. y n 19. y 20. y n n 21. y
circle
flu
vaccine? Avoid medications whenever possible. Vaccine administration inconvenient. Concern about severe reactions like Guillain-Barre. Concern about getting flu from the vaccine. Vaccine not effective. Concern about pain and discomfort. Prior adverse reaction to the vaccine. Cost to employee. Allergic to the vaccine. No one recommended it to me. Flu is not a serious disease. I’m not likely to get the flu. Friends decided not to get vaccine. Other (write in) Does your job include the possibility of exposure to patients’ blood/body fluids at least once a month? Have you had the disease hepatitis B? Have you completed the hepatitis B vaccine series? Are you currently taking the vaccine and “on schedule”?
hepatitis B vaccine? (If female) Concerns of pregnancy or breast feeding. Newness of vaccine. Schedule of doses too complicated. Concern of side effects. Avoid medications whenever possible. Concern of getting AIDS from the vaccine. Not enough exposure to hepatitis B to get vaccinated. Hepatitis B is not a serious disease. Vaccine is not effective. Cost to employee. Concern about pain and discomfort. Vaccine administration inconvenient. No one recommended it to me. Friends recommended against it. Concern about getting hepatitis B from the vaccine. Other (write in) Just Fold and Route
ceive hepatitis B vaccine.“” Two successful programs were cited. One was able to achieve a compliance rate of 80.6% of employees at risk, and the other had an initial compliance rate of 67%.” A nationwide survey of 200 persons found that only half had been vaccinated and “more than
American
100
Table
Christian
3.
Attitudes
!NFECTION
influencing
acceptance
of influenza
Jourw
0:
fONTF!O1~
vaccine _____-
AnRude
Yes/tot&l
%
No/Total
%
7. Avoid medications 8. Inconvenient 9. Severe reaction concern 10. Get flu from vaccine
961203 371194 731196 891199
47 19 37 45
107/203 571194 1231196 1101199
53 81 63 55
11, 12. 13. 14. 15. 16. 17. 18. 19. 20.
411185 301197 391199 141195 121193 481196 45/190 561193 51190 561213
22 15 20 7 6 2.5 24 29 3 26
1441185 1671197 1601199 1811195 1831193 1481196 1451190 137/193 185/190 1571213
78 85 80 93 94 76 76 7: 97 74
Vaccine ineffective Pain and discomfort Prior reaction cost Allergy No recommendation Flu not serious Not likely to get flu Friends do not get vaccine Write in
30% of emergency workers surveyed did not know a vaccine is available.“” Most of the research reviewed addressed acceptance of only hepatitis B vaccine. That vaccine was released in 1982, just after AIDS was recognized in 198 1. Since the cause of AIDS was unknown at the time, there was concern that the hepatitis B vaccine could transmit AIDS. That belief was “based on the fear that those considered to be at high risk for infection with the human immunodeficiency virus had donated serum for the manufacture of the vaccine.“13 The fear persisted “in spite of the fact that several clinical studies provided assurances of the safety of the Heptavax-B product .“I3
The health care workers studied included all employees of Valley Hospital for the following reasons: 1. Although the influenza vaccine recommendation specifies workers having extensive contact with patients who have high-risk chronic medical conditions, any employee may be implicated in influenza transmission in a small community hospital such as Valley Hospital and Medical Center. 2. Hepatitis B vaccine is offered to all employees. Since the attitudes of high-risk employees regarding refusal of the vaccine are especially important, a question identifying the employee’s risk was asked. High-risk is defined as having potential for exposure to patients’ blood or body fluids at least once a month. The sample represented a convenient and logical cluster, which included several sets of
subgroups: employees involved in patient care and those not involved in patient care, employees with the opportunity of exposure to blood and body fluids at least once a month and those expecting no exposure, and male and female employees.
A questionnaire (Table 2) was used to collect data regarding the variables. The instrument, along with a cover letter, was attached to each employee’s time sheet on March 19, 1990. The cover letter explained how the survey would-be used, how the results would be shared with them, and whom to contact with questions and was signed by the chief operating o&cer to show administrative approval. The light green questionnaire consisted of one page so that it would not appear to be an overwhelming task to complete it. Instructions were included to “just fold and route“; the design included routing instruction for the “in-house mail” system. A second letter was sent to all departments a week later to encourage participation and thank those who completed the questionrmaire. Managers were also reminded during meetings to encourage employees to complete the questionnaire. The study closed on April 16, 1990. An attempt was made to survey non-responders by asking the department managers to take questionnaires back to their departments and request anyone who had not completed one to do so. However, only one response was received from the use of this technique. A problem with this design was that commonly used inferential statistics were not appropriate
volume August
19 Number 1991
4
Influenza
Table 4. Influenza
vaccine,
write-in
Reaffirm questions 7-l 9 Did not think about it Pregnancy or breast feeding Not a priority or not interested Nos. 7-19 not marked but written Do not like shots Other medical condition Procrastinatinglforgot Not in high-risk group Did not know it was available Doctor said “no”
25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40.
influencing
acceptance
in
of hepatitis
acceptance
181
No. of responses
%
11/52 7152 6152 6152 6152 4152 3152 3152 3152 2152 l/52
20 13 12 12 12 8 6 6 6 4 2
B vaccine
Attitude
Yes/total
%
No/total
%
Pregnancy/breast feed Newness Complicated schedule Side effects Avoid medications Get AIDS from vaccine Not enough exposure Not a serious disease Vaccine not effective cost Pain and discomfort lncovenience Not recommendation Friends against Get hepatitis B Write in
141110 21/116 91114 501117 511117 51113 571110 71110 31107 al108 171112 171110 201113 l/110 261109 241124
13 18 8 43 44 4 52 6 3 7 15 16 18 1 24 19
961110 951116 105ll14 671117 661117 108/113 531110 103/110 104llO7 1001108 951112 931110 931113 109/110 831109 1001124
87 82 92 57 57 96 48 94 97 93 85 85 82 99 76 81
for analyzing data that resulted from the study. The study was exploratory in nature, and a majority of the results were descriptive statistics. The Statistical Package for the Social Sciences (SPSS) on the Vax at Gonzaga University was used to compile data for the tables. One inferential statistic, a x2 analysis, was used to evaluate the difference between men and women accepting hepatitis B vaccine. ETHICAL
B vaccine
attitudes
Attitude
Table 8. Attitudes
and hepatitis
ISSUES
“Persuasion by rational means, by offering a person reasons why he ought to act in some way, treats him as an equal and respects his right of free and informed choice.“14 The questionnaire includes “reasons” that have influenced other health care workers not to take the vaccine. Many of these reasons are not valid or true. However, just reading them may influence the Valley Hospital employees not to take the vaccine in the future. For each employee to make an informed
choice, future education programs must address correction of misinformation. Confidentiality was not an issue, since the questionnaire was completed anonymously. RESULTS
Of 379 questionnaires distributed 240 were returned, for a 63.3% return rate. The attitudes that did and did not influence health care workers to take the influenza vaccine are shown in Table 3, and a summary of write-in results for refusing influenza vaccine is presented in Table 4. The most common attitude given for not taking influenza vaccine was No. 7, “avoid medications whenever possible.” Forty-seven percent (96/203) of the respondents who answered that question said it influenced their behavior. Second most common was No. 10, “concern about getting flu from the vaccine” (45%, 89/ 199). Third was No. 9, “concern about severe reactions like Guillain-Barre” (37%, 731196). Fourth was No.
182
American INFECTON
Christian
TaMe 8. Hepatitis B vaccine write-in attitudes Attitude Reaffirm questions 25-39 Other medical condition Did not think/know about Procrastinating Doctor said “no” Do not like shots Not interested Plan to get it
No. of responses
it
6124 4124 3124 3124 2124 2124 2124 1124
% 25 17 13 13 8 8 8 4
18, “I’m not likely to get the flu” (29%, 561193). The most common attitude that did not influence the health care workers was No. 19, “friends decided not to get vaccine” (97%, 185/ 190). Second was No. 15 “allergic to the vaccine” (94%, 181/ 193). Third was No. 14, “cost to employee” (93%, 181/195). There currently is a $2 administration fee for influenza vaccine. Table 5 shows attitudes that did and did not influence health care workers to accept hepatitis B vaccine, and Table 6 presents a summary of write-in reasons for refusing hepatitis B vaccine. The most common attitude given for not accepting hepatitis B vaccine was No. 31, “not enough exposure to hepatitis B to get vaccinated.” Fifty-two percent (57/l 10) of the responders said it influenced their behavior. Second most common was No. 29, “avoid medications whenever possible” (44%, 511117). Third was No. 28, “concern of side effects” (43%, SO/ 117). Fourth was No. 39, “concern about getting hepatitis B from the vaccine” (24%, 261109). The most common attitude that did not influence health care workers to reject hepatitis B vaccine was No. 38, “friends recommended against it” (99%, 109/110). Second was No. 33, “vaccine is not effective” (97%, 104/107). Third was No. 30, “get AIDS from vaccine” (96%, 108/113). Table 7 shows a comparison of dependent variables and selected independent variables according to gender. There were 192 persons who gave reasons for not accepting the flu vaccine. Many gave more than one reason. The mean number of reasons was 3, the median was 4.5, and the mode was 1. The N - 1 SD was 1.795. There were 110 persons who gave reasons for not accepting hepatitis B vaccine. The mean was 2.9, the median was 5, the mode was 1. The N - 1 SD was 1.939.
Jourw oi CONTROL
There was a cluster of the top three variables for each of the vaccines. When the fourth variable was added to each list, the beliefs that influenced behavior were comparable, with some order reversal (Table 8). According to the health belief mode1,5 Valley Hospital and Medical Center can increase compliance with vaccine recommendations by addressing these issues. The results showed some other interesting points. Eighty-two percent (1961240) of the respondents had patient contact; of those, 10% (20/ 196) had taken flu vaccine. Twenty-two of the total respondents (9%) reported having taken flu vaccine. These are both higher rates than the 4.6% and 5.6% calculated through the hospital vaccine program. Very few health care workers took Amantadine to prevent the flu (6/240). Seventy percent of the health car& workers who had flulike symptoms (1001240) reported that they worked while ill (76/100). Perhaps a higher influenza vaccine acceptance rate would decrease the possibility of disease transmission within the hospital. Of the 82% (196/240) of the health care workers who had patient contact, 88% (172 / 199) also had potential exposure to blood and body fluids. Of the 44 (18%) who did not have patient contact, 5 (11%) reported potential exposure to blood and body fluids. This result reaffirms the policy to offer hepatitis B vaccine to all personnel. Twelve percent (22 / 177) of the respondents who reported potential exposure identified the belief “not enough exposure” as a reason not to take hepatitis B vaccine. This is an important misconception that needs to be addressed. Sixty-two percent (109/177) of the health care workers who reported potential exposure to blood and body fluids have had the hepatitis B vaccine or are on schedule in taking the series of inoculations. This rate fits in well with the 58%: and 68% new employee vaccine acceptance rates, Only 8 (3.3%) health care workers reported a history of hepatitis B. Crossley et al.” surveyed health care workers in two hospitals who did not accept hepatitis B vaccine and found that 6% and 16% of them marked the response “I’ve had hepatitis B” as a reason for refusal. He quoted the literature as showing that “hepatitis B virus infection ranges from 10% to 40% in physicians, dental staff, nurses and laboratory personnel.” The rate in questionnaire respondents may be artificially low, since there was no serologic analysis.
Volume19
Number
4
Influenza
August1991
Table 7. Comparison
of response
and hepatitis
B vaccine
Variable Patient contact Yes No Accept flu vaccine Yes No Blood and body fluid exposure Yes No Accept hepatitis B vaccine Yes No Vaccine on schedule Yes No
8. Comparison
of beliefs
influencing
rejection
Female %
No.
%
36 5
88 12
159 36
82 18
2 38
5 95
20 175
10 90
31 10
76 24
145 47
76 24
27 14
66 34
83 112
43 57
2 36
5 95
14 168
8 92
of vaccines Hepatitis
47% 45% 37% 29%
Avoid medications Get flu from vaccine Severe reaction concern Not likely to get flu
analysis
of male/female
Accept vaccine Reject vaccine Total
(n = 195)
No.
Influenza
Table 8. Chi-square
I83
by gender Male (n = 41)
Table
acceptance
B
Not enough exposure Avoid medications Concern of side effects Get hepatitis B from vaccine
acceptance
of hepatitis
52% 44% 43% 24%
B vaccine
Male
Female
Total
27( 19) 14(22) Ti
83(91) 112(104) 195
110 126 236 (O-E)2
0
E
O-E
27 83 14 112
19 91 22 104
-8 -8
8
8
Another difference noted in this study was the 66% hepatitis B vaccine acceptance rate for males as compared to the 43% acceptance rate for females. A total of 46.6% (110/236) accepted the vaccine overall. Chi-square analysis (Table 9) showed x2 = 7.595 (p = 0.01). The other comparisons noted in Table 7 were strikingly similar, as expected from reading the literature. It was also noted that among the reasons that did not influence health care workers to reject vaccine was the variable “get AIDS from vaccine”
(O-E)2 64 64 64 64
E 3.368 0.703 2.909 0.615 x2 = 7.595
(96%, 108 / 113). This was quite a change from the 1985 survey by Sienko et a1.8 and may show that educational programs and use of recombinant vaccines have changed health care workers’ beliefs. The following recommendations for Valley Hospital and Medical Center’s immunization program are a result of this study: 1. Use the employee newsletter to share the survey response rate and questionnaire results. 2. Give the first dose of hepatitis B vaccine at
184
3.
4.
5.
6.
7.
Christian the time of the physical examination to decrease the number of new employees who request and never start the series. Address misinformation issues through the existing mandatory education program. Specifically include risk of disease exposure and concern about getting disease as a result of the vaccine. Emphasize that the fact that a belief was listed in the questionnaire does not make it true. Publicize national recommendations for health care workers to accept influenza vaccine to protect patients in the hospital. Use any of the formal and informal communications systems (staff meetings, nursing council, ancillary forum, memos, and guest relations publications) that are available to share appropriate vaccine information. Drop the $2 administration fee for influenza vaccine, as has recently been done for hepatitis B vaccine. Take influenza and hepatitis B vaccine into the employees’ departments for administration.
LtMtTATtONS
OF THE STUDY
The 63.3% response rate and the small number of employees may make it difficult to generalize the data to the larger population of health care workers. An effective follow-up system was sacrificed by ensuring the employee’s anonymity. After the study was completed, a cross-check with payroll records showed that 10 nursery employees and 4 cafeteria employees were missed when the questionnaires were attached to the time sheets. This study was exploratory in nature, and the majority of the results were descriptive statistics rather than inferential. Physician response at Valley Hospital to vaccine recommendations is unknown. Scheckler’” cites an 8% physician acceptance rate of hepatitis B vaccine. It would have been helpful to include physicians in the study. Overall, the survey raised health care workers’ level of awareness of the vaccine program. As the recommendations are implemented, an increase in compliance can be expected. However, during the spring of 1990 there was a measles outbreak in the state of Washington.16 With emphasis on measles immunity, the influenza and hepatitis B vaccine acceptance rates may suffer.
Thanks are extended to Michael R. Carey, Assistant Professor of Organizational Leadership in the School of Professional Studies, Gonzaga University, for his crirical review of this research project and assistance with the statistical component at Gonzaga University. Michael Liepman, Chief Opet ating Officer of Valley Hospital and Medical Center in Sp+ kane, Washington, is also thanked for his administrative support. Thanks also go to Scott Weingarten, Mary Riedinger , Linda Burnes Bolton, Peggy Miles, and Mark Ault ft)r providing a copy of the survey instrument used in their study u! barriers to influenza vaccine acceptance iA&? J INFWL CO% TKOL 1989;17:202-7).
References for Disease Control, Prevention and Control ol 1. Centers Influenza. MMWR 1990;39:1-15. 2. Weingarten S, Riedinger M, Bolton LB, Miles P, Ault M. Barriers to influenza vaccine acceptance. AM J IE~FECT CONTROL 1989;17:202-7. 3. Hutchins CD. WISHA regional directive: subject. Enforcement procedures for occupational exposure to hepatitis B virus (HBV) and human immunodeficienry virus (HIV). Olympia, Washington: Division of Industrial Safety and Health, 1989. 4. Falvo D. Effective patient education: a guide to increased compliance. Rockville, Maryland: Aspen Systems 1985. 5. Feuerstein M, Labbe E, Kuczmierczyk A. Health psychology. New York: Plenum Press, 1987:248-58. 6. Sackett D, Haynes RB. Compliance with therapeutic regimens. Baltimore: Johns Hopkins University Press, 1976: 41-7. 7. Hanacik LJ, Iversen NM, Conrad KA, Lowenberg G. Hepatitis B vaccine programs give ICPs a shot in the arm. AM J INFECT CONTROL 1989;17:148-53. 8. Sienko D, Anda RF, McGee HB, et al. Hepatitis B vaccination programs for hospital workers: results of a statewide survey. AM J INFECT CONTROL 1988; 16: 193-7, 9. Bodenheimer HC, F&ton JP, Kramer PD. Acceptance of hepatitis B vaccine among hospital workers. Am J Public Health 1986;76:252-5. 10. Crossley KB, Gerding DN, Petzel RA. Acceptance of hepatitis B vaccine by hospital personnel. Infect Control 1985;6:146-9. Il. Merck Sharp & Dohme. Keys to compliance in HBV vaccination. Impact 1990; l(2): l-2. on AIDS and hepatitis B. New York: 12. Pease N, ed. Forum Professional Education Publications, Nov. 20-1, 1989:7 13. Lancaster D, Elam S, Kaiser AB. Immunogenicity of the intradermal route of hepatitis B vaccination with the use of recombinant hepatitis B vaccine. AM J INFXT CO~~ROI. 1989;17:126-9. 14. Regan T, ed. Just business: new introductory essays ir; business ethics. New York: Random House, 1984:250. 15. Scheckler WE. A creative method for determining the immunization status of a community hospital medical staff. AM J INFECT CONTROL 1988;16:147-51. 16. Centers for Disease Control. Measles-Washington, 1990. MMWR 1990;28:473-6.
