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Flu Vaccination: Using the Health Belief Model to Increase Vaccine Uptake
Felicia Gutierrez, PA-C, and Justin Wolfe, MHS, PA-C

September 27, 2022

The CDC Advisory Committee on Immunization Practices (ACIP) recommends all patients six months and older should receive the flu vaccination (unless contraindicated) during September or October (ref 1). Influenza vaccine recommendations were updated for the 2022-23 flu season to reflect a new vaccine composition (which changes most years based on surveillance data), a labeling change, and updates to the recommendations for patients ages 65 and older. These updates advise that senior adult patients preferentially receive a vaccination with a higher dose or with an adjuvant, the ingredient added to a vaccination to promote a better immune response (ref 2). Studies have shown this population has a lower risk of hospitalization when provided an adjuvanted influenza vaccine (ref 2). If the higher dose or adjuvanted vaccines are not available at the time of administration, any age-appropriate influenza vaccine should be given (ref 1). With these updated recommendations, healthcare providers must be prepared to discuss the influenza vaccine options and be ready for conversations to combat vaccine hesitancy now more than ever.

Each year influenza vaccination rates in the U.S. are lower than national recommendations. There are many factors that cause low compliance, including vaccination hesitancy. The Health Belief Model is a behavioral model providers can use to approach our patients during discussions about flu vaccination. This model asks the provider to consider five areas where vaccine hesitancy might be rooted: the patient’s perception of their perceived susceptibility to catching the flu; their perception of how severe the flu infection might be if they catch it; their perceived benefits of the vaccination; how they think about perceived barriers to the vaccination; and what providers call “cues to action,” which refers to the positive messages (cues) they are getting to encourage them to get the flu vaccine. Each of these elements in combination with motivational interviewing techniques can help guide flu vaccination conversations and potentially increase vaccination compliance.

The first element is the patient’s perception of the likelihood they will become sick with the flu (perceived susceptibility). This is a conversation about risk. A helpful way to convey risk is with visual aids like graphs or charts, which can be stored in an exam room for use when the discussion comes up. Natural frequencies work best and are simple to understand, such as: “In the United States, the yearly average of developing the symptomatic flu is X out of every 100 people” (ref 3). This is straightforward for the patient to understand compared to the use of a simple percentage or a relative risk, which may not be as clear to them.

Perceived severity is the patient’s belief that the flu can cause severe health complications. This element is crucial when discussing the newest ACIP guidelines, which are directed at patients 65 and older (ref 4). Talking about the number of hospitalizations and even deaths in this age group may increase the patient’s perceived severity of the disease (ref 5). Some research suggests patients are more likely to receive the vaccination if they believe the flu can cause hospitalization (ref 6).

Perceived benefits refers to the patient’s belief that receiving the vaccination will provide protection, reduce their symptoms, and reduce the risk of complications (ref 7). Many patients are aware that the flu vaccine’s efficacy changes each year. It is important to address this with your patients and maintain open communication about the benefits and possible risks of the vaccine (ref 8). Although the goal of these conversations is to increase the patient’s willingness to receive the vaccination, you should be completely transparent and honest with them about the facts. Mention that although the vaccination’s effectiveness does vary from year to year, the coverage it provides is still effective enough at reducing the flu’s spread and reducing symptoms of those infected to make it worth getting the shot. Emphasize that vaccination is the most effective way for patients to protect themselves and family members from the flu (ref 7). And even if vaccine effectiveness is low, vaccination is linked to decreased morbidity and mortality. Those who receive the vaccine are less likely to have pneumonia and to be hospitalized or die from influenza-related complications. With the updated ACIP recommendations, you can also discuss the increased added protection for this patient population via higher doses and adjuvanted vaccines.

Perceived barriers include any physical or mental barrier that is preventing the patient from receiving the vaccine – transportation issues, lack of access, lack of time, adverse reactions, and vaccine misconceptions, such as that it will cause the flu, it is unsafe, or it is ineffective (ref 6 and 9). It is important to address each of the patient’s concerns individually and express an understanding of their apprehensions. By acknowledging their beliefs and identifying why they have these concerns, trust can form, opening the patient up to further discussions. Provide facts and information without directly discrediting their beliefs, which can create tension during the encounter. For example, with the updated guidelines, patients may have concerns about the increased higher dose and may believe this puts them at increased risk for side effects. There may also be fear of adjuvanted vaccines and what this actually means. Discuss all of these concerns and be prepared to provide easy-to-understand information that addresses their concerns and acknowledges their hesitation. As providers, this may require a little extra reading on our part so that we can briefly explain some of these vaccine features. This is time well spent.

Cues to action is the final and strongest element in this model (ref 6). This includes any prompt that encourages the patient to receive the vaccination, perhaps even that day. This can take the form of social media, mail reminders, family, and – often the strongest influencer – their healthcare provider (ref 6). As a provider you may not feel you have time to discuss the flu vaccine with your patients, but just the most basic act of recommending the influenza vaccination can be enough to increase vaccine compliance. It is also a step in the right direction with regards to addressing vaccination hesitancy. It’s hard to know why patients are hesitant to get the vaccine if we don’t ask.

With the updated recommendations this flu season, it is essential for healthcare providers to be prepared to have these discussions with their patients, especially those 65 and older and anyone who lives with them. Knowing the features of the Health Belief Model can provide structure and guidance to providers willing to have this conversation with vaccine-hesitant patients.

References
  1. CDC. Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices — United States, 2022–23 Influenza Season. https://www.cdc.gov/mmwr/volumes/71/rr/rr7101a1.htm. Accessed Sept 12, 2022.
  2. CDC. Adjuvanted Flu Vaccine. https://www.cdc.gov/flu/prevent/adjuvant.htm. Accessed Sept 12, 2022.
  3. CDC. Key facts about influenza (flu). www.cdc.gov/flu/about/keyfacts.htm. Accessed July 13, 2022.
  4. CDC. People at higher risk for flu complications. www.cdc.gov/flu/highrisk/index.htm. Accessed July 13, 2022.
  5. Painter JE, Sales JM, Pazol K, et al. Developmental, theoretical framework, and lessons learned from implementation of a school-based influenza vaccination intervention. Health Promotion Practice. 2010;11(1):42S-52S.
  6. Kan T, Zhang J. Factors influencing seasonal influenza vaccination behavior among elderly people: a systematic review. Public Health. 2018;156(2018):67-78.
  7. Mo PKH, Lau JTF. Influenza vaccination uptake and associated factors among elderly population in Hong Kong: the application of the health belief model. Health Educ Res. 2015;30(5):706-718.
  8. Leask J, Kinnersley P, Jackson C, et al. Communicating with parents about vaccination: a framework for health professionals. BMC Pediatr. 2012;12:154.
  9. Chen MF, Wang RH, Schneider JK, et al. Using the health belief model to understand caregiver factors influencing childhood influenza vaccinations. J Community Health Nurs. 2011;28:29-40.